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Background and Objectives: Previous research identified numerous barriers to general practitioner (GP) use of cardiovascular disease (CVD) risk guidelines, and it is unclear whether these issues have been resolved. This study explored recent GP experiences., Method: Interviews with 18 GPs in an Australian state with relatively few COVID-19 cases in 2021 were transcribed and coded using a framework analysis approach, with data mapped to five previously identified CVD risk assessment strategies: absolute risk focused, absolute risk adjusted, clinical judgement, passive disregard and active disregard., Results: GPs used various CVD risk calculators to inform clinical decision making, but there were concerns about accuracy, the role of extra risk factors and less 'personalised' assessment. GPs addressed these concerns by requesting additional tests, subjectively adjusting the CVD risk assessment to account for extra risk factors and focusing on individual risk factors., Discussion: Many barriers to CVD risk assessment guidelines remain. GP support is needed to implement revised guidelines.

Objectives: Low health literacy is associated with worse health outcomes, including for cardiovascular disease (CVD). However, general practitioners (GPs) have limited support to identify and address patient health literacy needs in CVD prevention consultations. This study explored GPs' experiences of patient health literacy needs during CVD risk assessment and management consultations., Methods: Semi-structured interviews with 18 GPs in Tasmania, Australia in 2021. A Framework Analysis approach was used to code transcripts to a thematic framework., Results: GPs perceptions on patient health literacy informed three themes: 1. Methods of estimating health literacy; 2. GPs' perceptions about the impact of health literacy on CVD prevention including risk factor knowledge and behaviours; and 3. Strategies for communicating with patients experiencing health literacy challenges. The findings show that while no formal tools were used to assess health literacy in this sample, perceived health literacy can change GPs' communication and prevention strategies., Conclusion: The findings raise concerns about the equity of choices made available to patients, based on subjective perceptions of their health literacy level., Practice Implication: GPs could be better supported to assess and address patient health literacy needs in CVD prevention consultations., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Carissa Bonner reports financial support was provided by National Health and Medical Research Council. Carissa Bonner reports financial support was provided by Heart Foundation. Mark R. Nelson reports a relationship with Novartis Lipid Advisory Board that includes: board membership. CB and MRN are involved in the current CVD prevention guideline revision released in July 2023., (Copyright © 2024. Published by Elsevier B.V.)

Objective: To explore the effect of SMS nudge messages amongst people with varying health literacy on their intention to get a Heart Health Check., Methods: A 3 (Initial SMS: scarcity, regret, or control nudge) x 2 (Reminder SMS: social norm or control nudge) factorial design was used in a hypothetical online experiment. 705 participants eligible for Heart Health Checks were recruited. Outcomes included intention to attend a Heart Health Check and psychological responses., Results: In the control condition, people with lower health literacy had lower behavioural intentions compared to those with higher health literacy (p = .011). Scarcity and regret nudges closed this gap, resulting in similar intention levels for lower and higher health literacy. There was no interactive effect of the reminder nudge and health literacy (p = .724)., Conclusion: Scarcity and regret nudge messages closed the health literacy gap in behavioural intentions compared to a control message, while a reminder nudge had limited additional benefit. Health literacy should be considered in behavioural intervention evaluations to ensure health equity is addressed., Practice Implications: Results informed a national screening program using a universal precautions approach, where messages with higher engagement for lower health literacy groups were used in clinical practice., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier B.V. All rights reserved.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: TC and BN are supported by the National Health and Medical Research Council of Australia. TC is a member of the Scientific Committee of Preventing Overdiagnosis. BN and KP are members of the ECR Committee of Preventing Overdiagnosis. Provenance and peer review: Not commissioned; externally peer reviewed.

Objectives: In response to the COVID-19 pandemic, Australia implemented mandatory hotel quarantine for returned international travellers from March 2020-November 2021. Healthcare was rapidly transformed and scaled up to facilitate delivery of face-to-face and virtual healthcare within quarantine facilities. We sought to understand, from the patient perspective, what a virtual model of healthcare may need to be aware of to respond to, protect, and mitigate people's mental health within a 'public health protection' context of quarantine., Design: Qualitative study design using in-depth semi-structured interviews exploring experiences of the virtual model of healthcare in quarantine., Setting: Special Health Accommodation (SHA) quarantine facilities following Australian Federal and New South Wales (NSW) State quarantine policy, NSW, Australia., Participants: 25 returned international travellers aged 18 years or older of any COVID-19 status who quarantined within SHA between October 2020-March 2021., Results: Participants identified three broad areas of concern. Firstly, their potential to transmit COVID-19, that created anxiety for all participants. Secondly, the effects of losing personal freedoms in quarantine to protect the wider Australian community. Thirdly, many participants entered quarantine during intense biographical moments in their lives, compounding the stress of their experience. Participants felt lost within the 'faceless' quarantine administrative system they navigated prior to their actual arrival in Australia and during their mandated quarantine period. This cumulative experience compromised their expectations and experiences of person-centred care once in quarantine., Conclusions: Quarantine has been a critical public health measure for managing COVID-19 in Australia. The pandemic provides opportunities to learn from quarantine implementation. Participants struggled to separate healthcare provision from the broader quarantine systems and processes. Due to this confusion, blame was directed at healthcare providers for many, and in some cases all difficulties, including those encountered getting into and once within quarantine. Valuable lessons can be learnt from engaging with patients' perspectives to adapt and strengthen future quarantine to deliver responsive, person-centred healthcare., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

The infectious spread of COVID-19 has been accompanied by stigma in both global and local contexts, sparking concern about its negative effect on individuals, communities, and public health responses. The changing epidemiological context of the COVID-19 epidemic and evolving public health responses during the first year of the pandemic (2020) in Vietnam serve as a case study to qualitatively explore the fluidity of stigma. We conducted in-depth interviews with 38 individuals, (13 cases, 9 close contacts, and 16 community members) from areas affected by local outbreaks. Thematic analysis was conducted iteratively. Our analysis indicates that the extent and impacts of COVID-19-related stigma were uneven. Adapting the clinical term 'viral load' as a metaphor, we describe this variation through the wide range of 'stigma load' noted in participants' experiences. Individuals encountering more acute stigma, i.e. the highest 'stigma load', were those associated with COVID-19 at the start of the local outbreaks. These intensively negative social responses were driven by a social meaning-making process that misappropriated an inaccurate understanding of epidemiological logic. Specifically, contact tracing was presumed within the public consciousness to indicate linear blame, with individuals falsely considered to have engaged in 'transgressive mobility', with onward transmission perceived as being intentional. In contrast, as case numbers grew within an outbreak the imagined linearity of the infection chain was disrupted and lower levels of stigma were experienced, with COVID-19 transmission and association reframed as reflecting an environmental rather than behavioural risk. Our findings demonstrate the role of public health policies in unintentionally creating conditions for stigma to flourish. However, this is fluid. The social perceptions of infection risk shifted from being individualised to environmental, suggesting that stigma can be modified and mitigated through attending to the productive social lives of public health approaches and policies., Competing Interests: The authors have no conflicts of interest., (© 2022 The Authors.)

Background: Non-invasive prenatal screening (NIPS) is being increasingly used by expectant parents. Much provision of this test in Australia is occurring in clinical settings where specialised genetic counselling is unavailable, such as general practice. Potential psychosocial consequences from this kind of prenatal genetic screening remain largely unexplored., Aims: To explore clinicians' experiences with NIPS for aneuploidy, their perspectives of the benefits and harms of NIPS, clinicians' information needs, and their perceptions of the needs of expectant parents., Materials and Methods: Qualitative, semi-structured interviews with 17 health professionals (clinical geneticists, obstetricians, genetic counsellors and general practitioners) who request and counsel for NIPS in Australian hospital and private practice settings, conducted between June 2019 and February 2020., Results: Five themes were identified relating to clinicians' perceptions and experiences of NIPS in their practice: perceived benefits of NIPS, perceived harms of NIPS (with two subthemes: clinical harms and psychosocial harms), financial and equity-related concerns, counselling as a protective buffer against perceived harms, and clinicians' unmet education needs. While clinicians view NIPS as a useful and high-quality screening test, especially for detection of common trisomies, many participants had concerns about how NIPS has been implemented in practice, particularly the quality (and often absence) of pre-/post-test counselling and the routinisation of testing for sex chromosome aneuploidies, microdeletion and microduplication syndromes., Conclusion: These findings support the need for targeted clinician training around NIPS, and for a shared decision-making approach to support expectant parents' autonomous decisions about NIPS., (© 2022 The Authors. Australian and New Zealand Journal of Obstetrics and Gynaecology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

A shared decision-making approach is considered optimal in primary cardiovascular disease (CVD) prevention. Evidence-based patient decision aids can facilitate this but do not always meet patients' health literacy needs. Coronary artery calcium (CAC) scans are increasingly used in addition to traditional cardiovascular risk scores, but the availability of high-quality decision aids to support shared decision-making is unknown. We used an environmental scan methodology to review decision support for CAC scans and assess their suitability for patients with varying health literacy. We systematically searched for freely available web-based decision support tools that included information about CAC scans for primary CVD prevention and were aimed at the public. Eligible materials were independently evaluated using validated tools to assess qualification as a decision aid, understandability, actionability, and readability. We identified 13 eligible materials. Of those, only one qualified as a decision aid, and one item presented quantitative information about the potential harms of CAC scans. None presented quantitative information about both benefits and harms of CAC scans. Mean understandability was 68%, and actionability was 48%. Mean readability (12.8) was much higher than the recommended grade 8 level. Terms used for CAC scans were highly variable. Current materials available to people considering a CAC scan do not meet the criteria to enable informed decision-making, nor do they meet the health literacy needs of the general population. Clinical guidelines, including CAC scans for primary prevention, must be supported by best practice decision aids to support decision-making.

Objective: Decision aids have been developed to help prospective parents make informed, shared decisions about medical tests, but these options are rapidly changing. This study aimed to identify and evaluate publicly available decision aids written in English for prospective parents seeking prenatal test information., Methods: A systematic review process was followed using 3 sources: known decision aid repositories, fetal medicine organisations and Google. The search, screening process, quality assessment, and data extraction was performed by two independent researchers. The quality assessment of the decision aids was based on the International Patient Decision Aids Standards (IPDAS v.4.0)., Results: We identified 13 decision aids, which varied in the screening and diagnostic tests that they discussed. No decision aid met all the IPDAS v.4.0. criteria and no decision aid reported updated risk of miscarriage for amniocentesis and chorionic villus sampling (CVS). There was a lack of decision aids for some common decisions in the prenatal context., Conclusion: We identified outdated content in current prenatal decision aids. The findings will inform healthcare professionals of the quality of current prenatal decision aids, which may facilitate their patients' informed decision-making about prenatal tests., Innovation: Considerations for improving future decision aids are outlined., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 Published by Elsevier B.V.)

Background: Of the estimated 10 million people affected by (TB) each year, one-third are never diagnosed. Delayed case detection within the private healthcare sector has been identified as a particular problem in some settings, leading to considerable morbidity, mortality and community transmission. Using unannounced standardised patient (SP) visits to the pharmacies, we aimed to evaluate the performance of private pharmacies in the detection and treatment of TB., Methods: A cross-sectional study was undertaken at randomly selected private pharmacies within 40 districts of Vietnam. Trained actors implemented two standardised clinical scenarios of presumptive TB and presumptive multidrug-resistant TB (MDR-TB). Outcomes were the proportion of SPs referred for medical assessment and the proportion inappropriately receiving broad-spectrum antibiotics. Logistic regression evaluated predictors of SPs' referral., Results: In total, 638 SP encounters were conducted, of which only 155 (24.3%) were referred for medical assessment; 511 (80·1%) were inappropriately offered antibiotics. A higher proportion of SPs were referred without having been given antibiotics if they had presumptive MDR-TB (68/320, 21.3%) versus presumptive TB (17/318, 5.3%; adjusted OR=4.8, 95% CI 2.9 to 7.8). Pharmacies offered antibiotics without a prescription to 89.9% of SPs with presumptive TB and 70.3% with presumptive MDR-TB, with no clear follow-up plan., Conclusions: Few SPs with presumptive TB were appropriately referred for medical assessment by private pharmacies. Interventions to improve appropriate TB referral within the private pharmacy sector are urgently required to reduce the number of undiagnosed TB cases in Vietnam and similar high-prevalence settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Antimicrobial resistance is a global challenge that threatens our ability to prevent and treat common infectious diseases. Vietnam is affected by high rates of antimicrobial resistant infections, driven by the overuse of antibiotics and the Vietnamese government has recognised antimicrobial resistance as a health security priority. This study aimed to understand how people in Vietnam use antibiotics in community settings, and the factors that impact their practices and decision-making regarding antibiotics., Methods: We conducted 43 qualitative in-depth interviews with 50 community members in two urban and two rural sites in Vietnam. We conducted iterative, inductive thematic analysis alongside data collection through a process of systematic debriefings based on detailed interview summaries. Through this process, we developed a coding framework that was then applied to transcribed interview data., Results: Frequent and indiscriminate use of antibiotics was driven by the powerful appeal that antibiotics held for many Vietnamese consumers. Consumers were discerning in making decisions in their purchase and use of antibiotics. Consumers' decisions were affected by perceptions of what constitutes high-quality medicine (effective, strong, accessible and affordable); privileging symptom control over diagnosis; social constructions of antibiotics as a trusted remedy with embodied evidence of prior efficacy, which is reinforced by advice from trusted sources in their community; and varied, generally incomplete, understanding of the concept of antibiotic resistance and its implications for individuals and for public health., Conclusion: Antibiotic use at the community and primary care level in Vietnam is driven by community members' social and economic response to what constitutes effective healthcare, rather than biomedical logic. Community-based interventions to reduce unnecessary antibiotic use need to engage with the entangled socio-structural factors that 'resist' current public health efforts to ration antibiotic use, alongside biomedical drivers. This study has informed the design of a community-based trial to reduce unnecessary antibiotic use., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Chronic obstructive pulmonary disease (COPD) and asthma rank among the leading causes of respiratory morbidity, particularly in low- and middle-income countries. This qualitative study aimed to explore the healthcare pathways of patients with chronic respiratory disease, and factors influencing their ability to access healthcare in Vietnam, where COPD and asthma are prevalent., Methods: We conducted 41 in-depth interviews among patients, including 31 people with COPD, eight with asthma and two with asthma-COPD overlap syndrome. Participants were recruited at provincial- or national-level health facilities in two urban and two rural provinces in Vietnam. The interviews were audio-recorded, transcribed, and analysed using thematic analysis., Results: Patients' healthcare pathways were complex and involved visits to multiple health facilities before finally obtaining a definitive diagnosis at a provincial- or national-level hospital. Access to healthcare was affected considerably by participants' limited knowledge of their respiratory conditions, the availability of social support, especially from family members, the costs of healthcare as well as health system factors (including the coverage of public health insurance, the distance to health facilities, and attitude of healthcare providers)., Conclusion: The study demonstrated the need for improved access to timely diagnosis and treatment of chronic lung disease within the lower level of the health system. This can be achieved by enhancing the communication skills and diagnostic capacity of local healthcare workers. Health education programmes for patients and caregivers will contribute to improved control of lung disease.

Background: Dien Bien Province in northwest Vietnam is predominantly populated with ethnic minority groups, who experience worse maternal and child health outcomes than the general population. Various factors are associated with maternal health care utilisation in Vietnam, including ethnic minority status, which is recognised as a key determinant of inequity in health outcomes. The aim of this study is to explore how and why ethnic minority women utilise maternal health services, and the factors that influence women and families' decisions to access or not access facility-based care., Methods: We used a qualitative approach, interviewing primary health care professionals (n = 22) and key informants (n = 2), and conducting focus groups with Thai and Hmong women (n = 42). A thematic analysis was performed., Results: There were three main themes. 1. Prioritising treatment over prevention: women talked about accessing health services for health problems, such as unusual signs or symptoms during pregnancy, and often saw limited utility in accessing services when they felt well, or for a normal physiological event such as childbirth. Health professionals also saw their role as being mainly treatment-oriented, rather than prevention-focused. 2. Modernisation of traditional practices: health professionals and ethnic minority women discussed recent improvements in infrastructure, services, and economic circumstances that had increased access to health services. However, these improvements were less pronounced in Hmong communities, suggesting inequity. 3. Perceptions of quality influenced service utilisation: both health professionals and ethnic minority women perceived primary care facilities to be of lower quality compared to hospital, and some women made decisions about accessing services based on these perceptions, preferring to travel further and spend more to access higher quality services. Health professionals' perceptions of low service quality appeared to influence their referral practices, with even uncomplicated cases referred to higher level services as a matter of course., Conclusions: Primary health care facilities were technically available and accessible to ethnic minority women, however these services were likely to be underutilised if they were perceived to be of low quality. Some women had the means to access higher quality facilities, but others were limited to lower quality facilities, potentially reinforcing inequities in health outcomes.

Objectives: To explore how decisions are made in real-life general practice consultations with older patients (65+ years), and examine how general practitioners (GPs) communicate risk and benefit information and evidence, and integrate patient preferences., Methods: Secondary analysis of 20 video-recorded consultations with older patients in Australian primary healthcare settings. Consultations were analysed qualitatively using the Framework method and quantitatively using the Observer OPTION 5 scale and the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool., Results: Overall, Observer OPTION 5 and ACEPP scores were low, with mean total scores of 11.3 (out of 100) and 10.4 (out of 40) respectively. Together with qualitative findings, these results suggest that shared decision-making did not occur, and that healthcare options (including anticipated benefits and risks), evidence and patient preferences were rarely discussed in our sample of consultations with older people. GPs often unilaterally made treatment decisions (usually pharmacotherapy) while patients reverted to a passive decision-making role., Conclusion: We observed a lack of shared decision-making in our primary care study, with little engagement of older patients in decisions about their health., Practice Implications: Training and support tools may be needed to enhance the capacity and self-efficacy of providers and older patients to share healthcare decisions., (Copyright © 2018. Published by Elsevier B.V.)

Objectives: To explore older people's perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention., Design, Setting and Participants: Semi-structured interviews with 30 general practice patients aged 75 years and older in New South Wales, Australia, who had elevated CVD risk factors (blood pressure, cholesterol) or had received CVD-related lifestyle advice. Data were analysed by multiple researchers using Framework analysis., Results: Twenty eight participants out of 30 were on CVD prevention medication, half with established CVD. We outlined patient experiences using the four steps of the SDM process, identifying key barriers and challenges: Step 1. Choice awareness: taking medication for CVD prevention was generally not recognised as a decision requiring patient input; Step 2. Discuss benefits/harms options: CVD prevention poorly understood with emphasis on benefits; Step 3. Explore preferences: goals, values and preferences (eg, length of life vs quality of life, reducing disease burden vs risk reduction) varied widely but generally not discussed with the general practitioner; Step 4. Making the decision: overall preference for directive approach, but some patients wanted more active involvement. Themes were similar across primary and secondary CVD prevention, different levels of self-reported health and people on and off medication., Conclusions: Results demonstrate how older participants vary widely in their health goals and preferences for treatment outcomes, suggesting that CVD prevention decisions are preference sensitive. Combined with the fact that the vast majority of participants were taking medications, and few understood the aims and potential benefits and harms of CVD prevention, it seems that older patients are not always making an informed decision. Our findings highlight potentially modifiable barriers to greater participation of older people in SDM about CVD prevention medication and prevention in general., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Previous health literacy research has often focused on individual functional health literacy, ignoring the cultural contexts through which many people experience health care., Objective: We aimed to explore the nature of maternal health literacy among ethnic minority women in a low-resource setting in Vietnam., Methods: Using a qualitative approach, we conducted focus groups with 42 pregnant women, mothers, and grandmothers of children younger than age 5 years from the Thai and Hmong ethnic groups. Semi-structured interviews were conducted with key informants and thematic analysis was performed., Key Results: The findings of our thematic analysis aligned well with the concept of distributed health literacy. We found that ethnic minority women drew upon family and social networks of health literacy mediators to share knowledge and understanding, assess and evaluate information, communicate with health professionals, and support decision-making. Family members were also involved in making health decisions that had the potential to negatively affect women and children's health., Conclusions: Family members are an important source of information for ethnic minority women, and they influence decision-making. Relatives and husbands of pregnant women could be included in maternal health education programs to potentially strengthen the health literacy of the whole community. The distributed health literacy concept can be used to strengthen health promotion messages and to reduce the risk of negative health outcomes. [ HLRP: Health Literacy Research and Practice . 2019;3(1):e31-e42.] ., Plain Language Summary: Distributed health literacy refers to how health literacy skills and practices are distributed through social networks. This concept applies well to the maternal health context in Vietnam. Older women are trusted sources of information, and family influences decision-making during pregnancy. Women's limited autonomy increases the importance of family involvement. Distributed health literacy could be used to strengthen health promotion messages.

Objective: Cardiovascular disease (CVD) prevention guidelines recommend medication based on the probability of a heart attack/stroke in the next 5-10 years. However, heuristics and biases make risk communication challenging for doctors. This study explored how patients interpret personalised CVD risk results presented in varying formats and timeframes., Methods: GPs recruited 25 patients with CVD risk factors and varying medication history. Participants were asked to 'think aloud' while using two CVD risk calculators that present probabilistic risk in different ways, within a semi-structured interview. Transcribed audio-recordings were coded using Framework Analysis., Results: Key themes were: 1) numbers lack meaning without a reference point; 2) risk results need to be both credible and novel; 3) selective attention to intervention effects. Risk categories (low/moderate/high) provided meaningful context, but short-term risk results were not credible if they didn't match expectations. Colour-coded icon arrays showing the effect of age and interventions were seen as novel and motivating. Those on medication focused on benefits, while others focused on harms., Conclusion: CVD risk formats need to be tailored to patient expectations and experiences in order to counteract heuristics and biases., Practice Implications: Doctors need access to multiple CVD risk formats to communicate effectively about CVD prevention., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Ethnic minority groups in Vietnam experience economic, social and health inequalities. There are significant disparities in health service utilisation, and cultural, interpersonal and communication barriers impact on quality of care. Eighty per cent of the population of Dien Bien Province belongs to an ethnic minority group, and poor communication between health professionals and ethnic minority women in the maternal health context is a concern for health officials and community leaders. This study explores how ethnic minority women experience communication with primary care health professionals in the maternal and child health setting, with an overall aim to develop strategies to improve health professionals' communication with ethnic minority communities., Methods: We used a qualitative focused ethnographic approach and conducted focus group discussions with 37 Thai and Hmong ethnic minority women (currently pregnant or mothers of children under five) in Dien Bien Province. We conducted a thematic analysis., Results: Ethnic minority women generally reported that health professionals delivered health information in a didactic, one-way style, and there was a reliance on written information (Maternal and Child Health handbook) in place of interpersonal communication. The health information they receive (both verbal and written) was often non-specific, and not context-adjusted for their personal circumstances. Women were therefore required to take a more active role in interpersonal interactions in order to meet their own specific information needs, but they are then faced with other challenges including language and gender differences with health professionals, time constraints, and a reluctance to ask questions. These factors resulted in women interpreting health information in diverse ways, which in turn appeared to impact their health behaviours., Conclusions: Fostering two-way communication and patient-centred attitudes among health professionals could help to improve their communication with ethnic minority women. Communication training for health professionals could be included along with the nationwide implementation of written information to improve communication.

Background: Vietnam has made notable progress in reducing maternal mortality rates during the past 2 decades, but this overall improvement conceals regional and ethnic inequalities. Ethnic minorities in Vietnam experience high rates of poverty and mortality, and they face communication and cultural barriers when accessing health services. Poor communication with health professionals combined with limited health literacy is concerning, particularly in the maternal health context, and may exacerbate existing inequalities., Objective: This study explores primary health care professionals' perceptions of the quality of their communication with ethnic minority women during and after pregnancy., Methods: Semi-structured interviews were conducted with 22 primary health care professionals in Dien Bien province. A thematic analysis was performed using a framework analysis method., Key Results: Health professionals had mostly positive perceptions about their communication with ethnic minority women. However, they generally perceived the effectiveness of their communication as being based on women's individual capacities to understand health information (both the language used and the content) and factors such as ethnic and cultural differences, rather than reflecting on the suitability of information and materials or on their own communication skills. This placed much of the burden of communication and understanding health information on ethnic minority women and their families., Conclusions: Health professionals perceived of communication as being mainly a one-way street for the provision of health information, and rarely acknowledged the interactive nature of communication. Patient-professional communication and health literacy in Dien Bien province may be improved through the introduction of patient-centered communication skills training that applies health literacy approaches at the health professional level. [ Health Literacy Research and Practice . 2017;1(4):e163-e172.] ., Plain Language Summary: We looked at how primary health care professionals in Vietnam perceive their communication with ethnic minority women, particularly about pregnancy. Health professionals generally perceived the quality and effectiveness of their communication as being based on ethnic minority women's individual capacities and limitations. Applying a health literacy approach to communication skills training could improve patient-professional communication and health literacy.

Background: Primary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs' decision making about primary CVD prevention in patients aged 75 years and older., Method: 25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used., Results: Analysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear., Conclusion: Older patients receive different care depending on their GP's perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area., Competing Interests: The authors have declared that no competing interests exist.

Background: Guidelines on cardiovascular disease (CVD) risk reassessment intervals are unclear, potentially leading to detrimental practice variation: too frequent can result in overtreatment and greater strain on the healthcare system; too infrequent could result in the neglect of high risk patients who require medication. This study aimed to understand the different factors that general practitioners (GPs) consider when deciding on the reassessment interval for patients previously assessed for primary CVD risk., Methods: This paper combines quantitative and qualitative data regarding reassessment intervals from two separate studies of CVD risk management. Experimental study: 144 Australian GPs viewed a random selection of hypothetical cases via a paper-based questionnaire, in which blood pressure, cholesterol and 5-year absolute risk (AR) were systematically varied to appear lower or higher. GPs were asked how they would manage each case, including an open-ended response for when they would reassess the patient. Interview study: Semi-structured interviews were conducted with a purposive sample of 25 Australian GPs, recruited separately from the GPs in the experimental study. Transcribed audio-recordings were thematically coded, using the Framework Analysis method., Experiment: GPs stated that they would reassess the majority of patients across all absolute risk categories in 6 months or less (low AR = 52 % [CI95% = 47-57 %], moderate AR = 82 % [CI95% = 76-86 %], high AR = 87 % [CI95% = 82-90 %], total = 71 % [CI95% = 67-75 %]), with 48 % (CI95% = 43-53 %) of patients reassessed in under 3 months. The majority (75 % [CI95% = 70-79 %]) of patients with low-moderate AR (≤15 %) and an elevated risk factor would be reassessed in under 6 months. Interviews: GPs identified different functions for reassessment and risk factor monitoring, which affected recommended intervals. These included perceived psychosocial benefits to patients, preparing the patient for medication, and identifying barriers to lifestyle change and medication adherence. Reassessment and monitoring intervals were driven by patient motivation to change lifestyle, patient demand, individual risk factors, and GP attitudes., Conclusions: There is substantial variation in reassessment intervals for patients with the same risk profile. This suggests that GPs are not following reassessment recommendations in the Australian guidelines. The use of shorter intervals for low-moderate AR contradicts research on optimal monitoring intervals, and may result in unnecessary costs and over-treatment.

Background: Cardiovascular disease (CVD) prevention guidelines are generally based on the absolute risk of a CVD event, but there is increasing interest in using 'heart age' to motivate lifestyle change when absolute risk is low. Previous studies have not compared heart age to 5-year absolute risk, or investigated the impact of younger heart age, graphical format, and numeracy., Objective: Compare heart age versus 5-year absolute risk on psychological and behavioral outcomes., Design: 2 (heart age, absolute risk) × 3 (text only, bar graph, line graph) experiment., Setting: Online., Participants: 570 Australians aged 45-64 years, not taking CVD-related medication., Intervention: CVD risk assessment., Measurements: Intention to change lifestyle, recall, risk perception, emotional response, perceived credibility, and lifestyle behaviors after 2 weeks., Results: Most participants had lifestyle risk factors (95%) but low 5-year absolute risk (94%). Heart age did not improve lifestyle intentions and behaviors compared to absolute risk, was more often interpreted as a higher-risk category by low-risk participants (47% vs 23%), and decreased perceived credibility and positive emotional response. Overall, correct recall dropped from 65% to 24% after 2 weeks, with heart age recalled better than absolute risk at 2 weeks (32% vs 16%). These results were found across younger and older heart age results, graphical format, and numeracy., Limitations: Communicating CVD risk in a consultation rather than online may produce different results., Conclusions: There is no evidence that heart age motivates lifestyle change more than 5-year absolute risk in individuals with low CVD risk. Five-year absolute risk may be a better way to explain CVD risk, because it is more credible, does not inflate risk perception, and is consistent with clinical guidelines that base lifestyle and medication recommendations on absolute risk., (© The Author(s) 2015.)

Background: Clinical care for older adults is complex and represents a growing problem. They are a diverse patient group with varying needs, frequent presence of multiple comorbidities, and are more susceptible to treatment harms. Thus Clinical Practice Guidelines (CPGs) need to carefully consider older adults in order to guide clinicians. We reviewed CPG recommendations for primary cardiovascular disease (CVD) prevention and examined the extent to which CPGs address issues important for older people identified in the literature., Methods: We searched: 1) two systematic reviews on CPGs for CVD prevention and 2) the National CPG Clearinghouse, G-I-N International CPG Library and Trip databases for CPGs for CVD prevention, hypertension and cholesterol. We conducted our search between April and December 2013. We excluded CPGs for diabetes, chronic kidney disease, HIV, lifestyle, general screening/prevention, and pregnant or pediatric populations. Three authors independently screened citations for inclusion and extracted data. The primary outcomes were presence and extent of recommendations for older people including discussion of: (1) available evidence, (2) barriers to implementation of the CPG, and (3) tailoring management for this group., Results: We found 47 eligible CPGs. There was no mention of older people in 4 (9 %) of the CPGs. Benefits were discussed more frequently than harms. Twenty-three CPGs (49 %) discussed evidence about potential benefits and 18 (38 %) discussed potential harms of CVD prevention in older people. Most CPGs addressed one or more barriers to implementation, often as a short statement. Although 27 CPGs (58 %) mentioned tailoring management to the older patient context (e.g. comorbidities), concrete guidance was rare., Conclusion: Although most CVD prevention CPGs mention the older population to some extent, the information provided is vague and very limited. Older adults represent a growing proportion of the population. Guideline developers must ensure they consider older patients' needs and provide appropriate advice to clinicians in order to support high quality care for this group. CPGs should at a minimum address the available evidence about CVD prevention for older people, and acknowledge the importance of patient involvement.

Objective: Although current guidelines around the world recommend using absolute risk (AR) thresholds to decide whether cardiovascular disease (CVD) risk should be managed with lifestyle or medication, the use of AR in clinical practice is limited. The aim of this study was to explore the factors that influence general practitioner (GP) and patient decision making about CVD risk management, including the role of risk perception., Methods: Qualitative descriptive study involving semi-structured interviews with 25 GPs and 38 patients in Australia in 2011-2012. Transcribed audio-recordings were thematically coded and a Framework Analysis method was used., Results: GPs rarely mentioned AR thresholds but were influenced by their subjective perception of the patient's risk and motivation, and their own attitudes toward prevention, including concerns about medication side effects and the efficacy of lifestyle change. Patients were influenced by individual risk factors, their own motivation to change lifestyle, and attitudes toward medication: initially negative, but this improved if medication was more effective than lifestyle. High perceived risk led to medication being recommended by GPs and accepted by patients, but this was not necessarily based on AR. Patient perceptions of high risk also increased motivation to change lifestyle, particularly if they were resistant to the idea of taking medication., Conclusions: Perceived risk, motivation, and attitudes appeared to be more important than AR thresholds in this study. CVD risk management guidelines could be more useful if they include strategies to help GPs consider patients' risk perception, motivation, and attitudes as well as evidence-based recommendations., (PsycINFO Database Record (c) 2015 APA, all rights reserved.)

Recruiting general practitioners (GPs) for participation in primary care research is vitally important, but it can be very difficult for researchers to engage time-poor GPs. This paper describes six different strategies used by a research team recruiting Australian GPs for three qualitative interview studies and one experimental study, and reports the response rates and costs incurred. Strategies included: (1) mailed invitations via Divisions of General Practice; (2) electronic newsletters; (3) combining mailed invitations and newsletter; (4) in-person recruitment at GP conferences; (5) conference satchel inserts; and (6) combining in-person recruitment and satchel inserts. Response rates ranged from 0 (newsletter) to 30% (in-person recruitment). Recruitment costs perparticipant ranged from A$83 (in-person recruitment) to A$232 (satchel inserts). Mailed invitations can be viable for qualitative studies, especially when free/low-cost mailing lists are used, if the response rate is less important. In-person recruitment at GP conferences can be effective for short quantitative studies, where a higher response rate is important. Newsletters and conference satchel inserts were expensive and ineffective.

Background: Cardiovascular disease (CVD) prevention guidelines encourage assessment of absolute CVD risk - the probability of a CVD event within a fixed time period, based on the most predictive risk factors. However, few General Practitioners (GPs) use absolute CVD risk consistently, and communication difficulties have been identified as a barrier to changing practice. This study aimed to explore GPs' descriptions of their CVD risk communication strategies, including the role of absolute risk., Methods: Semi-structured interviews were conducted with a purposive sample of 25 GPs in New South Wales, Australia. Transcribed audio-recordings were thematically coded, using the Framework Analysis method to ensure rigour., Results: GPs used absolute CVD risk within three different communication strategies: 'positive', 'scare tactic', and 'indirect'. A 'positive' strategy, which aimed to reassure and motivate, was used for patients with low risk, determination to change lifestyle, and some concern about CVD risk. Absolute risk was used to show how they could reduce risk. A 'scare tactic' strategy was used for patients with high risk, lack of motivation, and a dismissive attitude. Absolute risk was used to 'scare' them into taking action. An 'indirect' strategy, where CVD risk was not the main focus, was used for patients with low risk but some lifestyle risk factors, high anxiety, high resistance to change, or difficulty understanding probabilities. Non-quantitative absolute risk formats were found to be helpful in these situations., Conclusions: This study demonstrated how GPs use three different communication strategies to address the issue of CVD risk, depending on their perception of patient risk, motivation and anxiety. Absolute risk played a different role within each strategy. Providing GPs with alternative ways of explaining absolute risk, in order to achieve different communication aims, may improve their use of absolute CVD risk assessment in practice.

Objective: To understand general practitioners' (GPs) use of individual risk factors (blood pressure and cholesterol levels) versus absolute risk in cardiovascular disease (CVD) risk management decision-making., Design: Randomised experiment. Absolute risk, systolic blood pressure (SBP), cholesterol ratio (total cholesterol/high-density lipoprotein (TC/HDL)) and age were systematically varied in hypothetical cases. High absolute risk was defined as 5-year risk of a cardiovascular event >15%, high blood pressure levels varied between SBP 147 and 179 mm Hg and high cholesterol (TC/HDL ratio) between 6.5 and 7.2 mmol/L., Setting: 4 GP conferences in Australia., Participants: 144 Australian GPs., Outcomes: GPs indicated whether they would prescribe cholesterol and/or blood pressure lowering medication. Analyses involved logistic regression., Results: For patients with high blood pressure: 93% (95% CI 86% to 96%) of high absolute risk patients and 83% (95% CI 76% to 88%) of lower absolute risk patients were prescribed blood pressure medication. Conversely, 30% (95% CI 25% to 36%) of lower blood pressure patients were prescribed blood pressure medication if absolute risk was high and 4% (95% CI 3% to 5%) if lower. 69% of high cholesterol/high absolute risk patients were prescribed cholesterol medication (95% CI 61% to 77%) versus 34% of high cholesterol/lower absolute risk patients (95% CI 28% to 41%). 36% of patients with lower cholesterol (95% CI 30% to 43%) were prescribed cholesterol medication if absolute risk was high versus 10% if lower (95% CI 8% to 13%)., Conclusions: GPs' decision-making was more consistent with the management of individual risk factors than an absolute risk approach, especially when prescribing blood pressure medication. The results suggest medical treatment of lower risk patients (5-year risk of CVD event <15%) with mildly elevated blood pressure or cholesterol levels is likely to occur even when an absolute risk assessment is specifically provided. The results indicate a need for improving uptake of absolute risk guidelines and GP understanding of the rationale for using absolute risk., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To identify factors that influence the extent to which general practitioners use absolute risk (AR) assessment in cardiovascular disease (CVD) risk assessment., Design, Setting and Participants: Semi-structured interviews with 25 currently practising GPs from eight Divisions of General Practice in New South Wales, Australia, between October 2011 and May 2012. Data were analysed using framework analysis., Results: The study identified five strategies that GPs use with patients in different situations, defined in terms of the extent to which AR was used and the reasons given for this: the AR-focused strategy, used when AR assessment was considered useful for the patient; the AR-adjusted strategy, used to account for additional risk factors such as family history; the clinical judgement strategy, used when GPs considered that their judgement took multiple risk factors into account as effectively as AR; the passive disregard strategy, used when GPs lacked sufficient time, access or experience to use AR; and the active disregard strategy, used when AR was considered to be inappropriate for the patient. The strategies were linked with different opportunity, capability and motivation barriers to the use of AR., Conclusions: This study provides an in-depth insight into the factors that influence GPs' use of AR in CVD risk assessment. The results suggest that GPs use a range of strategies in different situations, so different approaches may be required to improve the use of AR guidelines in practice.