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As pressure increases on public health systems globally, a potential consequence is that this is transferred to patients in the form of longer waiting times to receive care. In this review, we overview what waiting for health care encompasses, its measurement, and the data available in terms of trends and comparability. We also discuss whether waiting time is equally distributed according to socioeconomic status. Finally, we discuss the policy implications and potential approaches to addressing the burden of waiting time. Waiting time for elective surgery and emergency department care is the best described type of waiting time, and it either increases or remains unchanged across multiple developed countries. There are many challenges in drawing direct comparisons internationally, as definitions for these types of waiting times vary. There are less data on waiting time from other settings, but existing data suggest waiting time presents a significant barrier to health care access for a range of health services. There is also evidence that waiting time is unequally distributed to those of lower socioeconomic status, although this may be improving in some countries. Further work to better clarify definitions, identify driving factors, and understand hidden waiting times and identify opportunities for reducing waiting time or better using waiting time could improve health outcomes of our health services.

Many studies have now demonstrated the efficacy of text messaging in positively changing behaviours. We aimed to identify features and factors that explain the effectiveness of a successful text messaging program in terms of user engagement, perceived usefulness, behavior change and program delivery preferences. Mixed methods qualitative design combining four data sources; (i) analytic data extracted directly from the software system, (ii) participant survey, (iii) focus groups to identify barriers and enablers to implementation and mechanisms of effect and (iv) recruitment screening logs and text message responses to examine engagement. This evaluation was conducted within the TEXT ME trial-a parallel design, single-blind randomized controlled trial (RCT) of 710 patients with coronary heart disease (CHD). Qualitative data were interpreted using inductive thematic analysis. 307/352 (87% response rate) of recruited patients with CHD completed the program evaluation survey at six months and 25 participated in a focus group. Factors increasing engagement included (i) ability to save and share messages, (ii) having the support of providers and family, (iii) a feeling of support through participation in the program, (iv) the program being initiated close to the time of a cardiovascular event, (v) personalization of the messages, (vi) opportunity for initial face-to-face contact with a provider and (vii) that program and content was perceived to be from a credible source. Clear themes relating to program delivery were that diet and physical activity messages were most valued, four messages per week was ideal and most participants felt program duration should be provided for at least for six months or longer. This study provides context and insight into the factors influencing consumer engagement with a text message program aimed at improving health-related behavior. The study suggests program components that may enhance potential success but will require integration at the development stage to optimize up-scaling. Australia and New Zealand Clinical Trials Registry, ACTRN12611000161921.

Despite improvements in health outcomes for children, early childhood dental caries (ECC) remains a chronic lifestyle-mediated disease that affects an estimated 600 million children worldwide. Parental influence on oral health-promoting behaviours is pivotal in preventing ECC. The latest WHO publications Ending Early Childhood Dental Caries and Mobile Technologies for Oral Health highlights the opportunity for mobile Health programs (including text message programs) to improve oral health behaviours and oral health self-efficacy. In response, our team of parents, oral health professionals (academics and health promotion experts), and IT specialists co-designed a 12-week, behavioural theory-informed text message program (called SmilesUp) to address behavioural risk factors specific to ECC. This randomised trial aims to assess whether the SmilesUp program improves parents' oral health promoting behaviours (like tooth brushing twice a day with toothpaste) and oral health self-efficacy for their children compared to usual care. A randomised controlled trial with a 1:1 parallel design will be conducted among 150 parents with children diagnosed with ECC and accessing public dental care in NSW, Australia. Patients will be stratified by hospital site, and modality of care (Dental General Anaesthetic (DGA) or not) and then randomly assigned to either immediately receive the SMILESup text messaging intervention or receive the program at the end of the study period. The primary outcome at 12 weeks is twice daily brushing with fluoride toothpaste. Secondary outcomes include changes in the intake frequency of sugared drinks and foods, oral health promoting bedtime routines and oral health self-efficacy. The primary analysis will follow an intention-to-treat principle. In addition, a process evaluation will examine barriers, enablers, and opportunities to scale the program. Ethics approval has been obtained from the Western Sydney Local Health District Human Research Ethics Committee 2022/ETH01920. Study results will be disseminated via peer-reviewed publications and presentations at conferences. Trial registration number: This clinical trial has been prospectively registered on the ANZCTR from the 27th of March 2023. Registration number: ACTRN12623000325606.

Electronic health (eHealth) strategies are evolving making it important to have valid scales to assess eHealth and health literacy. Item response theory methods, such as the Rasch measurement model, are increasingly used for the psychometric evaluation of scales. This paper aims to examine the internal construct validity of an eHealth and health literacy scale using Rasch analysis in a population with moderate to high cardiovascular disease risk. The first 397 participants of the CONNECT study completed the electronic health Literacy Scale (eHEALS) and the Health Literacy Questionnaire (HLQ). Overall Rasch model fit as well as five key psychometric properties were analysed: unidimensionality, response thresholds, targeting, differential item functioning and internal consistency. The eHEALS had good overall model fit (χ2 = 54.8, p = 0.06), ordered response thresholds, reasonable targeting and good internal consistency (person separation index (PSI) 0.90). It did, however, appear to measure two constructs of eHealth literacy. The HLQ subscales (except subscale 5) did not fit the Rasch model (χ2: 18.18-60.60, p: 0.00-0.58) and had suboptimal targeting for most subscales. Subscales 6 to 9 displayed disordered thresholds indicating participants had difficulty distinguishing between response options. All subscales did, nonetheless, demonstrate moderate to good internal consistency (PSI: 0.62-0.82). Rasch analyses demonstrated that the eHEALS has good measures of internal construct validity although it appears to capture different aspects of eHealth literacy (e.g. using eHealth and understanding eHealth). Whilst further studies are required to confirm this finding, it may be necessary for these constructs of the eHEALS to be scored separately. The nine HLQ subscales were shown to measure a single construct of health literacy. However, participants' scores may not represent their actual level of ability, as distinction between response categories was unclear for the last four subscales. Reducing the response categories of these subscales may improve the ability of the HLQ to distinguish between different levels of health literacy.

Polypills can contain multiple pharmaceutical agents targeting the cardiovascular system. The use of polypills in the secondary prevention of cardiovascular disease (CVD) has received broad support; however, the use of polypills in the primary prevention of CVD is more controversial. This controversy stems from an inherent resistance to the medicalization of primary prevention, and the lower CVD event rate in this population means that smaller absolute benefits are derived. Indeed, drug-related adverse effects, such as from aspirin, might even outweigh the benefits. The role of fixed-dose combination (FDC) therapy for blood pressure (BP) lowering in combatting the widespread undertreatment of high BP — the leading modifiable risk factor contributing to the global burden of CVD — has gained momentum. Increasing evidence suggests that FDC pills containing multiple low doses of BP-lowering drugs produce more effective BP lowering than the use of fewer separate BP-lowering drugs at higher doses, without an increase in adverse effects. Trials of FDC pills comprising three half-dose or four quarter-dose BP-lowering drugs have shown substantial efficacy. In this Review, we summarize the current evidence on low-dose BP-lowering FDC pills and the justification for this approach in the context of polypills in the primary prevention of CVD.The use of polypills containing multiple pharmaceutical agents targeting the cardiovascular system in the primary prevention of cardiovascular disease is controversial. In this Review, Chow and Meng discuss the barriers to the use of polypills and focus in detail on the use of fixed-dose combination pills containing low doses of multiple blood pressure-lowering drugs.

Fixed-dose combination (FDC) therapy may provide a solution to treatment gaps by overcoming reasons for therapeutic inertia. To synthesise and report on available evidence on standard or low-dose combination medicines that combine at least three antihypertensive medicines. A literature search was conducted via Scopus, Embase, PubMed and the Cochrane clinical trials database. Studies were eligible for inclusion if they were randomised clinical trials that included adults (>18 years) and examined the impact of at least three antihypertensive medications on blood pressure (BP). A total of 18 trials (n=14 307) were identified that examined combinations of three or four antihypertensive medicines. Ten trials investigated the effect of a standard dose triple combination polypill, four the effect of a low-dose triple and four the effect of a low-dose quadruple combination polypill. The mean difference (MD) in systolic BP ranged from −10.6 to −41.4 for the standard dose triple combination polypill in comparison with 2.1 to −34.5 for dual combination; −9.8 to −20.6 for a low-dose combination polypill in comparison with a MD of −0.9 to −5.2 for placebo; −9.0 to −29.3 for a low-dose combination polypill compared with −2.0 to −20.6 for monotherapy or usual care. All trials reported similar rates of adverse events. Ten studies reported medication adherence, six reported >95% adherence. Triple and quadruple combination antihypertensive medications are effective. Studies of low-dose triple and quadruple combinations involving treatment naïve populations suggest initiating such combinations are safe and effective as first-line therapy for stage 2 hypertension (BP >140/90 mm Hg).

BackgroundDietary modification is a cornerstone of cardiovascular disease (CVD) prevention. A Mediterranean diet has been associated with a lower risk of CVD but no systematic reviews have evaluated this relationship specifically in women.ObjectiveTo determine the association between higher versus lower adherence to a Mediterranean diet and incident CVD and total mortality in women.MethodsA systematic search of Medline, Embase, CINAHL, Scopus, and Web of Science (2003–21) was performed. Randomised controlled trials and prospective cohort studies with participants without previous CVD were included. Studies were eligible if they reported a Mediterranean diet score and comprised either all female participants or stratified outcomes by sex. The primary outcome was CVD and/or total mortality. A random effects meta-analysis was conducted to calculate pooled hazard ratios (HRs) and confidence intervals (CIs).ResultsSixteen prospective cohort studies were included in the meta-analysis (n=7 22 495 female participants). In women, higher adherence to a Mediterranean diet was associated with a lower CVD incidence (HR 0.76, 95% CI 0.72 to 0.81; I2=39%, p test for heterogeneity=0.07), total mortality (HR 0.77, 95% CI 0.74 to 0.80; I2=21%, p test for heterogeneity=0.28), and coronary heart disease (HR 0.75, 95% CI 0.65 to 0.87; I2=21%, p test for heterogeneity=0.28). Stroke incidence was lower in women with higher Mediterranean diet adherence (HR 0.87, 95% CI 0.76 to 1.01; I2=0%, p test for heterogeneity=0.89), but this result was not statistically significant.ConclusionThis study supports a beneficial effect of the Mediterranean diet on primary prevention of CVD and death in women, and is an important step in enabling sex specific guidelines.

Conversational artificial intelligence (AI) allows for engaging interactions, however, its acceptability, barriers, and enablers to support patients with atrial fibrillation (AF) are unknown. This work stems from the Coordinating Health care with AI-supported Technology for patients with AF (CHAT-AF) trial and aims to explore patient perspectives on receiving support from a conversational AI support program. Patients with AF recruited for a randomized controlled trial who received the intervention were approached for semistructured interviews using purposive sampling. The 6-month intervention consisted of fully automated conversational AI phone calls (with speech recognition and natural language processing) that assessed patient health and provided self-management support and education. Interviews were recorded, transcribed, and thematically analyzed. We conducted 30 interviews (mean age 65.4, SD 11.9 years; 21/30, 70% male). Four themes were identified: (1) interaction with a voice-based conversational AI program (human-like interactions, restriction to prespecified responses, trustworthiness of hospital-delivered conversational AI); (2) engagement is influenced by the personalization of content, delivery mode, and frequency (tailoring to own health context, interest in novel information regarding health, overwhelmed with large volumes of information, flexibility provided by multichannel delivery); (3) improving access to AF care and information (continuity in support, enhancing access to health-related information); (4) empowering patients to better self-manage their AF (encouraging healthy habits through frequent reminders, reassurance from rhythm-monitoring devices). Although conversational AI was described as an engaging way to receive education and self-management support, improvements such as enhanced dialogue flexibility to allow for more naturally flowing conversations and tailoring to patient health context were also mentioned. Australian New Zealand Clinical Trials Registry ACTRN12621000174886; https://tinyurl.com/3nn7tk72. RR2-10.2196/34470.