Fasting insulin and endogenous hormones in relation to premenopausal breast density (Canada).

PURPOSE: Mammographic breast density (BD) is associated with increased risk of breast cancer. This study asks which circulating metabolic and reproductive biomarkers are associated with BD, particularly dense breast area, in premenopausal women not taking exogenous hormones. METHODS: In a cross-sectional study, 299 premenopausal women aged 40-49 completed questionnaires, provided a fasting blood sample, had height, weight, percentage body fat, waist and hip measurements taken, and attended a screening mammogram. Multivariate linear regression was used to calculate adjusted means for percentage BD, absolute dense and non-dense area, across categories of covariates, adjusted for day of menstrual cycle, age, parity, body mass index, percentage body fat, and ethnicity. RESULTS: Fasting insulin levels were inversely associated, and insulin-like growth factor-binding protein 1 levels directly associated with percentage BD, but lost statistical significance after multivariate adjustment. Sex hormone-binding globulin levels were directly associated with percentage BD, still significant after multivariate adjustment (p = 0.03). A significant inverse dose-response association was observed between progesterone levels and dense area (p < 0.01). CONCLUSIONS: Breast density in premenopausal women seems unrelated or inversely related to insulin resistance, levels of insulin-like growth factor 1 and its binding proteins, and levels of sex steroids; therefore, the mechanism by which radiodensity on a mammogram is related to breast cancer risk remains unclear.

Changing communication needs and preferences across the cancer care trajectory: insights from the patient perspective.

PURPOSE: In this program of research, we sought to expand our understanding of how cancer patients' communication needs and preferences change across the course of their illness trajectory. To address known limitations in the empirical knowledge base, we designed a study capitalizing on representative patient reports as they occurred within time and across experience obtaining care for this disease. METHODS: We used a longitudinal cohort design informed by interpretive description methodology to follow 125 patients over a multi-year period as they reflected on their ongoing experiences with cancer care communication. RESULTS: In relation to each phase of their cancer care trajectory, patients identified tension points and contextual challenges impinging on what they felt constituted helpful and unhelpful patient-provider communication. CONCLUSIONS: Findings from this study create a dynamic portrait of how we can better inform communication approaches and interventions through interpretations of population knowledge and individual experience.

Poor communication in cancer care: patient perspectives on what it is and what to do about it.

BACKGROUND: Communication in cancer care is a recognized problem for patients. Research to date has provided limited relevant knowledge toward solving this problem. OBJECTIVE: Our research program aims to understand helpful and unhelpful communication from the patient perspective and to document changes in patient needs and priorities over time. In this analysis, we focus on patient perceptions of poor communication. METHODS: Using a qualitative longitudinal approach informed by interpretive description methodology, we are following a cohort of adult cancer patients across their cancer journey. We used constant comparative analysis of repeated interviews to examine thematic patterns in their perceptions and interpret both commonalities and diversities. RESULTS: Patient accounts reveal 3 types of poor communication. "Ordinary misses" are everyday missteps for which maturation and socialization may be an adequate solution. "Systemic misunderstandings" are assumptive gaps between patients and professionals, which may be addressed through qualitative research. "Repeat offenders" are a subset of clinicians whose communication patterns become a particular source of patient distress. CONCLUSIONS: This typology offers a novel way to conceptualize the problem of poor communication in cancer care toward more effective solutions for the communication problem. Managing the communication of a problematic subset of clinicians will likely require strategic interventions at the level of organizational culture and models of care. IMPLICATIONS FOR PRACTICE: Nurses can play a meaningful role in detecting and buffering sources of poor communication in the practice context. Addressing poor communication may be a further reason to advocate for interprofessional team-based care models.

Homelessness as viewed by incarcerated women: participatory research.

PURPOSE: The purpose of this paper is to describe the development, by incarcerated women who were members of a prison participatory health research team, of a survey tool regarding homelessness and housing, the survey findings and recommendations for policy. DESIGN/METHODOLOGY/APPROACH: A survey was developed by incarcerated women in a minimum/medium security women's prison in Canada. Associations were examined between socio-demographic factors and reports of difficulty finding housing upon release, homelessness contributing to a return to crime, and a desire for relocation to another city upon release. Open-ended questions were examined to look for recurrent themes and to illuminate the survey findings. FINDINGS: In total, 83 women completed the survey, a 72 per cent response rate. Of the 71 who were previously incarcerated, 56 per cent stated that homelessness contributed to their return to crime. Finding housing upon release was a problem for 63 per cent and 34 per cent desired relocation to another city upon release. Women indicated that a successful housing plan should incorporate flexible progressive staged housing. RESEARCH LIMITATIONS/IMPLICATIONS: The present study focuses only on incarcerated women but could be expanded in future to include men. PRACTICAL IMPLICATIONS: Incarcerated women used the findings to create a housing proposal for prison leavers and created a resource database of the limited housing resources for women prison leavers. SOCIAL IMPLICATIONS: Lack of suitable housing is a major factor leading to recidivism. This study highlights the reality of the cycle of homelessness, poverty, crime for survival, street-life leading to drug use and barriers to health, education and employment that incarcerated women face. ORIGINALITY/VALUE: Housing is a recognized basic determinant of health. No previous studies have used participatory research to address homelessness in a prison population.

Prostate cancer support groups, health literacy and consumerism: are community-based volunteers re-defining older men's health?

In this article we describe the connections between prostate cancer support groups (PCSGs) and men's health literacy and consumer orientation to health care services. The study findings are drawn from participant observations conducted at 16 PCSGs in British Columbia, Canada and 54 individual interviews that focused on men's experiences of attending group meetings. Men's communication and interactions at PCSGs provide important insights for how men talk about and conceptualize health and illness. For example, biomedical language often predominated at group meetings, and men used numbers and measures to engage with risk discourses in linking prostate cancer markers to various treatment options and morbidity and mortality rates. Many groups afforded opportunities for men to interact with health care providers as a means to better understand the language and logic of prostate cancer management. The health literacy skills fostered at PCSGs along with specific group-informed strategies could be mobilized in the men's subsequent clinical consultations. Consumer discourses and strategies to contest power relations with health care professionals underpinned many men's search for prostate cancer information and their commitment to assisting other men. Key were patients' rights, and perhaps responsibility, to compare diverse health products and services in making decisions across the entire trajectory of their prostate cancer. Overall, the study findings reveal PCSGs as having the capacity to contest as well as align with medical expertise and services facilitating men's transition from patient to informed health care consumers. The processes through which this occurs may direct the design of older men's health promotion programs.

Masculinities, diet and senior Punjabi Sikh immigrant men: food for Western thought?

The high rates of diabetes and cardiovascular disease among Punjabi Sikh (PS) men are often linked to diet. Although some high fat and sugar foods in both traditional and Western foods negatively influence these illnesses, little is known about what underpins PS immigrant men's dietary practices. This article details the connections between masculinities and diet to reveal how varying gendered ideals can inform and influence the practices of senior PS Canadian immigrant men who attended community-based men's groups. Participants' masculine ideals and their alignment to those ideals were deeply rooted in spirituality and traditional cultures, which shaped the use of specific foods and beverages, yet there was also evidence that the availability and affordability of dairy products and alcohol in Canada strongly influenced men's diets. While the men's group leaders educated attendees about diet, ideologies reinforcing ties between femininities and the cooking of meals often prevailed. Linkages between participants' masculine ideals and dietary practices were both similar and discordant with the findings reported in studies of Western men. The findings drawn from this study may direct what, how and where dietary messages are targeted to senior PS Canadian immigrant men.

Family history, mammographic density, and risk of breast cancer.

PURPOSE: Mammographic density is a strong and highly heritable risk factor for breast cancer. The purpose of this study was to examine the extent to which mammographic density explains the association of family history of breast cancer with risk of the disease. SUBJECTS AND METHODS: We carried out three nested case-control studies in screening programs that included in total 2,322 subjects (1,164 cases and 1,158 controls). We estimated the independent and combined associations of family history and percent mammographic density at baseline with subsequent breast cancer risk. RESULTS: After adjustment for age and other risk factors, compared with women with no affected first-degree relatives, percent mammographic density was 3.1% greater for women with one affected first-degree relative, and 7.0% greater for women with two or more affected relatives (P = 0.001 for linear trend across family history categories). The odds ratios for breast cancer risk were 1.37 [95% confidence interval (95% CI), 1.10-1.72] for having one affected relative, and 2.45 (95% CI, 1.30-4.62) for having two or more affected relatives (P for trend = 0.0002). Adjustment for percent mammographic density reduced these odds ratios by 16% and 14%, respectively. Percent mammographic density explained 14% (95% CI, 4-39%) of the association of family history (at least one affected first-degree relative) with breast cancer risk. CONCLUSIONS: Percent mammographic density has features of an intermediate marker for breast cancer, and some of the genes that explain variation in percent mammographic density might be associated with familial risk of breast cancer.

Health promotion and illness demotion at prostate cancer support groups.

Although health promotion programs can positively influence health practices, men typically react to symptoms, rather than maintain their health, and are more likely to deny than discuss illness-related issues. Prostate cancer support groups (PCSGs) provide an intriguing exception to these practices, in that men routinely discuss ordinarily private illness experiences and engage with self-health. This article draws on individual interview data from 52 men, and participant observations conducted at the meetings of 15 groups in British Columbia, Canada to provide insights to how groups simultaneously facilitate health promotion and illness demotion. The study findings reveal how an environment conducive to men's talk was established to normalize prostate cancer and promote the individual and collective health of group members. From a gendered perspective, men both disrupted and embodied dominant ideals of masculinity in how they engaged with their health at PCSGs.

Primary health care: applying the principles within a community-based participatory health research project that began in a Canadian women's prison.

OBJECTIVES: the purpose of this research was to determine the feasibility of engaging incarcerated women in community-based participatory research and to identify, by and with the women, the health concerns to be addressed. DESIGN: the integration of primary health care, community-based participatory research, a settings approach to health promotion and transformative action research guided the overall design of this study. PARTICIPANTS: Incarcerated women, correctional centre staff and academic researchers participated collaboratively. Setting. The study was conducted in the main short sentence (two years or less) minimum/medium security women's correctional centre in a Canadian province. RESULTS: In-depth interviews were conducted with 16 incarcerated women; in-depth group interviews were facilitated with 16 correctional centre staff. Twenty-one themes, which emerged from participatory, inductive and content analysis of the data, were presented at a face-to-face meeting attended by 120 incarcerated women, 10 correctional centre staff and 5 academic researchers. Underlying values and principles for the project were identified prior to a discussion of the results. During the course of this meeting, the themes were converged into five major categories: addictions and mental health; HIV, hepatitis and infections; health care in prison; life skills and re-entry into society (including homelessness and housing); and children, family and relationships. Numerous suggestions for health interventions and participatory projects were generated, each relating to one of the five major categories. CONCLUSIONS: this study was unique in that, to our knowledge, no other studies have utilized community-based participatory research methods in which incarcerated women played a role in designing the research questions and tools, collecting the data, analyzing the data, interpreting the data and authoring the publications and presentations. This study demonstrated that it is feasible for incarcerated women to engage in developing and utilizing community-based participatory research methods and that these methods can be grounded in a settings approach to whole prison health promotion.

Comparison of breast cancer survival in two populations: Ardabil, Iran and British Columbia, Canada.

BACKGROUND: Patterns in survival can provide information about the burden and severity of cancer, help uncover gaps in systemic policy and program delivery, and support the planning of enhanced cancer control systems. The aim of this paper is to describe the one-year survival rates for breast cancer in two populations using population-based cancer registries: Ardabil, Iran, and British Columbia (BC), Canada. METHODS: All newly diagnosed cases of female breast cancer were identified in the Ardabil cancer registry from 2003 to 2005 and the BC cancer registry for 2003. The International Classification of Disease for Oncology (ICDO) was used for coding cancer morphology and topography. Survival time was determined from cancer diagnosis to death. Age-specific one-year survival rates, relative survival rates and weighted standard errors were calculated using life-tables for each country. RESULTS: Breast cancer patients in BC had greater one-year survival rates than patients in Ardabil overall and for each age group under 60. CONCLUSION: These findings support the need for breast cancer screening programs (including regular clinical breast examinations and mammography), public education and awareness regarding early detection of breast cancer, and education of health care providers.

Patient real-time and 12-month retrospective perceptions of difficult communications in the cancer diagnostic period.

Communication is a notoriously complex challenge in the cancer care context. Our program of research involves exploration of patient-provider communications across the cancer trajectory from the patient perspective.Toward this end, we have been following a cohort of 60 cancer patients, representing a range of tumor sites, from immediately after diagnosis through to recovery, chronic, or advanced disease. Drawing on interpretive description analytic techniques, we documented patterns and themes related to various components of the cancer journey. In this article, we report on findings pertaining to poor communication during the initial diagnostic period, as described by patients at the time of diagnosis and 1 year later.These findings illuminate the dynamics of communication problems during that complex period, and depict the mechanisms by which patients sought to confront these challenges to optimize their cancer care experience. On the basis of these findings, considered in the context of the body of available evidence, suggestions are proposed as to appropriate directions for system-level solutions to the complex communication challenges within cancer care.

Sources of health information among Chinese immigrants to the Pacific Northwest.

BACKGROUND: Chinese immigrants to North America experience cancer-related health disparities and underutilize preventive care. Little is known about Chinese immigrants' sources of health information. METHODS: A population-based survey of Chinese immigrants was conducted in Vancouver, British Columbia, Canada and Seattle, Washington. RESULTS: The study group included 899 individuals. Less than three fourths of the respondents reported receiving health information from health care providers, and only a minority used the Internet as a source of health information. We found significant differences between the sources of health information in Seattle and Vancouver. CONCLUSIONS: Health educators should consider available media outlets as well as the characteristics of a target community when planning intervention programs for Chinese immigrants.

A cross-border comparison of hepatitis B testing among chinese residing in Canada and the United States.

BACKGROUND: The Western Pacific region has the highest level of endemic hepatitis B virus (HBV) infection in the world, with the Chinese representing nearly one-third of infected persons globally. HBV carriers are potentially infectious to others and have an increased risk of chronic active hepatitis, cirrhosis, and hepatocellular carcinoma. Studies from the U.S. and Canada demonstrate that immigrants, particularly from Asia, are disproportionately affected by liver cancer. PURPOSE: Given the different health care systems in Seattle and Vancouver, two geographically proximate cities, we examined HBV testing levels and factors associated with testing among Chinese residents of these cities. METHODS: We surveyed Chinese living in areas of Seattle and Vancouver with relatively high proportions of Chinese residents. In-person interviews were conducted in Cantonese, Mandarin, or English. Our bivariate analyses consisted of the chi-square test, with Fisher's Exact test as necessary. We then performed unconditional logistic regression, first examining only the city effect as the sole explanatory variable of the model, then assessing the adjusted city effect in a final main-effects model that was constructed through backward selection to select statistically significant variables at alpha=0.05. RESULTS: Survey cooperation rates for Seattle and Vancouver were 58% and 59%, respectively. In Seattle, 48% reported HBV testing, whereas in Vancouver, 55% reported testing. HBV testing in Seattle was lower than in Vancouver, with a crude odds ratio of 0.73 (95% CI = 0.56, 0.94). However after adjusting for demographic, health care access, knowledge, and social support variables, we found no significant differences in HBV testing between the two cities. In our logistic regression model, the odds of HBV testing were greatest when the doctor recommended the test, followed by when the employer asked for the test. DISCUSSION: Findings from this study support the need for additional research to examine the effectiveness of clinic-based and workplace interventions to promote HBV testing among immigrants to North America.

Time-related communication skills from the cancer patient perspective.

OBJECTIVE: Although it is well recognized that skilled communication is an essential element of effective cancer care, lack of time to communicate is often cited as an explanation for the ongoing cancer care communications problems patients report. In this study, we sought to answer the question: How do cancer patients describe and explain the effects of health care communication upon their experience of time? METHODS: We conducted a qualitative secondary analysis, using interpretive description methodology, on a large data set that comprised transcribed interview data from two studies of cancer communication from the patient perspective. One primary study represented a cross-sectional study of helpful and unhelpful communications (n=200) and the other a longitudinal study of changes in communication needs and preferences over the illness trajectory (n=60). RESULTS: We found time a meaningful and symbolic construct for cancer patients. They describe clinician time-related attitudes and behaviors as significant factors in shaping the impact of clinical encounters on their overall psychosocial cancer experiences. They report a number of ways in which clinician communications have been particularly effective in buffering and manipulating the impact of time pressures and describe a capacity within exceptionally skilled clinicians to manufacture a perception of available time even in the context of such pressures. CONCLUSIONS: We believe that the patient perspective on cancer care communication provides an important angle of vision from which to discern strategies that may assist clinicians to buffer the untoward effects of the time pressure under which most care systems currently operate.

Connecting humor, health, and masculinities at prostate cancer support groups.

OBJECTIVE: Many commentaries about men's health practices and masculinities indicate that men do not typically engage with self-health or acknowledge illness, let alone openly discuss their health concerns with other men. Prostate cancer support groups (PCSGs) appear to run contrary to such ideals, yet the factors that influence men's attendance and engagement at group meetings are poorly understood. As part of a larger PCSG study, we noticed that humor was central to many group interactions and this prompted us to examine the connections between humor, health, and masculinities. METHODS: A qualitative ethnographic design was used to direct fieldwork and conduct participant observations at the meetings of 16 PCSGs in British Columbia, Canada. Individual semi-structured interviews were completed with 54 men who attended PCSGs to better understand their perceptions about the use of humor at group meetings. RESULTS: Four themes, disarming stoicism, marking the boundaries, rekindling and reformulating men's sexuality, and when humor goes south were drawn from the analyses. Overall, humor was used to promote inclusiveness, mark the boundaries for providing and receiving mutual help, and develop masculine group norms around men's sexuality. Although there were many benefits to humor there were also some instances when well-intended banter caused discomfort for attendees. CONCLUSIONS: The importance of group leadership was central to preserving the benefits of humor, and the specificities of how humor is used at PCSGs may provide direction for clinical practice and the design of future community-based men's health promotion programs.

Evaluation of a hepatitis B lay health worker intervention for Chinese Americans and Canadians.

Hepatitis B testing is recommended for immigrants from countries where hepatitis B infection is endemic. However, only about one-half of Chinese in North America have received hepatitis B testing. We conducted a randomized controlled trial to evaluate the effectiveness of a hepatitis B lay health worker intervention for Chinese Americans/Canadians. Four hundred and sixty individuals who had never been tested for hepatitis B were identified from community-based surveys of Chinese conducted in Seattle, Washington, and Vancouver, British Columbia. These individuals were randomly assigned to receive a hepatitis B lay health worker intervention or a direct mailing of physical activity educational materials. Follow-up surveys were completed 6 months after randomization. Self-reported hepatitis B testing was verified through medical records review. A total of 319 individuals responded to the follow-up survey (69% response rate). Medical records data verified hepatitis B testing since randomization for 9 (6%) of the 142 experimental group participants and 3 (2%) of the 177 control group participants (P = 0.04). At follow-up, a higher proportion of individuals in the experimental arm than individuals in the control arm knew that hepatitis B can be spread by razors (P < 0.001) and during sexual intercourse (P = 0.07). Our findings suggest that lay health worker interventions can impact hepatitis B-related knowledge. However, our hepatitis B lay health worker intervention had a very limited impact on hepatitis B testing completion. Future research should evaluate other intervention approaches to improving hepatitis B testing rates among Chinese in North America.

Hepatitis B testing and vaccination in immigrants attending English as a second language classes in British Columbia, Canada.

BACKGROUND: Hepatitis B virus (HBV) is a growing health issue in Canada, especially given that population growth is now largely the result of immigration. Immigrants from countries with high HBV prevalence and low levels of HBV vaccination have an excess risk of liver disease and there is a need for increased diligence in HBV blood testing and possibly vaccination among these populations. OBJECTIVE: This study describes the sociodemographic characteristics associated with a history of HBV testing and HBV vaccination in immigrants from several countries with high HBV prevalence who are attending English classes. METHODS: 759 adult immigrants attending English as a Second Language classes completed a self-administered questionnaire asking about sociodemographic characteristics and history of HBV testing and HBV vaccination. Descriptive statistics and adjusted ORs were calculated to explore these associations. RESULTS: 71% reported prior HBV testing, 8% reported vaccination without testing, and 21% reported neither testing nor vaccination. Age, education and country of birth all showed significant effects for both testing and vaccination. CONCLUSIONS: Health care practitioners need to be cognizant of HBV testing, and possibly vaccination, in some of their patients, including immigrants from countries with endemic HBV infection. Infected persons need to be identified by blood testing in order receive necessary care to prevent or delay the onset of liver disease as well as to adopt appropriate behaviours to reduce the risk of transmission to others. Close contacts of infected persons also require HBV testing and subsequent vaccination (if not infected) or medical management (if infected).

Treatment decision making among Chinese women with DCIS.

One result of the widespread screening mammography is a 200% increase in the rates of breast ductal carcinoma in situ (DCIS). Treatment decision making among Chinese women diagnosed with DCIS remains understudied. This study examined Chinese-Canadian women's experiences (N = 26): (1) with treatment decision making (mastectomy or breast conserving surgery) and (2) their reflections on the decision-making process. Interviews in Cantonese, Mandarin, or English were transcribed and translated, and a content analysis conducted. Women's treatment decisions reflected a lack of understanding of DCIS, the desire to rid themselves of breast cancer forever, and the influence of significant others. English as a second language and use of medical jargon impeded their ability to make informed treatment decisions. Women's reflections on the decision-making process provided insights into how to improve information and support treatment decision making in ways that are accessible to them.

Agreement between birthplace and self-reported ethnicity in a population-based mammography service.

BACKGROUND: Ethnicity is associated with genetic, environmental, lifestyle and social constructs. Difficult to define using a single variable, but strongly predictive of health outcomes and useful for planning healthcare services, it is often lacking in administrative databases, necessitating the use of a surrogate measure. A potential surrogate for ethnicity is birthplace. Our aim was to measure the agreement between birthplace and ethnicity among six major ethic groups as recorded at the population-based mammography service for British Columbia, Canada (BC). METHODS: We used records from the most-recent visits of women attending the Screening Mammography Program of British Columbia to cross-tabulate women's birthplaces and self-reported ethnicities, and separately considered results for the time periods 1990-1999 and 2000-2006. In general, we combined countries according to the system adopted by the United Nations, and defined ethnic groups that correspond to the nation groups. The analysis considered birthplaces and corresponding ethnicities for South Asia, East/Southeast Asia, North Europe, South Europe, East Europe, West Europe and all other nations combined. We used the kappa statistic to measure the concordance between self-reported ethnicity and birthplace. RESULTS: Except for the 'Other' category, the most-common birthplace was East/Southeast Asia and the most-common ethnicity was East/Southeast Asian. The agreement between birthplace and self-reported ethnicity was poor overall, as evidenced by kappa scores of 0.22 in both 1990-1999 and 2000-2006. There was substantial agreement between ethnicity and birthplace for South Asians, excellent agreement for East/Southeast Asians, but poor agreement for Europeans. CONCLUSION: Birthplace can be used as a surrogate for ethnicity amongst people with South Asian and East/Southeast Asian ethnicity in BC.

Three-year follow-up study of women who participated in a cervical cancer screening intervention while in prison.

OBJECTIVE: This study describes rescreening following a prison cervical cancer screening intervention: the numbers of women who received rescreening during the three-year follow-up period; their timing of rescreening in relationship to intervention follow-up recommendations; and socio-demographic factors associated with rescreening. METHODS: Socio-demographic information was collected from Corrections Branch records. Clinical and risk factor information was obtained by a self-administered questionnaire. Pap screening histories were collected from Cervical Cancer Screening Program (CCSP) client records using the client ID number for Pap smears taken during the intervention period, during the three-year follow-up period, and during the 30-month period preceding the intervention period. Results were entered in Excel and responses summarized with frequency tables; bivariate analysis of categoric variables was done using chi-square tests of independence. RESULTS: During the three-year follow-up period, only 28 (21%) of 138 women who participated in a prison cervical cancer screening intervention were rescreened within 6 months of the recommendation received at intervention Pap test. Women with fewer than 5 multiple names (aliases) were more likely to be rescreened (p = 0.02). Educational level approached statistical significance (p = 0.05), with women with least education receiving highest rescreening. There was no relationship between rescreening and ethnicity, injection drug use, having borne children and current methadone treatment. CONCLUSION: Only 50% of women who participated in a specifically designed prison screening intervention were rescreened during the subsequent three years. Further work is needed to design, implement and evaluate follow-up initiatives of community cervical cancer screening programs for women who are at higher risk of developing cervical dysplasia.