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Objectives: Farmers are faced with many stressors, along with numerous barriers to accessing traditional forms of mental health support. The ifarmwell online intervention was co-designed with farmers and is informed by Acceptance and Commitment Therapy to equip farmers with transferable coping strategies, particularly to help them cope with circumstances beyond their control. We aimed to evaluate the effect of ifarmwell on farmers’ short- and long-term distress and mental wellbeing. Methods: Australian farmers (21–73 years) who registered on www.ifarmwell.com.au completed measures at the commencement of module 1 (N = 228), the end of the intervention (N = 77) and 6-months post-intervention (N = 61). Primary outcomes included distress (Kessler Psychological Distress Scale) and mental wellbeing (Mental Health Continuum – Short Form). We also examined the relationship between distress, mental wellbeing, neuroticism (Quickscales-R) and ACT-based psychological mechanisms; psychological inflexibility (Acceptance and Action Questionnaire-II), cog-nitive fusion (Cognitive Fusion Questionnaire), believability of automatic thoughts (Automatic Thoughts Questionnaire-B), coping via acceptance (4 items from the situational COPE) and mind-fulness (Five Facet Mindfulness Questionnaire-Short Form). Secondary outcomes of acceptability (Client Satisfaction Questionnaire-8) and usability (System Usability Scale) were also explored. Results: Pre- to post-intervention, farmers’ distress decreased and mental wellbeing increased. These effects were maintained at 6-month follow-up. Changes in these outcomes were greatest for participants who entered the intervention with high baseline distress (^β= −0.59, 95%CI =[−0.70, −0.47]) and low mental wellbeing (^β= −0.33, 95%CI = [−0.47, −0.19]). Decreases in distress and increases in mental wellbeing were associated with decreases in psychological inflexibility, cognitive fusion, and believability of thoughts, and increases in coping via acceptance and mindfulness. Levels of satisfaction (M = 26.92/32) and usability (M = 84.70/100) were high, and 94.6% of participants said they would recommend ifarmwell to a friend in need of similar advice and tools. Conclusions: ifarmwell is an effective and usable intervention that is likely to help farmers reduce their levels of distress and improve their mental wellbeing, by improving their psychological flexibility, ability to focus on the present and accept things beyond their control, as well as by reducing the extent to which they believe unhelpful thoughts. Refereed/Peer-reviewed

Refereed/Peer-reviewed Purpose: The aim of this research was to develop a contextually and culturally appropriate scale to assess farmers’ barriers to health-related help-seeking. Methods: An initial pool of items was developed from the academic literature and input from an expert panel of farmers, rural academics, and rural clinicians. A draft 32-item questionnaire was then developed and sent to farmers registered with FARMbase, which is an Australian national farmer database. Findings: Two hundred and seventy-four farmers completed the draft questionnaire (93.7% male, 73.7% aged 56-75 years). An exploratory factor analysis identified 6 factors; “Health Issues are a Low Priority,” “Concerns about Stigma,” “Structural Health System Barriers,” “Minimization and Normalization,” “Communication Barriers,” and “Continuity of Care.”. Test-retest reliability was examined with a further 10 farmers (90% male, Mean age = 57, SD = 5.91), who completed the questionnaire twice (at 2- to 3-week intervals). Results indicated moderate-good test-retest reliability. Conclusions: The resulting 24-item Farmer Help-Seeking Scale provides a measure of help-seeking that is specifically designed to capture the unique context, culture, and attitudes that can interfere with farmers’ help-seeking, and inform the development of strategies to increase health-service utilization in this at-risk group.

Refereed/Peer-reviewed Introduction: Farmers face a range of factors that negatively influence their mental health and suicide risk, yet have limited access to appropriate support. Behavioural activation (BA) is an evidence-based therapy that can be effectively delivered by nonclinical workers. Working with members of farming communities to deliver BA to their peers has the potential to overcome many well-established barriers to mental health help-seeking and improve outcomes for this at-risk group. Objective: This paper describes the findings of a co-design phase informing the development of a peer (farmer)-led approach for delivering BA for farmers living with depression or low mood. Design: This qualitative study used a co-design approach involving members of the target community. Focus groups were transcribed and analysed using Thematic Analysis and the Framework approach. Findings: Ten online focus groups with 22 participants were held over 3 months. Four overarching, interlinked themes were identified: (i) filling the gap in rural mental health support; (ii) alignment with the farming context—tailoring how, where and when we engage about mental health; (iii) the ‘messenger’ is as important as the message; and (iv) sustainability, governance and support. Discussion: Findings suggest BA could be a contextually appropriate model of support for the farming community—given its practical and solution-focused approach—and could help improve access to support. Having peer workers deliver the intervention was viewed as appropriate. Ensuring governance structures are developed to support peers to deliver the intervention will be essential to facilitate effectiveness, safety and sustainability. Conclusion: Insights gained through co-design have been critical to the success of developing this new model of support for members of farming communities experiencing depression or low mood.

Refereed/Peer-reviewed Not monitoring adherence to oral anticancer therapies (OAT) can lead to poor clinical outcomes, including premature death as reported by Foulon et al. (Acta Clin Belg 66(2):85–96, 2011) and Greer et al. (Oncologist 21(3):354–76, 2016). Barriers to the implementation of supportive cancer care interventions in medication adherence occur with multiple hospital sites, cancer diagnoses, and numerous healthcare professionals. This commentary describes challenges and strategies from two OAT adherence trials in Australia and Switzerland to assist researchers in the design and implementation of future interprofessional trials.

Refereed/Peer-reviewed Issue Addressed: Rurality is associated with poorer health outcomes and access to health services, yet a strength of rural living includes community cohesion indicated by high rates of volunteering. While volunteerism is an effective means to target health needs in resource-restricted contexts, research on volunteerism to address rural Australian health needs is limited. This research aimed to explore rural adults' perspectives of volunteerism in local activities and programs that had a direct health related benefit (health volunteering). Methods: Eight people from the Murray Mallee region of South Australia participated during April 2021, ranging in age from 32 to 75 years. Participants were invited to one-on-one interviews that occurred via a phone call or teleconference meeting, which were audio-recorded and transcribed verbatim to facilitate thematic analysis. Results: Seven main themes emerged. Participants identified that (1) health volunteering takes many forms, (2) health volunteering affords local ownership and accessibility, (3) health volunteers have particular skills and values, but also (4) gain social benefits and learn new skills. Rural health volunteering was also associated with (5) a variety of personal costs, and (6) there are several environmental barriers and (7) facilitators to rural health volunteering that should be considered when designing health programs. Conclusion: Results provide insight into how rural communities can enhance the development and application of volunteering roles to support health volunteering. So What?: Including local champions, reducing the financial burden and developing support networks for volunteers are practical suggestions to enhance levels of volunteering for health in rural settings.

Refereed/Peer-reviewed Objective: To evaluate the psychometric properties of the Perceptions of Parental Illness Questionnaire for Cancer (PPIQ-C) among adolescents and young adults (AYAs). Methods: A sample of 372 AYAs (aged 12–24 years) who had a parent diagnosed with cancer completed the PPIQ-C and the Kessler Psychological Distress Scale (K10). Exploratory factor analyses were conducted to examine the dimensional structure of the PPIQ-C. Scale reliability was evaluated using Cronbach's alpha (α) and McDonald's omega (ω). Pearson correlation analyses were conducted to assess construct validity by examining correlations between PPIQ-C subscale scores and K10 total scores. Results: The PPIQ-C is organised into three sections, each with a separate factor structure for items representing identity, core (emotional representations, coherence, timeline, consequences, and controllability), and cause dimensions of the Common-Sense Model of Self-Regulation. Exploratory factor analyses determined the structure of each section: identity items comprised two subscales (12 items), core items comprised 10 subscales (38 items), and cause items comprised three subscales (11 items). Scale reliability was acceptable for all subscales, except the cause subscale chance or luck attributions (α = 0.665). Correlations between PPIQ-C subscale scores and K10 total scores provided support for construct validity. Conclusions: Preliminary evidence suggests that the PPIQ-C is a reliable, valid, and useful tool for assessing illness perceptions among AYAs with a parent with cancer. The PPIQ-C may be a useful addition to both clinical practice and future research, however further evaluation work is needed to confirm its structure and robustness prior to use.

Objective: To explore rural financial counsellors' experiences interacting with psychologically distressed farmers and identify contextually appropriate methods to maintain their own well-being and link farmers to psychological supports, within their existing roles. Setting: Rural, regional and remote Australia. Participants: Fifty rural financial counsellors participated. They worked across 6 Australian states/territories. Design: Individual semi-structured telephone interviews were audio-recorded with consent. Qualitative data were analysed using thematic analysis. Themes were identified using an essentialist, bottom-up approach. Results: Forty-six themes emerged relating to the 5 topics explored: (a) how to recognise distress in farmers (eg inability to focus/make decisions, deterioration in presentation/organisation, anger, blaming); (b) impact of farmers' psychological distress on the financial case management process (eg slows, disrupts or stops it, negatively impacts counsellor well-being); (c) strategies for working effectively with distressed farmers (eg flexibility, open-ended questions, listening to story, simplicity, instilling hope); (d) referral of distressed farmers to psychological support (eg willing if tried themselves/positive reports, lack of local rural face-to-face services, stigma and lack of understanding of importance challenging, a farming focus and support from family/ community assists); and (e) strategies to maintain their own well-being (eg compartmentalising, exercise, supervision). Conclusion: Rural financial counsellors play an important role by recognising signs of distress in farmers and referring them to appropriate psychological supports. However, this is a demanding role and ensuring counsellors have appropriate services to refer farmers to, and support with their own well-being, is imperative. Refereed/Peer-reviewed

Background: Rural Australians experience higher prevalence of several chronic diseases than metropolitan Australians and are less likely to access supportive health services. This study explored associations of sociodemographic factors and barriers to support seeking for health in a sample of rural South Australians. Methods: Participants (n = 610) from three rural regions participated in a computer-assisted telephone interview (CATI), based on the Barriers to Help Seeking Scale. Each participant reported on barriers in one of three health contexts: ‘general’ physical health, skin cancer, and mental health. Sociodemographic factors included gender, age, highest education, region of residence, and presence of chronic conditions. Chi-squared Automatic Interaction Detection (CHAID) determined independent associations of sociodemographic factors and barrier categories (high, medium and low importance). Results: Privacy was a high-importance barrier in the mental health context, particularly among participants of age < 63 years. The tendency to minimise and normalise health issues was also a high-importance barrier in the mental health context. In the physical health context, those with a chronic condition were more likely to perceive normalisation as a barrier than those without a chronic condition. Need for control and self-reliance was a high-importance barrier in the mental health context and a low-importance barrier in the skin cancer context, particularly among participants < 63 years. Structural factors and distrust of providers were high-importance barriers among those who did not complete secondary education, regardless of context. Conclusion: This study highlights the importance of a nuanced approach to promoting help-seeking in rural Australians, with message content and delivery tailored to specific health conditions and demographic circumstances. Refereed/Peer-reviewed

Aim: To determine feasibility and acceptability of completing PROs questionnaires at completion and 1 year after curative cancer treatment. Methods: Patients assessed in a nurse-led end of treatment survivorship clinic, at a tertiary referral centre, recruited between October 2015 and July 2016 were mailed a survey at baseline and at 12-month follow-up. The survey included validated PRO questionnaires. A target response rate for feasibility, defined as the proportion of the eligible population approached that completed the survey, was set at 70%. Qualitative feedback regarding the survey was collected from participants. Results: Of the 47 eligible patients approached, 34 (72.4%) agreed to participate with 29 (61.9%) completing the survey at baseline, and 21 (44.7%) at follow-up. Respondents lost to follow-up at 12 months had clinically meaningful lower scores on all QLQ-C30 functioning scales and 8 out of 9 symptom scales/items. Qualitative feedback from survey respondents indicated the content was relevant and acceptable. Participants expressed willingness to complete a similar survey approximately once per year and a higher preference for completing the survey in hard copy compared with online. Conclusions: Cancer survivors are willing to provide information on a range of PROs, but those with higher needs were the ones less likely to complete surveys. There is scope to improve the response rate and representativeness of the patient cohort captured. Future research should identify strategies to optimise recruitment when collecting PROs data from cancer survivors. Refereed/Peer-reviewed

Rural cancer patients have inferior cancer outcomes and unique unmet information needs. This paper explores the value of rural people affected by cancer delivering cancer-related education and support to their peers via 3–5 min online YouTube films. In part 1, 14 rural Australians affected by cancer (10 survivors, 4 carers), 50% (7/14) female, 55–79 years, "storytellers", were purposively invited to be filmed sharing their cancer-related experience and advice for others facing similar challenges. They then reflected on their storytelling experience during semi-structured interviews with an independent researcher. In part 2, 11 rural South Australians affected by cancer (8 survivors, 3 carers), 82% (9/11) female, 32–75 years, "viewers", who had watched at least three of the videos, were interviewed. When data saturation was reached, thematic analysis was employed. Storytellers were found to be highly satisfied with the film-making process and product. They valued rapport building prior to filming and the opportunity to help others. They also found storytelling cathartic and the films useful in communicating their cancer experience to family and friends. Rural viewers appreciated the honesty, authenticity, relatability and believability of the storytellers, the practical advice on rural-specific psychosocial issues, acknowledgment of the impact of isolation and the opportunity to understand others’ cancer experiences. The film’s short duration and professional film-making added appeal. Inclusion of younger storytellers and methods of delivery other than YouTube were suggested. This study highlights the value of this approach for storytellers and viewers. It may be particularly beneficial for isolated rural cancer survivors who feel that their unique challenges are not adequately addressed by mainstream cancer education resources However, further quantitative research to test acceptability and impact in representative rural samples is required.

Objective: Rural men affected by cancer are difficult to engage in psychosocial support services. This exploratory study tested whether exposure to printed brochures describing services, distinguished by a focus on rural men affected by cancer, resulted in more positive help‐seeking attitudes than exposure to material focused on rural location only or generic cancer support material. Methods: Targeted versions of a South Australian Cancer Council service brochure were developed to enhance cultural appropriateness, consistent with the Elaboration Likelihood Model. Rural men affected by cancer were recruited via supportive accommodation and randomized to receive one of the three brochures. The primary outcome was positive attitude to help‐seeking at post‐test (between 1‐2 days). Negative attitudes to help‐seeking, intention to seek help, perceived isolation, and service use were secondary outcomes; perceived information relevance at immediate post‐test was also measured. Results: Analysis (N=114) indicated no detectable group differences (rurality/male gender, n=33; rurality, n=41; control, n=40) on primary or secondary outcome measures (p>.05). Participants’ existing service use was high, due to the recruitment methods. Support service information was primarily sourced from other people (e.g., friends/family, 22.22%; medical professionals, 27.27%). Conclusions: Existing service use rates suggest that ceiling effects obscured any potential benefit from demographic targeting of materials. Further research should consider building understanding about the acceptability of targeting techniques in this population, replication with materials designed with greater consumer input, and employ samples recruited outside a support service. Refereed/Peer-reviewed

Purpose of review A great proportion of people affected by cancer experience psychological distress. To reduce pressure on limited health-management resources available, evidence-based eHealth or online interventions can fill an important gap by making psychosocial care more easily accessible. However, evidence of their effectiveness is mixed. This present review provides an update on the effectiveness of online interventions in reducing psychological distress in patients with cancer by including studies published from January 2018 to September 2019. Recent findings Thirty-three publications describing online interventions were included in the review, including web-based, blended care, telehealth, mHealth, and other online interventions. There was great heterogeneity across studies. The evidence of online interventions' effectiveness in reducing distress was mixed; there was partial support for reduction in psychological distress and depression, but limited evidence for reducing anxiety. Some important limitations should be taken into account when interpreting the results. Summary Online interventions for people affected by cancer, in general, are well received and seem to be a necessary component of comprehensive cancer care. However, these interventions should be more rigorously tested to provide more conclusive evidence about their effectiveness.

Aim: Nonadherence to oral chemotherapy (OC) can lead to health complications, including premature death. Mobile phones are increasingly used to deliver medication adherence interventions. However, there is limited evidence about mobile phone-based interventions to increase adherence to OC, specifically. This study explores the proof-of-concept of a smartphone program to support adherence to OC in people with cancer. Methods: This was a 10-week, nonrandomized, multisite trial. The outcomes assessed were acceptability, satisfaction with the intervention, adherence to OC, knowledge about OC, and side-effects presence and severity. The program consisted of short message service (SMS) reminders to take OC, as well as information about OC, including the management of side-effects. Results: Twenty-two participants (17-74 y/o, median age 60 y/o) were recruited at six hospitals. The sample included 10 different cancer diagnoses (predominance of breast cancer) and 11 OC medications. Acceptability of the intervention was high, with 95% of the enrolled participants completing postintervention measures, and 81% reporting high satisfaction with the program. The intervention was found to have no effect on supporting adherence to OC (assessed by self-report and medication event monitoring system) in this sample. An increase in knowledge about OC was observed at postintervention (p = 0.010). Conclusions: This study demonstrated proof-of-concept of the smartphone program and highlighted the need for intervention and trial design-related refinements. Future work should evaluate the effect of the program on adherence to OC with nonadherent patients. Refereed/Peer-reviewed

Purpose To explore the experiences of people caring for someone with cancer, while living in rural Australia, and the impact of the cancer-caring role on their well-being. Method Eighteen adults in regional or remote (‘rural’) Australia who cared for a person with cancer took part in semi-structured telephone interviews. Participants were aged 32–77 years and mainly female (66%). Data were analysed using thematic analysis and an essentialist approach. Results Eight themes were identified: (1) travel is hard, but supports are available; (2) frustration with systems that do not demonstrate understanding of the rural context; (3) the importance of lay and peer support; (4) the impact of access to trusted, local health care services; (5) the importance of access to rurally relevant information (particularly on relevant services and what to expect); (6) living with uncertainty and balancing loss with hope; (7) reluctance to seek or accept psychological support; and (8) the gendered nature of care. Conclusion Rural cancer carers’ roles can be made easier by improving health systems and coordination to ease the burden of travel, providing information about available support and what to expect throughout cancer treatment that is relevant to the rural context, and increasing access to quality health, community, and support services, including palliative care, in rural areas. More training on the specific needs of rural patients and their carers is needed for urban health care professionals. Peer support groups may have particular value for cancer carers in rural settings, where there are known to be multiple barriers to accessing professional sources of psychosocial support.

Purpose: To summarise what is currently known about the psychosocial morbidity, experiences, and needs of people with cancer and their informal caregivers, who live in rural or regional areas of developed countries. Methods: Eligible studies dating from August 2010 until May 2021 were identified through several online databases, including MEDLINE, EMBASE, PsychINFO, and RURAL (Rural and Remote Health Database). Results were reported according to the PRISMA guidelines and the protocol was registered on PROSPERO (CRD42020171764). Results: Sixty-five studies were included in this review, including 20 qualitative studies, 41 quantitative studies, and 4 mixed methods studies. Qualitative research demonstrated that many unique psychosocial needs of rural people remain unmet, particularly relating to finances, travel, and accessing care. However, most (9/19) quantitative studies that compared rural and urban groups reported no significant differences in psychosocial needs, morbidity, or quality of life (QOL). Five quantitative studies reported poorer psychosocial outcomes (social and emotional functioning) in urban cancer survivors, while three highlighted poorer outcomes (physical functioning, role functioning, and self-reported mental health outcomes) in the rural group. Conclusion: Recent research shows that rural people affected by cancer have unique unmet psychosocial needs relating to rurality. However, there was little evidence that rural cancer survivors report greater unmet needs than their urban counterparts. This contrasts to the findings from a 2011 systematic review that found rural survivors consistently reported worse psychosocial outcomes. More population-based research is needed to establish whether uniquely rural unmet needs are due to general or cancer-specific factors. Refereed/Peer-reviewed

BackgroundBehavioural activation (BA) is an effective treatment for depression; however, it is unclear if it can be used to manage pain.ObjectivesTo conduct a scoping review of primary research that reported using BA to support people living with chronic pain to understand how BA had been used in relation to pain. In addition, we wanted to understand whether there were any reported changes in that pain, and how and who delivered BA.Eligibility criteriaPrimary research published in English.Sources of evidenceWe searched seven databases MEDLINE, Ovid Embase, Ovid Emcare, PsycINFO, CINAHL, Scopus and Web of Science, for primary research. No initial date limit was used with the date the searches were conducted used as the end date limit (1 July 2021).Charting methodsA customised data extraction table was developed, piloted and used.Results551 papers were screened for inclusion, with 15 papers included in our review. Studies were conducted in North America and in Canada. These included three case studies, nine uncontrolled trials and three randomised controlled trials. Only two studies reported pain as the primary outcome. BA was applied across a range of pain related conditions. The dose of BA ranged from 3 to 16 sessions. Duration of treatment was 3 weeks to 12 months. Most studies reported reductions in pain following exposure to BA.ConclusionBA has the potential to reduce pain. Caution needs to be exercised in the interpretation of these findings as a high risk of bias was observed in most studies. High-quality research is required to test if BA is an effective intervention for chronic pain.

Purpose: To investigate the longitudinal associations between demographic, clinical and lifestyle factors, and changes in patient-reported outcomes (PROs) in cancer survivors 6–9 years post-diagnosis in Western Australia. Methods: A total of 290 individuals participated in this study. Three-quarters of participants were female, and 55%, 31%, and 14% were survivors of breast cancer, colon cancer, and non-Hodgkin lymphoma (NHL), respectively. PROs (fatigue, depression, and health-related quality of life (HRQOL)) were reported at two time points (2012–13 and 2017). Descriptive statistics were used to assess the overall changes over time and linear mixed models were used to identify factors associated with changes over time, after adjusting for confounders. Results: No significant changes were observed in PROs between time point 1 and follow-up at the population level, yet a notable proportion of participants (23% for fatigue, 10% for depression, and 39% for HRQOL) reported a negative minimal clinically important difference (MCID). Being non-Caucasian and having had NHL were associated with negative changes over time. Being obese and having had radiotherapy were related to improved outcomes. Conclusion: Cancer survivors whose levels of fatigue, depression, and quality of life are compromised during cancer treatment may require intervention even 6–9 years post-treatment. Our results suggest particular attention should be paid to those who are non-Caucasian and who have had NHL. This is crucial for providing appropriate care and to support those who are at increased risk of deteriorating naturally over time. Refereed/Peer-reviewed

Purpose To describe the theoretical, evidence-based and consumer-informed development of a smartphone self-management program aiming to support adherence to oral chemotherapy in adolescents and adults diagnosed with cancer. Methods The design of the program followed two frameworks for the development and evaluation of mHealth interventions and was conducted in three steps: 1) conceptualization, which involved an extensive literature review and a scoping review that led to the identification of the behavioral change strategies in the program; 2) definition of features and structure, based on a formative study with end-users to explore their preferences about the structure and elements of the program; and 3) selection of program delivery technology, whereby available technology platforms were examined and the most suitable tool to deliver the program was selected. Results Three main reasons for oral chemotherapy non-adherence were identified: forgetfulness, side-effects and poor knowledge about oral chemotherapy. Key behavior change strategies were also identified, namely, medication intake reminders and information about oral chemotherapy and managing side-effects. Based upon end-user feedback the method of delivery of these behavioral strategies that was deemed most appropriate was conventional text messages. The reminders were standard, short, text-only messages sent when each oral chemotherapy dose was due, one way (no need to reply) and addressed the end-users using their first name. Delivery of information about oral chemotherapy and side-effects was tailored to each individual's preferred frequency. Conclusion The careful design process described in this paper may serve to inform the development of future mobile phone-based medication adherence-enhancing interventions for people with cancer. A trial to explore end-users acceptability of and satisfaction with the intervention is currently underway.Trial Registration: ACTRN12618001987257p.

Purpose: People affected by cancer who live in rural Australia experience inferior survival compared to their urban counterparts. This study determines whether self-reported physical and mental health, as well as health-promoting behaviours, also differ between rural and urban Australian adults with a history of cancer. Methods: Weighted, representative population data were collected via the South Australian Monitoring and Surveillance System between 1 January 2010 and 1 June 2015. Data for participants with a history of cancer (n = 4295) were analysed with adjustment for survey year, gender, age group, education, income, family structure, work status, country of birth and area-level relative socioeconomic disadvantage (SEIFA). Results: Cancer risk factors and co-morbid physical and mental health issues were prevalent among cancer survivors regardless of residential location. In unadjusted analyses, rural survivors were more likely than urban survivors to be obese and be physically inactive. They were equally likely to experience other co-morbidities (diabetes, chronic obstructive pulmonary disease, cardiovascular disease, arthritis or osteoporosis). With adjustment for SEIFA, rural/urban differences in obesity and physical activity disappeared. Rural survivors were more likely to have trust in their communities, less likely to report high/very high distress, but equally likely to report a mental health condition, both with and without adjustment for SEIFA. Conclusions: There is a need for deeper understanding of the impact of relative socioeconomic disadvantage on health (particularly physical activity and obesity) in rural settings and the development of accessible and culturally appropriate interventions to address rural cancer survivors’ specific needs and risk factors. Refereed/Peer-reviewed

Objective: Carers of people with cancer provide uncompensated care that is often physically, emotionally, and financially demanding, which results in neglect of their own health. This study's objective was to conduct an economic evaluation following a randomised control trial (RCT) involving a proactive telephone outcall intervention aimed at improving health outcomes among carers of cancer patients. Methods: The trial was a single-blind, multicentre, RCT conducted across four Australian health services, comprising three outcalls from trained Cancer Council 131120 (Cancer Council telephone and information support services) nurses compared with three phone call reminders of the availability of 131120 services (control group). Outcalls consisted of telephone contacts to the caregivers initiated by the Cancer Council nurses. The primary trial outcome was reduced carer burden. Health care resource use was measured using a resource use questionnaire (RUQ), and costs were presented in 2013 $(AUS). Quality-adjusted-life-years (QALYs) were also used as health outcomes. An incremental cost-effectiveness ratio (ICER) was calculated, with bootstrapping used to quantify sampling variability. A $50 000 per QALY-gained willingness-to-pay threshold was used. Sensitivity analyses were conducted. Results: Results showed that the total mean QALYs-gained were higher (0.02 QALYs, P = 0.01) in the control group, and total mean costs were lower in the control group ($477, P < 0.001) over the trial duration. The intervention group was dominated by the control group. Results were robust to sensitivity analyses. Conclusions: Results suggest policy makers should not adopt this intervention into routine health care in its current form. Further research into the efficacy and cost-effectiveness of telephone-based interventions for carers is required. Refereed/Peer-reviewed

This research aimed to explore the self-management strategies that Australian male farmers use to improve or maintain their psychological wellbeing and their views on what would assist them to overcome barriers to seeking professional mental health assistance. Individual semi-structured telephone interviews were audio-recorded with consent. Qualitative data were analysed inductively using thematic analysis. Fifteen male farmers participated, who were an average of thirty-nine years of age (23–74 years) with twenty years of farming experience (5–57 years). Seven themes relating to self-management strategies were identified: (1) interacting with a supportive network; (2) involvement in groups and teams; (3) physical activity; (4) proactively educating themselves; (5) self-prioritising and deliberately maintaining work–life balance; (6) being grateful; and (7) focusing on the controllable aspects of farming. Five themes were identified that related to mitigating barriers to seeking mental health assistance: (1) actively welcoming mental health professionals into the community; (2) normalising help-seeking; (3) making seeking mental health assistance a priority; (4) offering services that are culturally appropriate and accessible for male farmers; and (5) tailoring mental health information delivery to farming populations. Australian male farmers already use strategies to maintain and improve their mental health that are culturally and contextually appropriate. These proactive strategies could form the basis of interventions aiming to further promote male farmers’ wellbeing. Barriers to seeking professional mental health assistance may be overcome by implementing solutions directly suggested by male farmers. Given the elevated risk of suicide in this group, investment in trialing promotion of these strategies is warranted.

Refereed/Peer-reviewed Objective: To explore what is currently known about the use of virtual reality (VR) as a patient education tool in healthcare. Methods: Arksey and O’Malley’s scoping review method and the PRISMA-ScR Checklist were employed. Four peer-reviewed databases were searched (Medline, Embase, PsychINFO, the Cochrane library). Pre-defined selection criteria identified 18 studies for inclusion. Results were synthesized using a narrative approach. Results: VR as an educational tool in healthcare is feasible and acceptable, and may improve patient’s knowledge about their illness and satisfaction with treatment. Most studies used the Oculus VR glasses or headset, educated patients though the use of 3D 360° VR anatomical models, and were conducted with people affected with cancer. Opportunities exist for exploring unintended consequences, and the role of VR in educating populations with lower health literacy. Conclusion: VR could assist in communicating medical information and knowledge to patients, but more research is needed, particularly to identify for whom and in what situations this method is most useful and to improve understanding about the potential unintended consequences. Practice implications: Health professionals should consider using VR to educate their patients, and researchers can use this as a road map on how to address knowledge gaps in this field.

Purpose: To investigate the successful strategies of health workers who support and regularly communicate with Aboriginal and Torres Strait Islander people about cancer and its treatment. Methods: Semi-structured interviews were conducted face-to face or via telephone and audio-recorded with twenty-three health professionals (medical and radiation oncologists, oncology nurses and Aboriginal Health Workers), 5 identifying as Aboriginal or Torres Strait Islander in the Northern Territory and South Australia. When data saturation was reached, thematic analysis using a bottom up, essentialist/realist approach was used. Results: Six themes emerged. (1) Create a safe environment, engender trust and build rapport. This involves considering the physical environment and allowing time in interviews to establish a relationship. (2) Employ specific communication strategies to explain cancer, treatment and its side effects through language choices and employing visual aids such as drawings, metaphors and relatable analogies. (3) Obtain support from Aboriginal and Torres Strait Islander staff and patient escorts who can assist in communication. (4) Consider culture which involves collective decision making, strong connection to country and community, with cultural obligations and a unique understanding of cancer. (5) Anticipate the contextual complexities of conflicts between Western medicine and Aboriginal culture, practitioner bias and difficulty maintaining contact with patients. (6) Develop personal qualities of good communicators, including being patient-centred, showing respect, patience, empathy and honesty. Conclusion: These insights will help foster more positive interactions with the health system and promote optimal outcomes for Aboriginal and Torres Strait Islander people with cancer. Refereed/Peer-reviewed

Primary producers face considerable risks for poor mental health. While this population can be difficult to engage in programs to prevent poor mental health, approaches tailored to reflect the context of primary producers’ life and work have been successful. This paper reports on the co-design phase of a project designed to prevent poor mental health for primary producers—specifically, the advantages, challenges and considerations of translating face-to-face co-design methods to an online environment in response to COVID-19 restrictions. The co-design phase drew upon the existing seven-step co-design framework developed by Trischler and colleagues. Online methods were adopted for all steps of the process. This paper models how this co-design approach can work in an online, primary producer context and details key considerations for future initiatives of this type. The development of online co-design methods is an important additional research method for use not only during a pandemic but also when operating with limited resources or geographic constraints. Results demonstrate the following: (i) co-designing online is possible given adequate preparation, training and resource allocation, (ii) “hard to reach” populations can be engaged using online methods providing there is adequate early-stage relationship building, (iii) co-design quality need not be compromised and may be improved when translating to online, and (iv) saved costs and resources associated with online methods can be realigned towards intervention/service creation, promotion and user engagement. Suggestions for extending Trischler and colleagues’ model are incorporated.

Rural Australians experience higher prevalence of several chronic diseases than metropolitan Australians and are less likely to access supportive health services. This study explored associations of sociodemographic factors and barriers to support seeking for health in a sample of rural South Australians.Participants (n = 610) from three rural regions participated in a computer-assisted telephone interview (CATI), based on the Barriers to Help Seeking Scale. Each participant reported on barriers in one of three health contexts: 'general' physical health, skin cancer, and mental health. Sociodemographic factors included gender, age, highest education, region of residence, and presence of chronic conditions. Chi-squared Automatic Interaction Detection (CHAID) determined independent associations of sociodemographic factors and barrier categories (high, medium and low importance).Privacy was a high-importance barrier in the mental health context, particularly among participants of age 63 years. The tendency to minimise and normalise health issues was also a high-importance barrier in the mental health context. In the physical health context, those with a chronic condition were more likely to perceive normalisation as a barrier than those without a chronic condition. Need for control and self-reliance was a high-importance barrier in the mental health context and a low-importance barrier in the skin cancer context, particularly among participants 63 years. Structural factors and distrust of providers were high-importance barriers among those who did not complete secondary education, regardless of context.This study highlights the importance of a nuanced approach to promoting help-seeking in rural Australians, with message content and delivery tailored to specific health conditions and demographic circumstances.

Background: There is no evidence that being a rural or regional organ transplant recipient has adverse physical health outcomes post‐surgery compared with those experienced by people living in cities, but the impact of living remotely from transplant centres on psychosocial outcomes has not been explored. Objective: To identify the social, emotional, psychological, spiritual, informational and practical issues associated with being a regionally based organ transplant recipient or carer and determine how support services could be improved for this group. Design/ Setting/ Participants: Twenty‐two purposively sampled adult Australians who lived outside metropolitan centres and had received an organ transplant (n = 15) or were the primary carer of someone who had received one (n = 7), participated in semi‐structured, telephone interviews. Qualitative data were collected until data saturation was reached and were analysed using thematic analysis. Results: Five key themes (plus subthemes) were identified: (a) travelling for specialist transplant care takes a toll, (b) unique transplant‐related psychological and emotional issues experienced before and after transplants, (c) caring for transplant recipients is a demanding role, (d) lay, peer and professional support, including rural general practitioners and accommodation facilities, help ease the burden, but (e) significant barriers to accessing transplant‐focused psychosocial support exist. Conclusion: Novel methods of delivering targeted, transplant‐specific information and psychosocial care to rural transplant recipients and their carers, employers and rural health professionals require development and evaluation. Strategies might be delivered by peers or professionals via telehealth, telephone, social media or websites for example, depending on preferences and level of need. Refereed/Peer-reviewed

Although illness perceptions have significant implications for psychological morbidity in those diagnosed with a physical illness, the strength of this relationship in their family members remains understudied. The validity of findings is dependent on the quality of the instruments used; therefore, it is essential that psychometrically robust measures of illness perceptions are available. The purpose of this systematic review was to identify, assess and compare the psychometric properties of instruments designed to measure illness perceptions in family members of individuals with chronic physical illnesses. A systematic search was conducted using MEDLINE, PubMed, CINAHL, Scopus and PsycINFO databases, and supplemented with forward and backward searches. Studies were included in the review if they described the development, adaptation or psychometric evaluation of an instrument designed to measure illness perceptions in family members of an individual with a chronic physical illness. The methodological quality of included studies was assessed using the COSMIN Risk of Bias checklist. The psychometric quality of instruments was evaluated using published quality assessment criteria. Eleven articles describing nine different instruments were included in the review. Almost all instruments were designed for parents of a child with a chronic illness. There was wide variation in the quality of methods used to develop, adapt or evaluate the instruments, and missing information restricted the evaluation of psychometric properties. Further validation is needed for all instruments before meaningful conclusions can be drawn. Findings indicate that measurement of illness perceptions in children or siblings of an individual with a chronic physical illness has been largely ignored. Future research addressing this gap would be an important addition to the current body of work examining illness perceptions in family members Refereed/Peer-reviewed

IntroductionChronic pain is a distressing condition and often poorly treated and managed. Psychological therapies are considered first-line intervention for people with chronic pain. Common psychological therapies require extensive clinician training and specialist qualifications. One approach that does not need lengthy training nor specialist qualification, but has empirical support in other health domains, is behavioural activation (BA). BA seeks to increase engagement in behaviours that are valued by the person and progress through behaviours that can increase mood and develop skills that build satisfying routines. BA can help people to manage their condition through scheduling behaviours, promoting routine and mastery over their condition. The extent to which BA has been used to support people living with chronic pain is not clear.Methods and analysisThis scoping review aims to identify published studies describing the application of BA to support people living with chronic pain. To map the evidence regarding BA and chronic pain, including the study type and the associated evidence, a scoping review was adopted. The search will be conducted in bibliographic databases, clinical trial registries and grey literature. No date limits will be applied to the search strategy. Screening of titles and abstracts, and full-text screening, will be independently undertaken by two investigators using Covidence software. Any disagreement between investigators will be resolved by a third investigator. Data from included publications will be extracted using a customised data extraction tool.Ethics and disseminationThe scoping review is an analysis of existing data and therefore ethics approval is not required. The findings of this scoping review will further our understanding of how BA has been used to support people living with chronic pain and inform future training and education programmes in this area.

Simple Summary: Existing programs to support cancer survivors post-treatment tend to be delivered face-to-face, reducing their accessibility to those living in rural and remote locations. Additionally, little is known about the acceptability of urban-developed survivorship care programs among rural cancer survivors who may have unique values and different attitudes towards help-seeking. The purpose of this study was to explore the experiences of cancer survivors who return to their rural communities upon completion of active treatment, and to identify the challenges these survivors experience in engaging with quality of life-related support services. The findings of this study will inform the design and development of new interventions, or modification of existing interventions, to better meet the preferences and needs of rural survivors. Identifying the specific challenges and intervention preferences of rural cancer survivors will help to ensure they benefit as much as urban survivors, from efforts to improve post-treatment quality of life. Abstract: The transition from urban centres back to rural and remote communities can be challenging for rural cancer survivors after treatment. This study aimed to (a) provide deeper understanding of the experiences of rural survivors who have completed active cancer treatment and returned to their rural communities, and (b) determine strategies to re-orient existing services or develop new interventions to more appropriately meet rural survivors’ service preferences and needs. Semi-structured interviews were conducted with 22 adults (64% female) who lived outside of a metropolitan area and had completed active cancer treatment (n = 13), were the carer for a rural/remote cancer survivor (n= 6), or were both a survivor and carer (n = 3). Thematic analysis was conducted to identify dominant themes in the qualitative data. A range of physical, psychological and practical challenges that impact quality of life among rural survivors post-treatment were found. These challenges appeared to be compounded by a lack of trust in local rural healthcare services and a lack of clear post-treatment pathways to quality of life-enhancing support services. Acceptable strategies to overcome barriers included nurse-led, telephone-based, or face-to-face interventions, initiated and continued by the same service provider, and that included support to manage emotional challenges associated with post-treatment survivorship. The findings will inform the design of interventions to better meet rural cancer survivors’ post-treatment support needs. Refereed/Peer-reviewed

Purpose: To explore strategies rural Australians use to cope with the financial consequences of their cancer diagnosis and how that impacts on their lives. Methods: Twenty adult cancer patients/survivors residing in regional-remote areas of Australia were purposively sampled and participated in audio-recorded, semi-structured interviews. When data saturation was reached, thematic analysis was employed to analyse the data. Results: Participants were 20–78 years (M=60), 70% female, 35% were undergoing treatment and the remaining 65% had finished treatment within the past 5 years. Three themes provide context to rural financial toxicity-related experiences (travelling to access cancer treatment away from home is expensive, being single or lacking family support exacerbates the financial strain, and no choice other than to adopt cost-saving strategies if wanted to access treatment). Strategies commonly employed to minimise financial toxicity include: accessing travel-related support, changes to lifestyle (buying cheaper food, saving on utilities), accessing savings and retirement funds, missing holidays and social activities, reduced car use and not taking a companion to cancer-related appointments at metropolitan treatment areas. Although cost-saving strategies can effectively increase the ability of rural people to cover cancer treatment-related and other costs, most have broader negative psychological, social and practical consequences for them and their families. Conclusions: Increasing rural cancer patients’ and survivors’ awareness of various cost-saving strategies and their impact (positive and negative) may decrease their risk of experiencing financial toxicity and unexpected unintended consequences of adopting cost-saving measures. Refereed/Peer-reviewed

Introduction: Farming is a physically and psychologically hazardous occupation and farmers face numerous attitudinal and structural barriers to accessing mainstream health and mental health services. As Internet access increases across rural Australia there is potential for online interventions to help overcome barriers and provide new avenues for improving farmers' mental health and wellbeing. However, little is known about how farmers perceive this approach which is problematic given the importance of building in their preferences, to ensure these interventions meet their interests and needs, and have maximum impact. The purpose of this study was to explore the scope of Australian farmers’ current Internet use and their views and preferences on the design and delivery of online, mental health and wellbeing-focused interventions. Methods: Eighteen farmers (11 men and 7 women, with a median age of 45.5 years) from grain, sheep and/or cattle farms across four states of Australia participated. Telephone-based, semi-structured interviews were used to explore their current Internet use practices and preferences regarding new websites to promote farmers’ mental health and wellbeing. Thematic Framework Analysis was used to analyze and organize the data. Results: Eight key topics were discussed and several themes within each topic emerged. The first topic related to farmers' current Internet use practices (found to be sporadic, used for weather, banking, emails and research, they are open to using it for health and wellbeing, and they reported that Twitter and other social media reduces social isolation). Themes demonstrating farmers' specific preferences on four aspects of web-design included; preferred aesthetics (authenticity, reflective of farmer diversity, simple layout and font, colours of nature, mix of cartoons and real-life, positive, masculine imagery); preferred language (lay, casual tone, careful use of humour, positive/empowering); preferred technical aspects/capabilities (unreliable Internet connections, limited downloads, compatibility with multiple devices, easy to use, inclusion of music problematic, mixed opinion about inclusion of scientific references and chat features, include videos, case studies) and preferred content/focus for websites of this type (early intervention/prevention, where and how to seek more help). More broadly, contextual influences to consider (multiple pressures of farm life, time poverty, farmers’ outlook is practical and outcome-driven, stigma about mental health decreasing but still exists); strategies to promote engagement (must feel engaged, know what is next, see benefits quickly) and marketing/promotion suggestions (women as advocates for men, use trusted sources to promote, emphasize that information can be accessed from privacy of own home/farm) were also highlighted by participants. Conclusions: Findings will help inform the development of new mental health and wellbeing-focused online interventions for farmers to maximize uptake, engagement and impact. In particular, these interventions need to be perceived as relevant and authentic, while also reflecting the diversity of the farming population, which farmers believe can be achieved by carefully considering their preferences for aesthetics, language, technological requirements and the unique farming context. Refereed/Peer-reviewed

To explore strategies rural Australians use to cope with the financial consequences of their cancer diagnosis and how that impacts on their lives.Twenty adult cancer patients/survivors residing in regional-remote areas of Australia were purposively sampled and participated in audio-recorded, semi-structured interviews. When data saturation was reached, thematic analysis was employed to analyse the data.Participants were 20-78 years (M=60), 70% female, 35% were undergoing treatment and the remaining 65% had finished treatment within the past 5 years. Three themes provide context to rural financial toxicity-related experiences (travelling to access cancer treatment away from home is expensive, being single or lacking family support exacerbates the financial strain, and no choice other than to adopt cost-saving strategies if wanted to access treatment). Strategies commonly employed to minimise financial toxicity include: accessing travel-related support, changes to lifestyle (buying cheaper food, saving on utilities), accessing savings and retirement funds, missing holidays and social activities, reduced car use and not taking a companion to cancer-related appointments at metropolitan treatment areas. Although cost-saving strategies can effectively increase the ability of rural people to cover cancer treatment-related and other costs, most have broader negative psychological, social and practical consequences for them and their families.Increasing rural cancer patients' and survivors' awareness of various cost-saving strategies and their impact (positive and negative) may decrease their risk of experiencing financial toxicity and unexpected unintended consequences of adopting cost-saving measures.

To investigate the longitudinal associations between demographic, clinical and lifestyle factors, and changes in patient-reported outcomes (PROs) in cancer survivors 6-9 years post-diagnosis in Western Australia.A total of 290 individuals participated in this study. Three-quarters of participants were female, and 55%, 31%, and 14% were survivors of breast cancer, colon cancer, and non-Hodgkin lymphoma (NHL), respectively. PROs (fatigue, depression, and health-related quality of life (HRQOL)) were reported at two time points (2012-13 and 2017). Descriptive statistics were used to assess the overall changes over time and linear mixed models were used to identify factors associated with changes over time, after adjusting for confounders.No significant changes were observed in PROs between time point 1 and follow-up at the population level, yet a notable proportion of participants (23% for fatigue, 10% for depression, and 39% for HRQOL) reported a negative minimal clinically important difference (MCID). Being non-Caucasian and having had NHL were associated with negative changes over time. Being obese and having had radiotherapy were related to improved outcomes.Cancer survivors whose levels of fatigue, depression, and quality of life are compromised during cancer treatment may require intervention even 6-9 years post-treatment. Our results suggest particular attention should be paid to those who are non-Caucasian and who have had NHL. This is crucial for providing appropriate care and to support those who are at increased risk of deteriorating naturally over time.

Refereed/Peer-reviewed Objective: To identify the modifiable psychological and behavioural coping strategies associated with low levels of psychological distress, independent of more stable personality and demographic factors, in a sample of farmers who reported being exposed to a recent stressful event during an extended drought. Results In the final multivariable model, distress was elevated among individuals reporting higher neuroticism and behavioural disengagement, and lower in individuals reporting greater use of acceptance. These 3 variables explained 44% of the variance in distress. Design/setting/participants: Three hundred and nine South Australian, drought-affected grain, sheep and/or cattle farmers completed printed or online questionnaires. Only those who reported experiencing a stressful event in the past month that they rated >= 7 on a scale ranging from 1 (not stressful at all) to 10 (extremely stressful) were included in the analyses (n = 175, 65.06%). Participants ranged in age from 24 to 85 years and 40% were female. Main outcome measures: Psychological distress was measured using the Kessler Psychological Distress Scale, and coping strategies were measured using a situational version of the COPE inventory. Five personality factors (extraversion, neuroticism, openness, conscientiousness and agreeableness) were assessed using the Quickscales-R. Results: In the final multivariable model, distress was elevated among individuals reporting higher neuroticism and behavioural disengagement, and lower in individuals reporting greater use of acceptance. These 3 variables explained 44% of the variance in distress. Conclusion: Farmers recently exposed to a significant stressor, who used acceptance as a coping strategy, did not engage in behavioural disengagement and scored low on neuroticism, were least likely to experience distress. Given the stability of personality factors, interventions that foster farmers' use of acceptance and prevent behavioural disengagement as coping strategies might assist them with the management of future stressors, particularly in times of drought.

Purpose of review The present review describes recent research on online psychosocial interventions for posttreatment cancer survivors from January 2018 to June 2019. Recent findings Twenty-three studies were included in the review (the majority included were feasibility studies and only five randomized controlled trials had large samples). Websites were the most common platforms for intervention delivery (9/23) and cognitive behavioral therapy was the most frequently used therapeutic approach (11/23). Three interventions based on this framework and delivered via websites or combined website-telehealth platforms showed to be effective in improving psychosocial issues (fear of cancer recurrence, insomnia, sleep quality, and prospective memory failures) in posttreatment cancer survivors. Web-based self-compassion writing was also found to be effective in addressing body image distress and body appreciation in breast cancer survivors. Feasibility studies mostly showed online interventions to be plausible and acceptable to cancer survivors. A good representation of online interventions for young adult cancer survivors (30%) was found. Summary Online interventions show promise in addressing the psychosocial needs of cancer survivors. Despite new online interventions being found to be feasible and acceptable and some showing promise in addressing important psychosocial issues in cancer survivors posttreatment, more rigorous studies are required to inform supportive care for this population.

Purpose: Adherence to oral antineoplastic drugs is a complex phenomenon, and knowledge about the reasons that people with cancer do not adhere to their prescriptions is essential to inform adherence-related support in clinical and research contexts. This study aims to provide an up-to-date summary of the key reasons for non-adherence to oral antineoplatic drugs (OAD) in people with cancer. Methods: Electronic databases Medline, Embase, Emcare, and PsychINFO were searched for systematic reviews and studies published between January 2010 and March 2018. Data was analyzed and extracted by two independent reviewers. Results: Three systematic reviews and two studies were included in the review. Key factors for non-adherence were classified as either modifiable or non-modifiable factors. Side effects, forgetfulness, and poor knowledge about OAD were identified as modifiable factors while co-payment, age, regimen complexity. and time since diagnosis were identified as non-modifiable factors. Most of the included studies focused on breast cancer and chronic myeloid leukemia (CML) patients. Low methodological quality and different adherence cut-off rates were observed in the included literature. Conclusions: More research with rigorous methodology and diverse cancer types is needed to increase evidence on the reasons for OAD non-adherence. However, findings from this study may serve to aid in drafting guidelines and suitable interventions for adherence-related support to OAD users. Refereed/Peer-reviewed

Background Farming is physically and psychologically hazardous. Farmers face many barriers to help seeking from traditional physical and mental health services; however, improved internet access now provides promising avenues for offering support. Objective This study aims to co-design with farmers the content and functionality of a website that helps them adopt transferable coping strategies and test its acceptability in the broader farming population. Methods Research evidence and expert opinions were synthesized to inform key design principles. A total of 18 farmers detailed what they would like from this type of website. Intervention logic and relevant evidence-based strategies were mapped. Website content was drafted and reviewed by 2 independent mental health professionals. A total of 9 farmers provided detailed qualitative feedback on the face validity of the draft content. Subsequently, 9 farmers provided feedback on the website prototype. Following amendments and internal prototype testing and optimization, prototype usability (ie, completion rate) was examined with 157 registered website users who were (105/157, 66.9%) female, aged 21-73 years; 95.5% (149/156) residing in inner regional to very remote Australia, and 68.2% (107/157) “sheep, cattle and/or grain farmers.” Acceptability was examined with a subset of 114 users who rated at least module 1. Interviews with 108 farmers who did not complete all 5 modules helped determine why, and detailed interviews were conducted with 18 purposively sampled users. Updates were then made according to adaptive trial design methodology. Results This systematic co-design process resulted in a web-based resource based on acceptance and commitment therapy and designed to overcome barriers to engagement with traditional mental health and well-being strategies—ifarmwell. It was considered an accessible and confidential source of practical and relevant farmer-focused self-help strategies. These strategies were delivered via 5 interactive modules that include written, drawn, and audio- and video-based psychoeducation and exercises, as well as farming-related jokes, metaphors, examples, and imagery. Module 1 included distress screening and information on how to speak to general practitioners about mental health–related concerns (including a personalized conversation script). Modules were completed fortnightly. SMS text messages offered personalized support and reminders. Qualitative interviews and star ratings demonstrated high module acceptability (average 4.06/5 rating) and suggested that additional reminders, higher quality audio recordings, and shorter modules would be useful. Approximately 37.1% (52/140) of users who started module 1 completed all modules, with too busy or not got to it yet being the main reason for non-completion, and previous module acceptability not predicting subsequent module completion. Conclusions Sequential integration of research evidence, expert knowledge, and farmers’ preferences in the co-design process allowed for the development of a self-help intervention that focused on important intervention targets and was acceptable to this difficult-to-engage group. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12617000506392; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372526

Background: Family members are increasingly involved in the care of cancer patients, however many are not prepared for this challenging role. Intervention-based studies are valuable to inform the most appropriate and effective support for caregivers. Barriers in the recruitment of patient/caregiver dyads exist but the reasons for nonparticipation are less well understood. This analysis determined the factors associated with participation in a randomized controlled trial involving patient/caregiver dyads, reasons for non-participation and factors associated with these reasons. Methods: Patients with any type of cancer (other than non-melanoma skin cancer), and their caregiver were recruited at four Australian health services. Eligible patients were invited to participate together with their caregiver (N = 737). Non-participation data were collected from non-participants. Bivariate and binary logistic regression analyses were conducted to examine factors associated with participation. Results: Of the 737 eligible dyads, 521 (71%) declined participation. Dyad characteristics associated with participation were caregiver gender, patient treatment modality and hospital type. The odds for participating were almost two times greater for female than male caregivers (p = 0.005); 13 times greater for patients receiving chemoradiotherapy compared to radiotherapy alone (p < 0.001); and three times greater for dyads attending a private versus public hospital (p < 0.001). Reasons for non-participation were lack of interest (33%), lack of time(29%), not requiring support (23%), too burdensome (15%); factors significantly associated with these reasons were treatment modality, patient age, cancer type, and hospital type. Patients diagnosed with prostate cancer and receiving chemotherapy alone were less likely to decline due to a lack of interest. Patients more likely to decline due to lack of time were those aged 40-59 years and receiving chemotherapy alone. Patients who were more likely to decline because they felt participation was too burdensome were those attending a private hospital for treatment. Conclusions: To optimize recruitment, it is recommended that special attention is given to different cancer types and treatment modalities, gender and age. Approaching dyads at varied time points when their need for support is high is recommended. This analysis provides important information for researchers undertaking randomized controlled trials involving people diagnosed with cancer and their caregivers. Refereed/Peer-reviewed

This research aims to identify the factors that influence caregivers’ decisions about the aged care providers they select for their elder relatives when caring from a distance and what they value once they have engaged a service. Adult long-distance carers for older relatives living within Australia were purposively sampled and they participated in audio-recorded interviews. A thematic analysis was employed to investigate the data. A sample of 13 participants enabled data saturation with no new major themes identified in the final three interviews. Participants were 50 to 65 years (Mean = 59.8) and mostly (77%) female. Four themes emerged relating to selection of care providers: (1) availability of care, (2) financial arrangements, (3) proximity and location, and (4) reputation of care provider. Five themes detailed valued qualities of care: (1) vigilant monitoring and responsivity, (2) communication with family, (3) flexibility and proactiveness of care, (4) staffing, and (5) access to appropriate and holistic care to maintain wellbeing. Long-distance caregivers face barriers in selecting and managing aged care services from afar within a complex Australian aged care system. They strongly value regular, proactive communication about the wellbeing of their relatives and may be particular beneficiaries of communication and assistive monitoring technologies Refereed/Peer-reviewed

Background Individuals construct beliefs about an illness based on their own perceptions, interpretation, and understanding of the illness and its treatment. These beliefs (collectively referred to as "illness cognitions" or "representations") can have implications for psychological outcomes in family members and carers of an individual with an illness. The aim of this study was to explore young people’s perceptions of their parent’s cancer using the Common-Sense Model of Self-Regulation as a theoretical framework.Methods Semi-structured, one-on-one interviews were conducted with young people who had a parent diagnosed with cancer.Interview transcripts were analysed using deductive thematic analysis techniques.Results Eleven young people aged 15–24 years participated in the study. Major themes aligned with the dimensions of the Common-Sense Model of Self-Regulation. Young people described their experiences with parental cancer with reference to cognitive representations (beliefs about the illness identity, their understanding or coherence of the illness, and consequences,curability or controllability, timeline, and cause of the illness) and emotional representations (emotional beliefs and subjective feelings about the illness). Conclusions Findings indicate that young people’s perceptions of their parent’s cancer can be usefully described within the framework of the Common-Sense Model of Self-Regulation. Future research should investigate the relationships between young people’s illness cognitions, coping strategies, and psychological adjustment following their parent’s cancer diagnosis. This will provide valuable insights for the development of interventions that target specific types of illness cognitions associated with maladaptive coping strategies and poor adjustment. Refereed/Peer-reviewed

Objective: To identify subgroups of Australian adults likely to receive physical activity advice from their general practitioner and to evaluate the content of the advice provided. Methods: Participants (n=1,799), recruited from the Australian Health and Social Science panel, completed an online survey. Signal Detection Analysis was used to identify subgroups that were more/less likely to have received physical activity recommendations. Results: Overall, 18% of participants received a physical activity recommendation from their general practitioner in the past 12 months and eight unique subgroups were identified. The subgroup with the highest proportion (54%) of participants reporting that they received a physical activity recommendation was those with poor physical and mental health-related quality of life and an average daily sitting time of

e24188 Background: To enable clinicians to effectively communicate about cancer and its treatment to Aboriginal and Torres Strait (Aboriginal) people with cancer who need to make informed choices about the Western medicine offered, we sought strategies from health professionals with experience in that field. Methods: Semi-structured interviews were conducted face-to face or via telephone with the experienced health professionals and audio-recorded. Thematic analysis using a bottom up, essentialist/realist approach was employed to analyse the data, when data saturation was reached. Results: The 23 health professionals interviewed were medical and radiation oncologists, oncology nurses and Aboriginal health workers. Twelve were female, 11 were male with 5 identifying as Aboriginal. Six themes emerged. (1) Create a safe environment, engender trust and build rapport. This involves avoiding assumptions, allowing time, considering the physical environment, asking about home and family, being aware of gender issues and noting non-verbals. (2) Employ specific strategies to explain cancer, treatment and its side effects by using simple language, employing visual aids such as drawings, metaphors and relatable analogies such as trees with roots, weeds, abandoned rusty cars and blocked pipes. Use repetition and ensure alignment with patient needs. Warning about upcoming sensitive issues minimised the chance of disengagement. (3) Obtain support from those who can assist in communication. This includes interpreters, aboriginal liaison officers and health workers, and patient escorts. (4) Consider the culture which involves collective decision-making, strong connection to country and community, with cultural obligations and unique understanding of cancer which can involve curses, shame and utilise bush medicine. (5) Develop personal qualities of good communicators, including showing respect, patience, empathy, honesty, being person centred and embracing personal reflection. (6) Understand the contextual complexity of multiple languages, possible disengagement with treatment, difficulty maintaining contact with patients, conflicts between Western medicine and Aboriginal culture and late stage presentations. Be aware of practitioner bias. Conclusions: These insights will help foster more positive interactions with the health system and promote optimal outcomes for Aboriginal people with cancer and enable the creation of educational modules for inexperienced clinicians.

Carers provide extended and often unrecognized support to people with cancer. The aim of this study is to test the hypothesis that excessive carer burden is modifiable through a telephone outcall intervention that includes supportive care, information and referral to appropriate psycho-social services. Secondary aims include estimation of changes in psychological health and quality of life. The study will determine whether the intervention reduces unmet needs among patient dyads. A formal economic program will also be conducted. This study is a single-blind, multi-centre, randomized controlled trial to determine the efficacy and cost-efficacy of a telephone outcall program among carers of newly diagnosed cancer patients. A total of 230 carer/patient dyads will be recruited into the study; following written consent, carers will be randomly allocated to either the outcall intervention program (n = 115) or to a minimal outcall / attention control service (n = 115). Carer assessments will occur at baseline, at one and six months post-intervention. The primary outcome is change in carer burden; the secondary outcomes are change in carer depression, quality of life, health literacy and unmet needs. The trial patients will be assessed at baseline and one month post-intervention to determine depression levels and unmet needs. The economic analysis will include perspectives of both the health care sector and broader society and comprise a cost-consequences analysis where all outcomes will be compared to costs. This study will contribute to our understanding on the potential impact of a telephone outcall program on carer burden and provide new evidence on an approach for improving the wellbeing of carers. Australian New Zealand Clinical Trials Registry ACTRN: 12613000731796 .