Factors influencing older women's decision-making related to treatment of operable breast cancer: A qualitative systematic review.

OBJECTIVE: There is variation in practice in the treatment of older women with breast cancer. International guidelines highlight the importance of patient autonomy in treatment decision-making. The aim of this study is to identify factors which influence decision-making in older women with operable breast cancer, which will enable us to further understand how to support these patients. METHODS: Systematic review in accordance with the PRISMA guidelines was performed to identify factors which influence treatment decision-making in older women with operable breast cancer. Medline, Web of Science and SCOPUS were searched. RESULTS: The search yielded 5840 results; 13 articles met the inclusion criteria and reported on a total of 1118 women. Thematic analysis identified three key themes in which decision-making factors could be categorised. These were healthcare-related factors, patient-related factors and impact of treatment. Healthcare-related factors included communication with clinicians and provision of information. Patient-related factors were age, pre-existing knowledge, preconceptions of breast cancer and treatment, decision-making style and co-morbidities. The impact of treatment considerations included body image and effect on quality of life. Decision-making style was frequently reported; older women did not demonstrate one preferred style. CONCLUSIONS: The findings have highlighted the complex interplay of factors which influence how older women make breast cancer treatment-decisions. Clinicians should have an awareness of the factors highlighted to maximise their ability to provide support and personalised care to older women with breast cancer whilst treatment decisions are made.

Barriers and facilitators to antenatal and delivery care in western Kenya: a qualitative study.

BACKGROUND: In western Kenya, maternal mortality is a major public health problem estimated at 730/100,000 live births, higher than the Kenyan national average of 488/100,000 women. Many women do not attend antenatal care (ANC) in the first trimester, half do not receive 4 ANC visits. A high proportion use traditional birth attendants (TBA) for delivery and 1 in five deliver unassisted. The present study was carried out to ascertain why women do not fully utilise health facility ANC and delivery services. METHODS: A qualitative study using 8 focus group discussions each consisting of 8-10 women, aged 15-49 years. Thematic analysis identified the main barriers and facilitators to health facility based ANC and delivery. RESULTS: Attending health facility for ANC was viewed positively. Three elements of care were important; testing for disease including HIV, checking the position of the foetus, and receiving injections and / or medications. Receiving a bed net and obtaining a registration card were also valuable. Four barriers to attending a health facility for ANC were evident; attitudes of clinic staff, long clinic waiting times, HIV testing and cost, although not all women felt the cost was prohibitive being worth it for the health of the child. Most women preferred to deliver in a health facility due to better management of complications. However cost was a barrier, and a reason to visit a TBA because of flexible payment. Other barriers were unpredictable labour and transport, staff attitudes and husbands' preference. CONCLUSIONS: Our findings suggest that women in western Kenya are amenable to ANC and would be willing and even prefer to deliver in a healthcare facility, if it were affordable and accessible to them. However for this to happen there needs to be investment in health promotion, and transport, as well as reducing or removing all fees associated with antenatal and delivery care. Yet creating demand for service will need to go alongside investment in antenatal services at organisational, staffing and facility level in order to meet both current and future increase in demand.

Policy Implications for Protecting Health from the Hazards of Fire Smoke. A Panel Discussion Report from the Workshop Landscape Fire Smoke: Protecting Health in an Era of Escalating Fire Risk.

Globally, and nationally in Australia, bushfires are expected to increase in frequency and intensity due to climate change. To date, protection of human health from fire smoke has largely relied on individual-level actions. Recent bushfires experienced during the Australian summer of 2019-2020 occurred over a prolonged period and encompassed far larger geographical areas than previously experienced, resulting in extreme levels of smoke for extended periods of time. This particular bushfire season resulted in highly challenging conditions, where many people were unable to protect themselves from smoke exposures. The Centre for Air pollution, energy and health Research (CAR), an Australian research centre, hosted a two-day symposium, Landscape Fire Smoke: Protecting health in an era of escalating fire risk, on 8 and 9 October 2020. One component of the symposium was a dedicated panel discussion where invited experts were asked to examine alternative policy settings for protecting health from fire smoke hazards with specific reference to interventions to minimise exposure, protection of outdoor workers, and current systems for communicating health risk. This paper documents the proceedings of the expert panel and participant discussion held during the workshop.

How to prevent and address safeguarding concerns in global health research programmes: practice, process and positionality in marginalised spaces.

Safeguarding is rapidly rising up the international development agenda, yet literature on safeguarding in related research is limited. This paper shares processes and practice relating to safeguarding within an international research consortium (the ARISE hub, known as ARISE). ARISE aims to enhance accountability and improve the health and well-being of marginalised people living and working in informal urban spaces in low-income and middle-income countries (Bangladesh, India, Kenya and Sierra Leone). Our manuscript is divided into three key sections. We start by discussing the importance of safeguarding in global health research and consider how thinking about vulnerability as a relational concept (shaped by unequal power relations and structural violence) can help locate fluid and context specific safeguarding risks within broader social systems. We then discuss the different steps undertaken in ARISE to develop a shared approach to safeguarding: sharing institutional guidelines and practice; facilitating a participatory process to agree a working definition of safeguarding and joint understandings of vulnerabilities, risks and mitigation strategies and share experiences; developing action plans for safeguarding. This is followed by reflection on our key learnings including how safeguarding, ethics and health and safety concerns overlap; the challenges of referral and support for safeguarding concerns within frequently underserved informal urban spaces; and the importance of reflective practice and critical thinking about power, judgement and positionality and the ownership of the global narrative surrounding safeguarding. We finish by situating our learning within debates on decolonising science and argue for the importance of an iterative, ongoing learning journey that is critical, reflective and inclusive of vulnerable people.

Sexual uses of alcohol and drugs and the associated health risks: a cross sectional study of young people in nine European cities.

BACKGROUND: Young people in European countries are experiencing high levels of alcohol and drug use and escalating levels of sexually transmitted infections. Individually these represent major public health priorities. Understanding of the association between sex and substance use, and specifically the strategic roles for which young people utilise substances to facilitate sexual activity, remains limited. METHODS: Respondent driven sampling methodology was used in nine European cities to survey 1,341 16-35 year olds representing youth and younger adults who routinely engage in nightlife. Participants self-completed questionnaires, designed to gather demographic, social, and behavioural data on historic and current substance use and sexual behaviour. RESULTS: Respondents reported strategic use of specific substances for different sexual purposes. Substances differed significantly in the purposes for which each was deployed (e.g. 28.6% of alcohol users use it to facilitate sexual encounters; 26.2% of cocaine users use it to prolong sex) with user demographics also relating to levels of sexual use (e.g. higher levels of: ecstasy use by males to prolong sex; cocaine use by single individuals to enhance sensation and arousal). Associations between substance use and sex started at a young age, with alcohol, cannabis, cocaine or ecstasy use before age 16 all being associated with having had sex before the age of 16 (odds ratios, 3.47, 4.19, 5.73, 9.35 respectively). However, sexes differed and substance use under 16 years was associated with a proportionately greater increase in early sex amongst girls. Respondents' current drug use was associated with having multiple sexual partners. Thus, for instance, regular cocaine users (c.f. never users) were over five times more likely to have had five or more sexual partners in the last 12 months or have paid for sex. CONCLUSION: An epidemic of recreational drug use and binge drinking exposes millions of young Europeans to routine consumption of substances which alter their sexual decisions and increase their chances of unsafe and regretted sex. For many, substance use has become an integral part of their strategic approach to sex, locking them into continued use. Tackling substances with both physiological and psychological links to sex requires approaching substance use and sexual behaviour in the same way that individuals experience them; as part of the same social process.

Effect of sustained insecticide-treated bed net use on all-cause child mortality in an area of intense perennial malaria transmission in western Kenya.

We present results from a study conducted in western Kenya where all-cause child mortality was assessed among a population with high levels of sustained insecticide-treated bed net (ITN) use for up to six years. Although ITNs were associated with significant reductions in all-cause mortality among infants 1-11 months old, there was no difference in the rate of all-cause mortality among children 12-59 months old with ITNs for 2-4 years, compared historically with children from villages without ITNs, after controlling for seasonality and underlying child mortality across calendar years (adjusted hazard ratio [AHR] = 0.91, 95% confidence interval [CI] = 0.77-1.07). There was no increase in the proportion of child deaths at older ages (12-59 months old) of all child deaths within villages with ITNs for 5-6 years (48.1%) compared historically with villages without ITNs (47.9%), after controlling for seasonality (AHR = 1.03, P = 0.834). We find no evidence that sustained ITN use increased the risk of mortality in older children in this area of intense perennial malaria transmission.

The potential value of comprehensive geriatric assessment in evaluating older women with primary operable breast cancer undergoing surgery or non-operative treatment--a pilot study.

OBJECTIVES: Breast cancer in older women raises a number of discrete issues, including how healthcare professionals can best decide which patients are candidates for surgery. A pilot study involving women aged ≥70years newly diagnosed with early operable primary breast cancer was conducted aiming to explore the potential value of comprehensive geriatric assessment (CGA). MATERIALS AND METHODS: Decision of primary treatment followed consultation with the clinical team and was not guided by any aspect of this study. CGA, using a validated cancer-specific tool, was conducted within 6weeks and 6months after diagnosis, complemented by formal measures of quality of life (QOL) (using EORTC QLQ-C30 and QLQ-BR23) and semi-structured interviews. A total of 47 female patients with a new diagnosis of clinically early (stage 1 or 2; cT0-2N0-1M0) operable primary breast cancer proven histologically, were recruited. RESULTS: CGA determined that increasing age (≥80years) (p=0.001), greater (≥4) comorbidity (p=0.022), greater number (≥4) of daily medications (p=0.002), and slower (≥19s) timed up and go (TUG) (p=0.016) score were significantly related to non-surgical treatment at 6weeks after diagnosis. Baseline QOL scores were generally good and they remained stable at 6months follow-up. As opposed to CGA, there was no correlation between QOL scores and the treatment modality identified. Semi-structured interviews identified themes consistent with findings from QOL assessment. CONCLUSION: The pilot study confirmed the feasibility of conducting CGA in a research setting which appeared to have value in assessing this patient population. More data will be required to definitively identify the components for geriatric assessment in this setting. The study has now extended into two more centres.

Exploring patients' experience of receiving information about cancer: a comparison of interview and questionnaire methods of data collection.

Patient information is widely regarded both as a resource and an entitlement: a means of 'empowering' patients to behave as 'consumers' of health care. Patient 'satisfaction' has come to be regarded as an important outcome of care. This article presents qualitative interview data regarding the experience of patient information provision and the results of a self-completed Information Satisfaction Questionnaire (ISQ) among patients and relatives affected by cancer. It considers the implications of the differences between these for service evaluation and current policy implementation promoting patients as informed and expert consumers of health care. The study findings contribute to growing evidence that the high rate of patients' expressed satisfaction with different aspects of service provision as indicated by structured questionnaire responses is largely an artefact of the method of data collection. Accounts of negative experiences were common, but did not translate into expressed criticism or overt dissatisfaction. It is important that the limitations of such surveys are contextualized in relation to qualitative findings such as those of the present study. Especially in the face of serious and life-threatening illness, professional constructs such as 'information delivery', 'satisfaction' and 'shared decision making' have little resonance for many patients, who prefer to trust in professional expertise and to eschew the acquisition of specialist knowledge and active involvement in decisions about health care.

Service user experiences of information delivery after a diagnosis of cancer: a qualitative study.

GOALS OF WORK: This paper presents findings from a qualitative study investigating service users' experiences of a patient information pathway after a diagnosis of cancer. MATERIALS AND METHODS: Patients (27) and relatives (20) were recruited from two identified Cancer Network sites representing a pathway that had been information mapped (Lung) and one which had not (Head and Neck). Respondents participated in up to three qualitative interviews in the year after diagnosis. MAIN RESULTS: The need for information in response to serious health problems has become widely accepted. Providing cancer patients and their carers with high-quality information throughout their care pathway is a policy priority. However, the study findings contribute to a growing body of evidence that far from embracing the active role of "expert patient", many patients continue to prefer verbal to written information, to trust in health professionals as their primary and preferred source of information, and to be quite cautious and selective about what they want to know about their illness. CONCLUSIONS: Good information is regarded as a prerequisite for informed decision making and a primary means of coping with the stress of illness. However, patient attitudes to information are complex and encompass resistance, ambivalence and indifference, active engagement and interest. The study findings reinforce the need for health professionals to develop competence as skilled communicators, and for efficient local systems of information transfer between service agencies and health professionals as prerequisites for delivery of the timely, tailored and personalized information which patients require.