Adult childhood cancer survivors' narratives of managing their health: the unexpected and the unresolved

Surveillance after childhood cancer: are survivors with an increased risk for cardiomyopathy regularly followed-up?

BACKGROUND

We aimed to study adherence to cardiac screening in long-term childhood cancer survivors (CCS) at high risk of cardiomyopathy.

METHODS

This study involved 976 5-year CCS at high risk for cardiomyopathy from the French Childhood Cancer Survivor Study. Determinants of adherence to recommended surveillance were studied using multivariable logistic regression models. Association of attendance to a long-term follow-up (LTFU) visit with completion of an echocardiogram was estimated using a Cox regression model.

RESULTS

Among participants, 32% had an echocardiogram within the 5 previous years. Males (adjusted RR [aRR] 0.71, 95% CI 0.58-0.86), survivors aged 36-49 (aRR 0.79, 95% CI 0.64-0.98), Neuroblastoma (aRR 0.53, 95% CI 0.30-0.91) and CNS tumour survivors (aRR 0.43, 95% CI 0.21-0.89) were less likely to adhere to recommended surveillance. Attendance to an LTFU visit was associated with completion of an echocardiogram in patients who were not previously adherent to recommendations (HR 8.20, 95% CI 5.64-11.93).

CONCLUSIONS

The majority of long-term survivors at high risk of cardiomyopathy did not adhere to the recommended surveillance. Attendance to an LTFU visit greatly enhanced the completion of echocardiograms, but further interventions need to be developed to reach more survivors.

Hodgkin lymphoma survivor perspectives on their engagement in treatment decision-making and discussion of late effects

BACKGROUND

Hodgkin lymphoma has a bimodal age distribution with the first peak occurring within young adulthood and the second, among older adults. Although current therapy provides excellent disease control, survivors are at risk of developing treatment-related late effects (LEs). We sought to understand how survivors in active survivorship care perceived their role in treatment decision-making and when they acquired an understanding of LEs.

METHODS

Semi-structured interviews were conducted until saturation was reached. Themes were identified through direct content analysis and consensus coding by a multidisciplinary team of coders, including hematology/oncology providers, patient navigators, and survivor stakeholders.

RESULTS

Seventeen interviews were conducted. Role in initial treatment decision-making fluctuated between passive and active engagement with providers identified as being crucial to this process. Half of interviewees (53%) expressed unmet information needs. Survivors reported having learned about LEs at multiple time points, spanning from before treatment commenced through when a LE was diagnosed. The majority (71%) expressed a desire to have learned about LEs before initial treatment ended. The impact of cancer and fertility discussions were also disclosed.

DISCUSSION

Participants highlighted the importance of discussions on LEs early in the care continuum. These preliminary data will be incorporated in a planned treatment decision-making tool that incorporates information on potential LEs.

IMPLICATIONS FOR CANCER SURVIVORS

Patient-centered communication approaches should be embraced to assist in treatment decision-making, while considering long-term health consequences. Survivors must be educated on their risk of LEs and encouraged to disclose their perspectives and preferences with their providers to optimize outcomes.

A qualitative study of young childhood cancer survivors and their parents' experiences with treatment-related late effects in everyday life post-treatment

AIMS

The purpose of this secondary analysis was to explore how young cancer survivors and their parents experience and manage treatment-related late effects in daily life post-treatment.

DESIGN

A phenomenological-hermeneutic explorative study.

METHODS

Using purposive sampling, we included 15 childhood cancer survivors (aged 11-18 years) and their parents who participated in semi-structured interviews from September 2019 through May 2020. We analysed the interviews paired using a thematic approach focused on meaning.

RESULTS

The central theme, 'Negotiation daily life', emerged as well as three interrelated sub-themes, that is 'A changed everyday life', 'Physical activity as a tool' and 'Friends as a tool'. The childhood cancer survivors and their parents experienced, understood and interpreted the late effects differently. The difference between the survivors' perceptions and those of their parents in managing treatment-related late effects in everyday life resulted in a continuous negotiation process between the parties. Parents highlighted the negative impact of late effects on their child's daily life in relation to physical activity, school and socialization while the survivors wished to leave the cancer experience behind and 'move on' with their friends. As a result, most of the survivors developed strategies to manage their social activities while their parents felt that the survivors neglected the late effects.

CONCLUSION

The ongoing negotiation process between the childhood cancer survivors and their parents show the complexity of the new family dynamics on returning to everyday life post-treatment. For clinical nurses, that means that there should be focus on family dynamics and how the childhood cancer survivors and parents, respectively, manage the childhood cancer survivors' late effects.

IMPACT

Healthcare providers should distinguish between the needs of the survivors and those of their parents as they transition from treatment to everyday life, and especially in the management of late effects caused by the treatment.

Persistent Symptoms, Quality of Life, and Correlates with Health Self-Efficacy in Adolescent and Young Adult Survivors of Childhood Cancer

Purpose: The numbers of adolescent and young adult (AYA) survivors of childhood cancer are exponentially growing. To ensure suitable services are available to meet the needs of this growing population, understanding the experience of late effects, quality of life, and potentially modifiable factors, such as self-efficacy, is required. Methods: AYA survivors of childhood cancer recruited through an After Cancer Therapy Service at a Children's Hospital rated their symptoms experience, quality of life, and self-efficacy using the Patient Reported Outcome Common Terminology Criteria for Adverse Events, Functional Assessment of Cancer Therapy-General (FACT-G), and Patient-Reported Outcomes Measurement Information System (PROMIS^®), respectively. Descriptive statistics were used to characterize the sample. Quality-of-life scores were compared with population norms. Regression analyses were used to explore the relationships between symptom experience, quality of life, and self-efficacy. Results: Thirty participants (mean age 22 ± 4.4 years) reported an average of nine symptoms as persistently experienced at moderate or higher rated intensity among participants (standard deviation ±8.7; range: 0-32; interquartile range: 2-16); over half (n = 17, 56.7%) had finished treatment 10 or more years ago. Participants scored lower on the FACT-G Physical Well-being and Emotional Well-being, and higher on Social Well-being subscales than the general population. Around two-thirds of participants were confident in their ability to self-manage their health based on their health self-efficacy score. Bivariate linear regression identified a statistically significant increase in the overall quality of life with increased self-efficacy, adjusted for age and sex (0.60, 95% confidence interval [CI] 0.30-0.90, p < 0.01). Higher symptom burden was associated with a lower overall quality of life after adjusting for age and sex (-0.95, 95% CI: -1.35 to -0.54, p < 0.001). Conclusion: Young cancer survivors experience a substantial number of persistent symptoms related to their cancer treatment that may negatively impact aspects of their quality of life. Health self-efficacy is a potential target for future interventions.

"I have to do things differently now, but I make it work"-young childhood cancer survivors' experiences of self-management in everyday living

PURPOSE

Living with late effects can affect young childhood cancer survivors' (CCSs) self-management (SM) abilities. In this study, we explored different approaches to SM of everyday life by young CCS.

METHODS

This is a sub-study of a larger study on Physical Activity among Childhood Cancer Survivors (the PACCS study). We conducted individual interviews with 22 CCS aged 9 to 18 years who were at least 1 year off-treatment. An hybrid inductive-decductive thematic analysis was used.

RESULTS

Three main themes were identified: (1) managing everyday life with fatigue, (2) building self-management competence, and (3) cancer survivor as part of identity. Late effects, especially fatigue, contributed to a perceived ability gap compared to peers, limiting participation in everyday activities. CCS developed new SM skills to overcome such challenges and pushed themselves physically and mentally to master and balance activities and rest to regain energy. CCS changed activities, adapted their expectations, or legitimized their apparent lack of SM skills to regain a sense of self-efficacy. Managing the impact of cancer on relationships with family and friends also required use of SM strategies.

CONCLUSIONS

The findings expand our currently limited knowledge of young CCS and SM skills they develop to manage everyday life after treatment completion. These, combined with ongoing support from family and peers, "make it work".

IMPLICATIONS FOR CANCER SURVIVORS

The perspectives of young CCS illustrate their SM skills and support needs beyond transitioning off-treatment. Conceptualizing this within follow-up care may contribute to a feeling of mastery and increased satisfaction among CCS.

Determinants of surveillance for late effects in childhood cancer survivors: a qualitative study using the Theoretical Domains Framework

PURPOSE

Most adult survivors of childhood cancer do not complete the recommended surveillance tests for late effects of their treatment. We used a theory-informed method to elucidate the barriers and enablers among childhood cancer survivors to accessing such tests.

METHODS

Semi-structured interviews were completed with adult survivors of childhood cancer. Participants were eligible for the surveillance tests of interest (echocardiogram, mammogram/breast MRI and/or colonoscopy) but had not attended a specialised aftercare clinic in over five years. The Theoretical Domains Framework (TDF), a tool specifically developed for implementation research to identify influences on desired behaviour(s), informed the interview guide and analysis; interview transcripts were coded line-by-line and mapped to domains in accordance with the framework.

RESULTS

Thirty childhood cancer survivors were interviewed (ages 25-60). The TDF domains described by survivors included: intention to complete the tests, which was facilitated by the fear of another cancer (emotion), confidence in the benefits of early detection (beliefs about consequences), and supportive reminders (memory, attention, and decision-making). In contrast, a lack of knowledge of late effects and relevant guidelines and the burden of arranging tests (social identity) were key barriers.

CONCLUSION

Interventions seeking to increase surveillance testing for late effects may be more effective if they feature components that explicitly address all the theory-informed determinants identified.

IMPLICATIONS FOR CANCER SURVIVORS

Awareness about the recommendations among survivors and their physicians is a necessary (but likely not sufficient) step towards implementation of guidelines regarding surveillance for late effects.

Cancer survivors' perspectives of dietary information provision after cancer treatment: A scoping review of the Australian context

ISSUE ADDRESSED

To support survivor-centred care in Australia, this review maps current knowledge regarding adult cancer survivors' perspectives of dietary information provision post-treatment.

METHODS

A scoping review of research conducted in Australia within the past decade reported using PRISMA-ScR guidelines. Seven databases were searched (01/01/2009-05/06/2020) and records were independently screened by two researchers using eligibility criteria. Papers in the peer-reviewed literature with dietary information post-treatment as a primary and secondary outcome were eligible for inclusion. Data charting included participant characteristics, study methodology and cancer survivors' reports of dietary information provision post-treatment.

RESULTS

Of 531 records identified, 12 met eligibility criteria. Most studies included breast (58%) and colorectal (42%) cancer survivors within 5 years post-diagnosis (84%). Three studies were conducted amongst specific ethnic groups (Indigenous Australians, Chinese-Australians, Greek-Australians). Participants in the included studies commonly reported limited or ineffective dietary information from healthcare providers post-treatment. Cancer survivors identified a need for individualised information regarding dietary strategies to manage ongoing symptoms, professional support for weight management, and practical skills for healthy eating. Amongst ethnic groups, there was a need for dietary information that considers traditional foods and cultural beliefs, and is available in their native language. Cancer survivors valued ongoing dietary follow-up and support post-treatment, and suggested a variety of face-to-face and online delivery modes. Those residing in rural and remote areas reported barriers to accessing dietary information post-treatment including time, cost, and availability of local services.

CONCLUSIONS

There is scope to improve dietary information provision after cancer treatment in Australia. SO WHAT?: Dietary guidance post-treatment should consider individual needs, cultural background, and opportunity for ongoing follow-up and support.

Identifying and exploring the self-management strategies used by childhood cancer survivors

PURPOSE

Childhood cancer survivors (CCSs) are at increased risk of chronic health problems. Effective self-management could help CCSs cope with the challenges that accompany survivorship and reduce their risk of developing further health problems. There is little evidence about the extent to which CCSs engage with self-management and the specific strategies they use. This study aimed to identify and explore the strategies that CCSs use to manage the consequences of cancer.

METHODS

Twenty-four CCSs were recruited via follow-up clinics. Participants completed a semi-structured interview which was audio-recorded and transcribed. Directed content analysis was used to identify self-reported self-management strategies and categorise them into main self-management types.

RESULTS

CCSs reported 118 specific self-management strategies which fell under 20 main self-management strategy types. All CCSs reported using several main self-management strategy types and specific self-management strategies. Main strategy types used by all CCSs were "adopting a healthy lifestyle", "self-motivating", "using support", "reasoned decision-making" and "creating a healthy environment". The most common specific self-management strategies were "receiving family support" (n = 20) and "attending follow-up and screening appointments" (n = 20).

CONCLUSIONS

This is the first study which has enabled CCSs to self-report the numerous strategies they employ to look after their health and well-being, contributing to a more comprehensive picture of self-management in CCSs.

IMPLICATIONS FOR CANCER SURVIVORS

These findings may increase healthcare professionals' awareness of the many ways in which CCSs manage their health and is a valuable first step in the development of a supported self-management intervention for CCSs in follow-up care.

Telling the Story of Childhood Cancer-The Experience of Families After Treatment

Background:

The Discovery Interview methodology was introduced to Oncology Services Group in 2012 as a service improvement strategy and was evaluated positively by staff and families. It enabled clinical staff to hear the deidentified families’ stories, understand their experience, and implement process and practice enhancements.

Objective:

This study collected family stories following treatment for childhood cancer at the tertiary center in Queensland, with the goal of raising awareness and improving family experience.

Method:

Twenty-five families were interviewed via an interview spine which covered the major stages of cancer treatment and themes were extracted.

Results:

Major themes were psychological support needs, adapting to the new normal, and rebuilding relationships. After treatment, the parent had time to reflect on their experience and lost the reassurance of regularly attending the tertiary hospital. There was ongoing anxiety regarding relapse. Parents reported various coping strategies and some wanted to maintain contact with other oncology families. Families strived to get back to a level of normality such as attending school and experienced some challenges in relationships with family and friends.

Conclusion:

Families needed support and reassurance from their local health professionals to navigate the ongoing challenges following treatment.

Psychosocial Late Effects in Adolescent and Young Adult Survivors of Childhood Cancer Diagnosed with Leukemia, Lymphoma, and Central Nervous System Tumor

Purpose: The prevalence of psychosocial late effects and quality of life in adolescent and young adult (AYA)-aged survivors of pediatric cancer have been studied. Methods: The study was conducted in AYA survivors who had been diagnosed with leukemia, lymphoma, or brain tumor, had completed treatment at least 1 year before the study, and were 15-39 years old at study enrollment. The control group consisted of healthy volunteers. A questionnaire comprised a demographic form, eight questions concerning mental health and the disease, and survey The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30. Controls received a questionnaire without questions concerning an illness. Results: Most of survivors believed that cancer treatment might have a serious influence on their health. Survivors significantly more frequently declared using drugs: neuroleptics, tranquilizers, and antidepressants than controls. Survivors of leukemia demonstrated significantly more problems in cognitive functioning than lymphoma survivors. Females were significantly more disabled in emotional functioning than males. Young adults more often reported dysfunction in emotional functioning compared to adolescents. Survivors who were assessed ≥10 years since therapy reported significantly more disadvantage in social functioning than those assessed <10 years since treatment completion. Survivors reported significantly more disadvantages in social functioning than controls. Allogeneic hematopoietic stem cell transplantation survivors more often suffered cognitive limitations. Irradiated survivors more often attended psychological therapy. Conclusions: Survivors of pediatric cancer are vulnerable to consequences of oncological treatment, making their quality life significantly worse in comparison with healthy controls. They need to be monitored, supported, and educated.

Survivor clinic attendance among pediatric- and adolescent-aged survivors of childhood cancer

PURPOSE

Childhood cancer survivors need regular, risk-adapted, long-term survivor care. This retrospective study describes the proportion of survivors seen for an initial survivor clinic visit within a large pediatric oncology program.

METHODS

Patients diagnosed with non-central nervous system childhood malignancies from 2007 to 2012 were followed from the time of survivor clinic eligibility (2 years following completion of therapy) through their initial survivor clinic visit or end of study. Demographic, cancer-related, and logistical factors related to clinic attendance were examined using Kaplan-Meier curves and Cox proportional regressions.

RESULTS

Eligible survivors were 53.0% male, 51.5% non-Hispanic white, and 30.9% survivors of leukemia. Among the 866 eligible survivors for this study, 610 (70.4%) completed their initial visit. After controlling for sex and time eligible, survivors who received surgery only (aHR 0.04 (0.02, 0.08)) or radiation only (0.24 (0.15, 0.39)) and who had Medicaid (0.77 (0.64, 0.92)) were significantly less likely to have an initial visit as were those of black or other/mixed race and those who lived > 25 mi from the clinic (p < 0.01). Survivors aged 6-11 years or 12-17 years at eligibility were significantly more likely to complete an initial visit as compared to those aged 2-5 years (1.55 (1.24, 1.93) and 1.44 (1.14, 1.83), respectively).

CONCLUSIONS

Nearly a third of survivors were not seen in a pediatric survivor clinic despite the importance of survivor care. These results identify populations at risk for not pursuing long-term survivorship care.

IMPLICATIONS FOR CANCER SURVIVORS

Failure to transition to pediatric survivor care may lead to lifelong non-engagement and incorrect perceptions about future health.

Adolescent and young adult cancer survivors narrate their stories: Predictive model of their personal growth and their follow-up acceptance

PURPOSE

Few studies have captured the unique ways in which cancer affects the growth and development of adolescent and young adult cancer survivors. This paper illustrates the daily life of childhood cancer survivors who are now adolescents and young adults, their post-traumatic growth and follow-up perceptions, adopting a narrative approach.

METHODS

One thousand adolescent and young adult cancer survivors, mean age at diagnosis being 9.26 years old (SD = 4.29) and current mean age of 19.28 (SD = 2.96), were interviewed in depth using a new version of Ecocultural Family Interview-Cancer (EFI-C), which has proved to be a psychometrically reliable instrument.

RESULTS

Post-traumatic growth was predicted directly by age at diagnosis and, indirectly, by the mediation of the health medical staff-patient relationship during the illness, hospitalization memories, and patient's narrating skills. Positive feelings towards follow-up visits were predicted by the health staff-patient relationship during the illness (Chi-Square = 2.87; df = 3, p-value = 0.41; RMSEA = 0.0001).

CONCLUSION

Adolescent and young adult cancer survivors who were older and had established strong relationships with health professionals at the clinic were more able to narrate their experiences, display a positive comprehension of the events with a pragmatic acceptance of the follow-up procedures. Relationships with health professionals should therefore be monitored and improved, both during the cancer treatment and in the off-therapy period. The narrative technique allows adolescent and young adult cancer survivors to reorganize and give shape to their traumatic experience.

Healthcare system barriers to long-term follow-up for adult survivors of childhood cancer in British Columbia, Canada: a qualitative study

PURPOSE

Risk-stratified life-long follow-up care is recommended for adult childhood cancer survivors (CCS) to ensure appropriate prevention, screening, and management of late effects. The identification of barriers to long-term follow-up (LTFU), particularly in varying healthcare service contexts, is essential to develop and refine services that are responsive to survivor needs. We aimed to explore CCS and healthcare professionals (HCP) perspectives of healthcare system factors that function as barriers to LTFU in British Columbia, Canada.

METHODS

We analyzed data from 43 in-depth interviews, 30 with CCS and 13 with HCP, using qualitative thematic analysis and constant comparative methods.

RESULTS

Barriers to accessible, comprehensive, quality LTFU were associated with the following: (1) the difficult and abrupt transition from pediatric to adult health services, (2) inconvenient and under-resourced health services, (3) shifting patient-HCP relationships, (4) family doctor inadequate experience with late effects management, and (5) overdue and insufficient late effects communication with CCS.

CONCLUSIONS

Structural, informational, and interpersonal/relational healthcare system factors often prevent CCS from initially accessing LTFU after discharge from pediatric oncology programs as well as adversely affecting engagement in ongoing screening, surveillance, and management of late effects.

IMPLICATIONS FOR CANCER SURVIVORS

Understanding the issues faced by adult CCS will provide insight necessary to developing patient-centered healthcare solutions that are key to accessible, acceptable, appropriate, and effective healthcare.

"It's Not JUST Skin Cancer": Understanding Their Cancer Experience From Melanoma Survivor Narratives Shared Online

Cancer survivors narrate their experiences in unique ways, articulating different aspects of the cancer journey. The purpose of this study was to analyze the content of cancer narratives that melanoma survivors share online in order to present the ways that survivors narrate their cancer experience, to identify survivors' motivations for sharing, and to better understand the ways in which survivors are impacted by and cope with the diagnosis and treatment of cancer. The sample consisted of 95 unique melanoma survivor narratives, accessed from the Melanoma Research Foundation in November 2015, that were inductively and deductively coded for key themes and subthemes. Emergent themes described different aspects of the melanoma experience during prediagnosis (identification of self-phenotype, searching for causes, suspicious findings, delay in diagnosis), diagnosis (communication of diagnosis, emotional responses), transition from diagnosis to beginning treatment (second opinion), treatment (positive reframing of attitude, proactive cancer management, side effects), and posttreatment phases (social support, vigilance behaviors posttreatment). Two themes that cut across all phases of the cancer journey included recognizing and dealing with uncertainty and survivors' motive for sharing narrative. These findings have implications for understanding how melanoma survivors may benefit personally from sharing their cancer experience online and for the potential for survivor narratives to motivate behavior change and facilitate coping among readers.

Feasibility and Acceptability of a Web Site to Promote Survivorship Care in Survivors of Hodgkin Disease

PURPOSE

Evaluate rates of enrollment, completion, and patient-reported acceptability of an educational survivorship-care Web site for survivors of Hodgkin disease (HD).

PATIENTS AND METHODS

The study was a mixed-method evaluation design. Eligible participants were adults who had completed treatment of a primary diagnosis of HD ≥ 2 years before enrollment. Patients were recruited through postal mail and telephone and were asked to review a Web site, complete an adapted version of the Acceptability E-scale (total score of 24 or greater indicates acceptability), and respond to a structured telephone or e-mail interview to discuss experiences with the Web site.

RESULTS

Of 259 potentially eligible participants identified by medical record review, 124 survivors had confirmed contact with study staff and were invited to participate; 63 people (50.8%; 90% CI, 43% to 59%) enrolled; 37 participants (58.7%) were men. The median age at time of enrollment was 51.0 years (range, 29.3 to 80.0 years), and the median time since completion of treatment of HD was 14.9 years (range, 3 to 38.75 years). Overall, 82.5% of those enrolled viewed all Web site content. Forty-eight participants completed the acceptability survey, which resulted in a mean acceptability score of 26.5 (standard deviation, 3.5). The majority of enrollees (67%) completed a follow-up interview.

CONCLUSION

Overall, HD survivor participants viewed the content and reviewed it favorably. A Web-based intervention is a promising way to provide survivors of HD with information about how to manage the long-term and late effects from cancer and treatment, and provide trusted survivorship resources.

The Quality of Working Life Questionnaire for Cancer Survivors (QWLQ-CS): a Pre-test Study

Background

Returning to and continuing work is important to many cancer survivors, but also represents a challenge. We know little about subjective work outcomes and how cancer survivors perceive being returned to work. Therefore, we developed the Quality of Working Life Questionnaire for Cancer Survivors (QWLQ-CS). Our aim was to pre-test the items of the initial QWLQ-CS on acceptability and comprehensiveness. In addition, item retention was performed by pre-assessing the relevance scores and response distributions of the items in the QWLQ-CS.

Methods

Semi-structured interviews were conducted after cancer survivors, who had returned to work, filled in the 102 items of the QWLQ-CS. To improve acceptability and comprehensiveness, the semi-structured interview inquired about items that were annoying, difficult, confusing, twofold or redundant. If cancer survivors had difficulty explaining their opinion or emotion about an item, the interviewer used verbal probing technique to investigate the cancer survivor’s underlying thoughts. The cancer survivors’ comments on the items were analysed, and items were revised accordingly. Decisions on item retention regarding the relevance of items and the response distributions were made by means of pre-set decision rules.

Results

The 19 cancer survivors (53 % male) had a mean age of 51 ± 11 years old. They were diagnosed between 2009 and 2013 with lymphoma, leukaemia, prostate cancer, breast cancer, or colon cancer. Acceptability of the QWLQ-CS was good - none of the items were annoying - but 73 items were considered difficult, confusing, twofold or redundant. To improve acceptability, for instance, the authors replaced the phrase ‘disease’ with ‘health situation’ in several items. Consequently, comprehensiveness was improved by the authors rephrasing and adjusting items by adding clarifying words, such as ‘in the work situation’. The pre-assessment of the relevance scores resulted in a sufficient number of cancer survivors indicating the items as relevant to their quality of working life, and no evident indication for uneven response distributions. Therefore, all items were retained.

Conclusions

The 104 items of the preliminary QWLQ-CS were found relevant, acceptable and comprehensible by cancer survivors who have returned to work. The QWLQ-CS is now suitable for larger sample sizes of cancer survivors, which is necessary to test the psychometric properties of this questionnaire.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1440-4) contains supplementary material, which is available to authorized users.