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Nelson D, Selby P, Kane R, Harding-Bell A, Kenny A, McPeake K, Cooke S, Hogue T, Oliver K, Gussy M, Lawler M. Implementing the European code of cancer practice in rural settings. J Cancer Policy 2024; 39:100465. [PMID: 38184144 DOI: 10.1016/j.jcpo.2023.100465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 12/08/2023] [Accepted: 12/21/2023] [Indexed: 01/08/2024]
Abstract
Existing evidence often indicates higher cancer incidence and mortality rates, later diagnosis, lower screening uptake and poorer long-term survival for people living in rural compared to more urbanised areas. Despite wide inequities and variation in cancer care and outcomes across Europe, much of the scientific literature explicitly exploring the impact of rurality on cancer continues to come from Australia and North America. The European Code of Cancer Practice or "The Code" is a citizen and patient-centred statement of the most salient requirements for good clinical cancer practice and has been extensively co-produced by cancer patients, cancer professionals and patient advocates. It contains 10 key overarching Rights that a cancer patient should expect from their healthcare system, regardless of where they live and has been strongly endorsed by professional and patient cancer organisations as well as the European Commission. In this article, we use these 10 fundamental Rights as a framework to argue that (i) the issues and needs identified in The Code are generally more profound for rural people with cancer; (ii) addressing these issues is also more challenging in rural contexts; (iii) interventions and support must explicitly account for the unique needs of rural residents living with and affected by cancer and (iv) new innovative approaches are urgently required to successfully overcome the challenges faced by rural people with cancer and their caregivers. Despite equitable healthcare being a key European policy focus, the needs of rural people living with cancer have largely been neglected.
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Affiliation(s)
- David Nelson
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK; Macmillan Cancer Support, London, UK.
| | - Peter Selby
- Faculty of Medicine and Health, University of Leeds, Leeds, UK; Lincoln Medical School, Universities of Nottingham and Lincoln, Lincoln, UK
| | - Ros Kane
- School of Health and Social Care, University of Lincoln, Lincoln, UK
| | | | - Amanda Kenny
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK; La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - Kathie McPeake
- Macmillan Cancer Support, London, UK; NHS Lincolnshire Integrated Care Board, Sleaford, UK
| | - Samuel Cooke
- School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Todd Hogue
- School of Psychology, University of Lincoln, Lincoln, UK
| | | | - Mark Gussy
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK; La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - Mark Lawler
- Patrick G Johnston Centre for Cancer Research, Faculty of Medicine, Health and Life Sciences, Queens University Belfast, Belfast, UK
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Cavanna L, Citterio C, Mordenti P, Proietto M, Bosi C, Vecchia S. Cancer Treatment Closer to the Patient Reduces Travel Burden, Time Toxicity, and Improves Patient Satisfaction, Results of 546 Consecutive Patients in a Northern Italian District. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2121. [PMID: 38138224 PMCID: PMC10744793 DOI: 10.3390/medicina59122121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/20/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: The distance to cancer facilities may cause disparities by creating barriers to oncologic diagnosis and treatment, and travel burden may cause time and financial toxicity. Materials and Methods: To relieve travel burden, a program to deliver oncologic treatment closer to the patient was initiated in the district of Piacenza (Northern Italy) several years ago. The oncologic activities are performed by oncologists and by nurses who travel from the oncologic ward of the city hospital to territorial centres to provide cancer patient management. This model is called Territorial Oncology Care (TOC): patients are managed near their home, in three territorial hospitals and in a health centre, named "Casa della Salute" (CDS). A retrospective study was performed and the records of patients with cancer managed in the TOC program were analysed. The primary endpoints were the km and time saved, the secondary endpoints: reduction of caregiver need for transport and patient satisfaction. Results: 546 cancer patients managed in the TOC program from 2 January 2021 to 30 June 2022 were included in this study. Primary endpoints: median km to reach the city hospital: 26 (range 11-79 km) median time: 44 min (range 32-116); median km to reach the territorial clinicians in the TOC program: 7 (range 1-35 km), median time: 16 minutes (range 6-54), p < 0.001. Secondary endpoints: 64.8% of patients who needed a caregiver for the city hospital could travel alone in the TOC program and 99.63% of patients were satisfied. Conclusions: The results of this retrospective study highlight the possibility of treating cancer patients near their residence, reducing travel burden and saving time.
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Affiliation(s)
- Luigi Cavanna
- Casa di Cura Piacenza, Internal Medicine and Oncology, Via Morigi 3, 29121 Piacenza, Italy
| | - Chiara Citterio
- Department of Oncology and Hematology, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy; (C.C.); (P.M.); (M.P.); (C.B.)
| | - Patrizia Mordenti
- Department of Oncology and Hematology, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy; (C.C.); (P.M.); (M.P.); (C.B.)
| | - Manuela Proietto
- Department of Oncology and Hematology, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy; (C.C.); (P.M.); (M.P.); (C.B.)
| | - Costanza Bosi
- Department of Oncology and Hematology, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy; (C.C.); (P.M.); (M.P.); (C.B.)
| | - Stefano Vecchia
- Pharmacy Unit, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy;
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Limited Health Literacy and Its Associated Health Outcomes Among Adults With at Least 2 Atopic Diseases. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1429-1438.e6. [PMID: 36634845 DOI: 10.1016/j.jaip.2022.12.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Health literacy (HL) is essential for patients with multiple atopic diseases to improve their health, given the complexity of their disease and treatment regimens. OBJECTIVE To estimate the proportion of adults with multiple atopic diseases (at least 2 of atopic dermatitis, asthma, allergic rhinitis, and food allergy) in the Dutch general population and to evaluate the prevalence of limited HL, and its association with socioeconomic status (SES), lifestyle factors, and health-related quality of life (HR-QoL) in this patient population. METHODS This cross-sectional study was conducted within the Lifelines Cohort Study via sending an add-on digital questionnaire, including (among others) questions on atopic dermatitis, to all adult participants (n = 135,950) between February and May 2020. Data on asthma, allergic rhinitis, lifestyle factors, HR-QoL, and SES were extracted from baseline assessment between 2006 and 2013. Functional, communicative, and critical HL were measured by validated items from Chew and the Dutch Functional Communicative and Critical Health Literacy questionnaires between 2012 and 2016. Food allergy was measured by the Food Allergy Questionnaire between 2014 and 2016. RESULTS In total, 11.8% of the overall study population reported ever having multiple atopic diseases; of those, 23.6% reported having limited functional HL, with a higher prevalence among those with a low SES. Limited functional HL showed positive associations with smoking, obesity, chronic stress, a low diet quality, and decreased HR-QoL among subjects with multiple atopic diseases. CONCLUSIONS We identified an HL deficit, and its association with a low SES and poor health outcomes among patients with multiple atopic diseases. Further research is warranted to utilize a more extensive assessment to measure HL and include more health outcomes, such as treatment adherence and disease control.
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Bhatia S, Landier W, Paskett ED, Peters KB, Merrill JK, Phillips J, Osarogiagbon RU. Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research. J Natl Cancer Inst 2022; 114:940-952. [PMID: 35148389 PMCID: PMC9275775 DOI: 10.1093/jnci/djac030] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/27/2021] [Accepted: 02/01/2022] [Indexed: 01/12/2023] Open
Abstract
Cancer care disparities among rural populations are increasingly documented and may be worsening, likely because of the impact of rurality on access to state-of-the-art cancer prevention, diagnosis, and treatment services, as well as higher rates of risk factors such as smoking and obesity. In 2018, the American Society of Clinical Oncology undertook an initiative to understand and address factors contributing to rural cancer care disparities. A key pillar of this initiative was to identify knowledge gaps and promote the research needed to understand the magnitude of difference in outcomes in rural vs nonrural settings, the drivers of those differences, and interventions to address them. The purpose of this review is to describe continued knowledge gaps and areas of priority research to address them. We conducted a comprehensive literature review by searching the PubMed (Medline), Embase, Web of Science, and Cochrane Library databases for studies published in English between 1971 and 2021 and restricted to primary reports from populations in the United States and abstracted data to synthesize current evidence and identify continued gaps in knowledge. Our review identified continuing gaps in the literature regarding the underlying causes of rural-urban disparities in cancer outcomes. Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients without directed effort to understand and address barriers to high-quality care in these areas. Research should be prioritized to address ongoing knowledge gaps about the drivers of rurality-based disparities and preventative and corrective interventions.
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Affiliation(s)
- Smita Bhatia
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Wendy Landier
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
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Consequences of Structural Urbanism: Urban-Rural Differences in Cancer Patients' Use and Perceived Importance of Supportive Care Services from a 2017-2018 Midwestern Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063405. [PMID: 35329094 DOI: 10.3390/ijerph19063405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Structural inequities, in part, undergird urban-rural differences in cancer care. The current study aims to understand the potential consequences of structural inequities on rural and urban cancer patients' access to and perceived importance of supportive cancer care resources. METHODS We used data collected from November 2017 to May 2018 from a larger cross-sectional needs assessment about patients' support needs, use of services, and perceptions at a Midwestern United States cancer center. Oncology patients received a study packet during their outpatient clinic visit, and interested patients consented and completed the questionnaires. RESULTS Among the sample of 326 patients, 27% of the sample was rural. In adjusted logistic regression models, rural patients were less likely to report using any secondary support services (15% vs. 27%; OR = 0.43, 95%CI [0.22, 0.85], p = 0.02) and less likely than urban counterparts to perceive secondary support services as very important (51% vs. 64%; OR = 0.57, 95%CI [0.33, 0.94], p = 0.03). CONCLUSION Structural inequities likely have implications on the reduced access to and importance of supportive care services observed for rural cancer patients. To eliminate persistent urban-rural disparities in cancer care, rural residents must have programs and policies that address cancer care and structural inequities.
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Kruse-Diehr AJ, Lewis-Thames MW, Wiedenman E, James A, Chambers L. Perspectives of cancer prevention and control resources from stakeholders in rural southern Illinois. J Rural Health 2022; 38:398-408. [PMID: 34143906 PMCID: PMC8683572 DOI: 10.1111/jrh.12606] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE Rural residents have a higher cancer burden than urban residents, which is likely related to multiple socioecological factors. This study sought to investigate the perspectives of a diverse set of rural stakeholders regarding access to cancer prevention and control resources in rural southern Illinois. METHODS Stakeholders were recruited from counties in southern Illinois and included residents (cancer survivors or caregivers), leaders of community-based organizations with health-related missions, and health care providers. Individual interviews and focus groups assessed recommended cancer prevention, control, and treatment resources; helpfulness of regional resources; and needed resources. The research team used an iterative approach to thematic analysis wherein codes were derived inductively and refined repeatedly to reveal overarching themes. FINDINGS Forty-four stakeholders reported challenges to health care access (eg, travel distance, financial burdens, and poor quality of care) and limited access to supportive care services (lack of caregiver support and "spotty" area resources). To mitigate these barriers, local residents used a combination of individual (self-reliance and adaptive measures) and organizational (patient navigation and financial services) approaches. Finally, stakeholders reported multiple forms of cancer control and prevention communication, including formal discussions with health care providers and various types of informal social support (eg, friends and family). CONCLUSIONS Stakeholders experienced barriers to cancer prevention and control often mitigated by a reliance on personal adaptations, nonclinical organizational supports, and informal support systems. While resources remain minimal in southern Illinois, researchers and practitioners must make efforts to leverage existing community organizations and social networks to improve cancer outcomes in this region.
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Affiliation(s)
- Aaron J. Kruse-Diehr
- Department of Health, Behavior & Society, University of Kentucky College of Public Health, Lexington, Kentucky, USA
| | - Marquita W. Lewis-Thames
- Department of Medical Social Science, Center for Community Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eric Wiedenman
- Implementation Science Center for Cancer Control and Prevention Research Center, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA,Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Aimee James
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lynne Chambers
- College of Humanities and Social Sciences, Southeastern Missouri State University, Cape Girardeau, Missouri, USA
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Holden CE, Wheelwright S, Harle A, Wagland R. The role of health literacy in cancer care: A mixed studies systematic review. PLoS One 2021; 16:e0259815. [PMID: 34767562 PMCID: PMC8589210 DOI: 10.1371/journal.pone.0259815] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/26/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients diagnosed with cancer face many challenges and need a good understanding of their diagnosis and proposed treatments to make informed decisions about their care. Health literacy plays an important role in this and low health literacy has been associated with poorer outcomes. The aims of this review are to identify which outcomes relate to health literacy in patients with cancer, and to combine this through a mixed studies approach with the patient experience as described through qualitative studies. METHODS Four electronic databases were searched in January 2021 to identify records relating to health literacy and patients with cancer. Records were independently screened then assessed for inclusion by two reviewers according to the following criteria: patients aged ≥18 years with cancer, English language publication AND health literacy measured with validated tool and measured outcome associated with health literacy OR qualitative study exploring the role of health literacy as patients make decisions about health. Quality was independently assessed by two reviewers. A narrative synthesis was performed, and findings integrated through concept mapping. This systematic review was registered with PROSPERO, entry CRD42020166454. RESULTS 4441 records were retrieved. Following de-duplication, 2496 titles and abstracts were screened and full texts of 405 papers were reviewed for eligibility. 66 papers relating to 60 studies met the eligibility criteria. Lower health literacy was associated with greater difficulties understanding and processing cancer related information, poorer quality of life and poorer experience of care. Personal and situational influences contributed to how participants processed information and reached decisions about their care. CONCLUSION This review highlights the important role of health literacy for patients with cancer. Outcomes are poorer for those who experience difficulties with health literacy. Further efforts should be made to facilitate understanding, develop health literacy and support patients to become more involved in their care.
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Affiliation(s)
- Chloe E. Holden
- Health Sciences, University of Southampton, Southampton, Hampshire, United Kingdom
- Dorset Cancer Centre, University Hospitals Dorset NHS Foundation Trust, Poole, Dorset, United Kingdom
| | - Sally Wheelwright
- Health Sciences, University of Southampton, Southampton, Hampshire, United Kingdom
| | - Amélie Harle
- Dorset Cancer Centre, University Hospitals Dorset NHS Foundation Trust, Poole, Dorset, United Kingdom
| | - Richard Wagland
- Health Sciences, University of Southampton, Southampton, Hampshire, United Kingdom
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Outcomes and Critical Factors for Successful Implementation of Organizational Health Literacy Interventions: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182211906. [PMID: 34831658 PMCID: PMC8622809 DOI: 10.3390/ijerph182211906] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/06/2021] [Accepted: 11/10/2021] [Indexed: 01/24/2023]
Abstract
Organizational health literacy (OHL)-interventions can reduce inequality and demands in health care encountered by patients. However, an overview of their impact and critical factors for organization-wide implementation is lacking. The aim of this scoping review is to summarize the evidence on: (1) the outcomes of OHL-interventions at patient, professional and organizational levels; and (2) the factors and strategies that affect implementation and outcomes of OHL-interventions. We reviewed empirical studies following the five-stage framework of Arksey and O'Malley. The databases Scopus, PubMed, PsychInfo and CINAHL were searched from 1 January 2010 to 31 December 2019, focusing on OHL-interventions using terms related to "health literacy", "health care organization" and "intervention characteristics". After a full-text review, we selected 24 descriptive stu-dies. Of these, 23 studies reported health literacy problems in relation to OHL-assessment tools. Nine out of thirteen studies reported that the use of interventions resulted in positive changes on OHL-domains regarding comprehensible communication, professionals' competencies and practices, and strategic organizational changes. Organization-wide OHL-interventions resulted in some improvement of patient outcomes but evidence was scarce. Critical factors for organization-wide implementation of OHL-interventions were leadership support, top-down and bottom-up approaches, a change champion, and staff commitment. Organization-wide interventions lead to more positive change on OHL-domains, but evidence regarding OHL-outcomes needs strengthening.
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Paterson C, Owusu E, Rolley J. What Are the Perceptions and Experiences of Care Delivery Among Faith Community Nurses? A Systematic Review. Semin Oncol Nurs 2021; 37:151211. [PMID: 34535344 DOI: 10.1016/j.soncn.2021.151211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This systematic review set out to identify the unique perceptions and experiences of care delivery among faith community nurses (FCNs). DATA SOURCES This review was conducted and has been reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was conducted using the following databases, Medline (OVID), EmCare for Nurses (OVID), PsycINFO (OVID), CINAHL (EBSCO), Cochrane, and PubMed. The search strategies included the use of truncations, adjacency search parameters, and Boolean operators using a range of key search terms. Predetermined eligibility criteria were applied to all studies. The review process was managed using Covidence systematic review software. Data extraction and quality assessment was conducted across all included studies. Data were analyzed using a narrative synthesis approach. CONCLUSION This review has made an important contribution by identifying the role that FCNs play in care delivery as trusted members of their communities who act as a conduit at the intersect of faith and health care. Irrespective of the location or faith denomination, what was common to FCNs was that they delivered care to address the physical, psychological, spiritual, congregational, communication, health system, and family-related needs of those in their care. IMPLICATIONS FOR NURSING PRACTICE The nurses represented in the included studies expressed concerns that patients experienced unmet supportive care needs because of a fragmented and highly complex existing health care system. Often, FCNs provided a valuable contribution in supporting patients in their care pathways and facilitated continuity of care among people who lived with preexisting comorbidities and who had complex health care needs. Further research is needed to understand the role that faith community nursing models might have in cancer care from the perspective of patients and other members of the multidisciplinary team across different international contexts.
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Affiliation(s)
- Catherine Paterson
- Faculty of Health, University of Canberra, Bruce, ACT, Australia; Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research Group, University of Canberra, Bruce, ACT, Australia; School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, ACT, Australia; Canberra Health Services & ACT Health, SYNERGY Nursing & Midwifery Research Centre, ACT Health Directorate Level 3, Canberra Hospital, Australia; Robert Gordon University, Aberdeen, Scotland, UK.
| | - Eric Owusu
- Faculty of Health, University of Canberra, Bruce, ACT, Australia; Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research Group, University of Canberra, Bruce, ACT, Australia
| | - John Rolley
- Faculty of Health, University of Canberra, Bruce, ACT, Australia; School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, ACT, Australia; Canberra Health Services & ACT Health, SYNERGY Nursing & Midwifery Research Centre, ACT Health Directorate Level 3, Canberra Hospital, Australia
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van der Kruk SR, Butow P, Mesters I, Boyle T, Olver I, White K, Sabesan S, Zielinski R, Chan BA, Spronk K, Grimison P, Underhill C, Kirsten L, Gunn KM. Psychosocial well-being and supportive care needs of cancer patients and survivors living in rural or regional areas: a systematic review from 2010 to 2021. Support Care Cancer 2021; 30:1021-1064. [PMID: 34392413 PMCID: PMC8364415 DOI: 10.1007/s00520-021-06440-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/13/2021] [Indexed: 01/16/2023]
Abstract
Purpose To summarise what is currently known about the psychosocial morbidity, experiences, and needs of people with cancer and their informal caregivers, who live in rural or regional areas of developed countries. Methods Eligible studies dating from August 2010 until May 2021 were identified through several online databases, including MEDLINE, EMBASE, PsychINFO, and RURAL (Rural and Remote Health Database). Results were reported according to the PRISMA guidelines and the protocol was registered on PROSPERO (CRD42020171764). Results Sixty-five studies were included in this review, including 20 qualitative studies, 41 quantitative studies, and 4 mixed methods studies. Qualitative research demonstrated that many unique psychosocial needs of rural people remain unmet, particularly relating to finances, travel, and accessing care. However, most (9/19) quantitative studies that compared rural and urban groups reported no significant differences in psychosocial needs, morbidity, or quality of life (QOL). Five quantitative studies reported poorer psychosocial outcomes (social and emotional functioning) in urban cancer survivors, while three highlighted poorer outcomes (physical functioning, role functioning, and self-reported mental health outcomes) in the rural group. Conclusion Recent research shows that rural people affected by cancer have unique unmet psychosocial needs relating to rurality. However, there was little evidence that rural cancer survivors report greater unmet needs than their urban counterparts. This contrasts to the findings from a 2011 systematic review that found rural survivors consistently reported worse psychosocial outcomes. More population-based research is needed to establish whether uniquely rural unmet needs are due to general or cancer-specific factors.
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Affiliation(s)
- Shannen R. van der Kruk
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
- Cancer Research Institute, University of South Australia, Adelaide, SA Australia
- Australian Centre for Precision Health, School of Health Sciences, University of South Australia, Adelaide, SA Australia
| | - Phyllis Butow
- Centre for Medical Psychology and Evidence-Based Decision-Making, The University of Sydney, Sydney, NSW Australia
| | - Ilse Mesters
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Terry Boyle
- Australian Centre for Precision Health, School of Health Sciences, University of South Australia, Adelaide, SA Australia
| | - Ian Olver
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA Australia
| | - Kate White
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
| | - Sabe Sabesan
- College of Medicine and Dentistry (CMD), James Cook University, QLD, Townsville, Australia
| | - Rob Zielinski
- Central West Cancer Care Centre, Orange Base Hospital, Orange, NSW Australia
- Western Sydney University, Sydney, NSW Australia
| | - Bryan A. Chan
- School of Medicine, Griffith University, Brisbane, QLD Australia
| | - Kristiaan Spronk
- Cancer Research Institute, University of South Australia, Adelaide, SA Australia
- Department of Rural Health, Allied Health and Human Performance, University of South Australia, Adelaide, SA Australia
| | - Peter Grimison
- Department of Medical Oncology, Chris O’Brien Lifehouse, Sydney, NSW Australia
| | | | | | - Kate M. Gunn
- Cancer Research Institute, University of South Australia, Adelaide, SA Australia
- Department of Rural Health, Allied Health and Human Performance, University of South Australia, Adelaide, SA Australia
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Nnamani Silva ON, Ammanuel SG, Segobiano BM, Edwards CS, Hoffman WY. Assessing the Readability of Online Patient Education Resources Related to Gynecomastia. Ann Plast Surg 2021; 87:123-125. [PMID: 33346559 DOI: 10.1097/sap.0000000000002620] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Internet has a plethora of online patient education resources for many symptoms and diseases. National medical governing bodies recommend that patient education materials are written at or below the eighth-grade level, and the literature suggests that health literacy has been linked to increased adherence to treatment regimens and improved outcomes. The primary aim of the study is to assess the readability of online patient materials relating to gynecomastia and ascertain the availability of patient materials in non-English languages. METHODS The readability of patient education materials relating to gynecomastia for academic-based websites and nonacademic websites was assessed using the Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), and Simple Measure of Gobbledygook (SMOG). The prevalence of non-English patient education materials was assessed for both academic-based and nonacademic websites. RESULTS Fifty-eight documents were collected across academic websites. Overall median values were 10.7 for the FKGL, 47.0 for the FRE, and 11.4 for the SMOG. For the 10 nonacademic institutions, the overall median values were 10.6 for the FKGL, 45.2 for the FRE, and 10.8 for the SMOG. No appreciable differences were observed for readability when stratified by region or source. The prevalence of non-English patient materials was 19.1% across institutions. None of the noninstitutional materials had information in non-English languages. CONCLUSIONS The readability of patient education materials related to gynecomastia is at higher levels than recommended by national organizations. There are limited non-English patient education materials. Future efforts should focus on improving the readability and accessibility of patient materials.
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Affiliation(s)
| | - Simon G Ammanuel
- From the University of California, San Francisco School of Medicine, San Francisco, CA
| | - Brett M Segobiano
- College of Arts and Letters, University of Notre Dame, South Bend, IN
| | - Caleb S Edwards
- From the University of California, San Francisco School of Medicine, San Francisco, CA
| | - William Y Hoffman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
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Price J, Brunet J. Feasibility and acceptability of a telehealth behavior change intervention for promoting physical activity and fruit and vegetable consumption among rural-living young adult cancer survivors. J Psychosoc Oncol 2021; 39:715-733. [PMID: 33798033 DOI: 10.1080/07347332.2021.1896616] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: We assessed the feasibility and acceptability of a 12-week telehealth behavior change intervention to promote physical activity and fruit and vegetable consumption among rural-living young adult cancer survivors.Methods: Participants met with a health coach once a week for 60 minutes for 12 weeks. Feasibility measures included rates of recruitment, enrollment, attrition, retention, adherence, and missing data. Acceptability was assessed using semi-structured interviews.Findings: Over 1-year, 18 individuals self-referred, 9 were eligible and consented to participate, and 2 dropped out. Retention was 74% and adherence was 95%. Participants considered the length of the intervention, synchronous communication with the health coach, and the distance-based delivery mode to be acceptable. Moreover, participants described key behavior change techniques and recommended minor changes.Implications: Findings provide information that can help refine future trials seeking to increase access to behavior change interventions and optimize participation in health-promoting behaviors for underserved populations.Trial registration: ClinicalTrials.gov. NCT03691545. Registered on October 1, 2018.
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Affiliation(s)
- Jenson Price
- School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada
| | - Jennifer Brunet
- School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada
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13
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Abstract
PROBLEM IDENTIFICATION Patients with cancer face high expectations for performing health literacy activities necessary for self-management and decision making, but only 12% of adults in the United States are proficient in health literacy. This review explores evidence regarding what is known about functional, interactive, and critical health literacy in adult oncology populations. LITERATURE SEARCH The review was conducted by searching extensively in the CINAHL® Plus database. DATA EVALUATION Of 614 articles retrieved from the literature search, 22 were included in the final sample. Most were cross-sectional, descriptive, correlational studies. SYNTHESIS Health literacy research in the United States focuses primarily on functional health literacy, but studies that include interactive and/or critical health literacy indicate their applicability in adult oncology populations. IMPLICATIONS FOR RESEARCH Additional research is needed to clarify the role of health literacy in cancer care to develop effective interventions that facilitate self-management and decision making.
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Fields AC, Lu PW, Vierra BM, Melnitchouk N. Refusal of Chemoradiation Therapy for Anal Squamous Cell Cancer. J Gastrointest Surg 2020; 24:2140-2142. [PMID: 32514652 DOI: 10.1007/s11605-020-04678-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/25/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Adam C Fields
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Pamela W Lu
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Benjamin M Vierra
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Nelya Melnitchouk
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
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15
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Joensen BM, Nielsen S, Róin Á. Barriers to Quality of Care for Cancer Patients in Rural Areas: A Study from the Faroe Islands. J Multidiscip Healthc 2020; 13:63-70. [PMID: 32021235 PMCID: PMC6974407 DOI: 10.2147/jmdh.s233313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/17/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Research has indicated that cancer patients living in rural areas receive poorer quality of treatment and care than their urban counterparts. With a population of approximately 51,000, the Faroe Islands may be characterized as a small-scale, rural society. Due to the geographical location and size of the Faroe Islands, patients who live there often receive part of their treatment abroad. Although a shift in the focus of cancer care from a disease-focused approach to a person-centered approach has been successfully implemented elsewhere, legal and structural conditions unique to the Faroe Islands might prohibit the realization of this paradigmatic shift in the Faroe Islands. The aim of this qualitative study was to examine how Faroese cancer patients have experienced their disease, treatment, and care and provide additional knowledge on cancer patients living in small-scale and rural societies. Methods Five men and three women who had been through a cancer treatment course with a good prognosis volunteered to be interviewed. Their ages varied from 40 to 80 years. “Active interviewing”, a constructionist approach to qualitative interviewing and latent thematic analysis, was applied. Results Three overlapping themes were identified from the categories: sense of coherence, resources and challenges in everyday life, and trust in the system. The analysis uncovered multiple factors related to legal and structural conditions that were barriers to ensuring the quality of cancer care for patients, for instance, shifting consultants, a lack of coherence in treatment, information loss and insufficient contact with cancer nurse specialists. Discussion This study is based on a limited number of participants. However, the findings from this study provide insight into the special conditions of cancer patients living in a small-scale, rural society and help explain disparities in the quality of cancer treatment and care between urban and rural areas.
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Affiliation(s)
| | - Sonja Nielsen
- Department of Internal Medicine, National Hospital, Tórshavn, Faroe Islands
| | - Ása Róin
- Department of Health and Nursing Science, University of the Faroe Islands, Tórshavn, Faroe Islands
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16
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Davis SN, Wischhusen JW, Sutton SK, Christy SM, Chavarria EA, Sutter ME, Roy S, Meade CD, Gwede CK. Demographic and psychosocial factors associated with limited health literacy in a community-based sample of older Black Americans. PATIENT EDUCATION AND COUNSELING 2020; 103:385-391. [PMID: 31466881 PMCID: PMC7012696 DOI: 10.1016/j.pec.2019.08.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 08/15/2019] [Accepted: 08/17/2019] [Indexed: 05/28/2023]
Abstract
OBJECTIVES Individuals with limited health literacy often experience suboptimal health outcomes. This study examined the frequency of limited health literacy and demographic and psychosocial factors associated with limited health literacy in a sample of older Black Americans. METHODS Participants (n = 330) enrolled in a community-based intervention to promote colorectal cancer (CRC) screening completed baseline surveys assessing health literacy with the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) test, CRC awareness, cancer fatalism, Preventive Health Model (PHM) constructs, and demographics. RESULTS Approximately 52% of participants had limited health literacy, the REALM-R score was 5.4 (SD = 2.7). Univariable correlates of limited health literacy were gender, employment, income, prior screening, cancer fatalism, CRC awareness, and PHM constructs (religious beliefs, salience/coherence, perceived susceptibility). Multivariable correlates of limited health literacy were male gender (OR = 2.3, CI = 1.4-3.8), unable to work (OR = 2.8, CI = 1.3-6.1), lower household income (OR = 3.0, CI = 1.6, 5.5), and higher PHM religious beliefs (OR = 1.1, CI = 1.0-1.2). CONCLUSION Limited health literacy was associated with multiple complex factors. Interventions should incorporate patient health literacy and low-literacy materials that can be delivered through multiple channels. PRACTICE IMPLICATIONS Future studies are needed to understand the role of health literacy in an individual's health behavior and the provision of effective healthcare.
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Affiliation(s)
- Stacy N Davis
- Health Behavior, Society and Policy, Rutgers the State University of New Jersey, New Brunswick, USA; Formally affiliated with Moffitt Cancer Center, Tampa, USA.
| | - Jonathan W Wischhusen
- Formally affiliated with Moffitt Cancer Center, Tampa, USA; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Steven K Sutton
- Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, USA; Morsani College of Medicine, University of South Florida, Tampa, USA
| | - Shannon M Christy
- Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, USA; Morsani College of Medicine, University of South Florida, Tampa, USA
| | - Enmanuel A Chavarria
- Formally affiliated with Moffitt Cancer Center, Tampa, USA; School of Public Health, University of Texas Health Science Center at Houston, Brownsville USA
| | - Megan E Sutter
- Formally affiliated with Moffitt Cancer Center, Tampa, USA; Department of Population Health, New York University, New York City, USA
| | - Siddhartha Roy
- Formally affiliated with Moffitt Cancer Center, Tampa, USA; Family and Community Medicine, Penn State College of Medicine, Hershey, USA
| | - Cathy D Meade
- Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, USA; Morsani College of Medicine, University of South Florida, Tampa, USA
| | - Clement K Gwede
- Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, USA; Morsani College of Medicine, University of South Florida, Tampa, USA
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17
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Funk LM, Dansereau L, Novek S. Carers as System Navigators: Exploring Sources, Processes and Outcomes of Structural Burden. THE GERONTOLOGIST 2020; 59:426-435. [PMID: 29165584 DOI: 10.1093/geront/gnx175] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 10/13/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Structural features of formal care systems influence the amount, difficulty, and complexity of what carers do as they interface with those systems. In this study, we explored how carers navigate health and social care systems, and their experiences of structural burden related to features such as complexity and fragmentation. RESEARCH DESIGN AND METHODS This qualitative descriptive inquiry drew on data from in-person interviews with 32 carers of older adults, which were analyzed first using inductive thematic analysis and then using structural burden as a conceptual lens. RESULTS Participant accounts revealed how navigating formal systems on behalf of older adult family members can exact considerable demands on carers in terms of time investment and emotional energy. In this way, care systems exacerbate the stress and structural burden experienced by carers, even when formal services alleviate other forms of carer burden. DISCUSSION AND IMPLICATIONS Our findings contribute to knowledge of how the structural context of formal services shapes carer experiences and outcomes. To promote equity and prevent burden, system navigation work should be considered as a public, structural issue, rather than an individual-level problem of skills and learning.
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Affiliation(s)
- Laura M Funk
- Department of Sociology, University of Manitoba, Winnipeg, Canada
| | | | - Sheila Novek
- Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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18
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Nilsen ML, Moskovitz J, Lyu L, Harrison C, Randazza E, Peddada SD, Johnson JT. Health literacy: Impact on quality of life in head and neck cancer survivors. Laryngoscope 2019; 130:2354-2359. [PMID: 31800111 DOI: 10.1002/lary.28360] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 07/03/2019] [Accepted: 09/23/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Although inadequate health literacy has been shown to impact health outcomes in other cancers, little is known about its impact in head and neck cancer (HNC). This study aimed to determine the prevalence and predictors of inadequate health literacy and evaluate the association between health literacy and quality of life (QOL) in HNC survivors. METHODS We conducted a retrospective analysis of HNC survivors evaluated in a multidisciplinary HNC survivorship clinic. Survivors had to be ≥1-year postcompletion of treatment to be included in the analysis. Health literacy was assessed via self-report with the Brief Health Literacy Screen (score <10 indicating inadequate health literacy), and QOL was measured using the University of Washington QOL questionnaire. Linear regression with robust standard errors was utilized to evaluate the association between health literacy and QOL. RESULTS Of the 218 survivors evaluated, 13.8% (n = 30) demonstrated inadequate health literacy. After adjusting for age, marital status, site, stage, treatment modality, and years since treatment completion, social-emotional QOL scores for survivors with adequate health literacy were estimated to be 10.67 points higher than those with inadequate health literacy (P = .013). Health literacy was not significantly associated with physical QOL after adjusting for covariates (P = .130). CONCLUSION Inadequate health literacy is associated with a lower social QOL in HNC survivors, and among those with inadequate health literacy, interventions to ameliorate the impact on QOL are needed. LEVEL OF EVIDENCE 4 Laryngoscope, 130:2354-2359, 2020.
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Affiliation(s)
- Marci Lee Nilsen
- University of Pittsburgh, School of Nursing, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Jessica Moskovitz
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Lingyun Lyu
- University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania, U.S.A
| | - Christine Harrison
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Evan Randazza
- UPMC, Department of Otolaryngology, Pittsburgh, Pennsylvania, U.S.A
| | - Shyamal Das Peddada
- University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania, U.S.A
| | - Jonas T Johnson
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, U.S.A
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19
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Jager M, de Zeeuw J, Tullius J, Papa R, Giammarchi C, Whittal A, de Winter AF. Patient Perspectives to Inform a Health Literacy Educational Program: A Systematic Review and Thematic Synthesis of Qualitative Studies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4300. [PMID: 31694299 PMCID: PMC6862529 DOI: 10.3390/ijerph16214300] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 01/22/2023]
Abstract
Patient-centred care is tailored to the needs of patients and is necessary for better health outcomes, especially for individuals with limited health literacy (LHL). However, its implementation remains challenging. The key to effectively address patient-centred care is to include perspectives of patients with LHL within the curricula of (future) healthcare providers (HCP). This systematic review aimed to explore and synthesize evidence on the needs, experiences and preferences of patients with LHL and to inform an existing educational framework. We searched three databases: PsychInfo, Medline and Cinahl, and extracted 798 articles. One-hundred and three articles met the inclusion criteria. After data extraction and thematic synthesis, key themes were identified. Patients with LHL and chronic diseases encounter multiple problems in the care process, which are often related to a lack of person-centeredness. Patient perspectives were categorized into four key themes: (1) Support system; (2) Patient self-management; (3) Capacities of HCPs; (4) Barriers in healthcare systems. "Cultural sensitivity" and "eHealth" were identified as recurring themes. A set of learning outcomes for (future) HCPs was developed based on our findings. The perspectives of patients with LHL provided valuable input for a comprehensive and person-centred educational framework that can enhance the relevance and quality of education for (future) HCPs, and contribute to better person-centred care for patients with LHL.
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Affiliation(s)
- Margot Jager
- Department of Health Sciences, University Medical Center Groningen and University of Groningen, 9700 AD Groningen, The Netherlands; (J.T.); (A.F.d.W.)
| | - Janine de Zeeuw
- Department of Health Sciences, University Medical Center Groningen and University of Groningen, 9700 AD Groningen, The Netherlands; (J.T.); (A.F.d.W.)
- Department of Medical Sciences, Educational Institute, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Janne Tullius
- Department of Health Sciences, University Medical Center Groningen and University of Groningen, 9700 AD Groningen, The Netherlands; (J.T.); (A.F.d.W.)
| | - Roberta Papa
- Regional Health Agency Marche Region, 60125 Ancona, Italy; (R.P.); (C.G.)
- IRCCS INRCA, 60124 Ancona, Italy
| | - Cinzia Giammarchi
- Regional Health Agency Marche Region, 60125 Ancona, Italy; (R.P.); (C.G.)
- IRCCS INRCA, 60124 Ancona, Italy
| | - Amanda Whittal
- Department of Psychology & Methods, Jacobs University, 28759 Bremen, Germany;
| | - Andrea F. de Winter
- Department of Health Sciences, University Medical Center Groningen and University of Groningen, 9700 AD Groningen, The Netherlands; (J.T.); (A.F.d.W.)
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20
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Grace JG, Schweers L, Anazodo A, Freyer DR. Evaluating and providing quality health information for adolescents and young adults with cancer. Pediatr Blood Cancer 2019; 66:e27931. [PMID: 31322817 PMCID: PMC7521147 DOI: 10.1002/pbc.27931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/07/2019] [Accepted: 07/08/2019] [Indexed: 11/11/2022]
Abstract
Adolescents and young adults (AYAs, 15-39 years old) are an ideal population to benefit from the ever-expanding number and variety of cancer information and health resources available via the Internet and other digital platforms. However, the ability of individual AYAs to fully utilize such resources depends on their degree of health literacy. Across the trajectory of cancer care, an important role for the oncology clinician is assisting AYAs and caregivers in accessing quality health information consistent with their level of health literacy. Working from the premise that all AYAs with cancer and their caregivers deserve to be empowered with maximal knowledge about their condition, this review provides information to assist oncology clinicians in (1) understanding the variety of contemporary online resources that are currently available, including their strengths and limitations; (2) evaluating the quality of health information; and (3) recommending specific health information resources to their AYA patients.
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Affiliation(s)
- Jacqueline Gilberto Grace
- Patient Family Education and Resources, Children’s Hospital Los Angeles, Los Angeles, California,Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, California
| | - Lisl Schweers
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, California
| | - Antoinette Anazodo
- Kids Cancer Centre, Sydney Children’s Hospital, Sydney, Australia,Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Sydney, Australia,School of Women and Children’s Health, University of South Wales, Sydney, Australia
| | - David R. Freyer
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, California,USC Norris Comprehensive Cancer Center, Los Angeles, California,Departments of Pediatrics and Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
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21
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Abstract
PurposeThe purpose of this paper is to examine how formal navigators interpret their roles supporting families of older adults.Design/methodology/approachThis study was an interpretive inquiry informed by critical gerontology and discourse analytic methods. Interview data were collected and analyzed from 22 formal service providers who helped older adults and their families navigate health and social care resources in one Western Canadian city.FindingsAlthough acknowledging structural barriers to service access, participants emphasized individual empowerment as their dominant strategy, interpreting their roles as providing information and education about services. In part, these interpretations may reflect the limited nature of their ability to help broker access or advocate; in part, they may also reflect the broader political and economic discourses surrounding care in Canada.Research limitations/implicationsWhen providers position navigation and access to care as individual problems, this can obscure structural burden as well as potential inequities among older adults. Future research should examine whether navigational role interpretations are similar or different to those of navigators in other regions. Navigators in other health and social care contexts may enact differing meanings in their work.Practical implicationsAlthough formal public navigators can play an important role, approaches that go beyond providing information may better meet families’ needs for support.Originality/valueThis is one of the first studies focused specifically on providers’ interpretations of the meaning of navigational work in health and social care for older adults, and to extend a critical gerontological gaze toward the issue of system navigation.
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22
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Fairfield KM, Black AW, Lucas FL, Murray K, Ziller E, Korsen N, Waterston LB, Han PKJ. Association Between Rurality and Lung Cancer Treatment Characteristics and Timeliness. J Rural Health 2019; 35:560-565. [PMID: 30779871 DOI: 10.1111/jrh.12355] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lung cancer is the leading cause of cancer-related mortality in the United States, and rural states bear a greater burden of disease. METHODS We analyzed tumor registry data to examine relationships between rurality and lung cancer stage at diagnosis and treatment. Cases were from the Maine Cancer Registry from 2012 to 2015, and rurality was defined using rural-urban commuting areas. Multivariable models were used to examine the relationships between rurality and treatment, adjusting for age, sex, poverty, education, insurance status, and cancer stage. RESULTS We identified 5,338 adults with incident lung cancer; 3,429 (64.2%) were diagnosed at a late stage (III or IV). Rurality was not associated with stage at diagnosis. For patients with early-stage disease (I or II), rurality was not associated with receipt of treatment. However, for patients with late-stage disease, residents of large rural areas received more surgery (10%) compared with metropolitan (9%) or small/isolated rural areas (6%), P = .01. In multivariable analyses, patients in large rural areas received more chemotherapy (OR 1.48; 95% CI: 1.08-2.02) than those in metropolitan areas. Patients with early-stage disease residing in small/ isolated rural areas had delays in treatment (median time to first treatment = 43 days, interquartile range [IQR] 22-68) compared with large rural (34 days, IQR 17-55) and metropolitan areas (35 days, IQR 17-60), P = .0009. CONCLUSION Rurality is associated with differences in receipt of specific lung cancer treatments and in timeliness of treatment.
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Affiliation(s)
- Kathleen M Fairfield
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine.,Department of Medicine, Maine Medical Center, Portland, Maine
| | - Adam W Black
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine.,Department of Medicine, Maine Medical Center, Portland, Maine
| | - Kimberly Murray
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine
| | - Erika Ziller
- Muskie School of Public Service, University of Southern Maine, Portland, Maine
| | - Neil Korsen
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine.,Department of Medicine, Maine Medical Center, Portland, Maine
| | - Leo B Waterston
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine
| | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine.,Department of Medicine, Maine Medical Center, Portland, Maine
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23
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Rollin A, Ridout B, Campbell A. Digital Health in Melanoma Posttreatment Care in Rural and Remote Australia: Systematic Review. J Med Internet Res 2018; 20:e11547. [PMID: 30249578 PMCID: PMC6231739 DOI: 10.2196/11547] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 11/13/2022] Open
Abstract
Background The melanoma incidence and mortality rates in rural and remote communities are exponentially higher than in urban areas. Digital health could be used to close the urban/rural gap for melanoma and improve access to posttreatment and support care services. Objective The aim of this review was to understand how digital health is currently used for melanoma posttreatment care and determine the benefits for Australian rural and remote areas. Methods A systematic search of PubMed, Medline, PsycINFO, and Scopus was conducted in March 2018. Findings were clustered per type of intervention and related direct outcomes. Results Five studies met the inclusion criteria, but none investigated the benefits of digital health for melanoma posttreatment care in rural and remote areas of Australia. Some empirical studies demonstrated consumers’ acceptance of digital intervention for posttreatment care. The findings did not take into consideration individual, psychological, and socioeconomic factors, even though studies show their significant impacts on melanoma quality of aftercare. Conclusions Digital interventions may be used as an adjunct service by clinicians during melanoma posttreatment care, especially in regions that are less-resourced by practitioners and health infrastructure, such as rural and remote Australia. Technology could be used to reduce the disparity in melanoma incidence, mortality rates, and accessibility to posttreatment care management between urban and rural/remote populations.
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Affiliation(s)
- Audrey Rollin
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Brad Ridout
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Andrew Campbell
- Faculty of Health Sciences, The University of Sydney, Sydney, Australia
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24
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Lee SC, Higashi RT, Sanders JM, Zhu H, Inrig SJ, Mejias C, Argenbright KE, Tiro JA. Effects of program scale-up on time to resolution for patients with abnormal screening mammography results. Cancer Causes Control 2018; 29:995-1005. [PMID: 30140972 DOI: 10.1007/s10552-018-1074-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 08/17/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE Effects of geographic program expansion to rural areas on screening program outcomes are understudied. We sought to determine whether time-to-resolution (TTR) varied significantly by service delivery time period, location, and participant characteristics across 19 North Texas counties. METHODS We calculated proportions undergoing diagnostic follow-up and resolved ≤ 60 days. We calculated median TTR for each time period and abnormal result BI-RADS 0, 4, 5. Cox proportional hazards regressions estimated time period and patient characteristic effects on TTR. Wilcoxon rank sum tests evaluated whether TTR differed between women who did or did not transfer between counties for services. RESULTS TTR ranged from 14 to 17 days for BI-RADs 0, 4, and 5; 12.4% transferred to a different county, resulting in longer median TTR (26 vs. 16 days; p < .001). Of those completing follow-up, 92% were resolved ≤ 60 days (median 15 days). For BI-RAD 3, TTR was 208 days (including required 180 day waiting period). Follow-up was significantly lower for women with BI-RAD 3 (59% vs. 96%; p < .0001). CONCLUSION Expansion maintained timely service delivery, increasing access to screening among rural, uninsured women. Policies adding a separate quality metric for BI-RAD 3 could encourage follow-up monitoring to address lower completion and longer TTR among women with this result.
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Affiliation(s)
- Simon Craddock Lee
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA.
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Drive, Dallas, TX, 75390, USA.
| | - Robin T Higashi
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
| | - Joanne M Sanders
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
| | - Hong Zhu
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Drive, Dallas, TX, 75390, USA
| | - Stephen J Inrig
- Mount St. Mary's University, 10 Chester Place, Los Angeles, CA, 90007, USA
| | - Caroline Mejias
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
| | - Keith E Argenbright
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Drive, Dallas, TX, 75390, USA
- Moncrief Cancer Institute, 400 W. Magnolia Ave, Fort Worth, TX, 76104, USA
| | - Jasmin A Tiro
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Drive, Dallas, TX, 75390, USA
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25
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Ranaghan C, Boyle K, Meehan M, Moustapha S, Fraser P, Concert C. Effectiveness of a patient navigator on patient satisfaction in adult patients in an ambulatory care setting: a systematic review. ACTA ACUST UNITED AC 2018; 14:172-218. [PMID: 27635752 DOI: 10.11124/jbisrir-2016-003049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND One approach to overcoming healthcare system barriers and facilitating timely access to quality care and patient satisfaction is with a patient navigator. A patient navigator is a trained person who individually assists patients, families and caregivers navigate the healthcare system barriers efficiently and effectively at any point along the care continuum, improving patient care at all levels of an organization. OBJECTIVES To synthesize the best available evidence on the effectiveness of a patient navigator on patient satisfaction in adult patients 18 years and older in ambulatory care settings. INCLUSION CRITERIA TYPES OF PARTICIPANTS This review considered studies that involved adults of any ethnicity, race or gender, aged 18 years or older, regardless of diagnoses, stage of illness, whether the illness is acute or chronic or previous treatment, who had been receiving care in an ambulatory care setting. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST This review considered studies on the use of a patient navigator as an additional intervention to usual care for promoting patient satisfaction for adult patients in an ambulatory care setting. Usual care without a patient navigator was considered as a comparator. TYPES OF STUDIES This review considered experimental and observational studies. OUTCOMES The outcome considered was patient satisfaction. SEARCH STRATEGY The literature search included published and unpublished studies in the English Language from 1990 through July 2015. A search of PubMed, CINAHL, Excerpta Medica Database (EMBASE), Academic Search Premier, Cochrane Library, PsycINFO and Health Source: Nursing/Academic Edition, Social Work Abstracts and Web of Science was conducted. A search for gray literature and electronic hand searching of relevant journals was also performed. METHODOLOGICAL QUALITY Two reviewers independently evaluated the included studies for methodological quality utilizing standardized critical appraisal instruments from the Joanna Briggs Institute. DATA EXTRACTION Standardized data extraction tools from Joanna Briggs Institute were used by two independent reviewers for data extraction. DATA SYNTHESIS A statistical meta-analysis was not possible due to heterogeneity between the included studies. Results are presented in a narrative form. RESULTS Four studies were included in this review, two were randomized controlled trials (RCTs), one was a quasi-experimental pre-post-test design study and one was a cohort study. The four studies showed that a patient navigator had clinical benefit for patient satisfaction, care coordination and patient access to timely healthcare services. One RCT reported a mean satisfaction score of 4.3 for navigated patients and 2.9 for non-navigated patients; P < 0.001. A second RCT showed an odds ratio 1.29; 95% confidence interval 0.92-1.82 for navigated versus non-navigated patients. The quasi-experimental pre-test-post-test study showed navigated patient satisfaction with a mean = 11.45 (standard deviation [SD], 3.69) in comparison with the non-navigated patient (mean, 14.95; SD, 1.69) (F = 11.85; P = 0.000). The cohort study demonstrated a mean satisfaction score of 90.7 for navigated patients and 85.5 for non-navigated patients; P = 0.03. The four studies showed no clinically significant results; however, the patient navigator role may promote relationships among the healthcare team, reducing barriers for patient-centered care and enhanced patient satisfaction. CONCLUSION There is a paucity of evidence on the effectiveness of a patient navigator on patient satisfaction. In the four studies selected for inclusion, a patient navigator had a positive effect on patient satisfaction, although none of the studies demonstrated statistical significance with a patient navigator on patient satisfaction. The effect of a patient navigator remains questionable with differences in perceptions on the best individual for the role and the expected role perception and performance. A standardized approach to the role of the patient navigator may maximize health outcomes and positively affect the quality of life for all patients.
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Affiliation(s)
- Coleen Ranaghan
- The Northeast Institute of Evidence Synthesis and Translation (NEST): a Joanna Briggs Institute Centre of Excellence
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Bergin R, Emery J, Bollard R, White V. How rural and urban patients in Australia with colorectal or breast cancer experience choice of treatment provider: A qualitative study. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28144993 DOI: 10.1111/ecc.12646] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 12/01/2016] [Indexed: 12/21/2022]
Abstract
Modern healthcare systems promote patient choice of cancer treatment provider, but little is known about how place of residence influences decision-making. This research explored how rural and urban patients with breast or colorectal cancer experience choice of cancer treatment provider in Victoria, Australia. Realist thematic analysis of 43 semi-structured telephone interviews identified little active participation in decision-making regardless of area of residence or cancer diagnosis. Perceptions of choice were impacted by urgency for treatment, insurance status and access to providers, a key issue for rural patients. All patients wanted high quality care, but needed to trust health professional's recommendations. Rural patients experienced more complex decision-making, balancing a range of social factors with perceptions about quality of accessible care. Further research into variation in quality of care and complex cancer pathways for rural and urban cancer patients is warranted to inform choices and enhance patient-centred care.
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Affiliation(s)
- R Bergin
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Vic., Australia.,Department of General Practice and Centre for Cancer Research, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Vic., Australia
| | - J Emery
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Vic., Australia
| | - R Bollard
- Division of Surgery, Ballarat Health Services, Ballarat, Vic., Australia
| | - V White
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Vic., Australia
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Abstract
Health literacy is usually described as a silent epidemic, which is challenging the sustainability of health care systems all over the world. The scientific literature has discussed the drawbacks of marginal health literacy on the functioning of the health care organizations. In particular, limited health literacy has been associated with: poorer ability of patients to comprehend health information, deficient medication adherence, insufficient use of prevention services, higher hospitalization rates, and greater health service utilization. In most of the cases, health literacy has been understood as an individual trait, which ultimately concerns the patients’ ability to obtain, process, and understand health information to navigate the health system. Alternatively, poor attention has been paid to the health literacy of the organizations operating within the health system, that is to say “organizational health literacy”. Indeed, neither the scholars nor the practitioners have adequately addressed the role played by the health care organizations to meet the needs of patients who live with limited health literacy. To contribute in filling such a gap, this study discusses the design and the structure of health-literate health care organizations. For this purpose, a systematic literature review was performed, involving 69 articles indexed in Scopus-Elsevier, Pub-Med, and Google Scholar to point out how the health care organizations face health literacy issues and to discuss what tools are used by the health care organizations to meet the information needs of people living with limited health literacy. Health-literate health care organizations turn out to be crucial to enhance patient engagement and improve health outcomes.
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Affiliation(s)
- Rocco Palumbo
- Department of Management & Innovation Systems, University of Salerno, Italy
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Halverson JL, Martinez-Donate AP, Palta M, Leal T, Lubner S, Walsh MC, Strickland JS, Smith PD, Trentham-Dietz A. Health Literacy and Health-Related Quality of Life Among a Population-Based Sample of Cancer Patients. JOURNAL OF HEALTH COMMUNICATION 2015; 20:1320-9. [PMID: 26161549 PMCID: PMC4751057 DOI: 10.1080/10810730.2015.1018638] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Health-related quality of life is an important outcome in cancer care. A few studies indicate that health literacy influences cancer patients' health-related quality of life, but additional investigation is needed. The authors examined the relation between health literacy and health-related quality of life among cancer patients. A cross-sectional survey was conducted with cancer patients in Wisconsin during 2006-2007. Data on sociodemographics, clinical characteristics, health-related quality of life, and health literacy were obtained from the state's cancer registry and a mailed questionnaire. Regression analyses were used to characterize the association between health-related quality of life and health literacy. The study sample included 1,841 adults, newly diagnosed with lung, breast, colorectal, or prostate cancer in 2004 (response rate = 68%). Health-related quality of life was measured with the Functional Assessment of Cancer Therapy-General. Adjusting for confounders, higher health literacy was associated with greater health-related quality of life (p < .0001). Controlling for covariates, we found significant differences between those in the highest and lowest health literacy categories (p < .0001) and in the physical (p < .0001), functional (p < .0001), emotional (p < .0001), and social (p = .0007) well-being subscales. These associations exceeded the minimally important difference threshold for overall health-related quality of life and functional well-being. Health literacy is positively and independently associated with health-related quality of life among cancer patients. These findings support adoption of health literacy best practices by cancer care systems.
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Affiliation(s)
- Julie L. Halverson
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ana P. Martinez-Donate
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Mari Palta
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ticiana Leal
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sam Lubner
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Matthew C. Walsh
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Paul D. Smith
- Department of Family Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Amy Trentham-Dietz
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Horne HN, Phelan-Emrick DF, Pollack CE, Markakis D, Wenzel J, Ahmed S, Garza MA, Shapiro GR, Bone LR, Johnson LB, Ford JG. Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults. Cancer Causes Control 2014; 26:239-246. [PMID: 25516073 DOI: 10.1007/s10552-014-0505-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 11/27/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE In recent years, colorectal cancer (CRC) screening rates have increased steadily in the USA, though racial and ethnic disparities persist. In a community-based randomized controlled trial, we investigated the effect of patient navigation on increasing CRC screening adherence among older African Americans. METHODS Participants in the Cancer Prevention and Treatment Demonstration were randomized to either the control group, receiving only printed educational materials (PEM), or the intervention arm where they were assigned a patient navigator in addition to PEM. Navigators assisted participants with identifying and overcoming screening barriers. Logistic regression analyses were used to assess the effect of patient navigation on CRC screening adherence. Up-to-date with screening was defined as self-reported receipt of colonoscopy/sigmoidoscopy in the previous 10 years or fecal occult blood testing (FOBT) in the year prior to the exit interview. RESULTS Compared with controls, the intervention group was more likely to report being up-to-date with CRC screening at the exit interview (OR 1.55, 95 % CI 1.07-2.23), after adjusting for select demographics. When examining the screening modalities separately, the patient navigator increased screening for colonoscopy/sigmoidoscopy (OR 1.53, 95 % CI 1.07-2.19), but not FOBT screening. Analyses of moderation revealed stronger effects of navigation among participants 65-69 years and those with an adequate health literacy level. CONCLUSIONS In a population of older African Americans adults, patient navigation was effective in increasing the likelihood of CRC screening. However, more intensive navigation may be necessary for adults over 70 years and individuals with low literacy levels.
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Affiliation(s)
- Hisani N Horne
- Cancer Prevention Fellowship Program, Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD, USA.
- National Institutes of Health/NCI/DCEG/HREB, 9609 Medical Center Drive, Rm 7E234, MSC 7234, Bethesda, MD, 20892-7234, USA.
| | - Darcy F Phelan-Emrick
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Craig E Pollack
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Diane Markakis
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer Wenzel
- Department of Oncology, Department of Acute and Chronic Care, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health and Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mary A Garza
- Department of Behavioral and Community Health, School of Public Health, University of Maryland College Park, College Park, MD, USA
| | - Gary R Shapiro
- Health Partners Cancer Program and Institute for Education and Research, Minneapolis, MN, USA
| | - Lee R Bone
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Jean G Ford
- The Brooklyn Hospital Center, Brooklyn, NY, USA
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