A Conceptual Foresight Model to Investigate the Adoption of Radio Frequency Identification Technology in the English National Health Service

Radio Frequency Identification Technology (RFID) adoption in healthcare settings has the potential to reduce errors, improve patient safety, streamline operational processes and enable the sharing of information throughout supply chains. RFID adoption in the English NHS is limited to isolated pilot studies. Firstly, this study investigates the drivers and inhibitors to RFID adoption in the English NHS from the perspective of the GS1 Healthcare User Group (HUG) tasked with coordinating adoption across private and public sectors. Secondly a conceptual model has been developed and deployed, combining two of foresight’s most popular methods; scenario planning and technology roadmapping. The model addresses the weaknesses of each foresight technique as well as capitalizing on their individual, inherent strengths. Semi structured interviews, scenario planning workshops and a technology roadmapping exercise were conducted with the members of the HUG over an 18-month period. An action research mode of enquiry was utilized with a thematic analysis approach for the identification and discussion of the drivers and inhibitors of RFID adoption. The results of the conceptual model are analysed in comparison to other similar models. There are implications for managers responsible for RFID adoption in both the NHS and its commercial partners, and for foresight practitioners. Managers can leverage the insights gained from identifying the drivers and inhibitors to RFID adoption by making efforts to influence the removal of inhibitors and supporting the continuation of the drivers. The academic contribution of this aspect of the thesis is in the field of RFID adoption in healthcare settings. Drivers and inhibitors to RFID adoption in the English NHS are compared to those found in other settings. The implication for technology foresight practitioners is a proof of concept of a model combining scenario planning and technology roadmapping using a novel process. The academic contribution to the field of technology foresight is the conceptual development of foresight model that combines two popular techniques and then a deployment of the conceptual foresight model in a healthcare setting exploring the future of RFID technology.

Medical advice, diabetes self-management, and health outcomes of a multi-ethnic population from the National Health and Nutrition Examination Survey 2007--2008

Diabetes self-management, an essential component of diabetes care, includes weight control practices and requires guidance from providers. Minorities are likely to have less access to quality health care than White non-Hispanics (WNH) (American College of Physicians-American Society of Internal Medicine, 2000). Medical advice received and understood may differ by race/ethnicity as a consequence of the patient-provider communication process; and, may affect diabetes self-management. ^ This study examined the relationships among participants’ report of: (1) medical advice given; (2) diabetes self-management, and; (3) health outcomes for Mexican-Americans (MA) and Black non-Hispanics (BNH) as compared to WNH (reference group) using data available through the National Health and Nutrition Examination Survey (NHANES) for the years 2007–2008. This study was a secondary, single point analysis. Approximately 30 datasets were merged; and, the quality and integrity was assured by analysis of frequency, range and quartiles. The subjects were extracted based on the following inclusion criteria: belonging to either the MA, BNH or WNH categories; 21 years or older; responded yes to being diagnosed with diabetes. A final sample size of 654 adults [MA (131); BNH (223); WNH (300)] was used for the analyses. The findings revealed significant statistical differences in medical advice reported given. BNH [OR = 1.83 (1.16, 2.88), p = 0.013] were more likely than WNH to report being told to reduce fat or calories. Similarly, BNH [OR = 2.84 (1.45, 5.59), p = 0.005] were more likely than WNH to report that they were told to increase their physical activity. Mexican-Americans were less likely to self-monitor their blood glucose than WNH [OR = 2.70 (1.66, 4.38), p<0.001]. There were differences among ethnicities for reporting receiving recent diabetes education. Black, non-Hispanics were twice as likely to report receiving diabetes education than WNH [OR = 2.29 (1.36, 3.85), p = 0.004]. Medical advice reported given and ethnicity/race, together, predicted several health outcomes. Having recent diabetes education increased the likelihood of performing several diabetes self-management behaviors, independent of race. ^ These findings indicate a need for patient-provider communication and care to be assessed for effectiveness and, the importance of ongoing diabetes education for persons with diabetes.^

GPs' implicit prioritization through clinical choices – evidence from three national health services

Acknowledgments The authors are grateful for valuable comments and inputs from participants at a series of seminars and conferences as well as to our three anonymous referees.

Market reforms and privatisation in the English National Health Service

The article examines developments in the marketisation and privatisation of the English National Health Service, primarily since 1997. It explores the use of competition and contracting out in ancillary services and the levering into public services of private finance for capital developments through the Private Finance Initiative. A substantial part of the article examines the repeated restructuring of the health service as a market in clinical services, initially as an internal market but subsequently as a market increasing opened up to private sector involvement. Some of the implications of market processes for NHS staff and for increased privatisation are discussed. The article examines one episode of popular resistance to these developments, namely the movement of opposition to the 2011 health and social care legislative proposals. The article concludes with a discussion of the implications of these system reforms for the founding principles of the NHS and the sustainability of the service.

Economic crisis and national health system

The text analyzes the impact of the economic crisis in some critical aspects of the National Health System: outcomes, health expenditure, remuneration policy and privatization through Private Public Partnership models. Some health outcomes related to social inequalities are worrying. Reducing public health spending has increased the fragility of the health system, reduced wage income of workers in the sector and increased heterogeneity between regions. Finally, the evidence indicates that privatization does not mean more efficiency and better governance. Deep reforms are needed to strengthen the National Health System.

The political economy of co-ordination challenges in the National Health Service: a postpositivist evaluation of diabetes policy and governance

The present PhD thesis develops and applies an evaluative methodology suited to the evaluation of policy and governance in complex policy areas. While extensive literatures exist on the topic of policy evaluation, governance evaluation has received less attention. At the level of governance, policymakers confront choices between different policy tools and governance arrangements in their attempts to solve policy problems, including variants of hierarchy, networks and markets. There is a need for theoretically-informed empirical research to inform decision-making at this level. To that end, the PhD develops an approach to evaluation by combining postpositivist policy analysis with heterodox political economy. Postpositivist policy analysis recognises that policy problems are often contested, that choices between policy options can involve significant trade-offs and that knowledge of policy options is itself dispersed and fragmented. Similarly, heterodox economics combines a concept of incommensurable values with an appreciation of the strengths and weaknesses of different institutional arrangements to realise them. A central concept of the field is coordination, which orientates policy analysis to the interactions of stakeholders in policy processes. The challenge of governance is to select the appropriate policy tools and arrangements which facilitate coordination. Via a postpositivist exploration of stakeholder ‘frames’, it is possible to ascertain whether coordination is occurring and to identify problems if it is not. Evaluative claims of governance can be made where arrangements can be shown to frustrate the realisation of shared values and objectives. The research makes a contribution to knowledge in a number of ways a) a distinctive evaluative approach that could be applied to other areas of health and public policy b) greater appreciation of the strengths and weaknesses of different forms of evidence in public policy and in particular health policy and c) concrete policy proposals for the governance and organisation of diabetes services, with implications for the NHS more broadly.

Falls and the Social Isolation of Older Adults in the National Health and Aging Trends Study

Thesis (Ph.D.)--University of Washington, 2016-08

Awareness and Coverage of the National Health Insurance Scheme among Formal Sector Workers in Ilorin, Nigeria

A prepayment scheme for health through the National Health Insurance Scheme (NHIS) was commenced in Nigeria about ten years ago. Nigeria operates a federal system of government. Sub- national levels possess a high degree of autonomy in a number of sectors including health. It is important to assess the level of coverage of the scheme among the formal sector workers in Nigeria as a proxy to gauge the extent of coverage of the scheme and derive suitable lessons that could be used in its expansion. This is a cross-sectional, descriptive survey carried out among formal sector workers in Ilorin Kwara State, Nigeria. A stratified sampling technique was used to select study participants. A self-administered questionnaire was used to collect data from respondents. Data was analysed with the SPSS. Ethical approval to conduct the study was obtained from the Bowen University Teaching Hospital Research Ethics Committee. A total of 370 people participated in the study. Majority, (78.9%) of the respondents were aware of the NHIS, however only 13.5 % paid for health care services through the NHIS. Logistic regression analysis shows that respondents with post-secondary education (OR = 9.032, CI = 2.562 – 31.847, p = 0.001) and in federal civil service (OR = 2.679, CI = 1.036 – 6.929, p = 0.042) were over nine and three times more likely to be aware of the scheme than others. Coverage of the scheme among the respondents was unimpressive. A lot still need to be done to fast-track the expansion of the scheme among this sector of the population.

Early consumption of liquids different to breast milk in Mexican infants under 1 year: results of the probabilistic National Health and Nutrition Survey 2012

Introduction: Studies on infant dietary intake do not generally focus on the types of liquids consumed. Objective: To document by age and breastfeeding status, the types of liquids present in the diet of Mexican children under 1 year of age (< 1 y) who participated in the National Health and Nutrition Survey 2012 (ENSANUT-2012). Methods: Analysis of the infant < 1 y feeding practices from the ENSANUT-2012 survey in non-breastfed (non-BF) and breastfed (BF) infants by status quo for the consumption of liquids grouped in: water, formula, fortified LICONSA milk, nutritive liquids (NL; thin cereal-based gruel with water or milk and coffee with milk) and non-nutritive liquids (non-NL) as sugared water, water-based drinks, tea, beans or chicken broth, aguamiel and coffee. In this infants < 1 y we analyzed the not grouped consumption of liquids in the first three days of life (newborns) from the mother's recall. Percentage and confidence intervals (95% CI) were calculated adjusting for survey design. Statistical differences were analyzed by Z test. Results: We observed a high consumption of human milk followed by formula (56.7%) and water (51.1%) in infants under 6 months of age (< 6 mo). The proportion of non-BF infants consuming non-NL was higher than for BF infants (p < 0.05). More than 60% of older infants (6 mo and < 1 y) consumed formula and were non-BF. In newborns formula consumption was predominant, followed by tea or infusion and water. Conclusions: Non-breast milk liquids are present undesirably in Mexican infants' diet and non-NL are consumed earlier than NL, revealing inadequate early dietary practices.

A new national women's health policy : legal, ethical and policy initiatives to support women's health

In 1989 the first National Women's Health Policy was launched in Australia. Now, 20 years later, the Federal Government has announced plans for the development of a new National Women's Health Policy to address the health needs of Australian women. The Policy will be based on five principles: gender equity; health equity between women; a focus on prevention; an evidence base for interventions; and a life course approach. This editorial examines the role for law in the development of a new National Women's Health Policy. It considers the relevance of regulatory frameworks for health research in supporting an evidence base for health interventions and analyses the requirement in the National Health and Medical Research Council's National Statement on Ethical Conduct in Human Research for "fair inclusion" of research participants. The editorial argues for a holistic approach to women's health that includes regulatory frameworks for research, identification of funding priorities for research, and the need for a dedicated government department or agency to promote women's health.

Lessons from the National Mental Health Integration Program

Three projects were funded under the national Mental Health Integration Program (MHIP) in 1999, each of which employed a different model aimed at improving linkages between disparate parts of the mental health system. A national evaluation framework guided local evaluations of these projects, and this paper presents a synthesis of the findings. For providers, the projects improved working relationships, created learning opportunities and increased referral and shared care opportunities. For consumers and carers, the projects resulted in a greater range of options and increased continuity of care. For the wider system, the projects achieved significant structural and cultural change. Cost-wise, there were no increases in expenditure, and even some reductions. Many of the lessons from the projects (and their evaluations) may be generalised to other mental health settings and beyond.

National Level Stakeholders’ Perceptions of Facilitators and Barriers in Utilization of World Health Organizations’ Preventing Early Pregnancy Guidelines in National Level Health Policy Creation

Thesis (Master's)--University of Washington, 2016-07

Conceptions of school based youth health nursing : a phenomenographic study

The School Based Youth Health Nurse Program was established in 1999 by the Queensland Government to fund school nurse positions in Queensland state high schools. Schools were required to apply for a School Based Youth Health Nurse during a five-phase recruitment process, managed by the health districts, and rolled out over four years. The only mandatory selection criterion for the position of School Based Youth Health Nurse was registration as a General Nurse and most School Based Youth Health Nurses are allocated to two state high schools. Currently, there are approximately 115 Full Time Equivalent School Based Youth Health Nurse positions across all Queensland state high schools. The literature review revealed an abundance of information about school nursing. Most of the literature came from the United Kingdom and the United States, who have a different model of school nursing to school based youth health nursing. However, there is literature to suggest school nursing is gradually moving from a disease-focused approach to a social view of health. The noticeable number of articles about, for example, drug and alcohol, mental health, and contemporary sexual health issues, is evidence of this change. Additionally, there is a significant the volume of literature about partnerships and collaboration, much of which is about health education, team teaching and how school nurses and schools do health business together. The surfacing of this literature is a good indication that school nursing is aligning with the broader national health priority areas. More particularly, the literature exposed a small but relevant and current body of research, predominantly from Queensland, about school based youth health nursing. However, there remain significant gaps in the knowledge about school based youth health nursing. In particular, there is a deficit about how School Based Youth Heath Nurses understand the experience of school based youth health nursing. This research aimed to reveal the meaning of the experience of school based youth health nursing. The research question was How do School Based Youth Health Nurses’ understand the experience of school based youth health nursing? This enquiry was instigated because the researcher, who had a positive experience of school based youth health nursing, considered it important to validate other School Based Youth Health Nurses’ experiences. Consequently, a comprehensive use of qualitative research was considered the most appropriate manner to explore this research question. Within this qualitative paradigm, the research framework consists of the epistemology of social constructionism, the theoretical perspective of interpretivism and the approach of phenomenography. After ethical approval was gained, purposeful and snowball sampling was used to recruit a sample of 16 participants. In-depth interviews, which were voluntary, confidential and anonymous, were mostly conducted in public venues and lasted from 40-75 minutes. The researcher also kept a researchers journal as another form of data collection. Data analysis was guided by Dahlgren and Fallsbergs’ (1991, p. 152) seven phases of data analysis which includes familiarization, condensation, comparison, grouping, articulating, labelling and contrasting. The most important finding in this research is the outcome space, which represents the entirety of the experience of school based youth health nursing. The outcome space consists of two components: inside the school environment and outside the school environment. Metaphorically and considered as whole-in-themselves, these two components are not discreet but intertwined with each other. The outcome space consists of eight categories. Each category of description is comprised of several sub-categories of description but as a whole, is a conception of school based youth health nursing. The eight conceptions of school based youth health nursing are: 1. The conception of school based youth health nursing as out there all by yourself. 2. The conception of school based youth health nursing as no real backup. 3. The conception of school based youth health nursing as confronted by many barriers. 4. The conception of school based youth health nursing as hectic and full-on. 5. The conception of school based youth health nursing as working together. 6. The conception of school based youth health nursing as belonging to school. 7. The conception of school based youth health nursing as treated the same as others. 8. The conception of school based youth health nursing as the reason it’s all worthwhile. These eight conceptions of school based youth health nursing are logically related and form a staged hierarchical relationship because they are not equally dependent on each other. The conceptions of school based youth health nursing are grouped according to negative, negative and positive and positive conceptions of school based youth health nursing. The conceptions of school based youth health nursing build on each other, from the bottom upwards, to reach the authorized, or the most desired, conception of school based youth health nursing. This research adds to the knowledge about school nursing in general but especially about school based youth health nursing specifically. Furthermore, this research has operational and strategic implications, highlighted in the negative conceptions of school based youth health nursing, for the School Based Youth Health Nurse Program. The researcher suggests the School Based Youth Health Nurse Program, as a priority, address the operational issues The researcher recommends a range of actions to tackle issues and problems associated with accommodation and information, consultations and referral pathways, confidentiality, health promotion and education, professional development, line management and School Based Youth Health Nurse Program support and school management and community. Strategically, the researcher proposes a variety of actions to address strategic issues, such as the School Based Youth Health Nurse Program vision, model and policy and practice framework, recruitment and retention rates and evaluation. Additionally, the researcher believes the findings of this research have the capacity to spawn a myriad of future research projects. The researcher has identified the most important areas for future research as confidentiality, information, qualifications and health outcomes.

Trends in demographic, health behaviour factors, and self-perceived weight status : influences on obesity in Australia from 1995 to 2005

Overweight and obesity are two of the most important emerging public health issues in our time and regarded by the World Health Organisation [WHO] (1998) as a worldwide epidemic. The prevalence of obesity in the USA is the highest in the world, and Australian obesity rates fall into second place. Currently, about 60% of Australian adults are overweight (BMI „d 25kg/m2). The socio-demographic factors associated with overweight and/or obesity have been well demonstrated, but many of the existing studies only examined these relationships at one point of time, and did not examine whether significant relationships changed over time. Furthermore, only limited previous research has examined the issue of the relationship between perception of weight status and actual weight status, as well as factors that may impact on people¡¦s perception of their body weight status. Aims: The aims of the proposed research are to analyse the discrepancy between perceptions of weight status and actual weight status in Australian adults; to examine if there are trends in perceptions of weight status in adults between 1995 to 2004/5; and to propose a range of health promotion strategies and furth er research that may be useful in managing physical activity, healthy diet, and weight reduction. Hypotheses: Four alternate hypotheses are examined by the research: (1) there are associations between independent variables (e.g. socio -demographic factors, physical activity and dietary habits) and overweight and/or obesity; (2) there are associations between the same independent variables and the perception of overweight; (3) there are associations between the same independent variables and the discrepancy between weight status and perception of weight status; and (4) there are trends in overweight and/or obesity, perception of overweight, and the discrepancy in Australian adults from 1995 to 2004/5. Conceptual Framework and Methods: A conceptual framework is developed that shows the associations identified among socio -demographic factors, physical activity and dietary habits with actual weight status, as well as examining perception of weight status. The three latest National Health Survey data bases (1995 , 2001 and 2004/5) were used as the primary data sources. A total of 74,114 Australian adults aged 20 years and over were recruited from these databases. Descriptive statistics, bivariate analyses (One -Way ANOVA tests, unpaired t-tests and Pearson chi-square tests), and multinomial logistic regression modelling were used to analyse the data. Findings: This research reveals that gender, main language spoken at home, occupation status, household structure, private health insurance status, and exercise are related to the discrepancy between actual weight status and perception of weight status, but only gender and exercise are related to the discrepancy across the three time point s. The current research provides more knowledge about perception of weight status independently. Factors which affect perception of overweight are gender, age, language spoken at home, private health insurance status, and diet ary habits. The study also finds that many factors that impact overweight and/or obesity also have an effect on perception of overweight, such as age, language spoken at home, household structure, and exercise. However, some factors (i.e. private health insurance status and milk consumption) only impact on perception of overweight. Furthermore, factors that are rel ated to people’s overweight are not totally related to people’s underestimation of their body weight status in the study results. Thus, there are unknown factors which can affect people’s underestimation of their body weight status. Conclusions: Health promotion and education activities should provide education about population health education and promotion and education for particular at risk sub -groups. Further research should take the form of a longitudinal study design ed to examine the causal relationship between overweight and/or obesity and underestimation of body weight status, it should also place more attention on the relationships between overweight and/or obesity and dietary habits, with a more comprehensive representation of SES. Moreover, further research that deals with identification of characteristics about perception of weight status, in particular the underestimation of body weight status should be undertaken.

Quality issues for the National Bowel Cancer Screening Program (NBCSP)

Purpose: This two-part research project was undertaken as part of the planning process by Queensland Health (QH), Cancer Screening Services Unit (CSSU), Queensland Bowel Cancer Screening Program (QBCSP), in partnership with the National Bowel Cancer Screening Program (NBCSP), to prepare for the implementation of the NBCSP in public sector colonoscopy services in QLD in late 2006. There was no prior information available on the quality of colonoscopy services in Queensland (QLD) and no prior studies that assessed the quality of colonoscopy training in Australia. Furthermore, the NBCSP was introduced without extra funding for colonoscopy service improvement or provision for increases in colonoscopic capacity resulting from the introduction of the NBCSP. The main purpose of the research was to record baseline data on colonoscopy referral and practice in QLD and current training in colonoscopy Australia-wide. It was undertaken from a quality improvement perspective. Implementation of the NBCSP requires that all aspects of the screening pathway, in particular colonoscopy services for the assessment of positive Faecal Occult Blood Tests (FOBTs), will be effective, efficient, equitable and evidence-based. This study examined two important aspects of the continuous quality improvement framework for the NBCSP as they relate to colonoscopy services: (1) evidence-based practice, and (2) quality of colonoscopy training. The Principal Investigator was employed as Senior Project Officer (Training) in the QBCSP during the conduct of this research project. Recommendations from this research have been used to inform the development and implementation of quality improvement initiatives for provision of colonoscopy in the NBCSP, its QLD counterpart the QBCSP and colonoscopy services in QLD, in general. Methods – Part 1 Chart audit of evidence-based practice: The research was undertaken in two parts from 2005-2007. The first part of this research comprised a retrospective chart audit of 1484 colonoscopy records (some 13% of all colonoscopies conducted in public sector facilities in the year 2005) in three QLD colonoscopy services. Whilst some 70% of colonoscopies are currently conducted in the private sector, only public sector colonoscopy facilities provided colonoscopies under the NBCSP. The aim of this study was to compare colonoscopy referral and practice with explicit criteria derived from the National Health & Medical Research Council (NHMRC) (1999) Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer, and describe the nature of variance with the guidelines. Symptomatic presentations were the most common indication for colonoscopy (60.9%). These comprised per rectal bleeding (31.0%), change of bowel habit (22.1%), abdominal pain (19.6%), iron deficiency anaemia (16.2%), inflammatory bowel disease (8.9%) and other symptoms (11.4%). Surveillance and follow-up colonoscopies accounted for approximately one-third of the remaining colonoscopy workload across sites. Gastroenterologists (GEs) performed relatively more colonoscopies per annum (59.9%) compared to general surgeons (GS) (24.1%), colorectal surgeons (CRS) (9.4%) and general physicians (GPs) (6.5%). Guideline compliance varied with the designation of the colonoscopist. Compliance was lower for CRS (62.9%) compared to GPs (76.0%), GEs (75.0%), GSs (70.9%, p<0.05). Compliance with guideline recommendations for colonoscopic surveillance for family history of colorectal cancer (23.9%), polyps (37.0%) and a past history of bowel cancer (42.7%), was by comparison significantly lower than for symptomatic presentations (94.4%), (p<0.001). Variation with guideline recommendations occurred more frequently for polyp surveillance (earlier than guidelines recommend, 47.9%) and follow-up for past history of bowel cancer (later than recommended, 61.7%, p<0.001). Bowel cancer cases detected at colonoscopy comprised 3.6% of all audited colonoscopies. Incomplete colonoscopies occurred in 4.3% of audited colonoscopies and were more common among women (76.6%). For all colonoscopies audited, the rate of incomplete colonoscopies for GEs was 1.6% (CI 0.9-2.6), GPs 2.0% (CI 0.6-7.2), GS 7.0% (CI 4.8-10.1) and CRS 16.4% (CI 11.2-23.5). 18.6% (n=55) of patients with a documented family history of bowel cancer had colonoscopy performed against guidelines recommendations (for general (category 1) population risk, for reasons of patient request or family history of polyps, rather than for high risk status for colorectal cancer). In general, family history was inadequately documented and subsequently applied to colonoscopy referral and practice. Methods - Part 2 Surveys of quality of colonoscopy training: The second part of the research consisted of Australia-wide anonymous, self-completed surveys of colonoscopy trainers and their trainees to ascertain their opinions on the current apprenticeship model of colonoscopy in Australia and to identify any training needs. Overall, 127 surveys were received from colonoscopy trainers (estimated response rate 30.2%). Approximately 50% of trainers agreed and 27% disagreed that current numbers of training places were adequate to maintain a skilled colonoscopy workforce in preparation for the NBCSP. Approximately 70% of trainers also supported UK-style colonoscopy training within dedicated accredited training centres using a variety of training approaches including simulation. A collaborative approach with the private sector was seen as beneficial by 65% of trainers. Non-gastroenterologists (non-GEs) were more likely than GEs to be of the opinion that simulators are beneficial for colonoscopy training (χ2-test = 5.55, P = 0.026). Approximately 60% of trainers considered that the current requirements for recognition of training in colonoscopy could be insufficient for trainees to gain competence and 80% of those indicated that ≥ 200 colonoscopies were needed. GEs (73.4%) were more likely than non-GEs (36.2%) to be of the opinion that the Conjoint Committee standard is insufficient to gain competence in colonoscopy (χ2-test = 16.97, P = 0.0001). The majority of trainers did not support training either nurses (73%) or GPs in colonoscopy (71%). Only 81 (estimated response rate 17.9%) surveys were received from GS trainees (72.1%), GE trainees (26.3%) and GP trainees (1.2%). The majority were males (75.9%), with a median age 32 years and who had trained in New South Wales (41.0%) or Victoria (30%). Overall, two-thirds (60.8%) of trainees indicated that they deemed the Conjoint Committee standard sufficient to gain competency in colonoscopy. Between specialties, 75.4% of GS trainees indicated that the Conjoint Committee standard for recognition of colonoscopy was sufficient to gain competence in colonoscopy compared to only 38.5% of GE trainees. Measures of competency assessed and recorded by trainees in logbooks centred mainly on caecal intubation (94.7-100%), complications (78.9-100%) and withdrawal time (51-76.2%). Trainees described limited access to colonoscopy training lists due to the time inefficiency of the apprenticeship model and perceived monopolisation of these by GEs and their trainees. Improvements to the current training model suggested by trainees included: more use of simulation, training tools, a United Kingdom (UK)-style training course, concentration on quality indicators, increased access to training lists, accreditation of trainers and interdisciplinary colonoscopy training. Implications for the NBCSP/QBCSP: The introduction of the NBCSP/QBCSP necessitates higher quality colonoscopy services if it is to achieve its ultimate goal of decreasing the incidence of morbidity and mortality associated with bowel cancer in Australia. This will be achieved under a new paradigm for colonoscopy training and implementation of evidence-based practice across the screening pathway and specifically targeting areas highlighted in this thesis. Recommendations for improvement of NBCSP/QBCSP effectiveness and efficiency include the following: 1. Implementation of NBCSP and QBCSP health promotion activities that target men, in particular, to increase FOBT screening uptake. 2. Improved colonoscopy training for trainees and refresher courses or retraining for existing proceduralists to improve completion rates (especially for female NBCSP/QBCSP participants), and polyp and adenoma detection and removal, including newer techniques to detect flat and depressed lesions. 3. Introduction of colonoscopy training initiatives for trainees that are aligned with NBCSP/QBCSP colonoscopy quality indicators, including measurement of training outcomes using objective quality indicators such as caecal intubation, withdrawal time, and adenoma detection rate. 4. Introduction of standardised, interdisciplinary colonoscopy training to reduce apparent differences between specialties with regard to compliance with guideline recommendations, completion rates, and quality of polypectomy. 5. Improved quality of colonoscopy training by adoption of a UK-style training program with centres of excellence, incorporating newer, more objective assessment methods, use of a variety of training tools such as simulation and rotations of trainees between metropolitan, rural, and public and private sector training facilities. 6. Incorporation of NHMRC guidelines into colonoscopy information systems to improve documentation, provide guideline recommendations at the point of care, use of gastroenterology nurse coordinators to facilitate compliance with guidelines and provision of guideline-based colonoscopy referral letters for GPs. 7. Provision of information and education about the NBCSP/QBCSP, bowel cancer risk factors, including family history and polyp surveillance guidelines, for participants, GPs and proceduralists. 8. Improved referral of NBCSP/QBCSP participants found to have a high-risk family history of bowel cancer to appropriate genetics services.