RESUMO
BACKGROUND: The BETTER intervention is an effective comprehensive evidence-based program for chronic disease prevention and screening (CDPS) delivered by trained prevention practitioners (PPs), a new role in primary care. An adapted program, BETTER HEALTH, delivered by public health nurses as PPs for community residents in low income neighbourhoods, was recently shown to be effective in improving CDPS actions. To obtain a nuanced understanding about the CDPS needs of community residents and how the BETTER HEALTH intervention was perceived by residents, we studied how the intervention was adapted to a public health setting then conducted a post-visit qualitative evaluation by community residents through focus groups and interviews. METHODS: We first used the ADAPT-ITT model to adapt BETTER for a public health setting in Ontario, Canada. For the post-PP visit qualitative evaluation, we asked community residents who had received a PP visit, about steps they had taken to improve their physical and mental health and the BETTER HEALTH intervention. For both phases, we conducted focus groups and interviews; transcripts were analyzed using the constant comparative method. RESULTS: Thirty-eight community residents participated in either adaptation (n = 14, 64% female; average age 54 y) or evaluation (n = 24, 83% female; average age 60 y) phases. In both adaptation and evaluation, residents described significant challenges including poverty, social isolation, and daily stress, making chronic disease prevention a lower priority. Adaptation results indicated that residents valued learning about CDPS and would attend a confidential visit with a public health nurse who was viewed as trustworthy. Despite challenges, many recipients of BETTER HEALTH perceived they had achieved at least one personal CDPS goal post PP visit. Residents described key relational aspects of the visit including feeling valued, listened to and being understood by the PP. The PPs also provided practical suggestions to overcome barriers to meeting prevention goals. CONCLUSIONS: Residents living in low income neighbourhoods faced daily stress that reduced their capacity to make preventive lifestyle changes. Key adapted features of BETTER HEALTH such as public health nurses as PPs were highly supported by residents. The intervention was perceived valuable for the community by providing access to disease prevention. TRIAL REGISTRATION: #NCT03052959, 10/02/2017.
Assuntos
Enfermeiros de Saúde Pública , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Crônica , Atenção à Saúde , Ontário , PobrezaRESUMO
BACKGROUND: A twelve-gene molecular expression assay (DCIS score) may help guide radiation oncology treatment under specific circumstances. We undertook a study to examine radiation oncologist (RO), surgeon, and decision maker views on implementing the DCIS score in practice for women with low-risk DCIS. METHODS: We conducted a qualitative study involving telephone interviews that were audio-recorded and transcribed. Two researchers conducted a thematic analysis of transcripts. RESULTS: Twenty-eight individuals (ROs, breast cancer surgeons, and cancer policy decision makers) were invited to participate; 22 out of the 28 people (79%) agreed. The final sample included 20 participants: 11 of 13 (85%) ROs, 5 of 7 (71%) surgeons, and 4 of 8 (50%) decision makers. Most ROs expressed concerns about overtreatment but could not predict with certainty which low-risk patients could safely avoid radiation. The DCIS score was viewed as contributing valuable personalized risk information as part of treatment decision making that included clinicopathological factors and women's preferences. Future implementation would require guidelines with input from the oncology team. CONCLUSIONS: ROs had concerns about the overtreatment of women with DCIS, but lacked the tools to reliably predict which women could safely avoid radiation. By providing oncologists and women with personalized tumor information, the DCIS score was an important component of treatment decision making.
Assuntos
Neoplasias da Mama , Carcinoma Intraductal não Infiltrante , Humanos , Feminino , Carcinoma Intraductal não Infiltrante/terapia , Carcinoma Intraductal não Infiltrante/patologia , Espécies Reativas de Oxigênio , Neoplasias da Mama/patologia , Risco , Pesquisa QualitativaRESUMO
PURPOSE: Ductal carcinoma in situ (DCIS) is routinely treated with adjuvant radiotherapy (RT) after breast-conserving surgery (BCS). The inability to accurately estimate an individual's risk of local recurrence (LR) and invasive LR using clinicopathologic factors (CPF) contributes to the overtreatment of DCIS. We examined the impact of the 12-gene DCIS Score (DS) and the 21-gene Recurrence Score (RS) on the accuracy of predicting LR and invasive LR. METHODS: A population-based cohort diagnosed with pure DCIS treated with BCS ± RT from 1994 to 2003 was used. All patients had expert pathology review and assessment of the DS and RS. Predictive models (CPF alone, DS + CPF, and RS + CPF) were developed using multivariable Cox regression analyses to predict 10-year LR and invasive LR risks. Models were evaluated on the basis of c-statistic, -2log likelihood estimate (-2LLE), and Akaike information criterion. Calibration was performed using bootstrap resamples, with replacement. RESULTS: The cohort includes 1,226 women treated with BCS; 712 received RT. 194 women (15.8%) experienced ipsilateral LR as a first event; 112 were invasive. Models including the DS or RS performed better in predicting the 10-year risk of LR compared with models on the basis of CPF alone with excellent calibration. The two molecular-based models also performed better in predicting invasive LR compared with the CPF model but the model incorporating the RS did not perform better in the prediction of invasive LR compared with the DS-based model. CONCLUSION: Models incorporating the DS or RS more accurately predicted the 10-year risk of LR and invasive LR after BCS compared with models on the basis of CPF alone. Inclusion of the RS, compared with DS, did not improve the prediction of the 10-year risk of invasive LR.
RESUMO
BACKGROUND: The original 'BETTER' (Building on Existing Tools To Improve Chronic Disease Prevention and Screening in Primary Care) approach consisted of a prevention-focused visit between participants aged 40-65 years and a "Prevention Practitioner" (PP), who empowered the participant to set achievable prevention and screening goals for cancers and chronic diseases. BETTER was successfully adapted for economically deprived communities (BETTER HEALTH) in Canada. Our objective was to conduct a review of guidelines in preparation for adapting the 'BETTER HEALTH' approach for younger adults aged 18-39 years living with lower income, a group known to have earlier mortality due to a higher prevalence of preventable chronic diseases than their peers with higher income. METHODS: We searched multiple electronic databases and grey literature for clinical practice guidelines on prevention/screening and included those that met the following criteria: published in English from 2008-2020 in Canada or any of the following countries (Australia, Ireland, New Zealand, Scotland, United States and England); and addressed prevention or screening. We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and extracted data (publication details, recommendations, and Quality/Level of evidence as reported by authors) from sources with overall scores of 5 or higher. Final recommendations were compiled after harmonization with input from diverse stakeholders (co-investigators, PPs, and the Community Advisory Committee). RESULTS: We included a total of 85 guidelines, and developed a final list of 42 recommendations for 18-39 year-olds across 21 topics. Specific recommendations fell under the following topics: cancers, cardiovascular disease, diabetes, obesity, lifestyle (alcohol; healthy nutrition/physical activity); healthy relationships and healthy sexuality, immunization, oral health, social determinants of health, and substance use. CONCLUSION: We identified evidence-based guidelines on individual-level prevention/screening actions for adults 18-39 years old and relevant for those living with lower income which will directly inform development and implementation of the BETTER LIFE intervention.
Assuntos
Guias de Prática Clínica como Assunto , Humanos , Adulto , Doença Crônica/prevenção & controle , Doença Crônica/epidemiologia , Adulto Jovem , Adolescente , Programas de Rastreamento , Atenção Primária à Saúde , Serviços Preventivos de SaúdeRESUMO
In epidemiological studies, inequitable access to breast cancer care aligns with such variables as income, age, education, ethnicity and residential location. These variables correspond to structural patterns of advantage and disadvantage, which in turn may constrain or facilitate timely access to care. The purpose of this study was to understand the complexities of women's pathways to diagnosis. Thirty-five women from diverse backgrounds and who had clinically detectable breast symptoms at time of diagnosis participated in semi-structured interviews. All were receiving or completing treatment when they participated. Data were analyzed using the strategies of induction, comparison and abduction. All of the participants described a variety of activities involved in seeking care for breast cancer. The findings illustrate how the social relations of health care, rather than simply patient or provider delay, may contribute barriers to timely diagnosis. We illustrate how women's widely differing social and material contexts offer opportunities and barriers to access.
Em estudos epidemiológicos, acessos desiguais para o cuidado ao câncer de mama alinham-se a outras variáveis como salário, idade, educação, etnia e local de moradia. Estas variáveis correspondem aos padrões estruturais de vantagens e desvantagens, as quais por sua vez podem restringir ou facilitar o tempo de acesso ao cuidado. A proposta deste estudo foi entender a complexidade da trajetória das mulheres para o diagnóstico. Trinta e cinco mulheres de diversos meios e que tinham sintomas clinicamente identificados no momento do diagnóstico, participaram de entrevistas semi-estruturadas. Os dados foram analisados utilizando-se estratégias de indução, comparação e abdução. Todas as participantes descreveram uma variedade de atividades envolvidas na busca do cuidado para o câncer de mama. Os achados ilustram como as relações sociais do cuidado a saúde, ao invés de simplificar para a paciente ou retardar o processo, podem se constituir em barreiras ao diagnóstico em tempo adequado. Nós ilustramos como os diferentes contextos sociais e materiais oferecem oportunidades e barreiras para o acesso às mulheres.
De acuerdo a los estudios epidemiológicos, la falta de equidad en el acceso a los servicios de cuidado y tratamiento del cáncer de mama se acompaña de variables tales como renta, edad, nivel de estudios, etnia y lugar de residencia. Estas variables corresponden a patrones estructurales favorecidos o desfavorecidos, que pueden por tanto facilitar o limitar el tiempo de acceso a dichos servicios. El objetivo de este estudio fue el de comprender la complejidad de las trayectorias de las mujeres hacia el diagnóstico. Treinta y cinco mujeres con experiencias diversas y con síntomas de cáncer de mama clínicamente detectables en el momento del diagnóstico, participaron en entrevistas parcialmente estructuradas. Todas ellas recibían y/o habían completado su tratamiento en el momento de su participación. Los datos fueron analizados mediante el empleo de estrategias de inducción, comparación y abducción. Las participantes describieron una amplia variedad de actividades involucradas en la búsqueda de atención de salud para el cáncer de mama. Los hallazgos ilustran cómo las relaciones sociales del cuidado en salud pueden constituir barreras al diagnóstico en un tiempo adecuado, más allá de lo que lo puedan ser el retraso por parte de la paciente o del profesional. Se ilustra además cómo los diversos contextos sociales y materiales de las mujeres generan oportunidades y barreras de acceso a dichos cuidados.