Search

Introduction Over 50% of people affected by cancer report unmet support needs. To address unmet information and psychological needs, non-government organisations such as Cancer Councils (Australia) have developed state-based telephone cancer information and support services. Due to competing demands, evidence of the value of these services is needed to ensure that future investment makes the best use of scarce resources. This research aims to determine the costs and broader economic and social value of a telephone support service, to inform future funding and service provision.Methods and analysis A codesigned, evaluative social return on investment analysis (SROI) will be conducted to estimate and compare the costs and monetised benefits of Cancer Council Victoria’s (CCV) telephone support line, 13 11 20, over 1-year and 3-year benefit periods. Nine studies will empirically estimate the parameters to inform the SROI and calculate the ratio (economic and social value to value invested): step 1 mapping outcomes (in-depth analysis of CCV’s 13 11 20 recorded call data; focus groups and interviews); step 2 providing evidence of outcomes (comparative survey of people affected by cancer who do and do not call CCV’s 13 11 20; general public survey); step 3 valuing the outcomes (financial proxies, value games); step 4 establishing the impact (Delphi); step 5 calculating the net benefit and step 6 service improvement (discrete choice experiment (DCE), ‘what if’ analysis). Qualitative (focus groups, interviews) and quantitative studies (natural language processing, cross-sectional studies, Delphi) and economic techniques (willingness-to-pay, financial proxies, value games, DCE) will be applied.Ethics and dissemination Ethics approval for each of the studies will be sought independently as the project progresses. So far, ethics approval has been granted for the first two studies. As each study analysis is completed, results will be disseminated through presentation, conferences, publications and reports to the partner organisations.

Abstract Background Healthy Together Victoria (HTV) was a Victorian Government initiative that sought to reduce the prevalence of overweight and obesity through targeting chronic disease risk factors including physical activity, poor diet quality, smoking, and harmful alcohol use. The intervention involved a boosted workforce of > 170 local-level staff in 12 communities; employed to deliver system activation around health and wellbeing for individuals, families and communities. A cluster randomised trial (CRT) of a systems thinking approach to obesity prevention was embedded within HTV. We present the two-year changes in overweight and obesity and associated behaviours among secondary school students across Victoria, Australia. Methods Twenty-three geographically bounded areas were randomised to intervention (12 communities) or comparison (11 communities). Randomly selected secondary schools within each community were invited to participate in the trial in 2014 and 2016. Students in Grade 8 (aged approximately 13–15 years) and Grade 10 (aged approximately 15–16 years) at participating schools were recruited using an opt-out approach across July–September 2014 and 2016. Primary outcomes were body mass index (BMI) and waist circumference. Secondary outcomes were physical activity, sedentary behaviour, diet quality, health-related quality of life, and depressive symptoms. Linear mixed models were fit to estimate the intervention effect adjusting for child/school characteristics. Results There were 4242 intervention children and 2999 control children in the final analysis. For boys, the two-year change showed improvement in intervention versus control for waist circumference (difference in change: − 2.5 cm; 95% confidence interval [CI]: − 4.6, − 0.5) and consumption of sugar-sweetened beverages per day (

Abstract Background Up to 70% of people diagnosed with upper gastrointestinal (GI) tract or hepato-pancreato-biliary (HPB) cancers experience substantial reductions in quality of life (QoL), including high distress levels, pain, fatigue, sleep disturbances, weight loss and difficulty swallowing. With few advocacy groups and support systems for adults with upper GI or HPB cancers (i.e. pancreas, liver, stomach, bile duct and oesophageal) and their carers, online supportive care programs may represent an alternate cost-effective mechanism to support this patient group and carers. iCare is a self-directed, interactive, online program that provides information, resources, and psychological packages to patients and their carers from the treatment phase of their condition. The inception and development of iCare has been driven by consumers, advocacy groups, government and health professionals. The aims of this study are to determine the feasibility and acceptability of iCare, examine preliminary efficacy on health-related QoL and carer burden at 3- and 6-months post enrolment, and the potential cost-effectiveness of iCare, from health and societal perspectives, for both patients and carers. Methods and analysis A Phase II randomised controlled trial. Overall, 162 people with newly diagnosed upper GI or HPB cancers and 162 carers will be recruited via the Upper GI Cancer Registry, online advertisements, or hospital clinics. Patients and carers will be randomly allocated (1:1) to the iCare program or usual care. Participant assessments will be at enrolment, 3- and 6-months later. The primary outcomes are i) feasibility, measured by eligibility, recruitment, response and attrition rates, and ii) acceptability, measured by engagement with iCare (frequency of logins, time spent using iCare, and use of features over the intervention period). Secondary outcomes are patient changes in QoL and unmet needs, and carer burden, unmet needs and QoL. Linear mixed models will be fitted to obtain preliminary estimates of efficacy and variability for secondary outcomes. The economic analysis will include a cost-consequences analysis where all outcomes will be compared with costs. Discussion iCare provides a potential model of supportive care to improve QoL, unmet needs and burden of disease among people living with upper GI or HPB cancers and their carers. Australian and New Zealand Clinical Trials Registry ACTRN12623001185651. This protocol reflects Version #1 26 April 2023.

Abstract Background Tools for measuring adherence to sustainable healthy diets among children and adolescents are lacking. Objective To advance methods for measuring adherence to sustainable healthy diets among children and adolescents by adapting an existing index, compare scores obtained using the original and adapted versions of the index in a sample of Chilean children, and describe the adapted index association with diet characteristics. Methods The Planetary Health Diet Index (PHDI) was adapted to better reflect children's and adolescents’ nutritional requirements. The adapted index (PHDI-C) comprises 16 components with a maximum score of 150 points. PHDI-C was piloted among a sample of 958 Chilean children (3–6 years) using dietary data collected in 2016 through single 24-h recalls. A decision tree and food disaggregation methodology were developed to guide the calculation of scores. Scores obtained using the original and adapted versions of the index were compared. Linear regression models adjusted by child’s gender and age were fitted to explore associations between total PHDI-C score, dietary recall characteristics and nutritional composition of children’s diets. Results PHDI accounted for 75.7% of children’s total caloric intake, whereas PHDI-C accounted for 99.6%. PHDI & PHCI-C scores were low among this sample of children; however, mean total score was lower when using PHDI compared to PHDI-C [40.7(12.1) vs 50.1(14.6)]. Children’s scores were very low for nuts & peanuts, legumes, dark green vegetables, whole cereals, tubers & potatoes, and added sugars components across both indices, but were higher for dairy products and eggs & white meats components when using the PHDI-C due to adjustments made to ensure nutritional adequacy. Mean total PHDI-C score was significantly lower on weekends and special occasions, and significantly higher when children reported having a special diet (e.g., vegetarian). Total PHDI-C score was negatively associated with total sugars, saturated fats, trans fats, and animal-based protein intake, and positively associated with total protein, plant-based protein, total carbohydrates, and total fibre intake. Conclusions This study provides a replicable method for measuring adherence to sustainable healthy diets among children and adolescents that can be used to monitor trends and measure the effectiveness of actions targeting improving children’s diets.

Abstract Objective: To determine whether primary school children’s weight status and dietary behaviours vary by remoteness as defined by the Australian Modified Monash Model (MMM). Design: A cross-sectional study design was used to conduct secondary analysis of baseline data from primary school students participating in a community-based childhood obesity trial. Logistic mixed models estimated associations between remoteness, measured weight status and self-reported dietary intake. Setting: Twelve regional and rural Local Government Areas in North-East Victoria, Australia. Participants: Data were collected from 2456 grade 4 (approximately 9–10 years) and grade 6 (approximately 11–12 years) students. Results: The final sample included students living in regional centres (17·4 %), large rural towns (25·6 %), medium rural towns (15·1 %) and small rural towns (41·9 %). Weight status did not vary by remoteness. Compared to children in regional centres, those in small rural towns were more likely to meet fruit consumption guidelines (OR: 1·75, 95 % CI (1·24, 2·47)) and had higher odds of consuming fewer takeaway meals (OR: 1·37, 95 % CI (1·08, 1·74)) and unhealthy snacks (OR = 1·58, 95 % CI (1·15, 2·16)). Conclusions: Living further from regional centres was associated with some healthier self-reported dietary behaviours. This study improves understanding of how dietary behaviours may differ across remoteness levels and highlights that public health initiatives may need to take into account heterogeneity across communities.

Abstract Objective: In this paper, we examined whether there are inequalities in access to food retail (by type and healthiness) across local government areas (LGA) in Greater Melbourne and by LGA grouped based on their distance from the central business district and Growth Area designation. We also examined whether these inequalities persisted over time. Design: This is a secondary analysis of a repeated cross-sectional census of food outlets collected at four time points (2008, 2012, 2014 and 2016) across 31 LGA. Using Geographical Information Systems, we present a spatial analysis of food retail environments in Melbourne, Australia, at these four times over eight years. Setting: Greater Melbourne, Australia. Participants: 31 LGA in Greater Melbourne. Results: Findings show significant inequalities in access to healthy food retail persisting over time at the LGA level. Residents in lower density urban growth areas had the least access to healthy food retail. Unhealthy food retail was comparatively more accessible, with a temporal trend indicating increased accessibility over time in urban growth areas only. Conclusion: Accessibility to food outlets, particularly healthy food outlets and supermarkets, in Greater Melbourne is not equal. To identify and address health inequalities associated with rapid urban growth, further understanding of how people interact with the food environment needs to be explored.

Abstract Objective: To report the prevalence of healthy weight and related behaviours among Victorian Aboriginal and non‐Aboriginal children and explore associations between these factors and health‐related quality of life (HRQoL). Methods: Analysis of cross‐sectional data from two cluster randomised controlled trials using logistic and linear mixed models. The sample included Aboriginal (n=303) and non‐Aboriginal (n=3,026) children aged 8–13 years. Results: More than two‐thirds of Aboriginal children met guidelines for fruit (75.9%), sweetened drinks (66.7%), sleep (73.1%), screen time (67.7%) and objectively measured physical activity (83.6%); and 79.1% reported consuming take‐away foods less than once per week. Aboriginal children were more likely to meet vegetable consumption guidelines (OR=1.42, 95%CI: 1.05, 1.93), but less likely to have a healthy weight (OR=0.66, 95%CI: 0.52, 0.85) than non‐Aboriginal children. Mean HRQoL scores were significantly higher among non‐Aboriginal children and both Aboriginal and non‐Aboriginal children meeting health guidelines. Conclusions: Most Aboriginal children in this study met guidelines for fruit, physical activity, screen time and sleep, and those meeting these guidelines had significantly higher HRQoL. Implications for public health: Promoting nutrition, physical activity and sleep is likely to benefit all children. Aboriginal community‐controlled organisations can use these data to design culturally‐specific programs that may improve disparities in healthy weight and HRQoL.

Research into the link between food environments and health is scarce. Research in this field has progressed, and new comprehensive methods (i.e., incorporating all food retail outlets) for classifying food retail environments have been developed and are yet to be examined alongside measures of obesity. In this study, we examine the association and temporal trends between the food environment and BMI of a repeated cross-sectional sample of the adult population between 2008 and 2016. Methods: Food retail data for 264 postal areas of Greater Melbourne was collected for the years 2008, 2012, 2014, and 2016, and a container-based approach was used to estimate accessibility to supermarkets, healthy and unhealthy outlets. Data on BMI for postal areas was obtained from the Victorian Population Health Survey (n = 47,245). We estimated the association between the food environment and BMI using linear mixed models. Results indicated that BMI increased as accessibility to healthy outlets decreased by up to −0.69 kg/m2 (95%CI: −0.95, −0.44). BMI was lower with high and moderate access to supermarkets compared to low access by −0.33 kg/m2 (−0.63, −0.04) and −0.32 kg/m2 (−0.56, −0.07), and with high access to unhealthy outlets compared to low access (−0.38 kg/m2: −0.64, −0.12) and moderate access (−0.54 kg/m2: −0.78, −0.30). Conclusion: Our results show that increasing access and availability to a diverse range of food outlets, particularly healthy food outlets, should be an important consideration for efforts to support good health. This research provides evidence that Australia needs to follow suit with other countries that have adopted policies giving local governments the power to encourage healthier food environments.

BackgroundIn March 2020, the Australian Government expanded general practitioner (GP) telehealth services in response to the COVID-19 pandemic. ObjectiveThis study sought to assess use patterns of GP telehealth services in response to changing circumstances (before and during the COVID-19 pandemic and with or without a lockdown) in regional Victoria, Australia. MethodsWe conducted a secondary analysis of monthly Medicare claims data from July 2019 to June 2021 from 140 regional GP practices in Western Victoria. The longitudinal patterns of proportion of GP telehealth consultations stratified by type of consultation (ie, videoconference vs telephone) and by geographical, consumer, and consultation characteristics were analyzed. ResultsTelehealth comprised 25.8% (522,932/2,025,615) of GP consultations over the 2-year period. After the introduction of the Australian telehealth expansion policy in March 2020, there was a rapid uptake in GP telehealth services (including telephone and video services), from 0% before COVID-19 to 15% (11,854/80,922) of all consultations in March 2020, peaking at 55% (50,828/92,139) in August 2020. Thereafter, the use of telehealth declined steadily to 31% (23,941/77,344) in January 2021 and tapered off to 28% (29,263/103,798) in June 2021. Telephone services and shorter consultations were the most dominant form, and those aged 15-64 years had higher telehealth use rates than younger or older age groups. The proportion of video consultations was higher during periods with government-imposed lockdowns and higher in the most socioeconomically advantaged areas compared to less socioeconomically advantaged areas. ConclusionsOur findings support the continuation of telehealth use in rural and regional Australia post pandemic. Future policy must identify mechanisms to reduce existing equity gaps in video consultations and consider patient- and system-level implications of the dominant use of short telephone consultations.

Abstract Background Approximately a quarter of Australian children are classified as overweight or obese. In high-income countries, childhood obesity follows a socio-economic gradient, with greater prevalence amongst the most socio-economically disadvantaged children. Community-based interventions (CBI), particularly those using a systems approach, have been shown to be effective on weight and weight-related behaviours. They are also thought to have an equitable impacts, however there is limited evidence of their effectiveness in achieving this goal. Methods Secondary analysis was conducted on data collected from primary school children (aged 6–13 years) residing in ten communities (five intervention, five control) involved in the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS) cluster randomised trial in Victoria, Australia. Outcomes included Body Mass Index z-score (BMI-z) derived from measured height and weight, self-reported physical activity and dietary behaviours and health related quality of life (HRQoL). Repeat cross-sectional data from 2015 (n = 1790) and 2019 (n = 2137) were analysed, stratified by high or low socio-economic position (SEP). Multilevel linear models and generalised estimating equations were fitted to assess whether SEP modified the intervention effect on the outcomes. Results There were no overall changes in BMI-z for either SEP strata. For behavioural outcomes, the intervention resulted in a 22.5% (95% CI 5.1, 39.9) point greater improvement in high-SEP compared to low-SEP intervention schools for meeting physical activity guidelines. There were also positive dietary intervention effects for high SEP students, reducing takeaway and packaged snack consumption, although there was no significant difference in effect between high and low SEP students. There were positive intervention effects for HRQoL, whereby scores declined in control communities with no change in intervention communities, and this did not differ by SEP. Conclusion The WHO STOPS intervention had differential effects on several weight-related behaviours according to SEP, including physical activity. Similar impacts on HRQoL outcomes were found between high and low SEP groups. Importantly, the trial evaluation was not powered to detect subgroup differences. Future evaluations of CBIs should be designed with an equity lens, to understand if and how these types of interventions can benefit all community members, regardless of their social and economic resources.

Research has explored how the COVID-19 pandemic triggered a wave of conspiratorial thinking and online hate speech, but little is empirically known about how different phases of the pandemic are associated with hate speech against adversaries identified by online conspiracy communities. This study addresses this gap by combining observational methods with exploratory automated text analysis of content from an Italian-themed conspiracy channel on Telegram during the first year of the pandemic. We found that, before the first lockdown in early 2020, the primary target of hate was China, which was blamed for a new bioweapon. Yet over the course of 2020 and particularly after the beginning of the second lockdown, the primary targets became journalists and healthcare workers, who were blamed for exaggerating the threat of COVID-19. This study advances our understanding of the association between hate speech and a complex and protracted event like the COVID-19 pandemic, and it suggests that country-specific responses to the virus (e.g., lockdowns and re-openings) are associated with online hate speech against different adversaries depending on the social and political context.

Introduction Systems science methodologies have been used in attempts to address the complex and dynamic causes of childhood obesity with varied results. This paper presents a protocol for the Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND) trial. RESPOND represents a significant advance on previous approaches by identifying and operationalising a clear systems methodology and building skills and knowledge in the design and implementation of this approach among community stakeholders.Methods and analysis RESPOND is a 4-year cluster-randomised stepped-wedge trial in 10 local government areas in Victoria, Australia. The intervention comprises four stages: catalyse and set up, monitoring, community engagement and implementation. The trial will be evaluated for individuals, community settings and context, cost-effectiveness, and systems and implementation processes. Individual-level data including weight status, diet and activity behaviours will be collected every 2 years from school children in grades 2, 4 and 6 using an opt-out consent process. Community-level data will include knowledge and engagement, collaboration networks, economic costs and shifts in mental models aligned with systems training. Baseline prevalence data were collected between March and June 2019 among >3700 children from 91 primary schools.Ethics and dissemination Ethics approval: Deakin University Human Research Ethics Committee (HREC 2018-381) or Deakin University’s Faculty of Health Ethics Advisory Committee (HEAG-H_2019-1; HEAG-H 37_2019; HEAG-H 173_2018; HEAG-H 12_2019); Victorian Government Department of Education and Training (2019_003943); Catholic Archdiocese of Melbourne (Catholic Education Melbourne, 2019-0872) and Diocese of Sandhurst (24 May 2019). The results of RESPOND, including primary and secondary outcomes, and emerging studies developed throughout the intervention, will be published in the academic literature, presented at national and international conferences, community newsletters, newspapers, infographics and relevant social media.Trial registration number ACTRN12618001986268p.

Abstract Background Environments within schools including the physical, social-cultural and policy/practice environments have the potential to influence children’s physical activity (PA) behaviours and weight status. This Australian first study comprehensively examined the association(s) of physical, social-cultural and policy/practice environments with PA, active transport (AT) and weight status among regional primary school children. Methods Data were from two childhood obesity monitoring systems in regional Victoria, Australia. Measured height and weight were collected from students in Year 2 (aged approx. 7–8 years), Year 4 (9–10 years), and Year 6 (11–12 years). Self–reported PA behaviour, including AT were collected from students in Year 4 and 6 and a sub-sample wore an ActiGraph (wGT3X-BT) accelerometer for 7-days. A school physical activity environment audit was completed by the school principal and responses were used to calculate school physical activity environment scores (PAES) and active transport environment scores (ATES). Mixed effects logistic regression was used to assess the relationship between the proportion of students meeting the PA guidelines (≥60mins/day of moderate-to-vigorous PA) and PAES tertiles (low, medium, high) and those using AT and school ATES tertiles, controlling for gender, school size/type and socioeconomic composition. Results The analysed sample included 54/146 (37%) schools and 3360/5376 (64%) students. In stratified analysis, girls in schools with a medium PAES score were more likely to meet the objectively measured PA guideline compared to low PAES score (OR 2.3, 95%CI 1.27, 4.16). Similarly, students in schools with a medium or high ATES score had higher odds of self-reported AT (medium OR 3.15, 95%CI 1.67, 5.94; high OR 3.71, 95%CI: 1.80, 7.64). No association between PAES or ATES and weight status were observed. Self-reported AT among boys (OR 1.59, 95%CI 1.19, 2.13) and girls (OR 1.56, 95%CI 1.08, 2.27) was associated with higher odds of meeting self-reported PA guidelines on all 7-days than those who did not report using AT. Conclusions In this study of regional Victorian primary schools, PA environments were only associated with girls’ adherence to PA guidelines. School AT environments were strongly associated with students’ AT behaviours and with increased likelihood of students being physically active.

Abstract Background Successful implementation and long-term maintenance of healthy supermarkets initiatives are crucial to achieving potential population health benefits. Understanding barriers and enablers of implementation of real-world trials will enhance wide-scale implementation. This process evaluation of a healthy supermarket intervention sought to describe (i) customer, retailer and stakeholder perspectives on the intervention; (ii) intervention implementation; and (iii) implementation barriers and enablers. Methods Eat Well @ IGA was a 12-month randomised controlled trial conducted in 11 Independent Grocers of Australia (IGA) chain supermarkets in regional Victoria, Australia (5 intervention and 6 wait-listed control stores). Intervention components included trolley and basket signage, local area and in-store promotion, and shelf tags highlighting the healthiest packaged foods. A sequential mixed-methods process evaluation was undertaken. Customer exit surveys investigated demographics, and intervention recall and perceptions. Logistic mixed-models estimated associations between customer responses and demographics, with store as random effect. Supermarket staff surveys investigated staff demographics, interactions with customers, and intervention component feedback. Semi-structured stakeholder interviews with local government, retail and academic partners explored intervention perceptions, and factors which enabled or inhibited implementation, maintenance and scalability. Interviews were inductively coded to identify key themes. Results Of 500 customers surveyed, 33%[95%CI:23,44] recalled the Eat Well @ IGA brand and 97%[95%CI:93,99] agreed that IGA should continue its efforts to encourage healthy eating. The 82 staff surveyed demonstrated very favourable intervention perceptions. Themes from 19 interviews included that business models favour sales of unhealthy foods, and that stakeholder collaboration was crucial to intervention design and implementation. Staff surveys and interviews highlighted the need to minimise staff time for project maintenance and to regularly refresh intervention materials to increase and maintain salience among customers. Conclusions This process evaluation found that interventions to promote healthy diets in supermarkets can be perceived as beneficial by retailers, customers, and government partners provided that barriers including staff time and intervention salience are addressed. Collaborative partnerships in intervention design and implementation, including retailers, governments, and academics, show potential for encouraging long-term sustainability of interventions. Trial registration ISRCTN, ISRCTN37395231 Registered 4 May 2017.

Abstract Objective: To undertake a census of the healthfulness of food venues providing lunch or dinner meals in a rural Australian setting and compare healthfulness by remoteness, using two measurement tools. Methods: A census of the rural local government area food venues was undertaken using two validated tools: the Healthfulness Rating Classification System (HRCS) and the Nutrition Environment Measures Survey (NEMS‐R). Data were collected covering an area of 3,438 square kilometres in Victoria, Australia, with a population of >21,000. Healthfulness by remoteness was described and variability between tools was explored. Results: Data were collected from all 95 eligible food venues. Both tools classified the food venues as relatively unhealthy. The mean HRCS score was ‐2.9 (unhealthy) and the mean NEMS‐R score was 10.8 (SD 7.0; possible range ‐27 to 64). There were no significant differences in healthiness of venues by remoteness (as measured by the Modified Monash Model), although the outer‐rural region had lower scores. Conclusions: This census of a rural food retail environment showed low access to healthy menu options along with minimal provision of nutrition information and promotion of healthy food in food venues. This environment has the potential to affect the dietary intake of more than 21,000 rural‐dwelling Australians and action to improve rural food environments is desperately needed. Implications for public health: If unhealthful rural food environments are not addressed, inequalities in the diet‐related disease burden for rural Australians will continue to persist. This study shows that interventions are needed for independent venues that could be targeted by researchers, local health promotion officers, community nutritionists or community education programs.

Abstract We aimed to determine the efficacy of multiple micronutrient supplementation on the biomarkers of iron, zinc, and vitamin A status across anthropometric status categories in Vietnamese school children. In this 22-week randomised controlled trial, 347 undernourished, normal weight, or overweight/obese children aged 6–9 years were allocated to receive every school day a multiple micronutrient supplement (10 mg iron, 10 mg zinc, 400 µg vitamin A) or a placebo. Haematological indices; circulating ferritin, zinc, and retinol (corrected for inflammation); and C-reactive protein were measured at baseline and 22 weeks. At week 22, linear mixed models showed that mean corpuscular volume increased by 0.3 fL, serum ferritin by 9.1 µg/L, plasma zinc by 0.9 µmol/L, and plasma retinol by 15%, and the prevalence of zinc deficiency decreased by 17.3% points in the intervention group compared to placebo. No intervention effects were found for other haematological indices, or the prevalence of anaemia. Multiple micronutrient supplementation for 22 weeks improved the biomarkers of zinc and vitamin A status and some biomarkers of iron status, and reduced the prevalence of zinc deficiency in Vietnamese school children. Trial registration: This trial was registered on 06/09/2016 at www.anzctr.org.au as ACTRN12616001245482.

Summary: Background: Human Papillomavirus (HPV) self-collection offered by community health workers (CHWs) during home visits has been hampered by low levels of triage Pap among HPV-positive women. We investigated effectiveness of a mHealth intervention to increase adherence to triage Pap. Methods: We conducted a hybrid type I cluster randomised effectiveness-implementation trial in Jujuy, Argentina. CHWs (clusters) were eligible if actively offering HPV self-collection and served at least 26 women aged 30 years and over. Women were eligible if they conducted self-collection and provided a mobile phone number. 260 CHWs were randomly allocated (3:2 ratio) to a multi-component intervention (Up to four SMS messages sent to HPV-positive women, and one SMS message to CHWs to prompt a visit of women with no triage Pap 60 days after a positive-test), or control group (Usual care: Women instructed to attend their health centre 30 days after HPV self-collection to pick-up results). The primary effectiveness outcome was percentage of HPV-positive women with triage 120 days after the HPV-test result. We evaluated implementation of the intervention using the RE-AIM framework. Findings: 221 CHWs (132 intervention, 89 control group) contacted 5389 women; and 5351 agreed to participate (3241 intervention, 2110 control group). In total 314/445 (70·5%) HPV-positive women of the intervention group had triage at 120 days after the HPV result, compared to 163/292 (55·1%) in the control group: 15·5% point improvement; 95%CI: 6·8–24·1; relative risk: 1·28; 95%CI: 1·11–1·48. 97·2% of women accepted the intervention and 86·9% of CHWs agreed to its adoption. Interpretation: The multicomponent mHealth intervention was effective in increasing the percentage of HPV-positive women who had triage Pap, allowing for many more women at risk of cervical cancer to receive timely follow-up. Funding: National Cancer Institute of the National Institutes of Health (USA) under Award Number R01CA218306.

Introduction Despite being an important period for the development of movement behaviours (physical activity, sedentary behaviour and sleep), few interventions commencing prior to preschool have been trialled. The primary aim of this trial is to assess the 12-month efficacy of the Let’s Grow mHealth intervention, designed to improve the composition of movement behaviours in children from 2 years of age. Let’s Grow is novel in considering composition of movement behaviours as the primary outcome, using non-linear dynamical approaches for intervention delivery, and incorporating planning for real-world implementation and scale-up from its inception.Methods and analysis A randomised controlled trial will test the effects of the 12-month parental support mHealth intervention, Let’s Grow, compared with a control group that will receive usual care plus electronic newsletters on unrelated topics for cohort retention. Let’s Grow will be delivered via a purpose-designed mobile web application with linked SMS notifications. Intervention content includes general and movement-behaviour specific parenting advice and incorporates established behaviour change techniques. Intervention adherence will be monitored by app usage data. Data will be collected from participants using 24-hour monitoring of movement behaviours and parent report at baseline (T0), mid-intervention (T1; 6 months post baseline), at intervention conclusion (T2; 12 months post baseline) and 1-year post intervention (T3; 2 years post baseline). The trial aims to recruit 1100 families from across Australia during 2021. In addition to assessment of efficacy, an economic evaluation and prospective scalability evaluation will be conducted.Ethics and dissemination The study was approved by the Deakin University Human Ethics Committee (2020-077). Study findings will be disseminated through publication in peer-reviewed journals, presentation at scientific and professional conferences, and via social and traditional media.Trial registration number ACTRN12620001280998; U1111-1252-0599.

Abstract Background Community-based interventions have shown promise in addressing the childhood obesity epidemic. Such efforts rely on the knowledge of key community members and their engagement with the drivers of obesity in their community. This paper presents the protocol for the measurement and evaluation of knowledge and engagement among community leaders within a whole-of-community systems intervention across 10 large intervention communities in Australia. Methods We will investigate the role of stakeholder knowledge and engagement in the implementation and effectiveness of the stepped wedge cluster randomised trial in ten communities in Victoria, Australia. Data will be collected using the Stakeholder-driven Community Diffusion Survey (SDCD) to measure levels of knowledge and engagement prior to commencement (2019), across the three separate levels of governance within the intervention at five time points. Primary outcomes will be baseline overall knowledge and engagement scores across the three levels of governance and change in overall knowledge and engagement over time. Discussion We hypothesise there will be heterogeneity between intervention sites on levels of knowledge and engagement and that these differences will be associated with variability in implementation success. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12618001986268 . Registered on 11 December 2018

Abstract Background Smartphone technology represents an opportunity to deliver practical solutions for people affected by cancer at a scale that was previously unimaginable, such as information, appointment monitoring, and improved access to cancer support services. This study aimed to determine whether a smartphone application (app) reduced the unmet needs among people newly diagnosed with cancer. Methods A single blind, multisite randomized controlled trial to determine the impact of an app‐based, 4‐month intervention. Newly diagnosed cancer patients were approached at three health service treatment clinics. Results Eighty‐two people were randomized (intervention; n = 43 and control; n = 39), average age was 59.5 years (SD: 12.9); 71% female; 67% married or in a de facto relationship. At baseline, there were no differences in participants’ characteristics between the groups. No significant effects, in reducing unmet needs, were demonstrated at the end of intervention (4‐month) or 12‐month follow‐up. Overall, 94% used the app in weeks 1‐4, which decreased to 41% in weeks 13‐16. Mean app use time per participant: Cancer Information, 6.9 (SD: 18.9) minutes; Appointment Schedule, 5.1 (SD: 9.6) minutes; Cancer Services 1.5 minutes (SD: 6.8); Hospital Navigation, 1.4 (SD: 2.8) minutes. Conclusions Despite consumer involvement in the design of this smartphone technology, the app did not reduce unmet needs. This may have been due to the study being underpowered. To contribute to a meaningful understanding and improved implementation of smartphone technology to support people affected by cancer, practical considerations, such as recruitment issues and access to, and confidence with, apps, need to be considered. Australian New Zealand Clinical Trials Registration (ACTRN) Trial Registration: 12616001251415; WEF 7/9/2016.

BackgroundThe Pediatric Quality of Life and Evaluation of Symptoms Technology Response to Pediatric Oncology Symptom Experience (PQ-Response) intervention aims to integrate specialized pediatric palliative care into the routine care of children, adolescents, and young adults (AYAs) with advanced cancer.AimsTo evaluate whether PQ-Response, compared to usual care, improves patient's health related quality of life (HRQoL) and symptom burden (aim 1), parent psychological distress and symptom-related stress (aim 2), and family and symptom treatment activation (aim 3).DesignMultisite, randomized (1:1), controlled, un-blinded, effectiveness trial comparing PediQUEST Response (intervention) vs usual cancer care (control).SettingFive US large, tertiary level pediatric cancer centers.ParticipantsChildren (≥2 years old)/AYAs who receive care at any of the participating sites because of advanced cancer or any progressive/recurrent solid or brain tumor and are palliative care "naïve." Target: 200 enrolled patient-parent dyads (minimum goal: 136 dyads randomized, N = 68/arm).InterventionsPediQUEST Response: combines patient-mediated activation (weekly feedback of patient- and parent-reported symptoms and HRQoL to families and providers using the PediQUEST web system) with integration of the palliative care team. Usual Cancer Care: participants receive usual care, which can include palliative care consultation, and use PediQUEST web to answer surveys, with no feedback.MethodsFollowing enrollment, patients (if ≥5 years) and one parent receive weekly PediQUEST-Surveys assessing HRQoL (Pediatric Quality of Life Inventory 4.0) and symptom burden (PediQUEST-Memorial Symptom Assessment Scale). After a 2-week run-in period, dyads who answer ≥2 PediQUEST surveys per participant (responders), are randomized (concealed allocation) and followed up for 16-weeks. Parents answer six additional surveys (parent outcomes).OutcomesPrimary: mean patient HRQoL score over 16-weeks as reported by a) the parent; and b) the patient if ≥5 years-old. Secondary: patient's symptom burden; parent's anxiety, depressive symptoms, symptom-related stress; family activation; and symptom treatment activation.Trial registrationClinicalTrials.gov (NCT03408314) 1/24/18. https://clinicaltrials.gov/ct2/show/NCT03408314.

IntroductionPromoting healthy eating and active play in early life is critical, however few interventions have been delivered or sustained at scale. The evaluation of interventions at scale is a crucial, yet under-researched aspect of modifying population-level health behaviours. INFANT is an evidence-based early childhood healthy lifestyle intervention that aims to improve parents’ knowledge and skills around promoting optimal energy balance-related behaviours that, in turn, influence children’s diet, activity and adiposity. It consists of: 1) Four group sessions delivered via first time parent groups across the first 12 months of life; 2) access to the My Baby Now app from birth to 18 months of age. This research aims to assess real-world implementation, effectiveness and cost-effectiveness of INFANT when delivered at scale across Victoria, Australia.Methods and AnalysisA hybrid type II implementation-effectiveness trial applying a mixed methods design will be conducted. INFANT will be implemented in collaboration with practice and policy partners including maternal and child health services, population health and Aboriginal health, targeting all local government areas (n=79) in Victoria, Australia. Evaluation is based on criteria from the ‘Outcomes for Implementation Research’ and ‘RE-AIM’ frameworks. Implementation outcomes will be assessed using descriptive quantitative surveys and qualitative interviews with those involved in implementation, and include intervention reach, organisational acceptability, adoption, appropriateness, cost, feasibility, penetration and sustainability. Process measures include organizational readiness, fidelity, and adaptation. Effectiveness outcomes will be assessed using a sample of INFANT participants and a non-randomized comparison group receiving usual care (1,500 infants in each group), recruited within the same communities. Eligible participants will be first time primary caregivers of an infant aged 0-3 months, owning a personal mobile phone and able to communicate in English. Effectiveness outcomes include infant lifestyle behaviours and BMIz at 12 and 18 months of age.ImpactThis is the first known study to evaluate the scale up of an evidence based early childhood obesity prevention intervention under real world conditions. This study has the potential to provide generalisable implementation, effectiveness and cost-effectiveness evidence to inform the future scale up of public health interventions both in Australia and internationally.Clinical Trial RegistrationAustralian and New Zealand Clinical Trial Registry https://www.anzctr.org.au/, identifier ACTRN12620000670976.

Abstract Background Many dedicated Coronary Care Units (CCUs) in Victoria, Australia, have been decommissioned and replaced with larger combined generic medical/cardiac precincts called hybrid units. Hybrid units are staffed with a low proportion of specialist critical care nurses. These changes may pose risks to nurse satisfaction and retention, and quality of patient care. The aims of this study were to explore specialist cardiac nurses’ perceived work satisfaction across four CCUs, and differences in satisfaction between dedicated and hybrid CCUs. Methods This concurrent mixed methods study comprised two Phases in four Victorian CCUs (2 dedicated, 2 hybrid). In Phase 1, 74 specialist cardiac nurses completed the Professional Practice Environment (PPE) Scale. In Phase 2, 17 specialist cardiac nurses were interviewed to further explore elements of the PPE subscales. Descriptive, inferential (Phase 1), and content analyses (Phase 2) were performed. Results Survey participants’ median age was 38 years (IQR 30, 45). The median PPE Scale score was 3.10 (IQR 2.90, 3.10) indicating high levels of satisfaction with their workplaces. Specialist cardiac nurses in one hybrid unit were significantly less satisfied compared with each of the other three units (p

Abstract Background There is a large disparity between alcohol treatment access and prevalence of hazardous drinking among same-sex attracted women (SSAW). Yet, this population typically report low satisfaction with care and a reluctance to attend mainstream health services. Currently, there are few culturally tailored services for SSAW available despite evidence indicating that many feel uncomfortable in mainstream services. This paper describes the protocol of a randomised controlled trial aimed at examining the impact of a culturally sensitive four-week short message service (SMS) alcohol intervention on SSAW’s alcohol intake, wellbeing, and engagement with alcohol treatment. Methods A randomised controlled trial comparing a culturally tailored SMS intervention (The Step One Program) with a generic ‘thank you’ message, and a nested qualitative study to further explore the intervention’s feasibility and acceptability. The Step One Program was co-designed using an Intervention Mapping framework and engaging potential consumers in the developmental process. Participants are block randomised (1:1 ratio) and followed up at the completion of the intervention and at 12 weeks post-intervention. The primary outcomes are alcohol reduction (as measured by the Alcohol Use Disorders Identification Test and self-reported alcohol intake), wellbeing (as measured by the Personal Wellbeing Index – Adult), and help-seeking (as measured by the number of alcohol services accessed and frequency of access). Upon completion of the 12-week post-intervention survey, participants in the intervention group were contacted via email regarding a phone interview on intervention acceptability. Discussion This study may have important implications for clinical practice, improve healthcare access and equity for SSAW, and provide direction for future research in this field. The outcomes of the current study may stimulate the development of other culturally tailored health programs for SSAW. The results will inform whether individually tailoring the messages according to content and delivery frequency may be warranted to increase its acceptability. Trial registration This trial was registered with the Australian New Zealand Clinical Trials Registry (trial ID: ACTRN12617000768392).

Abstract Background Cervical cancer is one of the leading causes of cancer death among women worldwide, with more than 85% of cases occurring in low- and middle-income countries. Human papillomavirus (HPV) screening allows for self-collection with the potential to increase coverage, but still requires triage to identify which HPV+ women need diagnostic and treatment procedures. However, achieving high levels of triage adherence can be challenging, especially among socially vulnerable women. This paper describes the ATICA protocol (Application of Communication and Information Technologies to Self-Collection, for its initials in Spanish), aimed at evaluating the implementation strategy and the effectiveness of a multi-component mobile health (mHealth) intervention to increase adherence to triage among women with HPV+ self-collected tests. Methods We will use an effectiveness-implementation hybrid type I trial with a mixed-methods evaluation approach. A cluster randomized trial design including 200 community health workers (CHWs) will evaluate whether the mHealth intervention increases adherence to triage among HPV+ women who self-collected at home during a CHW visit within 120 days after a positive result. The intervention includes an initial mobile phone text message (SMS) alert and subsequent reminders sent to HPV+ women. For those who do not adhere to triage within 60 days of a positive HPV test, an email and SMS will be sent to the CHWs to promote contact with these women during home visits. We will use the Consolidated Framework for Implementation Research (CFIR) as an organizing and analytic framework to evaluate the implementation of the intervention while also drawing on Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM). We will conduct a self-administered, semi-structured survey of CHWs, semi-structured interviews with local health authorities, and a survey of HPV+ women. Combining both qualitative and quantitative data will provide rich insights into local implementation challenges and successes. Discussion Findings from the implementation evaluation will be applicable to programs that use or are planning to incorporate HPV self-collection and/or mHealth interventions in different settings and countries. This innovative study will also serve as a model for using implementation science in the region. Trial registration ClinicalTrials.gov, NCT03478397. Registered on 20 March 2018.

Introduction: Most people in Australia buy most of their food in supermarkets. Marketing techniques promoting healthy foods in supermarkets can be important to encourage healthy eating at a population level. Shelf tags that highlight the healthiness of products have been identified as one such promising initiative. The aim of this study was to assess changes in the healthiness of foods sold in an Australian supermarket chain following implementation of a shelf tag intervention based on the Australian Health Star Rating (HSR) system. Methods: A controlled, non-randomised trial was undertaken in seven supermarkets (intervention: n = 3; control: n = 4) of a single chain in Victoria, Australia, over 12 weeks (4 weeks baseline, 8 weeks intervention period) between August and November 2015. The intervention involved provision of a shelf tag indicating the HSR of all packaged products that scored 4.5 or 5 stars (‘high-HSR products’) using the Australian HSR system. Posters indicating the healthiness of fresh fruits and vegetables (not eligible for an HSR rating, as they are not packaged) were also installed. Weekly per store sales data were provided by the retailer. In an intention-to-treat analysis (with intervention status of individual products based on their eligibility to be tagged), the proportion (%) of all ‘high-HSR’ packaged food sold and the volume of key nutrients (saturated fat, total fat, sodium, total sugar, protein, carbohydrates and energy) per 100 g sold were assessed. Difference-in-difference analyses were conducted to determine the difference between intervention and control stores in terms of mean outcomes between baseline and intervention periods. Customer exit surveys (n = 304) were conducted to evaluate awareness and use of the shelf tags and posters. Results: The proportion of ‘high-HSR products’ sold increased in the intervention period compared to the baseline period in each of the three intervention stores (average increase of 0.49%, 95% CI: −0.02, 0.99), compared to a decrease of −0.15% (−0.46, 0.15) in control stores (p = 0.034). The overall increase in intervention compared to control stores (difference-in-difference) of 0.64% represents an 8.2% increase in the sales of ‘high-HSR products’. Sales of total sugar, total fat, saturated fat, carbohydrates, sodium, protein and total energy in packaged food all decreased significantly more in intervention stores compared to control stores. Sales of fresh fruits and vegetables decreased in intervention stores compared to control stores. Customer surveys found that 34.4% noticed the shelf tags. Of those who noticed the tags, 58% believed the shelf tags influenced their purchases. Conclusions: With this study, we found that the use of shelf tags that highlight the healthiest packaged foods in a supermarket setting showed promise as a mechanism to improve the healthiness of purchases. Opportunities to scale up the intervention warrant exploration, with further research needed to assess the potential impact of the intervention on overall population diets over the longer term.

ObjectivesTo compare blood alkalosis, gastrointestinal symptoms and indicators of strong ion difference after ingestion of 500 mg.kg-1 BM sodium citrate over four different periods.MethodsSixteen healthy and active participants ingested 500 mg.kg-1 BM sodium citrate in gelatine capsules over a 15, 30, 45 or 60 min period using a randomized cross-over experimental design. Gastrointestinal symptoms questionnaires and venous blood samples were collected before ingestion, immediately post-ingestion, and every 30 min for 480 min post-ingestion. Blood samples were analysed for blood pH, [HCO3-], [Na+], [Cl-] and plasma [citrate]. Linear mixed models were used to estimate the effect of the ingestion protocols.ResultsFor all treatments, blood [HCO3-] was significantly elevated above baseline for the entire 480 min post-ingestion period, and peak occurred 180 min post-ingestion. Blood [HCO3-] and pH were significantly elevated above baseline and not significantly below the peak between 150-270 min post-ingestion. Furthermore, blood pH and [HCO3-] were significantly lower for the 60 min ingestion period when compared to the other treatments. Gastrointestinal symptoms were minor for all treatments; the mean total session symptoms ratings (all times summed together) were between 9.8 and 11.6 from a maximum possible rating of 720.ConclusionBased on the findings of this investigation, sodium citrate should be ingested over a period of less than 60 min (15, 30 or 45 min), and completed 150-270 min before exercise.

BackgroundBehavioural patterns are typically derived using unsupervised multivariate methods such as principal component analysis (PCA), latent profile analysis (LPA) and cluster analysis (CA). Comparability and congruence between the patterns derived from these methods has not been previously investigated, thus it's unclear whether patterns from studies using different methods are directly comparable. This study aimed to compare behavioural patterns derived across diet, physical activity, sedentary behaviour and sleep domains, using PCA, LPA and CA in a single dataset.MethodsParent-report and accelerometry data from the second wave (2011/12; child age 6-8y, n = 432) of the HAPPY cohort study (Melbourne, Australia) were used to derive behavioural patterns using PCA, LPA and CA. Standardized variables assessing diet (intake of fruit, vegetable, sweet, and savoury discretionary items), physical activity (moderate- to vigorous-intensity physical activity [MVPA] from accelerometry, organised sport duration and outdoor playtime from parent report), sedentary behaviour (sedentary time from accelerometry, screen time, videogames and quiet playtime from parent report) and sleep (daily sleep duration) were included in the analyses. For each method, commonly used criteria for pattern retention were applied.ResultsPCA produced four patterns whereas LPA and CA each generated three patterns. Despite the number and characterisation of the behavioural patterns derived being non-identical, each method identified a healthy, unhealthy and a mixed pattern. Three common underlying themes emerged across the methods for each type of pattern: (i) High fruit and vegetable intake and high outdoor play ("healthy"); (ii) poor diet (either low fruit and vegetable intake or high discretionary food intake) and high sedentary behaviour ("unhealthy"); and (iii) high MVPA, poor diet (as defined above) and low sedentary time ("mixed").ConclusionWithin this sample, despite differences in the number of patterns derived by each method, a good degree of concordance across pattern characteristics was seen between the methods. Differences between patterns could be attributable to the underpinning statistical technique of each method. Therefore, acknowledging the differences between the methods and ensuring thorough documentation of the pattern derivation analyses is essential to inform comparison of patterns derived through a range of approaches across studies.

The supermarket environment impacts the healthiness of food purchased and consumed. Shelf tags that alert customers to healthier packaged products can improve the healthiness of overall purchases. This study assessed the potential value-for-money of implementing a three-year shelf tag intervention across all major supermarket chains in Australia. Cost–benefit analyses (CBA) and cost–utility analyses (CUA) were conducted based on results of a 12-week non-randomised controlled trial of a shelf tag intervention in seven Australian supermarkets. The change in energy density of all packaged foods purchased during the trial was used to estimate population-level changes in mean daily energy intake. A multi-state, multiple-cohort Markov model estimated the subsequent obesity-related health and healthcare cost outcomes over the lifetime of the 2019 Australian population. The CBA and CUA took societal and healthcare sector perspectives, respectively. The intervention was estimated to produce a mean reduction in population body weight of 1.09 kg. The net present value of the intervention was approximately AUD 17 billion (B). Over 98% of the intervention costs were borne by supermarkets. CUA findings were consistent with the CBA—the intervention was dominant, producing both health benefits and cost-savings. Shelf tags are likely to offer excellent value-for-money from societal and healthcare sector perspectives.

Introduction Limited evidence exists on the cost-effectiveness of interventions to prevent obesity and promote healthy body image in adolescents. The SHINE (Supporting Healthy Image, Nutrition and Exercise) study is a cluster randomised control trial (cRCT) aiming to deliver universal education about healthy nutrition and physical activity to adolescents, as well as targeted advice to young people with body image concerns who are at risk of developing disordered eating behaviours. This paper describes the methods for the economic evaluation of the SHINE cRCT, to determine whether the intervention is cost-effective as an obesity prevention measure.Methods and analysis A public payer perspective will be adopted, with intervention costs collected prospectively. Within-trial cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) will quantify the incremental costs and health gains of the intervention as compared with usual practice (ie, teacher-delivered curriculum). CEA will present results as cost per body mass index unit saved. CUA will present results as cost per quality-adjusted life year gained. A modelled CUA will extend the target population, time horizon and decision context to provide valuable information to policymakers on the potential for incremental cost offsets attributable to disease prevention arising from intervention. Intervention costs and effects will be extrapolated to the population of Australian adolescents in Grade 7 of secondary school (approximate age 13 years) and modelled over the cohort’s lifetime. Modelled CUA results will be presented as health-adjusted life years saved and healthcare cost-savings of diseases averted. Incremental cost-effectiveness ratios will be calculated as the difference in costs between the intervention and comparator divided by the difference in benefit. Semi-structured interviews with key intervention stakeholders will explore the potential impact of scalability on cost-effectiveness. These data will be thematically analysed to inform sensitivity analysis of the base case economic evaluation, such that cost-effectiveness evidence is reflective of the potential for scalability.Ethics and dissemination Ethics approval was obtained from the Deakin University Human Research Ethics Committee (#2017–269) and the Victorian Department of Education and Training (#2018_003630). Study findings will be disseminated through peer-reviewed academic papers and participating schools will receive annual reports over the 3 years of data collection.Trial registration number ACTRN 12618000330246; Pre-results.

Background Waist circumference and hip circumference are both strongly associated with risk of death; however, their joint association has rarely been investigated. Methods and Results The MONICA Risk, Genetics, Archiving, and Monograph (MORGAM) Project was conducted in 30 cohorts from 11 countries; 90 487 men and women, aged 30 to 74 years, predominantly white, with no history of cardiovascular disease, were recruited in 1986 to 2010 and followed up for up to 24 years. Hazard ratios were estimated using sex‐specific Cox models, stratified by cohort, with age as the time scale. Models included baseline categorical obesity measures, age, total and high‐density lipoprotein cholesterol, systolic blood pressure, antihypertensive drugs, smoking, and diabetes mellitus. A total of 9105 all‐cause deaths were recorded during a median follow‐up of 10 years. Hazard ratios for all‐cause death presented J‐ or U‐shaped associations with most obesity measures. With waist and hip circumference included in the same model, for all hip sizes, having a smaller waist was strongly associated with lower risk of death, except for men with the smallest hips. In addition, among those with smaller waists, hip size was strongly negatively associated with risk of death, with ≈20% more people identified as being at increased risk compared with waist circumference alone. Conclusions A more complex relationship between hip circumference, waist circumference, and risk of death is revealed when both measures are considered simultaneously. This is particularly true for individuals with smaller waists, where having larger hips was protective. Considering both waist and hip circumference in the clinical setting could help to best identify those at increased risk of death.

ObjectiveTo assess the impact of a sugar-sweetened beverage (SSB) reduction initiative on customer purchasing patterns, including volume sales of healthy and unhealthy packaged drinks and sales value of all packaged drinks, in a major Australian aquatic and recreation provider, YMCA Victoria.DesignProspectiveSetting16 aquatic and recreation centres in Victoria, Australia.InterventionsThe SSB-reduction initiative aimed to remove all SSBs (excluding sports drinks) and increase healthier drink availability over a 1-year period.Primary and secondary outcome measuresItemised monthly drink sales data were collected for 16 centres, over 4 years (2 years preimplementation, 1 year implementation and 1 year postimplementation). Drinks were classified as ‘green’ (best choice), ‘amber’ (choose carefully) or ‘red’ (limit). Interrupted time series analysis was conducted for each centre to determine the impact on volume sales of ‘red’ and ‘green’ drinks, and overall sales value. A novel meta-analysis approach was conducted to estimate the mean changes across centres.ResultsFollowing implementation, volume sales of ‘red’ drinks reduced by 46.2% across centres (95% CI: −53.2% to −39.2%), ‘green’ drink volume did not change (0.0%, 95% CI: −13.3% to 13.2%) and total drink sales value decreased by 24.3% (95% CI: −32.0% to −16.6%).ConclusionsThe reduction of SSBs in health-promoting settings such as recreation centres is a feasible, effective public health policy that is likely to be transferable to other high-income countries with similarly unhealthy beverage offerings. However, complementary strategies should be considered to encourage customers to switch to healthier alternatives, particularly when translating policies to organisations with less flexible income streams.

This study aimed to explore the diagnostic accuracy of the Patient-Generated Subjective Global Assessment (PG-SGA) malnutrition risk screening tool when used to score patients based on their electronic medical records (EMR), compared to bedside screening interviews. In-patients at a rural health service were screened at the bedside (n = 50) using the PG-SGA, generating a bedside score. Clinical notes within EMRs were then independently screened by blinded researchers. The accuracy of the EMR score was assessed against the bedside score using area under the receiver operating curve (AUC), sensitivity, and specificity. Participants were 62% female and 32% had conditions associated with malnutrition, with a mean age of 70.6 years (SD 14.9). The EMR score had moderate diagnostic accuracy relative to PG-SGA bedside screen, AUC 0.74 (95% CI: 0.59–0.89). The accuracy, specificity and sensitivity of the EMR score was highest for patients with a score of 7, indicating EMR screen is more likely to detect patients at risk of malnutrition. This exploratory study showed that applying the PG-SGA screening tool to EMRs had enough sensitivity and specificity for identifying patients at risk of malnutrition to warrant further exploration in low-resource settings.

Abstract Background Point-of-care ultrasound (POCUS) has been used in various vascular access contexts; however, to date, it has not been widely adopted in haemodialysis clinics. People with end-stage kidney disease receiving haemodialysis require an arteriovenous fistula (AVF), arteriovenous graft (AVG), or central venous access device (CVAD) in order to access their blood for therapy/treatment. Cannulation issues, such as haematoma and extravasation, related to AVFs and AVGs are common. This pilot and feasibility study will assess the feasibility of a randomised controlled trial aimed at evaluating whether POCUS-guided cannulation results in more successful and accurate AVF needle placement than the standard practice of blind cannulation. Methods A controlled, random order crossover design will be used to evaluate two clinical conditions: (1) POCUS-guided cannulation and (2) standard practice of blind cannulation, when used by haemodialysis nurses. The feasibility of conducting this type of trial for these two clinical conditions will be assessed through recruitment, retention, and attrition rates; perceptions of acceptability; implementation measures; and assessment of methods of data collection. Clinical outcomes to be assessed are overall cannulation success on first attempt, accuracy of needle tip placement, number of extravasations, procedural time, and patient and nurse perceptions. The setting is a 16-chair dialysis unit in regional Australia. Participants will include adult haemodialysis patients with an AVF in situ for greater than 2 months and haemodialysis-trained registered nurses working full- or part-time. Clinical outcomes will be analysed using generalised linear mixed models. Feasibility data will be reported using descriptive statistics. Qualitative audio data will be digitally recorded, transcribed verbatim, and analysed using thematic analysis. Discussion Point-of-care ultrasound for cannulation has the potential to promote high-quality, safe nursing care and decrease cannulation damage for patients on haemodialysis. Due to the lack of evidence for patient benefit and its innovative and niche use in haemodialysis centres, POCUS is currently only specified in one international guideline. This study will inform sample size calculations for a future multi-site trial. Trial registration Australian New Zealand Clinical Trials Registry, (21/11/2017) ACTRN12617001569392

Abstract Background People with a melanoma diagnosis are at risk of recurrence, developing a new primary or experiencing disease progression. Previous studies have suggested that fear of a cancer recurrence is clinically relevant in this group of patients and, if not addressed, can lead to distress. Mindfulness-based interventions have been shown to alleviate symptoms of anxiety and depression among various groups of cancer patients. Online mindfulness-based interventions have the potential to reach people unable to attend face-to-face interventions due to limitations such as cancer-related illness, transportation or time constraints. This study aims to (1) examine whether individuals with a melanoma diagnosis are willing to participate and adhere to a 6-week online mindfulness-based intervention and (2) explore potential benefits of the program on fear of cancer recurrence, worries, rumination, perceived stress and trait mindfulness to inform the design of a clinical trial. Methods/design This is a single-site randomised controlled trial of a feasibility study. Seventy-five participants with stage 2c or 3 melanoma will be recruited from a melanoma outpatient clinic and randomised (2:1) either to an online mindfulness-based program (intervention) or to usual care (control). The intervention is a 6-week program specifically developed for this study. It consists of videos describing the concept of mindfulness, short daily guided meditation practices (5–10 min), automated meditation reminders and instructions for applying mindfulness in daily life to enhance wellbeing. All participants will complete questionnaires at baseline and at 6-week post-randomisation. Participants in the control group will be given access to the online program at the end of the study. Primary outcomes are overall recruitment; retention; extent of questionnaire completion; and usability and acceptability of, and adherence to, the program. The secondary outcomes are fear of cancer recurrence, worries, rumination, perceived stress and trait mindfulness measured using validated instruments. Discussion This feasibility study will evaluate participants’ satisfaction with the program and identify barriers to recruitment and adherence. The recruitment and data collection process will highlight methodological aspects to address in the planning of a larger scale study assessing the impact of an online mindfulness-based intervention on fear of cancer recurrence and wellbeing. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12617000081314. Registered on 16 January 2017.

Abstract Background MINI SALTEN is a program developed to increase moderate to vigorous physical activity (PA) and improve eating habits at home and school in first grade children. It aims to assess the effects of a technology family-based and PA school-based intervention. The purpose of this manuscript is to describe the protocol design and the MINISALTEN intervention. Methods This is cluster-randomized controlled trial designed to run from July 2015 to November 2016 in 12 public schools of the city of Buenos Aires, matched for socio-demographic characteristics. The intervention is based on two main components: (a) “active breaks” (AB): implemented during school breaks by a PA instructor; (b) “virtual” (V): web-based contents delivered to the families via a multiplatform application. Using a computer generated random sequence participants are allocated to one of four intervention conditions: (AB), (V), (AB + V), and control (C). Outcomes are measured at baseline and 12 months post intervention, and will include data collected from the child and her/his mother/father or guardian. Primary outcome measures are: PA and sedentary behaviour (measured with accelerometers). Secondary outcome measures related are: percentage of kilocalories (kcal) from added sugars, and from total and saturated fats; grams of fruits and vegetables; and number of snacks and kcal coming from their added sugars and total and saturated fats. Family socio-economic level, home environment, and school environment will also be assessed. Statistical analysis is on an intention-to-treat principle. Baseline characteristics are described using summary measures and mixed models (with school as random effect). The effect of the two interventions will be estimated using a generalized mixed linear model with link and distribution selected according to the type of outcome. Included random effects are: child (or mother/father or guardian) accounting for repeated measures; school accounting for cluster induced by school. The most parsimonious model for each outcome will be reported. The False Discovery Rate criterion will be used to correct for multiple testing in non-planned analyses. Discussion It is a pioneer assessment of the impact of a technology-based virtual intervention and a school-based PA program, designed to prevent obesity, and involving the parents at public schools of Buenos Aires. Trial registration Current Controlled Trials ISRCTN58093412 . Registered March 14th, 2016 (retrospectively registered).

Abstract Background Sample selection can substantially affect the solutions generated using exploratory factor analysis. Validation studies of the 12-item World Health Organization (WHO) Disability Assessment Schedule 2.0 (WHODAS 2.0) have generally involved samples in which substantial proportions of people had no, or minimal, disability. With the WHODAS 2.0 oriented towards measuring disability across six life domains (cognition, mobility, self-care, getting along, life activities, and participation in society), performing factor analysis with samples of people with disability may be more appropriate. We determined the influence of the sampling strategy on (a) the number of factors extracted and (b) the factor structure of the WHODAS 2.0. Methods Using data from adults aged 50+ from the six countries in Wave 1 of the WHO’s longitudinal Study on global AGEing and adult health (SAGE), we repeatedly selected samples (n = 750) using two strategies: (1) simple random sampling that reproduced nationally representative distributions of WHODAS 2.0 summary scores for each country (i.e., positively skewed distributions with many zero scores indicating the absence of disability), and (2) stratified random sampling with weights designed to obtain approximately symmetric distributions of summary scores for each country (i.e. predominantly including people with varying degrees of disability). Results Samples with skewed distributions typically produced one-factor solutions, except for the two countries with the lowest percentages of zero scores, in which the majority of samples produced two factors. Samples with approximately symmetric distributions, generally produced two- or three-factor solutions. In the two-factor solutions, the getting along domain items loaded on one factor (commonly with a cognition domain item), with remaining items loading on a second factor. In the three-factor solutions, the getting along and self-care domain items loaded separately on two factors and three other domains (mobility, life activities, and participation in society) on the third factor; the cognition domain items did not load together on any factor. Conclusions High percentages of participants with no disability (i.e., zero scores) produce heavily censored data (i.e., floor effects), limiting data heterogeneity and reducing the numbers of factors retained. The WHODAS 2.0 appears to have multiple closely-related factors. Samples of convenience and those collected for other purposes (e.g., general population surveys) would usually be inadequate for validating measures using exploratory factor analysis.

Abstract To compare the effect of 500 mg·kg−1 body mass (BM) sodium citrate ingested in solution or capsules on induced alkalosis, gastrointestinal symptoms and palatability. Twenty‐four healthy and active participants completed two testing sessions, ingesting 500 mg·kg−1 BM sodium citrate within solution or capsules. Capillary blood samples were collected pre‐ingestion, and every 30‐min for 240‐min post‐ingestion; samples were analyzed for blood pH and [HCO3−]. A validated questionnaire was used to quantify gastrointestinal symptoms at the same 30‐min intervals. Palatability was quantified immediately after ingestion using a validated scale. There was a greater peak and change from baseline for capsules versus solution for blood pH (P

Abstract Background HPV test self-collection has been shown to reduce barriers to cervical screening and increase uptake. However, little is known about women’s preferences when given the choice between self-collected and clinician-collected tests. This paper aims to describe experiences with HPV self-collection among women in Jujuy, the first Argentinean province to have introduced HPV testing as the primary screening method, provided free of cost in all public health centers. Methods Between July and December 2012, data on acceptability of HPV self-collection and several social variables including past screening were collected from 2616 self-collection accepters and 433 non-accepters, and were analyzed using multivariate regression. In addition, in-depth interviews (n = 30) and 2 focus groups were carried out and analyzed using thematic analysis. Results Quantitative findings indicate that main reasons for choosing self-collection are those reducing barriers related to women’s roles of responsibility for domestic work and work/family organization, and to health care services’ organization. No social variables were significantly associated with acceptability. Among those who preferred clinician-collection, the main reasons were trust in health professionals and fear of hurting themselves. Qualitative findings also showed that self-collection allows women to overcome barriers related to the health system (i.e. long wait times), without sacrificing time devoted to work/domestic responsibilities. Conclusions Findings have implications for self-collection recommendations, as they show it is the preferred method when women are given the choice, even if they are not screening non-attenders. Findings also highlight the importance of incorporating women’s needs/preferences in HPV screening recommendations.

Aim: To explore the knowledge, attitudes, and practices associated with meditation among people with melanoma and investigate the relationship between perceived stress, trait mindfulness, and meditation. Factors associated with interest to participate in an online meditation program were also explored. Methods: A survey-based cross-sectional study of 291 patients attending a melanoma outpatient clinic assessed knowledge of meditation, attitudes toward meditation using Determinants of Meditation Practice Inventory (DMPI), and meditation experience. Perceived stress and trait mindfulness were measured using the Perceived Stressed Scale and Cognitive and Affective Mindfulness Scale, respectively. Results: Participants who had tried meditation (43%) were likely to be younger, female, and have completed higher education or be employed. Perceived stress score was higher among women, younger participants, and those treated in the past year but did not differ by melanoma stage. Participants reported a good understanding of the potential benefits of meditation, but even among people with meditation experience, common misconceptions prevailed. The main barrier to meditation was a perceived lack of knowledge about meditation . Higher DMPI scores were associated with lower education, moderate to low access to service centers, or living in disadvantaged neighborhoods . Participants practicing meditation that involved self-reflection reported less stress and higher trait mindfulness compared with participants practicing another type of meditation. People interested in participating in an online meditation-based program reported higher perceived stress than those not interested. Conclusion: A meditation-based intervention teaching self-reflective practices, targeted at people with melanoma, may have the potential to assist them with managing their stress.

Little is known about the prevalence of anaemia and associated factors in school children in Vietnam. In this cross-sectional study, we aimed to determine the prevalence of anaemia and its subtypes, and the associations of types of anaemia with demographic, socio-economic and anthropometric factors among 6−9-year-old primary school children in rural areas of Hai Phong City, Vietnam. Haemoglobin (Hb) and mean corpuscular volume (MCV) were measured, and demographic, socio-economic and anthropometric data were collected in 893 children from eight primary schools. The prevalence of anaemia (Hb < 115 g/L) was 12.9% (95% CI: 8.1%, 19.9%), microcytic anaemia (Hb < 115 g/L and MCV < 80 fL) was 7.9% (95% CI: 5.3%, 11.6%) and normocytic anaemia (Hb < 115 g/L and MCV 80−90 fL) was 5.3% (95% CI: 2.9%, 9.5%). No child presented with macrocytic anaemia (Hb < 115 g/L and MCV > 90 fL). Children who were underweight, wasted, or in anthropometric failure (either underweight, stunted or wasted) were more likely to be anaemic (all p ≤ 0.004), and specifically, to have normocytic anaemia (all p ≤ 0.006), than those who were not underweight, wasted or in anthropometric failure. Stunted children were more likely to be anaemic (p = 0.018) than those who were not stunted. Overweight/obese children were less likely to be anaemic (p = 0.026) or have normocytic anaemia (p = 0.038) compared with children who were not overweight/obese. No anthropometric status indicator was associated with the risk of microcytic anaemia. No demographic or socio-economic factor was associated with any type of anaemia. Anaemia remains a public health issue in rural areas in Hai Phong City, Vietnam, and future approaches for its prevention and control should target undernourished primary school children.

A double burden of malnutrition in Vietnamese children has emerged as a key challenge: childhood undernutrition remains a public health concern while childhood overweight/obesity has gradually increased. This study aimed to (1) estimate the prevalence of undernutrition and overnutrition among 6–9-year-old primary school children in rural areas of Vietnam, and (2) identify sociodemographic factors associated with undernutrition and overnutrition in this population. A cross-sectional survey was conducted in October 2016 in 2334 children from eight primary schools in rural areas in Hai Phong City, Vietnam. Anthropometric and demographic data were collected. The prevalence of underweight, stunting, wasting, and anthropometric failure was 8.0%, 5.1%, 5.3%, and 11.9%, respectively. Up to 22.1% of children were affected by overweight/obesity, and 31.0% by abdominal overweight/obesity. Low maternal education was associated with higher odds of underweight and anthropometric failure, whereas overweight/obesity or abdominal overweight/obesity were more likely in boys and children of mothers with a high education level. This study provides evidence for a double burden of diseases among primary school children in rural areas in Hai Phong City. Future interventions for the prevention and control of childhood undernutrition and overweight/obesity should take into account child sex and maternal education level.

Background: Control of cervical cancer in developing countries has been hampered by a failure to achieve high screening uptake. HPV DNA self-collection could increase screening coverage, but implementation of this technology is difficult in countries of middle and low income. We investigated whether offering HPV DNA self-collection during routine home visits by community health workers could increase cervical screening. Methods: We did a population-based cluster-randomised trial in the province of Jujuy, Argentina, between July 1, 2012, and Dec 31, 2012. Community health workers were eligible for the study if they scored highly on a performance score, and women aged 30 years or older were eligible for enrolment by the community health worker. 200 community health workers were randomly allocated in a 1:1 ratio to either the intervention group (offered women the chance to self-collect a sample for cervical screening during a home visit) or the control group (advised women to attend a health clinic for cervical screening). The primary outcome was screening uptake, measured as the proportion of women having any HPV screening test within 6 months of the community health worker visit. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02095561. Findings: 100 community health workers were randomly allocated to the intervention group and 100 were assigned to the control group; nine did not take part. 191 participating community health workers (94 in the intervention group and 97 in the control group) initially contacted 7650 women; of 3632 women contacted by community health workers in the intervention group, 3049 agreed to participate; of 4018 women contacted by community health workers in the control group, 2964 agreed to participate. 2618 (86%) of 3049 women in the intervention group had any HPV test within 6 months of the community health worker visit, compared with 599 (20%) of 2964 in the control group (risk ratio 4·02, 95% CI 3·44–4·71). Interpretation: Offering self-collection of samples for HPV testing by community health workers during home visits resulted in a four-fold increase in screening uptake, showing that this strategy is effective to improve cervical screening coverage. This intervention reduces women's barriers to screening and results in a substantial and rapid increase in coverage. Our findings suggest that HPV testing could be extended throughout Argentina and in other countries to increase cervical screening coverage. Funding: Instituto Nacional del Cáncer (Argentina).

Evidence suggests individuals less sensitive to fat taste (high fat taste thresholds (FTT)) may be overweight or obese and consume greater amounts of dietary fat than more sensitive individuals. The aims of this study were to assess associations between FTT, anthropometric measurements, fat intake, and liking of fatty foods. FTT was assessed in 69 Australian females (mean age 41.3 (15.6) (SD) years and mean body mass index 26.3 (5.7) kg/m2) by a 3-alternate forced choice methodology and transformed to an ordinal scale (FT rank). Food liking was assessed by hedonic ratings of high-fat and reduced-fat foods, and a 24-h food recall and food frequency questionnaire was completed. Linear mixed regression models were fitted. FT rank was associated with dietary % energy from fat ( β ^ = 0.110 [95% CI: 0.003, 0.216]), % energy from carbohydrate ( β ^ = −0.112 [−0.188, −0.035]), and frequency of consumption of foods per day from food groups: high-fat dairy ( β ^ = 1.091 [0.106, 2.242]), meat & meat alternatives ( β ^ = 0.669 [0.168, 1.170]), and grain & cereals ( β ^ = 0.771 [0.212, 1.329]) (adjusted for energy and age). There were no associations between FT rank and anthropometric measurements or hedonic ratings. Therefore, fat taste sensitivity appears to be associated with short-term fat intake, but not body size in this group of females.

BACKGROUND: A century after its discovery, Chagas disease still represents a major neglected tropical threat. Accurate diagnostics tools as well as surrogate markers of parasitological response to treatment are research priorities in the field. The purpose of this study was to evaluate the performance of PCR methods in detection of Trypanosoma cruzi DNA by an external quality evaluation. METHODOLOGY/FINDINGS: An international collaborative study was launched by expert PCR laboratories from 16 countries. Currently used strategies were challenged against serial dilutions of purified DNA from stocks representing T. cruzi discrete typing units (DTU) I, IV and VI (set A), human blood spiked with parasite cells (set B) and Guanidine Hidrochloride-EDTA blood samples from 32 seropositive and 10 seronegative patients from Southern Cone countries (set C). Forty eight PCR tests were reported for set A and 44 for sets B and C; 28 targeted minicircle DNA (kDNA), 13 satellite DNA (Sat-DNA) and the remainder low copy number sequences. In set A, commercial master mixes and Sat-DNA Real Time PCR showed better specificity, but kDNA-PCR was more sensitive to detect DTU I DNA. In set B, commercial DNA extraction kits presented better specificity than solvent extraction protocols. Sat-DNA PCR tests had higher specificity, with sensitivities of 0.05-0.5 parasites/mL whereas specific kDNA tests detected 5.10(-3) par/mL. Sixteen specific and coherent methods had a Good Performance in both sets A and B (10 fg/µl of DNA from all stocks, 5 par/mL spiked blood). The median values of sensitivities, specificities and accuracies obtained in testing the Set C samples with the 16 tests determined to be good performing by analyzing Sets A and B samples varied considerably. Out of them, four methods depicted the best performing parameters in all three sets of samples, detecting at least 10 fg/µl for each DNA stock, 0.5 par/mL and a sensitivity between 83.3-94.4%, specificity of 85-95%, accuracy of 86.8-89.5% and kappa index of 0.7-0.8 compared to consensus PCR reports of the 16 good performing tests and 63-69%, 100%, 71.4-76.2% and 0.4-0.5, respectively compared to serodiagnosis. Method LbD2 used solvent extraction followed by Sybr-Green based Real time PCR targeted to Sat-DNA; method LbD3 used solvent DNA extraction followed by conventional PCR targeted to Sat-DNA. The third method (LbF1) used glass fiber column based DNA extraction followed by TaqMan Real Time PCR targeted to Sat-DNA (cruzi 1/cruzi 2 and cruzi 3 TaqMan probe) and the fourth method (LbQ) used solvent DNA extraction followed by conventional hot-start PCR targeted to kDNA (primer pairs 121/122). These four methods were further evaluated at the coordinating laboratory in a subset of human blood samples, confirming the performance obtained by the participating laboratories. CONCLUSION/SIGNIFICANCE: This study represents a first crucial step towards international validation of PCR procedures for detection of T. cruzi in human blood samples.

Background Few studies have explored behavioural and financial impacts of retail initiatives after 2 years to address the unhealthy food environments common in local government sporting settings.Aims To evaluate the impact of a 2-year local government capacity building intervention in sporting facility food outlets on (1) the healthiness of refrigerated drink choices available and visible to customers, (2) healthiness of refrigerated drinks sold and (3) refrigerated drink revenue.Methods 52 sporting facilities within 8 local governments from Victoria, Australia, participated in an intervention between March 2018 and February 2020 by limiting ‘red’ (least healthy) drinks to ≤20% of refrigerator display and increasing ‘green’ (healthiest) drinks to ≥50% of display. Mixed models assessed changes in mean percentage of ‘red’, ‘amber’ and ‘green’ drinks displayed over time, compared with baseline.Facilities provided electronic weekly itemised sales data (December 2015 to February 2020). Weekly volume of ‘red’ or ‘green’ drinks sold as a proportion of total drinks sold, and total refrigerated drinks revenue were compared preimplementation and postimplementation using mixed models (seasonal facilities), and mixed-effect interrupted time series models (non-seasonal facilities).Results Display of ‘red’ drinks decreased by mean −17.1 percentage points (pp) (95% CI −23.9 to −10.3) and ‘green’ drinks increased 16.1 pp (95% CI 9.30, 22.9) between baseline and 18-month audits.At nine seasonal facilities, compared with the summer preimplementation, the mean volume of ‘red’ drinks sold decreased by −19.0 pp (95% CI −28.6, to –9.51) and refrigerated drink revenue decreased by−AU$81.8 (95% CI −AU$123 to –AU$40.8) per week. At 15 non-seasonal facilities, by February 2020, the volume of ‘red’ drinks sold decreased on average by −11.0 pp (95% CI −21.6 to –0.41) with no change in drink revenue.Conclusion Reducing the display of unhealthy drinks can be an effective public health policy to improve the healthiness of customer purchases, provided there is consideration of potential impacts on revenue.