Barriers and Explanatory Mechanisms of Delays in the Patient and Diagnosis Intervals of Care for Breast Cancer in Mexico.

BACKGROUND: Most breast cancer patients in low- and middle-income settings are diagnosed at advanced stages due to lengthy intervals of care. This study aimed to understand the mechanisms through which delays occur in the patient interval and diagnosis interval of care. MATERIALS AND METHODS: We conducted a cross-sectional survey including 886 patients referred to four major public cancer hospitals in Mexico City. Based in a conceptual model of help-seeking behavior, a path analysis strategy was used to identify the relationships between explanatory factors of patient delay and diagnosis delay. RESULTS: The patient and the diagnosis intervals were greater than 3 months in 20% and 65% of participants, respectively. We present explanatory models for each interval and the interrelationship between the associated factors. The patient interval was longer among women who were single, interpreted their symptoms as not worrisome, concealed symptoms, and perceived a lack of financial resources and the difficulty of missing a day of work as barriers to seek care. These barriers were more commonly perceived among patients who were younger, had lower socioeconomic status, and lived outside of Mexico City. The diagnosis interval was longer among those who used several different health services prior to the cancer hospital and perceived medical errors in these services. More health services were used among those who perceived errors and long waiting times for appointments, and who first consulted private services. CONCLUSION: Our findings support the relevance of strengthening early cancer diagnosis strategies, especially the improvement of quality of primary care and expedited referral routes to cancer services. IMPLICATIONS FOR PRACTICE: This study's findings suggest that policy in low- and middle-income countries (LMICs) should be directed toward reducing delays in diagnosis, before the implementation of mammography screening programs. The results suggest several factors susceptible to early diagnosis interventions. To reduce patient delays, the usually proposed intervention of awareness promotion could better work in LMIC contexts if the message goes beyond the advertising of screening mammography to encourage the recognition of potential cancer symptoms and sharing of symptoms with significant others. To reduce diagnosis delay, efforts should focus on strengthening the quality of public primary care services and improving referral routes to cancer care centers.

Long-memory and the sea level-temperature relationship: a fractional cointegration approach.

Through thermal expansion of oceans and melting of land-based ice, global warming is very likely contributing to the sea level rise observed during the 20th century. The amount by which further increases in global average temperature could affect sea level is only known with large uncertainties due to the limited capacity of physics-based models to predict sea levels from global surface temperatures. Semi-empirical approaches have been implemented to estimate the statistical relationship between these two variables providing an alternative measure on which to base potentially disrupting impacts on coastal communities and ecosystems. However, only a few of these semi-empirical applications had addressed the spurious inference that is likely to be drawn when one nonstationary process is regressed on another. Furthermore, it has been shown that spurious effects are not eliminated by stationary processes when these possess strong long memory. Our results indicate that both global temperature and sea level indeed present the characteristics of long memory processes. Nevertheless, we find that these variables are fractionally cointegrated when sea-ice extent is incorporated as an instrumental variable for temperature which in our estimations has a statistically significant positive impact on global sea level.