Options for change in the Australian cervical cancer screening program in context of HPV detection and vaccination

Introduction:
Cervical cancer screening has been implemented for over a decade in Australia and has significantly reduced the mortality and morbidity of the disease. The emergence of new technologies for cervical cancer, such as the Human Papillomavirus (HPV) vaccine and DNA testing has encouraged debate regarding the effective use of resources in cervical cancer prevention. The present study evaluates the cost-effectiveness, from a health sector perspective, of various screening strategies in the era of these new technologies.

Methods:
A stochastic epidemiological model using a discrete event and continuous algorithm was developed to describe the natural history of cervical cancer. By allowing one member of the cohort into the model at a time, this micro-simulation model encompasses the characteristics of heterogeneity and can track individual life histories. To evaluate the cost-effectiveness of the HPV vaccine a Markov model was built to simulate the effect on the incidence of HPV and subsequent cervical cancer. A number of proposed screening strategies were evaluated with the stochastic model for the application of HPV DNA testing, with changes in the screening interval and target population. Health outcomes were measured by Disability-Adjusted Life-Years (DALYs), adjusted for application within an evaluation setting (i.e. the mortality component of the DALY was adjusted by a disability weight when early mortality due to cervical cancer is avoided). Costs in complying with the Australian updated guidelines were assessed by pathway analysis to estimate the resources associated with cervical cancer and its pre-cancerous lesion treatment. Sensitivity analyses were performed to investigate the key parameters that influenced the cost-effectiveness results.

Results:
Current practice has already brought huge health gain by preventing more than 4,000 deaths and saving more than 86,000 life-years in a cohort of a million women. Any of the alternative screening strategies alter the total amount of health gain by a small margin compared to current practice. The results of incremental analyses of the alternative screening strategies compared to current practice suggest the adoption of the HPV DNA test as a primary screening tool every 3 years commencing at age 18, or the combined pap smear/HPV test every 3 years commencing at age 25, are more costly than current practice but with reasonable ICERs (AUD$1,810 per DALY and AUD$18,600 per DALY respectively). Delaying commencement of Pap test screening to age 25 is less costly than current practice, but involves considerable health loss. The sensitivity analysis shows, however, that the screening test accuracy has a significant impact on these conclusions. Threshold analysis indicates that a sensitivity ranging from 0.80 to 0.86 for the combined test in women younger than 30 is required to produce an acceptable incremental cost-effectiveness ratio.

Conclusions:
The adoption of HPV and combined test with an extended screening interval is more costly but affordable, resulting in reasonable ICERs. They appear good value for money for the Australian health care system, but need more information on test accuracy to make an informed decision. Potential screening policy change under current Australian HPV Vaccination Program is current work in progress. A Markov model is built to simulate the effect on the incidence of HPV and subsequent cervical cancer. Adoption of HPV DNA test as a primary screening tool in the context of HPV vaccination is under evaluation.

People management issues in a third sector health care organisation: preliminary findings

Objective – To use inductive convergent interviewing to generate the perceived critical people management issues of the day as perceived by staff. This was used as preliminary to longitudinal ongoing survey in a third sector health care organisation.

Design – Convergent interviewing is a qualitative technique that addresses research topics that lack theoretical underpinning and is an inductive, flexible, evolving research instrument. The key issues converged after six rounds of interviews as well as a further round to ensure that all of the common people management issues had been generated.

Setting - There is very little in the way of tested models of predictors of employee behaviour in third sector organisations in the Australian health care industry. This study investigates a range of facilities and positions, in various hospitals and aged care facilities within the one third sector health care organisation.

Subjects – The study proposed twenty seven extensive interviews over a range of facilities and positions. Twenty one interviewees participated in the final convergent process.

Conclusions - Critical issues included: workload across occupational groups, internal management support, adequate training, the appropriate skill mix in staff, physical risk in work, satisfaction, as well as other issues. These issues confirm the proposition of sector-ness in health organisations that are multi-dimensional rather than uni-dimensional.

Third-generation responses to holocaust video-testimony

This research investigated responses of grandchildren of Holocaust survivors ("third generation") to Holocaust video-testimony. The analysis revealed that video-testimony can transmit memories of survival experiences to viewers, enabling them to "work through" their positions as witnesses and make active decisions relating to remembrance.

Participation, relational justice and social identity in cervical cancer screening

Extending existing health literature by drawing on social and community psychology, this thesis represents the first attempt to explore the conceptualisation of 'participation' in cervical cancer screening. Quantitative and qualitative findings suggested that women's experiences of 'patient participation' and 'voice opportunity' were important and related to various social processes and variables in this health context. Using four case studies, the professional portfolio demonstrates a biopsychosocial approach to assessment and intervention as used by a provisional health psychologist working with clients with intellectual disabilities in order to promote sexual health.

Public relations in the third sector

This chapter explore the growth of the third sector (NGOs, not for profits and community action groups) and their use of communication techniques from a socio-cultural perspective.

Association between sexual behavior and cervical cancer screening

Background: Not much is known about whether women who follow Pap testing recommendations report the same pattern of sexual behavior as women who do not.
Methods: Data come from part of a larger population-based computer-assisted telephone survey of 8656 Australians aged 16–64 years resident in Australian households with a fixed telephone line (Australian Longitudinal Study of Health and Relationships [ALSHR]). The main outcome measure in the current study was having had a Pap test in the past 2 years.
Results: Data on a weighted sample of 4052 women who reported sexual experience (ever had vaginal intercourse) were analyzed. Overall, 73% of women in the sample reported having a Pap test in the past 2 years. Variables individually associated with Pap testing behavior included age, education, occupation, cohabitation status, residential location, tobacco and alcohol use, body mass index (BMI), lifetime and recent number of opposite sex partners, sexually transmitted infection (STI) history, and condom reliance for contraception. In adjusted analyses, women in their 30s, those who lived with their partner, and nonsmokers were more likely to have had a recent Pap test. Those who drank alcohol at least weekly were more likely to have had a recent test than irregular drinkers or nondrinkers. Women with no sexual partners in the last year were less likely to have had a Pap test, and women who reported a previous STI diagnosis were more likely to have had a Pap test in the past 2 years.
Conclusions: There are differences in Pap testing behavior among Australian women related to factors that may affect their risk of developing cervical abnormalities. Younger women and regular smokers were less likely to report a recent test. Screening programs should consider the need to focus recruitment strategies for these women.

Identification and disruption of the gene encoding the third member of the low-molecular-mass rhoptry complex in Plasmodium falciparum

The low-molecular-mass rhoptry complex of Plasmodium falciparum consists of three proteins, rhoptry-associated protein 1 (RAP1), RAP2, and RAP3. The genes encoding RAP1 and RAP2 are known; however, the RAP3 gene has not been identified. In this study we identify the RAP3 gene from the P. falciparum genome database and show that this protein is part of the low-molecular-mass rhoptry complex. Disruption of RAP3 demonstrated that it is not essential for merozoite invasion, probably because RAP2 can complement the loss of RAP3. RAP3 has homology with RAP2, and the genes are encoded on chromosome 5 in a head-to-tail fashion. Analysis of the genome databases has identified homologous genes in all Plasmodium spp., suggesting that this protein plays a role in merozoite invasion. The region surrounding the RAP3 homologue in the Plasmodium yoelii genome is syntenic with the same region in P. falciparum; however, there is a single gene. Phylogenetic comparison of the RAP2/3 protein family from Plasmodium spp. suggests that the RAP2/3 duplication occurred after divergence of these parasite species.

The effects of testing procedure on critical fall height determination for third-generation synthetic turf

Test procedures and their accuracy in determining critical fall height (CFH) on sporting grounds are paramount to player safety. The procedure currently adopted for synthetic turf in Australian football [1] consists of four consecutive drops at various drop heights at three test locations on the sample. The quantity and packing of the infill in third-generation turf and the pooling effect of the rubber particles with consecutive drops suggests that the current standard protocol may need re-assessment. Therefore, the purpose of this pilot study was to investigate whether current methods of testing for CFH are appropriate for third-generation synthetic turf or whether an alternative or adapted method needs to be developed. CFH was measured, using a HISUN Uniaxe-II Impact Tester, on 12 combinations of synthetic turf samples (four different products with three shock pad options). Three conditions were investigated on each sample; the existing protocol; an alternative 12 single-drop protocol and four single drops from the CFH determined from the existing protocol. A significant difference was found for both absolute and percentage difference between the existing and 12 single-drop protocol, with p = 0.001 and t = 4.33 and p < 0.001 and t = 6.03, respectively. There was also a significant difference between the CFH reached with and without a shock pad for both the existing protocol and the 12 single-drop protocol. The results of this pilot study demonstrate that differences do occur with alterations to the existing protocol and highlight the need for a more detailed characterisation of testing methods on third-generation synthetic turf and the response of surfaces to them.