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STUDY QUESTION: What is the impact of co-designed, evidence-based information regarding the anti-Mullerian hormone (AMH) test on women's interest in having the test? SUMMARY ANSWER: Women who viewed the evidence-based information about the AMH test had lower interest in having an AMH test than women who viewed information produced by an online company selling the test direct-to-consumers. WHAT IS KNOWN ALREADY: Online information about AMH testing often has unfounded claims about its ability to predict fertility and conception, and evidence suggests that women seek out and are recommended the AMH test as a measure of their fertility potential. STUDY DESIGN, SIZE, DURATION: An online randomized trial was conducted from November to December 2022. Women were randomized (double-blind, equal allocation) to view one of two types of information: co-designed, evidence-based information about the AMH test (intervention), or existing information about the AMH test from a website which markets the test direct-to-consumers (control). A total of 967 women were included in the final analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were women recruited through an online panel, who were aged 25-40 years, living in Australia or The Netherlands, had never given birth, were not currently pregnant but would like to have a child now or in the future, and had never had an AMH test. The primary outcome was interest in having an AMH test (seven-point scale; 1 = definitely NOT interested to 7 = definitely interested). Secondary outcomes included attitudes, knowledge, and psychosocial and behavioural outcomes relating to AMH testing. MAIN RESULTS AND THE ROLE OF CHANCE: Women who viewed the evidence-based information about the AMH test had lower interest in having an AMH test (MD = 1.05, 95% CI = 0.83-1.30), less positive attitudes towards (MD = 1.29, 95% CI = 4.57-5.70), and higher knowledge about the test than women who viewed the control information (MD = 0.75, 95% CI = 0.

BACKGROUND: Surgery can help patients with leg pain caused by sciatica recover faster, but by 12 months outcomes are similar to nonsurgical management. For many the decision to have surgery may require reflection, and patient decision aids are an evidence-based clinical tool that can help guide patients through this decision. OBJECTIVE: The aim of this study was to develop and refine a decision aid for patients with sciatica who are deciding whether to have surgery or 'wait and see' (i.e., try nonsurgical management first). DESIGN: Semistructured interviews with think-aloud user-testing protocol. PARTICIPANTS: Twenty clinicians and 20 patients with lived experience of low back pain or sciatica. OUTCOME MEASURES: Items from Technology Acceptance Model, Preparation for Decision Making Scale and Decision Quality Instrument for Herniated Disc 2.0 (knowledge instrument). METHODS: The prototype integrated relevant research with working group perspectives, decision aid standards and health literacy guidelines. The research team refined the prototype through seven rounds of user-testing, which involved discussing user-testing feedback and implementing changes before progressing to the next round. RESULTS: As a result of working group feedback, the decision aid was divided into sections: before, during and after a visit to the surgeon. Across all rounds of user-testing, clinicians rated the resource 5.9/7 (SD = 1.0) for perceived usefulness, and 6.0/7 for perceived ease of use (SD = 0.8). Patients reported the decision aid was easy to understand, on average correctly answering 3.4/5 knowledge questions (SD = 1.2) about surgery for sciatica. The grade reading score for the website was 9.0. Patients scored highly on preparation for decision-making (4.4/5, SD = 0.7), suggesting strong potential to empower patients. Interview feedback showed that patients and clinicians felt the decision aid would encourage question-asking and help patients reflect on personal values. CONCLUSION

Health literacy is an important aspect of equitable, safe, and high-quality care. For organizations implementing health literacy initiatives, using 'change champions' appears to be a promising strategy. This systematic review aimed to identify the empirical and conceptual research that exists about health literacy champions. We conducted the systematic literature search using MEDLINE, Embase, CINAHL, Scopus, and PubMed, with additional studies identified by searching references and citations of included studies and reviews of organizational health literacy. Seventeen articles were included in the final review (case studies, n = 9; qualitative research, n = 4; quasi-experimental, n = 2; opinion articles without case studies, n = 2). Using JBI critical appraisal tools, most articles had a high risk of bias. Often champions were not the focus of the article. Champions included staff across frontline, management, and executive levels. Only five studies described training for champions. Key champion activities related to either (i) increasing organizational awareness and commitment to health literacy, or (ii) influencing organizational strategic and operational planning. The most common output was ensuring that the organization's health information materials met health literacy guidelines. Articles recommended engaging multiple champions at varying levels within the organization, including the executive level. Limited funding and resources were key barriers. Two of four articles reported positive impacts of champions on implementation of health literacy initiatives. Overall, few of the articles described health literacy champions in adequate detail. More comprehensive reporting on this implementation strategy and further experimental and process evaluation research are needed to progress this area of research. This systematic review was registered with PROSPERO (CRD42022348816).

Producing health information that people can easily understand is challenging and time-consuming. Existing guidance is often subjective and lacks specificity. With advances in software that reads and analyzes text, there is an opportunity to develop tools that provide objective, specific, and automated guidance on the complexity of health information. This paper outlines the development of the SHeLL (Sydney Health Literacy Lab) Health Literacy Editor, an automated tool to facilitate the implementation of health literacy guidelines for the production of easy-to-read written health information. Target users were any person or organization that develops consumer-facing education materials, with or without prior experience with health literacy concepts. Anticipated users included health professionals, staff, and government and nongovernment agencies. To develop this tool, existing health literacy and relevant writing guidelines were collated. Items amenable to programmable automated assessment were incorporated into the Editor. A set of natural language processing methods were also adapted for use in the SHeLL Editor, though the approach was primarily procedural (rule-based). As a result of this process, the Editor comprises 6 assessments: readability (school grade reading score calculated using the Simple Measure of Gobbledygook (SMOG)), complex language (percentage of the text that contains public health thesaurus entries, words that are uncommon in English, or acronyms), passive voice, text structure (eg, use of long paragraphs), lexical density and diversity, and person-centered language. These are presented as global scores, with additional, more specific feedback flagged in the text itself. Feedback is provided in real-time so that users can iteratively revise and improve the text. The design also includes a "text preparation" mode, which allows users to quickly make adjustments to ensure accurate calculation of readability. A hierarchy of assessments also helps u

OBJECTIVE: To examine the impact of self-reported human papillomavirus (HPV) test result (HPV negative, HPV positive, HPV result unknown) on a range of psychosocial outcomes. METHODS: Women and other people with a cervix in Australia aged 25-74 years who reported having participated in cervical screening since December 2017 were recruited through Facebook and Instagram to complete an online survey. The primary outcome measures were anxiety, emotional distress, and general distress. RESULTS: Nine hundred fifteen participants completed the online survey; 73.2% reported testing HPV negative ('HPV-'), 15% reported testing HPV positive ('HPV+') and 11.8% reported that they did not know/remember their test result ('HPV unknown'). Compared to participants testing HPV-, participants testing HPV+ had higher mean anxiety (41.67 vs. 37.08, p < 0.001) and emotional distress scores (11.88 vs. 7.71, p < 0.001). Concern about test result (34.3% vs. 1.3%, p < 0.001), perceived risk compared to average women (55.4% vs. 14.1%, p < 0.001), and cancer worry (27.8% vs. 5.9%, p < 0.001) were also greater among HPV+ participants than participants testing HPV-. Participants testing HPV+ felt less reassured about their screening result than participants testing HPV- (16% vs. 75.1%, p < 0.001). Participants testing HPV+ had greater knowledge of HPV (11.96 vs. 10.36 out of 16, p < 0.001) and HPV testing (3.94 vs 3.28 out of 5, p < 0.001) than participants who reported testing HPV-. CONCLUSIONS: Elevated levels of anxiety and emotional distress were found in those testing HPV+ compared with those testing HPV-. Future research should examine what strategies should be used to deliver test results and what additional information is provided, in order to alleviate anxiety among individuals testing HPV+.

Communicating health information quickly and effectively with diverse populations has been essential during the COVID-19 pandemic. However, health communication practices are often top down and poorly designed to rapidly meet diverse health literacy, cultural and contextual needs of the population. This paper describes a research and practice partnership focused on health literacy, multicultural health, and community engagement to address COVID-19 in Australia. The partnership became influential in the local and state-based response to the COVID-19 Delta outbreak in Western and South Western Sydney, an area of high cultural and socioeconomic diversity. Our approach, bringing together academic researchers and frontline health staff working with multicultural populations using a model of co-design and community engagement and action via the "4 M model," has been successful. It supported the Western Sydney community to achieve some of the highest vaccination rates in the world (>90%). There is an ongoing need to engage respectfully and responsively with communities to address specific challenges that they face and tailor communications and supports accordingly for successful pandemic management. Combining co-designed empirical research with community engagement and action ensures needs are robustly identified and can be appropriately addressed to support an effective public health response.

ISSUE ADDRESSED: To investigate whether Australians have experienced any positive effects during the COVID-19 pandemic. METHODS: National online longitudinal survey. As part of a June 2020 survey, participants (n = 1370) were asked 'In your life, have you experienced any positive effects from the COVID-19 pandemic' (yes/no) and also completed the World Health Organisation-Five well-being index. Differences were explored by demographic variables. Free-text responses were thematically coded. RESULTS: Nine hundred sixty participants (70%) reported experiencing at least one positive effect during the COVID-19 pandemic. Living with others (P = .045) and employment situation (P < .001) at baseline (April) were associated with experiencing positive effects. Individuals working for pay from home were more likely to experience positive effects compared to those who were not working for pay (aOR = 0.45, 95% CI: 0.32, 0.63, P < .001) or who were working for pay outside the home (aOR = 0.40, 95% CI: 0.28, 0.58, P < .001). 54.2% of participants reported a sufficient level of well-being, 23.2% low well-being and a further 22.6% very low well-being. Of those experiencing positive effects, 945/960 (98%) provided an explanation. The three most common themes were 'Family time' (33%), 'Work flexibility' (29%) and 'Calmer life' (19%). CONCLUSIONS: A large proportion of participants reported positive effects resulting from changes to daily life due to the COVID-19 pandemic in Australia. SO WHAT: The needs of people living alone, and of those having to work outside the home or who are unemployed, should be considered by health policymakers and employers in future pandemic preparedness efforts.

There is moderate quality evidence that exercise can help to prevent future low back pain (LBP). This study aimed to explore patient needs and preferences for exercise programs to prevent LBP and the outcomes of these programs that would be most important to a patient. Researchers conducted 26 semistructured interviews with people with LBP. Interviews were audio-recorded, transcribed, and analysed using framework thematic analysis. Three themes were developed. Theme 1 emphasised that everyone's LBP was different, translating to preferences for tailored prevention programs with a high level of initial supervision and individualised biomedical explanations for the program. Theme 2 highlighted important outcomes. Pain was considered not only for intensity but also for the duration, frequency, and severity of flare-ups or episodes. Other important outcomes were general fitness and capacity to engage in everyday activities, social interactions, and work. Theme 3 outlined aspects of exercise programs that were considered important for people with fluctuating pain, including how to foster a sense of "progress," set realistic expectations, and support patients to establish exercise routines that can adapt to fluctuating pain. Theme 4 discussed participants' desire for social connection. Patients want exercise programs for LBP prevention, which are highly individualised, provide meaningful explanations of exercises, and help them maintain exercise in the long-term. Clinicians should discuss with patients the transition from a focus on treatment to the prevention of LBP. This provides greater opportunity to adjust goals and expectations and provide relevant education. Balancing the need for individualised care against affordability presents an ongoing challenge.

BACKGROUND: Although there is some qualitative research on physiotherapists' experiences of delivering low back pain treatment, we do not know the extent that these findings apply to low back pain prevention. OBJECTIVE: To explore physiotherapists' understanding, attitudes and experiences related to delivering low back pain prevention programs. DESIGN: Qualitative interview study. METHOD: Interviews from 25 Australian physiotherapists (56% female; 44% male) were analysed using framework thematic analysis. RESULTS: Theme 1 explored physiotherapists' hesitancy about 'low back pain prevention,' raising concerns this term might inadvertently entrench unhelpful beliefs. They preferred language about minimising the risk and impact of recurrences, and promoting an active lifestyle. Theme 2 emphasised that as pain receded, engaging patients could be challenging. Some discussed that person-centred care and individualised programs helped overcome this challenge. Several wanted more training in counselling skills, and more consistent external messaging about low back pain prevention. Theme 3 highlighted uncertainty about delivering high-value prevention care. Some perceived the programs as potentially placing unnecessary financial burden on some patients. Many physiotherapists were uncertain about how to support patients when they weren't in pain (i.e., remission) and wanted training in tailored exercise prescription. CONCLUSIONS: Many of the physiotherapists had some hesitations and unmet needs regarding delivery of exercise programs for secondary prevention of low back pain. Clinicians may find it useful to ask patients directly about their interest in prevention programs and work with interested patients to develop tailored, progressive programs that continue to be motivating, even during periods when there is no pain.

OBJECTIVE: To explore the psychological, social and financial outcomes of COVID-19-and the sociodemographic predictors of those outcomes-among culturally and linguistically diverse communities in Sydney, Australia. DESIGN: Cross-sectional survey informed by the Framework for Culturally Competent Health Research conducted between March and July 2021. SETTING: Participants who primarily speak a language other than English at home were recruited from Greater Western Sydney, New South Wales. PARTICIPANTS: 708 community members (mean age: 45.4 years (range 18-91)). 88% (n=622) were born outside of Australia, 31% (n=220) did not speak English well or at all, and 41% (n=290) had inadequate health literacy. OUTCOME MEASURES: Thirteen items regarding COVID-19-related psychological, social and financial outcomes were adapted from validated scales, previous surveys or co-designed in partnership with Multicultural Health and interpreter service staff. Logistic regression models (using poststratification weighted frequencies) were used to identify sociodemographic predictors of outcomes. Surveys were available in English or translated (11 languages). RESULTS: In this analysis, conducted prior to the 2021 COVID-19 outbreak in Sydney, 25% of the sample reported feeling nervous or stressed most/all of the time and 22% felt lonely or alone most/all of the time. A quarter of participants reported negative impacts on their spousal relationships as a result of COVID-19 and most parents reported that their children were less active (64%), had more screen time (63%) and were finding school harder (45%). Mean financial burden was 2.9/5 (95% CI 2.8 to 2.9). Regression analyses consistently showed more negative outcomes for those with comorbidities and differences across language groups. CONCLUSION: Culturally and linguistically diverse communities experience significant psychological, social and financial impacts of COVID-19. A whole-of-government approach is needed to support rapid co-des

BACKGROUND: In 2017, the Australian National Cervical Screening Program (NCSP) implemented five-yearly primary human papillomavirus (HPV) screening for women aged 25-74. It is important that clinicians are able to explain the NCSP changes to women and confidently address concerns. AIMS: This study examined Australian clinicians' attitudes toward and experiences of the NCSP renewal since its implementation. MATERIALS AND METHODS: Cross-sectional survey of clinicians (general practitioners, obstetricians and gynaecologists) involved in cervical screening, distributed two years after implementation of the renewed NCSP. Responses were analysed using descriptive statistics and thematic analysis. RESULTS: Six hundred and seven participants completed the survey. More than 80% of clinicians were comfortable with the main NCSP changes: extended screening intervals, increased age of first screening, and screening test used. However, only 47% of clinicians reported having utilised the National Cancer Screening Register, and a third of clinicians did not believe that self-collection was a reasonable alternative to practitioner-collected screening for under-screened women. Increased demands for colposcopy were reported. All clinicians identified at least one area of educational need, including the management of women with a history of screen-detected abnormalities in the previous program (34.9%), post-colposcopy management for women with no abnormalities detected (25.5%), and screening in complex scenarios (eg immunocompromise) (26.5%). CONCLUSIONS: Overall, Australian clinicians are comfortable with the main changes to the cervical screening program. Certain areas may require further policy review, such as screening in complex clinical scenarios, colposcopy availability, accessibility of the Register and self-collection. These issues could be meaningful for other countries switching to HPV-based screening.

Background: Misinformation about COVID-19 is common and has been spreading rapidly across the globe through social media platforms and other information systems. Understanding what the public knows about COVID-19 and identifying beliefs based on misinformation can help shape effective public health communications to ensure efforts to reduce viral transmission are not undermined. Objective: This study aimed to investigate the prevalence and factors associated with COVID-19 misinformation in Australia and their changes over time. Methods: This prospective, longitudinal national survey was completed by adults (18 years and above) across April (n=4362), May (n=1882), and June (n=1369) 2020. Results: Stronger agreement with misinformation was associated with younger age, male gender, lower education level, and language other than English spoken at home (P<.01 for all). After controlling for these variables, misinformation beliefs were significantly associated (P<.001) with lower levels of digital health literacy, perceived threat of COVID-19, confidence in government, and trust in scientific institutions. Analyses of specific government-identified misinformation revealed 3 clusters: prevention (associated with male gender and younger age), causation (associated with lower education level and greater social disadvantage), and cure (associated with younger age). Lower institutional trust and greater rejection of official government accounts were associated with stronger agreement with COVID-19 misinformation. Conclusions: The findings of this study highlight important gaps in communication effectiveness, which must be addressed to ensure effective COVID-19 prevention.

Disease labels and causal explanations for certain symptoms or conditions have been found to have both positive and negative outcomes. For example, a diagnosis of polycystic ovary syndrome could conceivably motivate a person to engage in weight management, which is the recommended first line treatment. Furthermore, doctors may feel more comfortable discussing weight when linked to a medical condition. However, such a diagnosis may elicit feelings of increased anxiety, perceived severity and reduced sense of control. Mixed findings are also evident for impacts of genetic explanations on psychosocial outcomes and behaviours. Using hypothetical scenarios presented in an online survey, participants were asked to imagine that they were visiting their general practitioner due to experiencing weight gain, irregular periods, and more pimples than usual. Participants were randomised to receive different diagnostic labels ('polycystic ovary syndrome', 'weight' or no label/description) and causal explanations (genetic or environmental) for their symptoms. Primary outcomes assessed included intention to eat a healthier diet and perceived personal control of weight (average score on scale 1-7 across 3 items). Secondary outcomes included weight stigma, blameworthiness, worry, perceived severity, self-esteem, belief diet will reduce risks and menu item choice. Participants were 545 females aged 18-45 years (mean = 33 years), living in Australia, recruited through a national online recruitment panel. The sample was overweight on average (BMI = 26.5). Participants reporting a PCOS diagnosis were excluded from analyses. We found no main effects of the label or explanation on intention to eat healthier or perceived personal control of weight. For secondary outcomes, those given the genetic explanation reported higher weight stigma (range 1-7; MD = 0.27, 95%CI: 0.011,0.522), greater worry (range 1-7; MD = 0.27, 95%CI: 0.037,0.496), lower self-esteem (range 10-40; MD = 1.26, 95%CI: 0.28

Background: It is unclear how people with hypertension are responding to the COVID-19 pandemic given their increased risk, and whether targeted public health strategies are needed. Objective: This retrospective case-control study compared people with hypertension to matched healthy controls during the COVID-19 lockdown to determine whether they have higher risk perceptions, anxiety, and vaccination intentions. Methods: Baseline data from a national survey were collected in April 2020 during the COVID-19 lockdown in Australia. People who reported hypertension with no other chronic conditions were randomly matched to healthy controls of similar age, gender, education, and health literacy level. A subset including participants with hypertension was followed up at 2 months after restrictions were eased. Risk perceptions, anxiety, and vaccination intentions were measured in April and June. Results: Of the 4362 baseline participants, 466 (10.7%) reported hypertension with no other chronic conditions. A subset of 1369 people were followed up at 2 months, which included 147 (10.7%) participants with hypertension. At baseline, perceived seriousness was high for both hypertension and control groups. The hypertension group reported greater anxiety compared to the controls and were more willing to vaccinate against influenza, but COVID-19 vaccination intentions were similar. At follow-up, these differences were no longer present in the longitudinal subsample. Perceived seriousness and anxiety had decreased, but vaccination intentions for both influenza and COVID-19 remained high across groups (>80%). Conclusions: Anxiety was above normal levels during the COVID-19 lockdown. It was higher in the hypertension group, which also had higher vaccination intentions. Groups that are more vulnerable to COVID-19 may require targeted mental health screening during periods of greater risk. Despite a decrease in perceived risk and anxiety after 2 months of lockdown restrictions, vaccination

In December 2017, the Australian National Cervical Screening Program (NCSP) changed from 2-yearly cervical cytology to 5-yearly primary human papillomavirus (HPV) testing, starting at age 25 and with an exit test when aged 70-74. Women showed limited awareness of these changes prior to their implementation. We explored women's preferences for how similar cancer screening changes could be communicated to the public in the future, including when, how, and using what methods. Six focus groups including 49 women aged 18-74 were conducted in November 2017. Focus groups were guided by information available on the NCSP website and information developed by the researchers. Generally, women suggested that communication of changes to cancer screening programs would ideally occur between 6 and 12 months ahead of their implementation and that they would like the opportunity to be involved in consultation about the changes. The NCSP website was described as answering basic questions, but also raising further questions for which there were no answers provided. Most groups preferred information which included evidence behind the changes and wanted an option of more information. Similar suggestions were made across all focus groups about how communications could be delivered, with recognition that the mode of delivery should differ by age. Women were still seeking information about the test itself and a symptom list, in order to be aware of these over the five-year period. These findings make an important and timely contribution which could help inform other countries considering making changes to their cancer screening programs in the future.

BACKGROUND: A significant proportion of new parents in high-income countries have lower health literacy, but few health literacy interventions exist for this group. OBJECTIVE: This study investigated the feasibility of delivering health literacy content within existing postnatal parenting groups. METHODS: Multicenter feasibility study using a seven-group pre-test post-test design. Parents older than age 16 years with children between age 4 and 26 weeks with sufficient English fluency were invited to participate in a 4-week health literacy program (four 2-hour sessions) delivered by trained facilitators (e.g., child and family health nurses). Mixed-methods evaluation was used, with quantitative data analyzed descriptively and qualitative data (e.g., focus groups, observations, interviews) analyzed using the Framework approach. KEY RESULTS: Our health literacy program was successfully delivered at six sites in New South Wales, Australia, in 2018. Our recruitment strategy was successful in reaching diverse learners (N = 73), many who were born in a country other than Australia. However, few had limited health literacy as assessed by a subjective, single-item measure, and only half completed the follow-up questionnaires. High baseline knowledge, skills, and confidence among participants limited the potential for change in these quantitative outcomes but shed light on the utility of different measurement instruments in this context. Qualitative analyses suggested that the health literacy program aligned well with the institutional objectives of child and family health services and was acceptable to learners from diverse cultural backgrounds. However, in its current form, it may be perceived as too simple for learners with higher levels of education and literacy. CONCLUSIONS: Our study has offered practical insights into the feasibility of embedding a health literacy intervention into established postnatal parenting groups and shown how program resources and facilitator t

OBJECTIVE: Existing instruments for assessing health literacy skills in parents have limited scope to inform the design and evaluation of health literacy interventions. In this study we aimed to develop and validate a new performance-based measure of health literacy for Australian parents, the Parenting Plus Skills Index (PPSI). The instrument aimed to assess functional, communicative and critical health literacy skills. METHODS: The PPSI was developed in three phases: 1) Modified Delphi Expert Panel to provide feedback on 34 initial items; 2) Evaluation of psychometric properties of each item using a multidimensional item response theory model in a sample of Australian adults of parenting age (20-44 years) (N = 500); 3) Assessment of subset of items in an independent sample (N = 500). RESULTS: Following the three phases, 13 items were included in the final instrument. Participants scored on average 8.9/13 (69 %). The instrument demonstrated acceptable reliability (r = 0.70) and was significantly correlated with other performance-based health literacy instruments. CONCLUSIONS: The PPSI is a validated 13-item performance-based instrument that assesses health literacy skills for parents in an Australian setting. PRACTICE IMPLICATIONS: The PPSI fills an important gap in available health literacy instruments that may be useful for facilitating development and evaluation of health literacy interventions.

BACKGROUND: In response to the COVID-19 pandemic, telehealth has rapidly been adopted to deliver health care services around the world. To date, studies have not compared people's experiences with telehealth services during the pandemic in Australia to their experiences with traditional in-person visits. OBJECTIVE: This study aimed to compare participants' perceptions of telehealth consults to their perceptions of traditional in-person visits and investigate whether people believe that telehealth services would be useful after the pandemic. METHODS: A national, cross-sectional, community survey was conducted between June 5 and June 12, 2020 in Australia. In total, 1369 participants who were aged ≥18 years and lived in Australia were recruited via targeted advertisements on social media (ie, Facebook and Instagram). Participants responded to survey questions about their telehealth experience, which included a free-text response option. A generalized linear model was used to estimate the adjusted relative risks of having a poorer telehealth experience than a traditional in-person visit experience. Content analysis was performed to determine the reasons why telehealth experiences were worse than traditional in-person visit experiences. RESULTS: Of the 596 telehealth users, the majority of respondents (n=369, 61.9%) stated that their telehealth experience was "just as good as" or "better than" their traditional in-person medical appointment experience. On average, respondents perceived that telehealth would be moderately useful to very useful for medical appointments after the COVID-19 pandemic ends (mean 3.67, SD 1.1). Being male (P=.007), having a history of both depression and anxiety (P=.016), and lower patient activation scores (ie, individuals' willingness to take on the role of managing their health/health care) (P=.036) were significantly associated with a poor telehealth experience. In total, 6 overarching themes were identified from free-text responses for why

BACKGROUND: Adult education targeting health literacy (HL) may bring added value in the form of improved health. OBJECTIVE: This study evaluated the effects of a HL program as part of an adult education curriculum for adults with low literacy and numeracy. METHODS: This was a partial-cluster randomized controlled trial among 308 adults enrolled in basic education programs in Australia. Of the 308 participants, 141 (46%) were randomized to either the standard program (language, literacy, and numeracy [LLN]), or the HL intervention (LLN with embedded health content); the remainder (n = 167) were allocated to standard intervention programs by the education provider at the class level. The main outcomes were functional HL, self-reported confidence, patient activation, generic HL (ie, HLQ, health knowledge, and self-reported health behavior). Data were collected at baseline, immediately after, and at 6 months post-intervention. KEY RESULTS: Of the 308 participants, 71% had limited literacy and 60% spoke a language other than English at home. Both interventions benefited participants, with improvements from baseline to immediate follow up on individual-level functional HL (e.g., reading a thermometer; HL group 18.4% vs. standard group 7.2%; p = .001), confidence (HL group 0.34 vs. standard group 0.06; p = .014) and health literacy questionnaire (HLQ) subscales. At 6 months, improvements in confidence (p < .001) and some HLQ measures were retained. A consistent pattern of increased improvement in the HL program was observed compared to the standard program, although only some measures reached statistical significance: reading a food label (HL group 6.03/10 correct vs. standard group 5.49/10 correct; p = .022); confidence (p = .008); ability to actively manage health (HLQ) (p = .017), and health knowledge at 6 months (HL group 68% vs. standard group 60% correct, p = .052). HL participants reported being more likely to share course information and rated the program more usef

Background: Shared decision-making (SDM) has been found to be significantly and positively associated with improved patient outcomes. For an SDM process to occur, patients require functional, communicative, and critical health literacy (HL) skills. Objective: This study aimed to evaluate the impact of a program to improve health literacy skills for SDM in adults with lower literacy. Methods: An HL program including an SDM component (HL + SDM) and teaching of the three "AskShareKnow" questions was delivered in adult basic education settings in New South Wales, Australia. The program was evaluated using a partially cluster-randomized controlled trial comparing it to standard language, literacy, and numeracy (LLN) training. We measured the effect of these programs on (1) HL skills for SDM (conceptual knowledge, graphical literacy, health numeracy), (2) types of questions considered important for health decision-making, (3) preferences for control in decision-making, and (4) decisional conflict. We also measured AskShareKnow question recall, use, and evaluation in HL + SDM participants. Key Results: There were 308 participants from 28 classes enrolled in the study. Most participants had limited functional HL (71%) and spoke a language other than English at home (60%). In the primary analysis, the HL + SDM program compared with the standard LLN program significantly increased conceptual knowledge (19.1% difference between groups in students achieving the competence threshold; p = .018) and health numeracy (10.9% difference; p = .032), but not graphical literacy (5.8% difference; p = .896). HL + SDM participants were significantly more likely to consider it important to ask questions that would enable SDM compared to standard LLN participants who prioritized nonmedical procedural questions (all p < .01). There was no difference in preferences for control in decision-making or in decisional conflict. Among HL + SDM participants, 79% (n = 85) correctly recalled at least one

© The Author 2017. Published by Oxford University Press. All rights reserved. Adults with low literacy are less empowered to take care of their health, have poorer health outcomes and higher healthcare costs. We facilitated partnerships between adult literacy teachers and community health providers to deliver a health literacy training program in adult basic education classrooms. Following course completion we interviewed 19 adult education teachers (15 delivering the health literacy program; 4 delivering standard literacy classes) and four community health providers (CHPs) about their experiences, and analysed transcripts using Framework analysis. Written feedback from eight teachers on specific course content was added to the Framework. Health literacy teachers reported a noticeable improvement in their student's health behaviours, confidence, vocabulary to communicate about health, understanding of the health system and language, literacy and numeracy skills. CHP participation was perceived by teachers and CHPs as very successful, with teachers and CHPs reporting they complemented each other's skills. The logistics of coordinating CHPs within the constraints of the adult education setting was a significant obstacle to CHP participation. This study adds to existing evidence that health is an engaging topic for adult learners, and health literacy can be successfully implemented in an adult basic learning curriculum to empower learners to better manage their health. Health workers can deliver targeted health messages in this environment, and introduce local health services. Investment in adult literacy programs teaching health content has potential both to meet the goals of adult language and literacy programs and deliver health benefit in vulnerable populations.

© 2017 The Author(s). Background: In the two-stage randomised trial design, a randomly sampled subset of study participants are permitted to choose their own treatment, while the remaining participants are randomised to treatment in the usual way. Appropriate analysis of the data from both arms of the study allows investigators to estimate the impact on study outcomes of treatment preferences that patients may have, in addition to evaluating the usual direct effect of treatment. In earlier work, we showed how to optimise this design by making a suitable choice of the proportion of participants who should be assigned to the choice arm of the trial. However, we ignored the possibility of some participants being indifferent to the treatments under study. In this paper, we extend our earlier work to consider the analysis of two-stage randomised trials when some participants have no treatment preference, even if they are assigned to the choice arm and allowed to choose. Methods: We compare alternative characterisations of the response profiles of the indifferent or undecided participants, and derive estimates of the treatment and preference effects on study outcomes. We also present corresponding test statistics for these parameters. The methods are illustrated with data from a clinical trial contrasting medical and surgical interventions. Results: Expressions are obtained to estimate and test the impact of treatment choices on study outcomes, as well as the impact of the actual treatment received. Contrasts are defined between patients with stated treatment preferences and those with no preference. Alternative assumptions concerning the outcomes of undecided participants are described, and an approach leading to unbiased estimation and testing is identified. Conclusions: Use of the two-stage design can provide important insights into determinants of study outcomes that are not identifiable with other designs. The design can remain attractive even in the presence of part

© 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd Background: Enhancing health literacy can play a major role in improving healthcare and health across the globe. To build higher-order (communicative/critical) health literacy skills among socially disadvantaged Australians, we developed a novel shared decision making (SDM) training programme for adults with lower literacy. The programme was delivered by trained educators within an adult basic education health literacy course. Objective: To explore the experience of teaching SDM within a health literacy programme and investigate whether communicative/critical health literacy content meets learner needs and teaching and institutional objectives. Design and participants: Qualitative interview study with 11 educators who delivered the SDM programme. Transcripts were analysed using the Framework approach; a matrix-based method of thematic analysis. Results: Teachers noted congruence in SDM content and the institutional commitment to learner empowerment in adult education. The SDM programme was seen to offer learners an alternative to their usual passive approach to healthcare decision making by raising awareness of the right to ask questions and consider alternative test/treatment options. Teachers valued a structured approach to training building on foundational skills, with language reinforcement and take-home resources, but many noted the need for additional time to develop learner understanding and cover all aspects of SDM. Challenges for adult learners included SDM terminology, computational numerical risk tasks and understanding probability concepts. Discussion and conclusions: SDM programmes can be designed in a way that both supports teachers to deliver novel health literacy content and empowers learners. Collaboration between adult education and healthcare sectors can build health literacy capacity of those most in need.

Background: Variation in graphic format can substantially influence interpretation of data. Despite a large body of literature on the optimal design of graphs, little attention has been paid to the format of charts for health monitoring. Aims: This study assessed the effect of aspect ratio (x:y ratio) and interconnecting lines on visual identification of change in biological data, such as during asthma exacerbations. Methods: Eighty volunteers viewed 72 sets of six consecutive blocks of unidentified biological data, recording if each block of data was increasing, decreasing, or the same as the previous block. Three chart aspect ratios were examined (A, 5.2:1; B, 3.0:1; C, 1.1:1), with or without lines between data points. Datasets from lung function monitoring by asthma patients included a mild/moderate/severe fall ('exacerbation') or no exacerbation. False negative (missing true exacerbations) and false positive (identifying non-existent exacerbations) responses were calculated. Results: 84% of exacerbation blocks were correctly identified. There was a significant interaction between exacerbation severity and aspect ratio (p=0.0048). The most compressed chart (C) had the fewest false negative responses. Moderate falls were missed in 24%, 12%, and 5% of trials on charts A, B, and C, respectively (C vs A: adjusted relative risk 0.19 (95% CI 0.12 to 0.30)). False positive responses were infrequent (A, 2.5%; B, 3.8%; C, 8.3%), increasing slightly if data points were joined with lines (4.3% vs 5.1%, p=0.004). Conclusions: Compressed charts can improve the visual detection of change in biological data by up to 80%. The aspect ratio of charts should be standardised to facilitate clinical pattern recognition. © 2012 Primary Care Respiratory Society UK.