Health system organisation and patient pathways: breast care patients' trajectories and medical doctors' practice in Mali.

BACKGROUND: Information on pathways of women seeking diagnostic services due to breast- related symptoms can help highlight challenges related to the healthcare system in improving early diagnosis of breast cancer. METHODS: We retrospectively analysed the entire patient pathway, from first symptom recognition via initial healthcare visit up to final diagnosis at the pathology service in Mali. Data from questionnaire-based structured patient interviews (n = 124) were used to calculate time to first healthcare visit (median 91 days) and consecutive time to diagnosis (median 21 days) and to extract information on type of initially visited healthcare facility (community healthcare centre, referral hospital, tertiary hospital, private clinic). Median time to first healthcare visit and time to diagnosis and type of initially-visited healthcare facility were cross-tabulated with patient characteristics. An additional survey among (n = 30) medical doctors in the community healthcare centres and referral hospitals in Bamako was conducted to understand current knowledge and referral practice with respect to female patients with breast-related symptoms. RESULTS: Patients who initially visited private clinics had the shortest time to first healthcare visit (median 44 days), but the longest time to diagnosis (median 170 days). Patients visiting community healthcare centres and referral hospitals took longest for a first healthcare visit (median 153 and 206 days, respectively), but the time to diagnosis was shorter (median 95 and 7 days, respectively). The majority of patients (45%) initially visited a tertiary hospital; these patients had shortest total time to diagnosis (median 56 days health seeking and 8 days diagnostic time), but did not follow the recommended pathway for patients in the pyramidal healthcare system in Mali. The doctors' survey showed lower breast cancer knowledge in the community healthcare centres than in the referral hospitals. However, most doctors felt able to recognise suspected cases of cancer and referred patients directly to a hospital. CONCLUSIONS: The role of different healthcare facilities in ensuring triage of patients with breast-related symptoms needs to be defined before any early detection initiatives are implemented. Especially at the entry level of the healthcare system, the access and quality of health services need to be strengthened.

Factors associated with time to first healthcare visit, diagnosis and treatment, and their impact on survival among breast cancer patients in Mali.

OBJECTIVE: To analyse patient and healthcare system related factors influencing the time to first healthcare visit, diagnosis and treatment of breast cancer patients in sub-Saharan Africa and the impact on survival in order to advise on early detection strategies. METHODS: A prospective hospital cohort study was conducted at the only pathology department in Mali, at the University Hospital in Bamako. All the female patients with a breast cancer diagnosis between January and April 2016 were interviewed with a structured questionnaire (N = 64) to gather information about breast symptom recognition and first healthcare visit. Information on beginning of treatment and survival were collected at 18-months follow-up. Simple Cox regression analyses were performed. RESULTS: The median time to first healthcare visit was 4.8 months, from first healthcare visit to diagnosis was 0.9 months and for the patients who started treatment (N = 46) the time from diagnosis to treatment was 1.3 months. Knowledge of breast-self-examination and correct symptom interpretation increased the chance of an earlier healthcare visit. Prolonged time to diagnosis was found with shorter duration to first healthcare visit, for working women compared to housewives and for those living within Bamako. Living outside Bamako and smaller tumour size (T1/T2) prolonged time to treatment. Visit of a traditional healer and larger tumour size (T3/T4) shortened survival time, whereas time to first healthcare visit and subsequent time to diagnosis had no influence on survival. CONCLUSIONS: Down-staging strategies are only useful if the continuum of breast cancer care is warranted for the majority of patients.

Why Do Women with Breast Cancer Get Diagnosed and Treated Late in Sub-Saharan Africa? Perspectives from Women and Patients in Bamako, Mali.

BACKGROUND: Breast cancer, the most common cancer among women worldwide, has a high mortality rate in low-income countries. In sub-Saharan Africa, most breast cancer patients are diagnosed with advanced disease. Some studies have quantified the time delay to diagnosis in sub-Saharan Africa, but very few have used qualitative methods to understand barriers leading to delay. This study analyses barriers throughout a breast cancer patient's pathway from symptom recognition to treatment in Mali. METHOD: Three focus group discussions were conducted. The model of pathways to treatment was used to structure the results into 4 time intervals: appraisal, help-seeking, diagnosis, and treatment, with a focus on barriers during each interval. RESULTS: The main barriers during the appraisal interval were a low level of breast cancer knowledge among women, their families, and medical professionals, and during the help-seeking interval, mistrust in the community health care centers and economic hardship. Barriers during the diagnosis interval were low quality of health care services and lack of social support, and during the pretreatment interval high costs and lack of specialized services. CONCLUSION: Multilevel interventions are needed to ensure access, availability, and affordability of a minimum standard of care for breast cancer patients in sub-Saharan Africa.

Prevalence of breast-related symptoms, health care seeking behaviour and diagnostic needs among women in Burkina Faso.

BACKGROUND: The prevalence of breast cancer has been increasing in sub-Saharan Africa over the last few years. Patients often present with late stage disease, resulting in a high mortality rate. This study aims to estimate the prevalence of breast -related symptoms in the female population of Burkina Faso. The findings can be used to advise on adequate diagnostic health services for breast symptoms to ensure early detection and down-staging of breast cancer. METHODS: A cross-sectional, population based study of 996 women was conducted to investigate the proportion of women with breast-related symptoms. A semi-structured questionnaire was used to collect sociodemographic data, information about breast cancer knowledge and details about breast-related symptoms, health care seeking and medical care. Breast-related symptoms were categorised as currently present/not currently present to estimate the current prevalence of women requiring a diagnostic service. RESULTS: Among the 996 women, 120 reported having had a breast-related symptom in their life. Only 36 women sought medical advice and eight women had diagnostic confirmation by histological or imaging techniques. Current breast-related symptoms were reported by 33 women (3.3% of the sample). An extrapolation to Burkina Faso's female population suggests that 184,562 women are in current need of diagnostic services due to any breast-related symptoms. CONCLUSIONS: Imaging techniques at the community and referral level are needed in order to triage women with breast-related symptoms. Specialised services need to be strengthened to ensure appropriate diagnosis and treatment of breast diseases. Education campaigns among the general population and among health care professionals are required to increase awareness of breast cancer and improve prompt health care seeking and referral.

Breast Cancer Awareness among Middle Class Urban Women--a Community-Based Study from Mumbai, India.

Targeting breast cancer awareness along with comprehensive cancer care is appropriate in low and middle income countries like India, where there are no organized and affordable screening services. It is essential to identify the existing awareness about breast cancer in the community prior to launching an organized effort. This study assessed the existing awareness about breast cancer amongst women and their health seeking practices in an urban community in Mumbai, India. A postal survey was undertaken with low or no cost options for returning the completed questionnaires. The majority of the women were aware about cancer but awareness about symptoms and signs was poor. Women were willing to accept more information about cancer and those with higher awareness scores were more likely to seek medical help. They were also more likely to have undergone breast examination in the past and less likely to use alternative medicines. High income was associated with better awareness but this did not translate into better health seeking behaviour. Organized programmes giving detailed information about breast cancer and its symptoms are needed and women from all income categories need to be encouraged for positive change towards health seeking. Further detailed studies regarding barriers to health seeking in India are necessary.

Determinants of participation in a breast cancer screening trial in trivandrum district, India.

BACKGROUND: Conspicuous differences in participation rates for breast self-examination (BSE), clinical breast examination (CBE), and referral for further investigations have been observed indicating involvement of a number of different factors. This study analysed determinants for participation in different levels of the breast cancer screening process in Indian females. MATERIALS AND METHODS: An intervention group of 52,011 women was interviewed in a breast cancer screening trial in Trivandrum district, India. In order to assess demographic, socio-economic, reproductive, and cancer-related determinants of participation in BSE, CBE, and referral, uni- and multi-variate logistic regression was employed. RESULTS: Of the interviewed women, 23.2% reported practicing BSE, 96.8% had attended CBE, and 49.1% of 2,880 screen-positives attended referral. Results showed an influence of various determinants on participation; women who were currently not married or who had no family history of cancer were significantly less likely to attend the screening process at any level. CONCLUSIONS: Increasing awareness about breast cancer, early detection methods, and the advantages of early diagnoses among women, and their families, as well as health care workers offering social support, could help to increase participation over the entire screening process in India.

Late response to patient-reported outcome questionnaires after surgery was associated with worse outcome.

OBJECTIVES: Nonresponse to patient-reported outcome (PRO) questionnaires after surgery might bias the results. Our aim was to gauge the potential impact of nonresponse bias by comparing the outcomes of early and late responders. STUDY DESIGN AND SETTING: This study compares 59,565 early and 20,735 late responders who underwent a hip or knee replacement, hernia repair, or varicose vein (VV) surgery. The association between timeliness of response and three outcomes (the mean postoperative disease-specific PRO and generic PRO scores and the proportion reporting a fair or poor result) was examined by regression analysis. RESULTS: Late responders were slightly more likely to be young, nonwhite, deprived, and have a more severe preoperative condition with poorer quality of life. Late response was associated with a slightly poorer outcome in all four procedures although not statistically significant (P < 0.05) for VV surgery. Adjusting for preoperative characteristics reduced the strength of the associations, but they remained statistically significant. CONCLUSION: As nonresponse to PRO questionnaires introduces slight bias, differences in response rates between hospitals should be taken into account when making comparisons so as to avoid overestimating the performance of those with lower response rates and failing to detect poor performing hospitals.

Factors associated with non-response in routine use of patient reported outcome measures after elective surgery in England.

BACKGROUND: Patient-reported outcome measures are increasingly being used to compare providers. We studied whether non-response rates to post-operative questionnaires are associated with patients' characteristics and organisational features of providers. METHODS: 131,447 patients who underwent a hip or knee replacement, hernia repair or varicose vein surgery in 2009-10 in England. Multivariable logistic regression to calculate adjusted odds ratios of non-response for characteristics of the patients and organisational characteristics of providers. Multiple imputation was used for missing patient characteristics. Providers were included as random effects. RESULTS: Response rates to the post-operative questionnaire were 85.1% for hip replacement (n = 37 961), 85.3% for knee replacements (n = 44 422), 72.9% for hernia repair (n = 34 964), and 64.8% for varicose vein surgery (n = 14 100). Across the four procedures, there were higher levels of non-response in men (odds ratios 1.03 [95% CI 0.95-1.11] - 1.35 [1.25-1.46]), younger patients (those under 55 years 3.01 [2.72-3.32] - 6.05 [5.49-6.67]), non-white patients (1.24 [1.11-1.38] - 2.08 [1.89-2.31]), patients in the most deprived quintile of socio-economic status (1.47 [1.34-1,62] - 1.86 [1.71-2.03]), those who lived alone (1.11 [0.99-1.23] - 1.27 [1.18-1.36]) and those who had been assisted when completing their pre-operative questionnaire (1.26 [1.10-1.46] -1.67 [1.56-1.79]). Non-response rates were also higher in patients who had poorer pre-operative health (three or more comorbidities: 1.14 [0.96-1.35] - 1.45 [1.30-1.63]). Providers' patient recruitment rates before surgery and the timing of pre-operative questionnaire administration did not affect the rates of response to post-operative questionnaires. CONCLUSION: If non-response can be shown to be associated with outcome, then rates of non-response to post-operative questionnaires would need to be taken into account when these measures are being used to compare the performance of providers or to evaluate surgical procedures.

Single item on patients' satisfaction with condition provided additional insight into impact of surgery.

OBJECTIVE: To determine the value of a single item on patients' satisfaction with their condition for assessing outcome in four common surgical procedures. STUDY DESIGN AND SETTING: Four cohorts undergoing surgery for inguinal hernia (715), varicose veins (539), hip (8,383), or knee (10,187) disease. Patients completed questionnaires before and after surgery that included a single item on satisfaction with their health (based on the International Prostate Symptom Score [IPSS] Bother Question), disease-specific measures of symptoms/disability (Oxford Hip and Knee Scores, Aberdeen Varicose Vein Questionnaire), generic measures of symptoms/disability and of quality of life (QoL) (EQ [EuroQoL]-5D index), and single transitional items. Nonparametric Spearman's correlations explored relationships between measures. RESULTS: Before surgery, in all conditions, satisfaction was associated with other dimensions (P<0.05): generic QoL (r=0.5-0.7), disease-specific symptoms/disability (r=0.6-0.8), and generic symptoms/disability (r=0.2-0.4). Significant improvements in satisfaction after surgery correlated strongly with change in disease-specific symptoms/disability (r=0.6 for major operations and r=0.35 for minor surgery) and with single transitional items (r=0.4-0.6) but less so with change in generic QoL (0.3-0.4) and generic symptoms/disability (0.1-0.2). CONCLUSION: Inclusion of a single item on satisfaction provides additional insight into the impact of surgery.

Psychosocial stress at work and perceived quality of care among clinicians in surgery.

BACKGROUND: Little is known about the association between job stress and job performance among surgeons, although physicians' well-being could be regarded as an important quality indicator. This paper examines associations between psychosocial job stress and perceived health care quality among German clinicians in surgery. METHODS: Survey data of 1,311 surgeons from 489 hospitals were analysed. Psychosocial stress at work was measured by the effort-reward imbalance model (ERI) and the demand-control model (job strain). The quality of health care was evaluated by physicians' self-assessed performance, service quality and error frequency. Data were collected in a nationwide standardised mail survey. 53% of the contacted hospitals sent back the questionnaire; the response rate of the clinicians in the participating hospitals was about 65%. To estimate the association between job stress and quality of care multiple logistic regression analyses were conducted. RESULTS: Clinicians exposed to job stress have an increased risk of reporting suboptimal quality of care. Magnitude of the association varies depending on the respective job stress model and the indicator of health care quality used. Odds ratios, adjusted for gender, occupational position and job experience vary between 1.04 (CI 0.70-1.57) and 3.21 (CI 2.23-4.61). CONCLUSION: Findings indicate that theoretical models of psychosocial stress at work can enrich the analysis of effects of working conditions on health care quality. Moreover, results suggest interventions for job related health promotion measures to improve the clinicians' working conditions, their quality of care and their patients' health.

Burnout and perceived quality of care among German clinicians in surgery.

OBJECTIVE: Burnout is highly prevalent among clinicians but there is not much known about the association between burnout and quality of care. In this paper, burnout, perceived quality of care and medical errors among German clinicians in surgery are explored. DESIGN: Data were collected during 2008 by a cross-sectional, standardized mail survey. PARTICIPANTS: and SETTING: A total of 1311 clinicians in surgery in 489 German hospitals. Measure(s) Burnout was measured by using the Copenhagen Burnout Inventory (CBI). The measurement of self-rated patient care was based on a 13 item instrument (Chirurgisches Qualitätssiegel) and two questions assessing the frequency of medical errors. RESULTS: About 48.7% of the clinicians meet the criteria for burnout according to the CBI. Moreover, in multivariate logistic regression analyses, burnout is significantly associated with perceived quality of care among male (odds ratios vary from 1.5 to 2.6) but not among female surgeons (odds ratios vary from 1.3 to 1.5). CONCLUSIONS: The high prevalence of burnout in our study corresponds with former studies of burnout among physicians. Furthermore, the results of the study suggest a relationship between burnout and perceived quality of care among men. Thus, reducing burnout among surgeons could not only improve their health and well-being but also the quality of care.

Psychosocial stress among hospital doctors in surgical fields: results of a nationwide survey in Germany.

BACKGROUND: The aim of this paper is to analyze psychosocial stress in the workplace among hospital doctors working in surgical fields in Germany with the aid of the demand-control model, the effort-reward imbalance model, and selected additional indicators. METHODS: A written questionnaire was answered by a stratified random sample consisting of 1311 hospital doctors working in surgical fields in 489 hospitals in Germany. Validated instruments were used to make measurements according to the demand-control and effort-reward imbalance models. RESULTS: The working conditions of about a quarter of the hospital doctors surveyed were characterized by an effort-reward imbalance. 22% of them have "job strain" according to the demand-control model, i.e., they are confronted with high demands, yet have a low degree of control. Residents and assistant physicians not occupying training positions were both found to have an especially high degree of psychosocial stress. Furthermore, about one-fifth of the hospital doctors surveyed thought about giving up their profession at least a few times per month. 44% of them considered that the quality of patient care was sometimes or often impaired by an excessive physician workload. CONCLUSION: An investigation of psychosocial stress in the workplace among hospital doctors in surgical fields in Germany indicates that this group suffers from more severe stress at work than other occupational groups. Such working conditions pose a threat to these physicians' own health and to the quality of the health care that they provide.

[Effort-reward imbalance, job strain and burnout among clinicians in surgery]. / Berufliche Gratifikationskrisen, Job Strain und Burnout bei chirurgisch tätigen Krankenhausärzten.

The aim of the study is to analyse the association between psychosocial stress at work and burnout among clinicians in surgery in Germany. For the conceptualisation of work stress the demand-control model (job strain) and the effort-reward imbalance model (ERI) were used. Based on a stratified probability sample a mail survey of 1 311 clinicians from 489 hospitals was conducted. Burnout was measured by the Copenhagen Burnout Inventory. Results of logistic regressions show that both models are significantly associated with burnout (odds ratio job strain: 6.53 (95% confidence interval 4.50-9.46), odds ratio ERI: 5.39 (95% confidence interval 3.94-7.36). Clinicians who are exposed to both, job strain and ERI, have an additionally increased risk. The demand-control model and the effort-reward imbalance model suggest theory-driven interventions for job related health promotion measures which aim for improved working conditions and a decrease of health risks among clinicians in surgery.

Education and self-reported health care seeking behaviour in European welfare regimes: results from the European Social Survey.

OBJECTIVES: This study investigates educational inequalities in the perception of need for seeking health care in 24 European countries belonging to five different welfare regimes (Scandinavian, Anglo-Saxon, Bismarckian, Eastern and Southern). METHODS: Based on the European Social Survey Round 2 (N = 38,122), associations between years of education and intended doctor consultation in case of four hypothetical symptoms (backache, sore throat, sleeping problems and headache) are analysed by multiple logistic regressions. RESULTS: People with less years of education tend to be more likely to consult a doctor compared to people with more education years after adjustment for age and gender. Associations are significant in all welfare regimes, except for the Southern. CONCLUSION: Educational inequalities in the perception of need for seeking health care can be found in different welfare regimes.

Social inequality, lifestyles and health - a non-linear canonical correlation analysis based on the approach of Pierre Bourdieu.

OBJECTIVES: Based on the theoretical and empirical approach of Pierre Bourdieu, a multivariate non-linear method is introduced as an alternative way to analyse the complex relationships between social determinants and health. METHODS: The analysis is based on face-to-face interviews with 695 randomly selected respondents aged 30 to 59. Variables regarding socio-economic status, life circumstances, lifestyles, health-related behaviour and health were chosen for the analysis. In order to determine whether the respondents can be differentiated and described based on these variables, a non-linear canonical correlation analysis (OVERALS) was performed. RESULTS: The results can be described on three dimensions; Eigenvalues add up to the fit of 1.444, which can be interpreted as approximately 50 % of explained variance. The three-dimensional space illustrates correspondences between variables and provides a framework for interpretation based on latent dimensions, which can be described by age, education, income and gender. CONCLUSION: Using non-linear canonical correlation analysis, health characteristics can be analysed in conjunction with socio-economic conditions and lifestyles. Based on Bourdieus theoretical approach, the complex correlations between these variables can be more substantially interpreted and presented.