A multilevel investigation of inequalities in clinical and psychosocial outcomes for women after breast cancer

Background In Australia, breast cancer is the most common cancer affecting Australian women. Inequalities in clinical and psychosocial outcomes have existed for some time, affecting particularly women from rural areas and from areas of disadvantage. We have a limited understanding of how individual and area-level factors are related to each other, and their associations with survival and other clinical and psychosocial outcomes. Methods/Design This study will examine associations between breast cancer recurrence, survival and psychosocial outcomes (e.g. distress, unmet supportive care needs, quality of life). The study will use an innovative multilevel approach using area-level factors simultaneously with detailed individual-level factors to assess the relative importance of remoteness, socioeconomic and demographic factors, diagnostic and treatment pathways and processes, and supportive care utilization to clinical and psychosocial outcomes. The study will use telephone and self-administered questionnaires to collect individual-level data from approximately 3, 300 women ascertained from the Queensland Cancer Registry diagnosed with invasive breast cancer residing in 478 Statistical Local Areas Queensland in 2011 and 2012. Area-level data will be sourced from the Australian Bureau of Statistics census data. Geo-coding and spatial technology will be used to calculate road travel distances from patients' residence to diagnostic and treatment centres. Data analysis will include a combination of standard empirical procedures and multilevel modelling. Discussion The study will address the critical question of: what are the individual- or area-level factors associated with inequalities in outcomes from breast cancer? The findings will provide health care providers and policy makers with targeted information to improve the management of women with breast cancer, and inform the development of strategies to improve psychosocial care for women with breast cancer.

Methodological challenges when estimating the effects of season and seasonal exposures on birth outcomes

Background Many previous studies have found seasonal patterns in birth outcomes, but with little agreement about which season poses the highest risk. Some of the heterogeneity between studies may be explained by a previously unknown bias. The bias occurs in retrospective cohorts which include all births occurring within a fixed start and end date, which means shorter pregnancies are missed at the start of the study, and longer pregnancies are missed at the end. Our objective was to show the potential size of this bias and how to avoid it. Methods To demonstrate the bias we simulated a retrospective birth cohort with no seasonal pattern in gestation and used a range of cohort end dates. As a real example, we used a cohort of 114,063 singleton births in Brisbane between 1 July 2005 and 30 June 2009 and examined the bias when estimating changes in gestation length associated with season (using month of conception) and a seasonal exposure (temperature). We used survival analyses with temperature as a time-dependent variable. Results We found strong artificial seasonal patterns in gestation length by month of conception, which depended on the end date of the study. The bias was avoided when the day and month of the start date was just before the day and month of the end date (regardless of year), so that the longer gestations at the start of the study were balanced by the shorter gestations at the end. After removing the fixed cohort bias there was a noticeable change in the effect of temperature on gestation length. The adjusted hazard ratios were flatter at the extremes of temperature but steeper between 15 and 25°C. Conclusions Studies using retrospective birth cohorts should account for the fixed cohort bias by removing selected births to get unbiased estimates of seasonal health effects.

A randomised trial of a psychosocial intervention for cancer patients integrated into routine care: The PROMPT study (promoting optimal outcomes in mood through tailored psychosocial therapies)

Background Despite evidence that up to 35% of patients with cancer experience significant distress, access to effective psychosocial care is limited by lack of systematic approaches to assessment, a paucity of psychosocial services, and patient reluctance to accept treatment either because of perceived stigma or difficulties with access to specialist psycho-oncology services due to isolation or disease burden. This paper presents an overview of a randomised study to evaluate the effectiveness of a brief tailored psychosocial Intervention delivered by health professionals in cancer care who undergo focused training and participate in clinical supervision. Methods/design Health professionals from the disciplines of nursing, occupational therapy, speech pathology, dietetics, physiotherapy or radiation therapy will participate in training to deliver the psychosocial Intervention focusing on core concepts of supportive-expressive, cognitive and dignity-conserving care. Health professional training will consist of completion of a self-directed manual and participation in a skills development session. Participating health professionals will be supported through structured clinical supervision whilst delivering the Intervention. In the stepped wedge design each of the 5 participating clinical sites will be allocated in random order from Control condition to Training then delivery of the Intervention. A total of 600 patients will be recruited across all sites. Based on level of distress or risk factors eligible patients will receive up to 4 sessions, each of up to 30 minutes in length, delivered face-to-face or by telephone. Participants will be assessed at baseline and 10-week follow-up. Patient outcome measures include anxiety and depression, quality of life, unmet psychological and supportive care needs. Health professional measures include psychological morbidity, stress and burnout. Process evaluation will be conducted to assess perceptions of participation in the study and the factors that may promote translation of learning into practice. Discussion This study will provide important information about the effectiveness of a brief tailored psychological Intervention for patients with cancer and the potential to prevent development of significant distress in patients considered at risk. It will yield data about the feasibility of this model of care in routine clinical practice and identify enablers and barriers to its systematic implementation in cancer settings.

A mixed-method study to investigate the relationship between the number of social support people present during labour, women’s perceptions and birth outcomes

The birth of a baby is a significant event for women and their families, with the event being influenced by the prevailing social and cultural context. Historically, women throughout the world have given birth at home assisted by other women who helped them cope with the stress of labour and birth. In the middle of the twentieth century, the togetherness, caring and support that were provided within the social and cultural context of childbirth began to change; women in most developed countries, and to some extent in developing countries, laboured and gave birth in institutions that isolated them from the support of family and friends. This practice is referred to as the medical model of childbirth and, over time, birthing within this model has come to be viewed by women as a dehumanising experience. In an attempt to secure a more supportive experience, women began to demand the presence of a supportive companion; namely their partner. This event became the catalyst for a number of studies focusing on different types of support providers and their contribution to the phenomenon of social support during labour. More recently, it has become a common practice for some women to be supported during labour by a number of people from their social network. However, research on the influence of such supportive people on women’s experience of labour and birth and on birth outcomes is scarce. The aim of this study is to examine the influence of various support arrangements from a woman’s family and social network on her experience of labour and birth and on birth outcomes. The mixed-method study was conducted to answer three research questions: 1. Do women with more than one support person present during labour and birth have similar perceptions and experiences of support compared to women with one support person? 2. Do women with more than one support person present during labour and birth have similar birth outcomes compared to women with one support person? 3. Do women with different types of support providers during labour and birth have similar birth outcomes? Methods Phase one of this study developed, pilot tested and administered a newly developed instrument designed to measure women’s perceptions of supportive behaviours provided during labour. Specific birth outcome data were extracted from the medical records. Phase two consisted of in-depth interviews with a sample of women who had completed the survey. Results: The results identified a statistically significant relationship between women’s perceptions of social support and the number of support providers: women supported by one person only rated the supportive behaviours of that person more highly compared to women who were supported by a number of people. The results also identified that women supported by one person used less analgesia. An additional qualitative finding was that some women sacrificed the support of female relatives at the request of their partners. Conclusion: By using a mixed-method approach, this study found that women were selective in their choice of support providers, as they chose individuals with whom they had an enduring affectionate attachment. Women place more emphasis on a support person’s ability to fulfil their attachment needs of close proximity and a sense of security and safety, rather than their ability to provide the expected functional supportive behaviours.

The increased popularity of mopeds and motor scooters : exploring usage patterns and safety outcomes

Increased use of powered two-wheelers (PTWs) often underlies increases in the number of reported crashes, promoting research into PTW safety. PTW riders are overrepresented in crash and injury statistics relative to exposure and, as such, are considered vulnerable road users. PTW use has increased substantially over the last decade in many developed countries. One such country is Australia, where moped and scooter use has increased at a faster rate than motorcycle use in recent years. Increased moped use is particularly evident in the State of Queensland which is one of four Australian jurisdictions where moped riding is permitted for car licence holders and a motorcycle licence is not required. A moped is commonly a small motor scooter and is limited to a maximum design speed of 50 km/h and a maximum engine cylinder capacity of 50 cubic centimetres. Scooters exceeding either of these specifications are classed as motorcycles in all Australian jurisdictions. While an extensive body of knowledge exists on motorcycle safety, some of which is relevant to moped and scooter safety, the latter PTW types have received comparatively little focused research attention. Much of the research on moped safety to date has been conducted in Europe where they have been popular since the mid 20th century, while some studies have also been conducted in the United States. This research is of limited relevance to Australia due to socio-cultural, economic, regulatory and environmental differences. Moreover, while some studies have compared motorcycles to mopeds in terms of safety, no research to date has specifically examined the differences and similarities between mopeds and larger scooters, or between larger scooters and motorcycles. To address the need for a better understanding of moped and scooter use and safety, the current program of research involved three complementary studies designed to achieve the following aims: (1) develop better knowledge and understanding of moped and scooter usage trends and patterns; and (2) determine the factors leading to differences in moped, scooter and motorcycle safety. Study 1 involved six-monthly observations of PTW types in inner city parking areas of Queensland’s capital city, Brisbane, to monitor and quantify the types of PTW in use over a two year period. Study 2 involved an analysis of Queensland PTW crash and registration data, primarily comparing the police-reported crash involvement of mopeds, scooters and motorcycles over a five year period (N = 7,347). Study 3 employed both qualitative and quantitative methods to examine moped and scooter usage in two components: (a) four focus group discussions with Brisbane-based Queensland moped and scooter riders (N = 23); and (b) a state-wide survey of Queensland moped and scooter riders (N = 192). Study 1 found that of the PTW types parked in inner city Brisbane over the study period (N = 2,642), more than one third (36.1%) were mopeds or larger scooters. The number of PTWs observed increased at each six-monthly phase, but there were no significant changes in the proportions of PTW types observed across study phases. There were no significant differences in the proportions or numbers of PTW type observed by season. Study 2 revealed some important differences between mopeds, scooters and motorcycles in terms of safety and usage through analysis of crash and registration data. All Queensland PTW registrations doubled between 2001 and 2009, but there was an almost fifteen-fold increase in moped registrations. Mopeds subsequently increased as a proportion of Queensland registered PTWs from 1.2 percent to 8.8 percent over this nine year period. Moped and scooter crashes increased at a faster rate than motorcycle crashes over the five year study period from July 2003 to June 2008, reflecting their relatively greater increased usage. Crash rates per 10,000 registrations for the study period were only slightly higher for mopeds (133.4) than for motorcycles and scooters combined (124.8), but estimated crash rates per million vehicle kilometres travelled were higher for mopeds (6.3) than motorcycles and scooters (1.7). While the number of crashes increased for each PTW type over the study period, the rate of crashes per 10,000 registrations declined by 40 percent for mopeds compared with 22 percent for motorcycles and scooters combined. Moped and scooter crashes were generally less severe than motorcycle crashes and this was related to the particular crash characteristics of the PTW types rather than to the PTW types themselves. Compared to motorcycle and moped crashes, scooter crashes were less likely to be single vehicle crashes, to involve a speeding or impaired rider, to involve poor road conditions, or to be attributed to rider error. Scooter and moped crashes were more likely than motorcycle crashes to occur on weekdays, in lower speed zones and at intersections. Scooter riders were older on average (39) than moped (32) and motorcycle (35) riders, while moped riders were more likely to be female (36%) than scooter (22%) or motorcycle riders (7%). The licence characteristics of scooter and motorcycle riders were similar, with moped riders more likely to be licensed outside of Queensland and less likely to hold a full or open licence. The PTW type could not be identified in 15 percent of all cases, indicating a need for more complete recording of vehicle details in the registration data. The focus groups in Study 3a and the survey in Study 3b suggested that moped and scooter riders are a heterogeneous population in terms of demographic characteristics, riding experience, and knowledge and attitudes regarding safety and risk. The self-reported crash involvement of Study 3b respondents suggests that most moped and scooter crashes result in no injury or minor injury and are not reported to police. Study 3 provided some explanation for differences observed in Study 2 between mopeds and scooters in terms of crash involvement. On the whole, scooter riders were older, more experienced, more likely to have undertaken rider training and to value rider training programs. Scooter riders were also more likely to use protective clothing and to seek out safety-related information. This research has some important practical implications regarding moped and scooter use and safety. While mopeds and scooters are generally similar in terms of usage, and their usage has increased, scooter riders appear to be safer than moped riders due to some combination of superior skills and safer riding behaviour. It is reasonable to expect that mopeds and scooters will remain popular in Queensland in future and that their usage may further increase, along with that of motorcycles. Future policy and planning should consider potential options for encouraging moped riders to acquire better riding skills and greater safety awareness. While rider training and licensing appears an obvious potential countermeasure, the effectiveness of rider training has not been established and other options should also be strongly considered. Such options might include rider education and safety promotion, while interventions could also target other road users and urban infrastructure. Future research is warranted in regard to moped and scooter safety, particularly where the use of those PTWs has increased substantially from low levels. Research could address areas such as rider training and licensing (including program evaluations), the need for more detailed and reliable data (particularly crash and exposure data), protective clothing use, risks associated with lane splitting and filtering, and tourist use of mopeds. Some of this research would likely be relevant to motorcycle use and safety, as well as that of mopeds and scooters.

Negative change and job outcomes : the impact of subjective fit in public sector health care organization

There is an ongoing level of organizational-wide change (such as empowerment and downsizing) occurring within the Australian health care sector. However, there is a paucity of empirical evidence on how public and nonprofit sector nurses cope with these organizational-wide change initiatives and their consequences on individual and work outcomes. This will be the primary aim of the current paper. To this end, a path model is developed base on an integration of existing theoretical perspectives on occupational stress, change management, and person-organizational fit. Data were collected from 252 public and not-for-profit sector nurses. The path analysis suggests that public and nonprofit nurses experience positive and negative change initiatives. Negative change initiatives resulted in an increase in the level of administrative-related stressors. Nurses with more congruent values report less experience with administrative stressors. As nurses experienced more administrative stressors, they tend to report more job dissatisfaction. Nurses whose values were more congruent during organizational change reported higher level of psychological wellbeing. Nurses who were had higher level of psychological wellbeing were found to have higher job satisfaction, which subsequently led to a higher level of organizational commitment.