Australian behavioural research in cancer


Behavioural Research and Evaluation (BREU), South Australia

Support for smoke-free hospitality venues in South Australia
On 1 November 2007, a complete ban on smoking was implemented inside all South Australian hospitality venues following a three year phase-in period. Separate surveys were conducted at two time points (during the final phase-in period in early 2007 and four to five months post-legislation in early 2008) to assess community support, attitudes and opinions of licensed venue managers regarding the changes and the impact of legislation and legislation compliance. Overall, community support for the legislation significantly increased; the most common reason for approval was the harmful effects of passive smoking. Results also indicated that the number of individuals who were likely to quit in response to the ban significantly increased to almost 30% in 2008. Awareness, support and compliance among venue managers was high, with a significant increase in approval of the legislation to 86% in 2008. Nearly one third of venue managers highlighted that their staff were still exposed to smoke in outdoor areas as part of their jobs.

Cancer risk factors in South Australia
In 2007 BREU released a report from a state-wide, face-to-face survey of 2507 South Australians tracking knowledge and prevalence of risk factors for cancer. Results indicated the community perceived family history, pollution and pesticides on food as more important risk factors for developing cancer than modifiable lifestyle behaviours such as fruit and vegetable intake, body weight, physical activity and alcohol consumption. The majority of South Australians did not meet dietary recommendations nor recommended levels of physical activity for cancer prevention, and less than half of South Australians reported checking their skin for suspicious spots that may be skin cancer. A small but statistically significant increase in the proportion of overweight or obese South Australians from 2001 to 2007 was observed. The survey highlights the need to invest more resources to increase awareness and encourage healthy behaviours through the creation of healthy environments and infrastructure to facilitate, support and sustain such change in the community.

SMS trials to attract young smokers to the Quitline
In 2007, text messaging by mobile phone (SMS) was introduced as an option for contacting the South Australian Quitline. Evaluation results indicated that an SMS option at the conclusion of television commercials motivated a large group of young smokers to initiate contact with the Quitline. SMS respondents were significantly younger than callers to the Quitline and included a large proportion of smokers living in areas of most disadvantage. Results from a second trial in 2008 were very similar to 2007 in terms of age, area of disadvantage and general periods of responses, however the results suggested programming genre affected responses. Also, during periods of advertising without SMS contact options, young respondents appeared to stop contacting the Quitline; supporting the utilisation of SMS as a viable option for initiating contact with young smokers. Quit attempts and rates will be assessed at a six month follow-up of respondents and will be reported in mid-2009.

Viertel Centre for Research in Cancer Control (VCRCC), Queensland

Colorectal Cancer and Quality of Life study
Colorectal cancer is the second most common invasive cancer in Australia, with over 12,000 new cases diagnosed each year. Over 60% will survive the disease but are faced with ongoing psychosocial and physical problems including: depression; poor self-esteem and body image; fatigue; pain; and nausea. As such, there is increasing interest in how to improve quality of life during survivorship. The Colorectal Cancer and Quality of Life study is a population based longitudinal study, which aims to identify the predictors of quality of life in approximately n=2000 colorectal cancer survivors up to five years post diagnosis. The study is in its final year of data collection and has collected data on physical symptoms and the factors that improve recovery and quality of life, including: support and information from health care providers; satisfaction with medical care; knowledge and uptake of supportive care services; lifestyle factors such as physical activity and stress; and coping factors such as coping strategies and social support. To date the study has produced eight publications and has been presented at nine conferences. 

The Colorectal Cancer and Quality of Life study study has shown that at 12 months post-diagnosis, 61% of colorectal survivors are overweight/obese, 62% are insufficiently active and 22% are high risk drinkers. There is also a link between distress and lifestyle variables, with distressed colorectal survivors having increased likelihood of poor lifestyle variables and health outcomes, including smoking, physical activity and obesity. To address this, we have developed a lifestyle intervention (CanChange) that is telephone delivered to improve the reach of the intervention. CanChange is designed to promote improvements in psychosocial outcomes and lifestyle behaviours and includes fortnightly telephone sessions from an experienced health coach over a six month period. 

We have recently completed a pilot study demonstrating that CanChange was highly acceptable and potentially effective. These findings have recently been accepted for publication in the journal Psycho-Oncology (special issue on physical activity and cancer). A large scale randomised controlled trial will commence early 2009 to test the longer term effectiveness of this approach.


Centre for Behavioural Research in Cancer (CBRC) Victoria

Adolescents’ use of purpose-built shade in secondary schools: a cluster randomised control trial
Despite good knowledge of skin cancer, Australian adolescents are typically resistant to sun protection, with education-based interventions likely to have limited benefit. This study examined whether students use or avoid newly shaded areas created by shade-sails installed at schools. We used a cluster randomised trial, involving 51 secondary schools with limited available shade – 25 schools were randomly assigned to have a purpose-built shade-sail installed during winter 2005 at full-sun study sites and 26 schools provided an observation-only control group. The mean number of students using the primary study sites was monitored weekly during spring and summer lunch breaks at pre-test (2004-05) and post-test (2005-06). Over the study period, the mean change in students using the primary study site from pre-test to post-test was 2.63 students in intervention schools and –0.03 students in control schools. There was an intervention effect (p=0.011), with on average 2.67 more students using the newly shaded sites at intervention schools compared with the full-sun sites at control schools. Comparison of the mean change in use of alternate sites in intervention and control schools provided no evidence of shade avoidance. This study provides evidence that secondary school students will use rather than avoid shade-sails in schools, suggesting a practical means of reducing adolescents’ exposure to ultraviolet radiation.   

National Secondary Students’ Diet and Activity (NaSSDA) survey
One in five Australian children are overweight or obese, increasing their risk of chronic disease. The NaSSDA survey is designed to fill a significant gap in existing data by establishing an ongoing commitment to the standardised monitoring of adolescents’ body weight, and dietary and physical activity behaviour at both a state and national level. The study is jointly funded by the state and territory Cancer Councils, Cancer Council Australia and the National Heart Foundation of Australia. Pilot testing of the study methods and measures was conducted in 2008. The first round of fieldwork will commence in 2009 and be triennial thereafter. A nationally representative sample of 20,000 secondary school students from years 8 to 11, from over 200 schools will be surveyed. Data on food intake, dietary habits, physical activity, sedentary behaviour and barriers and enablers of physical activity will be collected via web-based survey. Data on the school food and activity environment will also be collected. Anthropometric measurements of height, weight and waist circumference will be taken by trained researchers, in private. A Technical Advisory Group chaired by Professor Louise Baur, comprising Australian researchers with specific expertise in conducting nutrition and physical activity research with children and adolescents, has provided input on the design and conduct of the survey. The results of the survey will help shape future policy and program development in relation to overweight/obesity, with the ultimate aim of reducing health risks among young people.      


Centre for Health Research and Psycho-oncology (CHeRP), NSW

Supermarket Nagging and Children’s Choices (SNACC)
Childhood obesity is an increasing problem in Australia and parents are increasingly concerned about how to manage their children’s eating habits. There is an alarming amount of unhealthy food marketing and advertising directed at children, and research suggests that this may influence children’s preferences, purchase behaviour and consumption. Children may place pressure on their parents for food items – the phenomenon where children request foods as a result of food marketing is referred to as “pester power”. The prevalence of pester power and how parents deal with this pressure from their children is largely unknown.

CHeRP is conducting research incorporating both face-to-face intercept interviews and focus group discussions with parents to better understand pester power. The intercept interviews will involve 400 parents as they exit a supermarket after a shopping trip accompanied by at least one child. Parents will be recruited from randomly selected supermarkets in the Newcastle region. Focus group discussions will also be conducted with parents in an effort to elicit a greater understanding of parents’ perspective of pester power and will explore the role of self-efficacy, stress, attitudes, beliefs, time pressure and parenting issues.

This project will contribute to the growing evidence suggesting the need for policy change to enable parents to gain greater control over their childrens food preferences. It aims to assist in determining which policy changes are most important and whether a multi-strategy approach is necessary to promote healthy eating and help overcome obesogenic environments.

National survey of palliative care specialists’ referral practices
Cancer specialists can facilitate timely and appropriate access to specialised palliative care (SPC) services. To better match patients’ needs with access to SPC services, we must understand factors associated with referral. A survey of all oncologists, clinical haematologists, respiratory physicians and colorectal surgeons in Australia was conducted to investigate cancer specialists’ referral practices, perceptions of, barriers to and triggers for referral of people with advanced cancer to SPC services.

Of the 699 specialists who participated, 48% reported referring more than 60% of patients to SPC services. The most frequent reasons for referral related to symptom control; psychosocial issues rarely triggered referral. The main reasons reported for not referring included the specialist’s ability to manage patients’ symptoms, the absence of symptoms or rapid deterioration. The significant predictors of higher rates of referral were related to specialist characteristics (female, more than 10 years in practice), perceived SPC service availability and attitudes (a belief that all people with advanced cancer should be referred to SPC services for multi-disciplinary care).

These results suggest that referrals to SPC services are largely precipitated by physical and disease-related characteristics and less frequently by psychosocial concerns. Initiatives are needed to upskill health professionals to better recognise complex needs across the spectrum of needs (physical, psychological, social, cultural and spiritual), where multi-disciplinary SPC services, even accessed for limited periods or in a consultative capacity, may improve patient outcomes. These findings also support the importance of training all doctors in a palliative approach, so that people without complex needs can continue to be cared for by doctors whose substantive work is not in palliative care. 


Centre for Behavioural Research in Cancer Control (CBRCC)

SunSmart practices in Western Australian high schools
Australia leads the world in the incidence of skin cancer and melanoma morbidity and skin cancer death rates rival that of the annual road toll. Adolescents are identified as having the lowest skin protection rates of all age groups. Only 33% of adolescents in a recent WA survey wore a hat or used sunscreen when outdoors at peak times. Schools can play a vital role in preventing skin cancer, but there are currently no SunSmart high schools in WA. Research has been undertaken to identify barriers to high schools implementing SunSmart policies. In both government and independent schools administrators and principals were interviewed and teachers were given a self administered questionnaire. To date the research suggests that teachers do not view themselves as role models in respect to sun protective behaviours and many are unaware of any school policy relating to SunSmart. Furthermore, teachers indicated that they desired a tan and a significant proportion did not wear hats, protective clothing or sunscreen when exposed to the sun either at school or during out-of-school hours. The lack of sun protection behaviours by high school teachers, and their lack of awareness about relevant school policies have implications for health promotion. As well as relevant to skin cancer prevention amongst teachers, it is clear that programs are needed to protect high school students.

Personal liberty versus government responsibility: exploring the limits of publically acceptable tobacco control regulation
Tobacco control advocates are accustomed to the accusation they are trying to impose a ‘nanny state’ on society by infringing upon smokers’ ‘personal liberties’ and ‘freedom of choice’. This vitriol usually originates from vested interest groups (or politicians receiving donations from such groups), but what are lay perspectives regarding personal liberties versus government responsibilities? Fifty-six laypeople participated in eight focus groups stratified by smoking status, sex and age-group (18–29 and 30–55 years). Participants’ perceptions of “how far is too far?” with regards to government regulation versus personal freedoms were elicited via group discussions. Tobacco was the underlying topic of interest to the researchers, however participants were not overtly prompted to discuss smoking. Participants expressed general consensus about the following three principles: 1) For all risky behaviours governments have a duty-of-care to educate the public thereby enabling individuals to make informed choices; 2) Governments have a duty-of-care to restrict individuals’ risky behaviours that impact on others; and 3) For risky behaviours that don’t directly impact on others restrictive government intervention should be proportionate to societal cost as a whole. Any individual’s behaviour that impacts upon the wellbeing of other individuals is fair game for government restrictions, up to, and including draconian legislation. Governments also have a clear mandate to relegate the cost to society of individuals’ risky behaviours via educational and regulatory dissuasive strategies. Therefore, in order to resonate with the laity, public health advocacy should be articulated and contextualised in these terms.

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