Medically unexplained illness and the diagnosis of hysterical conversion reaction (HCR) in women’s medicine wards of Bangladeshi hospitals: a record review and qualitative study

Background

Breast cancer is the leading cause of cancer mortality among Jordanian women. Breast malignancies are detected at late stages as a result of deferred breast health-seeking behaviour. The aim of this study was to explore Jordanian women’s views and perceptions about breast cancer and breast health.

Methods

We performed an explorative qualitative study with purposive sampling. Ten focus groups were conducted consisting of 64 women (aged 20 to 65?years) with no previous history and no symptoms of breast cancer from four governorates in Jordan. The transcribed data was analysed using latent content analysis.

Results

Three themes were constructed from the group discussions: a) Ambivalence in prioritizing own health; b) Feeling fear of breast cancer; and c) Feeling safe from breast cancer. The first theme was seen in women’s prioritizing children and family needs and in their experiencing family and social support towards seeking breast health care. The second theme was building on women’s perception of breast cancer as an incurable disease associated with suffering and death, their fear of the risk of diminished femininity, husband’s rejection and social stigmatization, adding to their apprehensions about breast health examinations. The third theme emerged from the women’s perceiving themselves as not being in the risk zone for breast cancer and in their accepting breast cancer as a test from God. In contrast, women also experienced comfort in acquiring breast health knowledge that soothed their fears and motivated them to seek early detection examinations.

Conclusions

Women’s ambivalence in prioritizing their own health and feelings of fear and safety could be better addressed by designing breast health interventions that emphasize the good prognosis for breast cancer when detected early, involve breast cancer survivors in breast health awareness campaigns and catalyse family support to encourage women to seek breast health care.     

The Impact of Rural Health Care Accessibility on Cancer-Related Behaviors and Outcomes

Background

This research seeks to identify the relationship between economic factors related to the ability to receive and pay for health services and adverse cancer outcomes, as well as preventative screening and behavioral factors that influence the risk of cancer. We focus on the Northern High Plains region, where we are able to compare regions with extremely low access to health services with those with relatively high levels of access.

Objective

This study aims to identify health disparities in rural communities, particularly among Native American populations, and, thereby, begin to determine the most effective means by which to deliver health services to areas where geography, economics, and culture might prevent traditional models of health delivery from providing sufficient incentives for the prevention of adverse cancer-related outcomes.

Methods

The Health Care Accessibility Index (HCAI) is computed through the use of principal component analysis and includes economic variables as well as variables concerning institutional and geographic access to health care. Index values are then regressed onto cancer outcomes, cancer-prevention outcomes, and cancer-related risk, using weighted least squares and quantile regressions.

Results

Counties with relatively poor access to health care (low HCAI) also have statistically (1) lower breast cancer screening rates, (2) higher smoking prevalence, (3) higher obesity prevalence, and (4) higher cancer-related mortality rates. Breast cancer screening is found to be especially sensitive to areas of low health accessibility.

Conclusions

Empirical results provide support for policy efforts to increase the accessibility of health care services that are targeted to areas with low mammography screening rates, high obesity rates, high smoking prevalence, as well as areas near Native American reservation territories.     

Evolution of educational inequalities in mortality among young adults in an urban setting

Objectives

To gain insight into the evolution in educational inequalities in adolescent and young adult all-cause and cause-specific mortality in the urban setting of the Brussels-Capital Region.

Methods

Data were derived from record linkage between the censuses of 1991 and 2001 and register data on all-cause and cause-specific mortality and emigration in the respective periods of 1st October 1991 to 1st January 1996 and 1st October 2001 to 1st January 2006. Both directly and indirectly standardised mortality rates and the relative index of inequality (RII) were computed.

Results

Mortality rates among adolescents and young adults have dropped significantly, especially infections and traffic accidents. However, educational inequalities among men have slightly increased: men with a maximum primary education are four times more likely to die than those who are higher educated [RII = 4.09 (2.78–6.03)]. Among women, no social gradient is observed in either period, but a clear split between the lowest educated and other educational groups is apparent in the 2000s.

Conclusions

There is a positive evolution towards lower mortality among adolescents and young adults, but educational inequalities remain a public health concern.     

Modeling the potential impact of emerging innovations on achievement of Sustainable Development Goals related to maternal,newborn, and child health

Background

Innovations that improve the affordability, accessibility, or effectiveness of health care played a major role in the Millennium Development Goal achievements and will be critical for reaching the ambitious new Sustainable Development Goal (SDG) health targets. Mechanisms to identify and prioritize innovations are essential to inform future investment decisions.

Methods

Innovation Countdown 2030 crowdsourced health innovations from around the world and engaged recognized experts to systematically assess their lifesaving potential by 2030. A health impact modeling approach was developed and used to quantify the costs and lives saved for select innovations identified as having great promise for improving maternal, newborn, and child health.

Results

Preventive innovations targeting health conditions with a high mortality burden had the greatest impact in regard to the absolute number of estimated lives saved. The largest projected health impact was for a new tool for small-scale water treatment that automatically chlorinates water to a safe concentration without using electricity or moving parts. An estimated 1.5 million deaths from diarrheal disease among children under five could be prevented by 2030 by scaling up use of this technology. Use of chlorhexidine for umbilical cord care was associated with the second highest number of lives saved.

Conclusions

The results show why a systematic modeling approach that can compare and contrast investment opportunities is important for prioritizing global health innovations. Rigorous impact estimates are needed to allocate limited resources toward the innovations with great potential to advance the SDGs.

     

Beliefs and attitudes about breast cancer and screening practices among Arab women living in Qatar: a cross-sectional study

Background

Despite rising breast cancer incidence and mortality rates, breast cancer screening (BCS) rates among women in Qatar remain low. Previous studies indicate the need to better understand the many complex beliefs, values, and attitudes that influence Arab women’s health seeking behavior for the development of culturally appropriate and effective intervention strategies to address breast cancer in the Middle East. This study investigates beliefs, attitudes, and BCS practices of Arabic-speaking women in Qatar.

Methods

A multicenter, cross-sectional quantitative survey of 1,063 (87.5% response rate) Arabic-speaking female Qatari citizens and non-Qatari residents, 35 years of age or older, was conducted in Qatar from March 2011 to July 2011. Associations between beliefs and BCS practice were estimated using chi-square tests and multivariate logistic regression analyses. Participants who adhered to BCS guidelines (BCS practice?=?Yes) were compared to those who did not (BCS practice?=?No).

Results

In addition to low levels of awareness and low participation rates in BCS, one quarter of the participants stated their doctors talked to them about breast cancer, and less than half of the women interviewed believed breast cancer can be prevented. Women who engaged in BCS practice were more likely to have a doctor who talked to them about breast cancer, to believe they were in good–excellent health, that cancer can be prevented, or that cancer might be hereditary. The majority wanted to know if they had cancer and felt their health care needs were being met. The main reasons given for not planning BCS were lack of a doctor’s recommendation, fear, and embarrassment.

Conclusions

These findings indicate that a variety of channels (health care providers, media, breast cancer survivors, community leaders) should be utilized to create culturally appropriate breast cancer intervention programs and increased awareness of breast cancer, BCS, and the benefits of early detection of breast cancer. Employment of these measures will reduce breast cancer mortality rates among Arabic-speaking women living in the State of Qatar.

     

Die Leitlinie „Brustkrebs-Früherkennung in Deutschland“

Background

Guidelines aim to improve the quality of health care by providing scientific knowledge for physicians and patients regarding specific options for everyday healthcare practice. Their purpose is to describe current knowledge, based on scientific evidence and practice experience for specific problems of health care; to evaluate methodological and clinical aspects; to clarify conflicting points of view; and to weigh benefits and risks in order to make recommendations for the optimum procedures and actions.

Methods

The question was raised on how to update the stage 3 guideline for early detection of breast cancer in Germany in view of the difficulties of this complex chain of health care, the high methodological requirements, and the limited time and finances for the development of guidelines. It was assumed that, besides incorporating advances in scientific knowledge, such updating requires a check of the present applications of the guideline in clinical practice, including its dissemination, implementation, and consequences on healthcare services and outcomes.

Results

The concept of quality management for the stage 3 guideline of the Association of the Scientific Medical Societies in Germany (AWMF) was expanded for continous updating under systematically defined conditions.

Conclusions

The stepwise concept proved to be practical. The update was realized successfully with clearly lower expenditures compared with development of the first guideline for early detection of breast cancer in Germany.     

Quality comparison of electronic versus paper death certificates in France, 2010

Background

National cancer survival statistics are available for the total Australian population but not Indigenous Australians, although their cancer mortality rates are known to be higher than those of other Australians. We aimed to validate analysis methods and report cancer survival rates for Indigenous Australians as the basis for regular national reporting.

Methods

We used national cancer registrations data to calculate all-cancer and site-specific relative survival for Indigenous Australians (compared with non-Indigenous Australians) diagnosed in 2001-2005. Because of limited availability of Indigenous life tables, we validated and used cause-specific survival (rather than relative survival) for proportional hazards regression to analyze time trends and regional variation in all-cancer survival between 1991 and 2005.

Results

Survival was lower for Indigenous than non-Indigenous Australians for all cancers combined and for many cancer sites. The excess mortality of Indigenous people with cancer was restricted to the first three years after diagnosis, and greatest in the first year. Survival was lower for rural and remote than urban residents; this disparity was much greater for Indigenous people. Survival improved between 1991 and 2005 for non-Indigenous people (mortality decreased by 28%), but to a much lesser extent for Indigenous people (11%) and only for those in remote areas; cancer survival did not improve for urban Indigenous residents.

Conclusions

Cancer survival is lower for Indigenous than other Australians, for all cancers combined and many individual cancer sites, although more accurate recording of Indigenous status by cancer registers is required before the extent of this disadvantage can be known with certainty. Cancer care for Indigenous Australians needs to be considerably improved; cancer diagnosis, treatment, and support services need to be redesigned specifically to be accessible and acceptable to Indigenous people.     

Form follows function: pragmatic controlled trials (PCTs) have to answer different questions and require different designs than randomized controlled trials (RCTs)

Aim

Rising concern for demonstrated real world comparative effectiveness has heightened interest in “pragmatic trials” design. Pragmatic trials investigate whether the efficacy, presumed or found in explanatory trials under ideal conditions, can also be detected under real world conditions, i.e. effectiveness. It is also recognized that ‘real world’ effects which are usually addressed in public health research gain growing interest in confirming the ‘road capability’ of results obtained under ideal study conditions. This paper demonstrates that studies under ideal or real world conditions use different methods, generate different information and cannot replace each other.

Subjects and methods

The PCT design meets four requirements of public health and of effectiveness research. It includes all individuals who presented with the selected condition. It classifies the included individuals according to baseline risks. It enables plausibility controls. Finally, it compares the outcomes resulting from specified and not-specified interventions or treatments.

Proposal

We propose a pragmatic controlled trial (PCT) design in which patient preference and other co-factors crucial in determining the actual effectiveness of interventional options will not be neutralized by concealed randomization and blinding. This design is applicable to record the selected interventions and generated outcomes in day-to-day health care and is capable of incorporating preference and other participative factors into assessment of effectiveness.

Conclusions

The PCT design is useful for public health research, e.g. the effectiveness of interventions to change smoking habits or to prevent death from breast cancer, as well as for comparative effectiveness research where it will supplement the traditional randomized controlled trial (RCT).     

Schutz vor Zoster

Background

Discussions on health sector reform in low-income and middle-income countries increasingly focus on the recognition of private-sector health care providers.

Aim

A review of recent literature presents trends of private stakeholder involvement as well as the potential for private sector participation in health system development and primary health care in these countries.

Results

Appropriate incentive structures may encourage private sector investments in health care as well as in service delivery in an efficient way and at reasonable cost – not only for the better-off. The role of government lies with regulation, health politics, and stewardship for health system financing. This approach may constitute an important contribution to achieving the goal of universal access to health care in the 21st century.     

Mortality in nursing home residents without cognitive impairment and its relation to self-reported health-related quality of life, sociodemographic factors, illness variables and cancer diagnosis: a 5-year follow-up study

Purpose

It is generally known that health-related quality of life (HRQOL) predicts cause-specific mortality. Few studies have explored whether generic self-reported HRQOL, sociodemographic factors and illness variables are independently associated with mortality among cognitively intact nursing home (NH) residents with and without cancer. We hypothesized that sociodemographic factors and illness variables would be associated with mortality and that HRQOL, measured using the SF-36 Health Survey, would predict mortality among NH residents with and without cancer.

Methods

We followed a cohort of 227 cognitively intact (Clinical Dementia Rating scale score ≤0.5) older residents (60 with cancer and 167 without) from 30 NH from 2004–2005 to 2010. We collected data by face-to-face interview. We obtained sociodemographic variables and medical diagnoses from the records.

Results

Survival did not differ between residents with and without cancer (P = 0.31). Twenty percent of the residents with cancer and 13% without cancer were still alive. After adjustment for sociodemographic and illness variables, increasing age (P < 0.001), higher education (P = 0.009), comorbidity (P = 0.04) and the subdimension physical functioning (P = 0.009) predicted mortality. Bodily pain was only marginally associated with mortality (P = 0.08).

Conclusions

Independent of cancer, HRQOL and comorbidity predicted mortality among NH residents without cognitive impairment.     

Revisiting the evidence on health and health care disparities among the Roma: a systematic review 2003–2012

Objectives

To conduct a systematic review of the epidemiological and health service utilization literature related to the Roma population between 2003 and 2012.

Methods

Systematic review of empirical research related to Roma health and health care utilization published between 2003 and 2012 identified through electronic databases (PsycInfo, Medline, Google Scholar). Methodological rigor was evaluated using a six-point set of design criteria.

Results

We found evidence for lower self-reported health and significantly higher mortality risk for Roma compared to non-Roma, and greater prevalence of health risk factors for Roma children, including environmental risks, low birth weight, and lower vaccination coverage. Studies of non-communicable and infectious disease remain insufficient to make firm conclusions on disparities. Barriers to care include lack of documentation and affordability of care, though more studies on health care utilization are needed.

Conclusions

Roma youth and adults are in need of programs that reduce health disparities and their increased mortality risk. Reducing exposure to risk factors such as smoking, obesity, and poor living conditions may be a target for interventions. More intervention studies and rigorous evaluations are needed.     

Analyzing spatial aggregation error in statistical models of late-stage cancer risk: a Monte Carlo simulation approach

Purpose

This paper examines the effect of spatial aggregation error on statistical estimates of the association between spatial access to health care and late-stage cancer.

Methods

Monte Carlo simulation was used to disaggregate cancer cases for two Illinois counties from zip code to census block in proportion to the age-race composition of the block population. After the disaggregation, a hierarchical logistic model was estimated examining the relationship between late-stage breast cancer and risk factors including travel distance to mammography, at both the zip code and census block levels. Model coefficients were compared between the two levels to assess the impact of spatial aggregation error.

Results

We found that spatial aggregation error influences the coefficients of regression-type models at the zip code level, and this impact is highly dependent on the study area. In one study area (Kane County), block-level coefficients were very similar to those estimated on the basis of zip code data; whereas in the other study area (Peoria County), the two sets of coefficients differed substantially raising the possibility of drawing inaccurate inferences about the association between distance to mammography and late-stage cancer risk.

Conclusions

Spatial aggregation error can significantly affect the coefficient values and inferences drawn from statistical models of the association between cancer outcomes and spatial and non-spatial variables. Relying on data at the zip code level may lead to inaccurate findings on health risk factors.     

Adoption of an innovation to repair aortic aneurysms at a Canadian hospital: a qualitative case study and evaluation

Background

Priority setting in health care is a challenge because demand for services exceeds available resources. The increasing demand for less invasive surgical procedures by patients, health care institutions and industry, places added pressure on surgeons to acquire the appropriate skills to adopt innovative procedures. Such innovations are often initiated and introduced by surgeons in the hospital setting. Decision-making processes for the adoption of surgical innovations in hospitals have not been well studied and a standard process for their introduction does not exist. The purpose of this study is to describe and evaluate the decision-making process for the adoption of a new technology for repair of abdominal aortic aneurysms (endovascular aneurysm repair [EVAR]) in an academic health sciences centre to better understand how decisions are made for the introduction of surgical innovations at the hospital level.

Methods

A qualitative case study of the decision to adopt EVAR was conducted using a modified thematic analysis of documents and semi-structured interviews. Accountability for Reasonableness was used as a conceptual framework for fairness in priority setting processes in health care organizations.

Results

There were two key decisions regarding EVAR: the decision to adopt the new technology in the hospital and the decision to stop hospital funding. The decision to adopt EVAR was based on perceived improved patient outcomes, safety, and the surgeons' desire to innovate. This decision involved very few stakeholders. The decision to stop funding of EVAR involved all key players and was based on criteria apparent to all those involved, including cost, evidence and hospital priorities. Limited internal communications were made prior to adopting the technology. There was no formal means to appeal the decisions made.

Conclusion

The analysis yielded recommendations for improving future decisions about the adoption of surgical innovations. ese empirical findings will be used with other case studies to help develop guidelines to help decision-makers adopt surgical innovations in Canadian hospitals.

     

Explaining length of stay variation of episodes of care in the Netherlands

Objectives

Diagnosis Related Group (DRG) systems aim to classify patients into mutually exclusive groups of patients, with the patients in each group having the same expected length of stay (LOS). We examined the ability of current classification variables to explain LOS variation between DRG-like Diagnosis Treatment Combination (DBC)s for ten episodes of care in the Netherlands, including breast cancer, stroke and inguinal hernia repair. Additionally, we assessed the predictive ability of some other classification variables.

Methods

For each episode of care, the relevant DBC codes of all hospitalizations in 2008 were identified and all available determinants that may serve as classification variables were acquired from the national database. Ordinary least squares regression was used to examine the predictive ability of these classification variables.

Results

The current classification variables are not sufficiently distinct to classify patients into mutually exclusive groups of patients. ICU admissions and hospital type may serve as valuable classification variables. Additionally, episode-specific variables may improve the Dutch grouping algorithm.

Conclusions

Although it may not be feasible in the short term, grouping algorithms would benefit greatly from the introduction of classification variables tailored to the needs of specific episodes of care. A first step would be to focus on ‘general’ classification variables meaningful for specific episodes of care.     

Self-reported medical morbidity among informal caregivers of chronic illness: the case of cancer

Purpose

Informal care provided by family and friends of patients with chronic illness, such as cancer, makes an invaluable contribution to the medical system and to society, yet it also imposes challenges that result in increased morbidity and mortality of the caregivers. Researchers studying this topic confront major difficulties in acquiring information about caregivers’ morbidity from medical records, a procedure that is costly and time consuming.

Methods

As an alternative, we developed a brief self-administered measure of morbid conditions for informal caregivers of persons with medical illness. We tested the measure, named the Morbidities Index for Caregivers of Chronic Illnesses (MICCI), using a large cancer caregiver sample (N = 774).

Results

The validity of the MICCI was supported by evidence that self-reports of the majority of morbidities were related to well-known demographic correlates of such morbidities, such as older age and being male, and that overall scores are related to widely used indicators of health status of medical populations as measured by the MOS SF. Caregivers reported an average of 4.5 morbid conditions. A higher number of morbidities were predicted by caregivers’ poorer physical and mental health scores on the MOS.

Conclusions

MICCI has the advantage of providing both an overall index of morbidities and information about specific diagnostic categories that are of potential interest to researchers.     

Why equal treatment is not always equitable: the impact of existing ethnic health inequalities in cost-effectiveness modeling

Background

A critical first step toward incorporating equity into cost-effectiveness analyses is to appropriately model interventions by population subgroups. In this paper we use a standardized treatment intervention to examine the impact of using ethnic-specific (Māori and non-Māori) data in cost-utility analyses for three cancers.

Methods

We estimate gains in health-adjusted life years (HALYs) for a simple intervention (20% reduction in excess cancer mortality) for lung, female breast, and colon cancers, using Markov modeling. Base models include ethnic-specific cancer incidence with other parameters either turned off or set to non-Māori levels for both groups. Subsequent models add ethnic-specific cancer survival, morbidity, and life expectancy. Costs include intervention and downstream health system costs.

Results

For the three cancers, including existing inequalities in background parameters (population mortality and comorbidities) for Māori attributes less value to a year of life saved compared to non-Māori and lowers the relative health gains for Māori. In contrast, ethnic inequalities in cancer parameters have less predictable effects. Despite Māori having higher excess mortality from all three cancers, modeled health gains for Māori were less from the lung cancer intervention than for non-Māori but higher for the breast and colon interventions.

Conclusions

Cost-effectiveness modeling is a useful tool in the prioritization of health services. But there are important (and sometimes counterintuitive) implications of including ethnic-specific background and disease parameters. In order to avoid perpetuating existing ethnic inequalities in health, such analyses should be undertaken with care.

     

Iraq War mortality estimates: A systematic review

Background

In March 2003, the United States invaded Iraq. The subsequent number, rates, and causes of mortality in Iraq resulting from the war remain unclear, despite intense international attention. Understanding mortality estimates from modern warfare, where the majority of casualties are civilian, is of critical importance for public health and protection afforded under international humanitarian law. We aimed to review the studies, reports and counts on Iraqi deaths since the start of the war and assessed their methodological quality and results.

Methods

We performed a systematic search of 15 electronic databases from inception to January 2008. In addition, we conducted a non-structured search of 3 other databases, reviewed study reference lists and contacted subject matter experts. We included studies that provided estimates of Iraqi deaths based on primary research over a reported period of time since the invasion. We excluded studies that summarized mortality estimates and combined non-fatal injuries and also studies of specific sub-populations, e.g. under-5 mortality. We calculated crude and cause-specific mortality rates attributable to violence and average deaths per day for each study, where not already provided.

Results

Thirteen studies met the eligibility criteria. The studies used a wide range of methodologies, varying from sentinel-data collection to population-based surveys. Studies assessed as the highest quality, those using population-based methods, yielded the highest estimates. Average deaths per day ranged from 48 to 759. The cause-specific mortality rates attributable to violence ranged from 0.64 to 10.25 per 1,000 per year.

Conclusion

Our review indicates that, despite varying estimates, the mortality burden of the war and its sequelae on Iraq is large. The use of established epidemiological methods is rare. This review illustrates the pressing need to promote sound epidemiologic approaches to determining mortality estimates and to establish guidelines for policy-makers, the media and the public on how to interpret these estimates.     

Choice of relative or cause-specific approach to cancer survival analysis impacts estimates differentially by cancer type,population, and application: evidence from a Canadian population-based cohort study

Background

Cause-specific (CS) and net survival in a relative survival framework (RS) are two of the most common methods for estimating cancer survival. In this paper, we assess the differences in results produced by two permutations of cause-specific and relative survival applied to estimating cancer survival and disparities in cancer survival, using data from First Nations and non-Aboriginal populations in Canada.

Methods

Subjects were members of the 1991 Canadian Census Mortality Cohort, a population-based cohort of adult respondents to the 1991 Long Form Census who have been followed up for incident cancers and death through linkage to administrative databases. We compared four methods: relative survival analyses with ethnicity-specific life tables (RS-ELT); relative survival with general population life tables (RS-GLT); cause-specific survival with a broad definition of cancer death (CS-Broad); and cause-specific survival with a narrow definition of cause of death (CS-Narrow) and applied these to the nine most common cancers among First Nations.

Results

Apart from breast and prostate cancers, RS-ELT, RS-GLT, and CS-Broad tended to produce similar estimates of age-standardized five-year survival, whereas CS-Narrow yielded higher estimates of survival. CS-Narrow estimates were particularly unlike those based on the other methods for cancers of the digestive and respiratory tracts. Estimates of disparities in survival were generally comparable across the four methods except for breast and prostate cancers.

Conclusions

Cancer surveillance efforts in sub-populations defined by race, ethnicity, geography, socioeconomic status, or similar factors are necessary for identifying disparities and monitoring progress toward reducing them. In the absence of routine monitoring of cancer survival and cancer survival disparities in these populations, estimates generated by different methods will inevitably be compared over time and across populations. In this study, we demonstrate that caution should be exercised in making these comparisons, particularly in interpreting cause-specific survival rates with an unknown or narrow definition of cancer death and in estimates of breast and prostate cancer survival and/or disparities in survival generated by different methods.