Integrative Review of Literature on the Determinants of Health Outcomes of Women Living with Breast Cancer in Canada and Nigeria from 1990-2014: A Comparative Study

Background and Aim: Globally, breast cancer is the most common cancer among women. The stage of the disease at diagnosis is a core determinant of its health outcome. In low to middle-income countries like Nigeria, advanced stage of disease presentation for medical care represents a significant problem. While mortality rates from breast cancer are declining in developed countries like Canada, they are increasing in developing countries like Nigeria. It is well documented that presentation for medical care at the early stages of the disease improves outcome. Knowledge of the factors that impact seeking medical care after breast cancer symptom discovery in women and knowledge of the factors that impact participation in breast health activities by women is important in reducing breast cancer-related mortality. Methods and Design: This integrative review critically examined the determinants of health outcomes of women living with breast cancer in Canada and Nigeria from 1990-2014. Specifically, it examined the factors that impact seeking medical care after breast cancer symptom discovery in women. It also explored the factors that impact participation in breast health activities by women in the two countries from 1990 to 2014. A total of 303 articles were identified and retrieved by searching the following databases: CINAHL, MEDLINE, and EMBASE. Grey literature from relevant organizations websites were identified using Google Scholar. Among the 303 articles identified, 55 met the inclusion criteria. Results and Conclusion: Findings from the articles that met the inclusion criteria showed that Canadians have a high level of breast health awareness. The findings also suggest that women in Nigeria have rather poor knowledge of breast health awareness and breast cancer. In Nigeria, presentation with an advanced stage of the disease made survival very low. This also compromises the quality of life of the patients. The major factors responsible for the late presentations were a lack of breast cancer awareness and education. Other social factors that mitigate against early presentations for medical care include misconceptions about breast cancer treatment and outcomes. In line with the findings of this study, it is recommended that wide spread culturally sensitive, linguistically appropriate, health education programs to teach breast health awareness should be developed and disseminated. Such health awareness programs should be targeted at women through various channels such as the media, the television, and radio. Also, within the hospital, the developed education programs should be integrated into the existing women health education programs. Non-government and other charitable organizations can also make significant contributions to breast health awareness through sponsoring health talks and workshops targeted at relevant segments of the population. Key search words: Breast cancer, breast neoplasm, diagnosis, prevention and control, health knowledge, patient attitude and practice, breast self-examination, awareness, patient education as topic, mass screening, early detection of cancer, Nigeria, Canada.

Preventive Maintenance Decision Modeling in Health and Service Systems

This dissertation focuses on the preventive maintenance decision modeling in healthcare and service systems. In the first part of this dissertation, some issues in preventive health decisions for breast cancer are addressed, and in the second part, the required characteristics for preventive maintenance of an unreliable queuing system are derived. Adherence to cancer screening is the first issue that is addressed in this dissertation. Women’s adherence or compliance with mammography screening remained low in the recent years. In this dissertation, we first develop a design-based logistic regression model to quantify the probability of adherence to screening schedules based on women’s characteristics. In Chapter 3, we develop a randomized finite-horizon partially observable Markov chain to evaluate and compare different mammography screening strategies for women with different adherence behaviors in terms of quality adjusted life years (QALYs) and lifetime breast cancer mortality risk. The results imply that for the general population, the American Cancer Society (ACS) policy is an efficient frontier policy. In Chapter 4, the problem of overdiagnosis in cancer screening is addressed. Overdiagnosis is a side effect of screening and is defined as the diagnosis of a disease that will never cause symptoms or death during a patient\u27s lifetime. We develop a mathematical framework to quantify the lifetime overdiagnosis and mortality risk for different screening policies, and derive the (near) optimal policies with minimum overdiagnosis risk. In the second part, we consider an unreliable queuing system with servers stored in a shared stack. In such a system, servers have heterogeneous transient usage since servers on the top of the stack are more likely to be used. We develop a continuous-time Markov chain model to derive the utilization and usage time of servers in the system. These quantities are critical for the decision maker for deriving a maintenance policy

DETERMINANTS OF PAP SCREENING AMONG SUB-SAHARAN AFRICAN IMMIGRANT WOMEN

The purpose of this dissertation was to explore the determinants of Pap screening completion among sub-Saharan African immigrant women. Cervical cancer is a public health problem globally. The risk of invasive cervical cancer remains high among sub- Saharan African immigrant women in the US despite being a preventable cancer. Early detection through Pap screening is crucial for prevention, treatment and prognosis. The specific aims of this dissertation were to 1) examine Pap screening practices among African immigrant women and to identify gaps to guide future research; 2) explore barriers and motivators that influence Pap screening decisions among African immigrant women; and 3) explore African immigrant men’s knowledge of Pap screening and attitudes about supporting their wives/female partners to utilize Pap screening, and 4) explore predictors of Pap screening use among sub-Saharan African immigrant women, Specific aim one was addressed by a review and synthesis of literature focused on Pap screening among African immigrant women. Common factors influencing Pap screening completion included immigration status, health care interactions, knowledge deficiency, religiosity, and certain personal characteristics. Specific aim two was addressed by the conduct of a qualitative descriptive study of barriers and motivators contributing to Pap screening decisions in 22 African immigrant women. Women experienced different barriers including low knowledge of screening, cultural beliefs, fear and communication issues. Addressing knowledge gaps and other barriers related to Pap screening may improve Pap screening participation in this group. Specific aim three was addressed by a qualitative descriptive study of men’s attitudes and beliefs regarding Pap screening and support for their wives for Pap screening participation. African immigrant men demonstrated suboptimal knowledge and awareness of cervical cancer screening. Most men had a lack of knowledge regarding HPV and its link with cervical cancer. Despite knowledge deficiency men showed significant interest in supporting their wife/female partners. Specific aim four was addressed by conducting an analysis of cross sectional data collected from 108 sub-Saharan African women. Predictors of Pap screening completion was determined using logistic regression while controlling for age and education. Pap screening awareness and provider’s recommendations were independent predictors of Pap screening. Given the unequitable burden of cervical cancer experienced by this population, the findings from this dissertation point to the need for a multilevel targeted health interventions directed toward African immigrant population are needed to increase the rates of Pap screening among African immigrant women. Prevention efforts should focus on individual level factors and develop culturally relevant strategies that will effectively provide educational outreach interventions and alleviate barriers to Pap screening. Engaging spousal support and addressing social norms related to spouses/partners’ roles that may influence partaking in cervical cancer screening is important among African immigrant women. Cervical cancer is preventable; Pap screening will lead to early detection of cervical cancer in female African immigrants

Epidemiology, Pathology, Management and Open Challenges of Breast Cancer in Central Sudan: A Prototypical Limited Resource African Setting

Little is known about breast cancer in Sudan. According to the recent data published by the Khartoum Cancer Registry, breast cancer was the most common cancer among Sudanese women. Generally, breast cancer in native African women is characterized by young age at onset, occurrence in multiparous premenopausal patients, advanced stage at diagnosis, large tumor size, high‐grade and triple‐negative phenotype, with correspondingly poor prognosis. In Sudan, it was reported that about 70% of the women diagnosed with breast cancer were younger than 50 years old. We present here data from local and international publications as well as primary information from the National Cancer Institute in Wad Medani (one of the only two cancer hospitals of the country, both located in Central Sudan in Khartoum and Wad Medani). We provide an up‐to‐date situation analysis of breast cancer in Central Sudan as an example for an African reality and the various open challenges of breast cancer in a limited resource setting. A better understanding of breast cancer in black African women is of global relevance, as there is an alarming increase in breast cancer among young black women worldwide, and these patients have the lowest survival rates

Essays in ‘global’ health utilization: How distance, gender, and stigma condition whether and when we seek care

The landscape of health service use varies across, and even within, countries and health sectors irrespective of payment model or health system, yet the fundamental purpose motivating its study is aimed at overcoming the challenges that prevent better and equitable uptake of effective interventions. This dissertation is fuelled by such purpose. Although each chapter poses a specific utilization question relevant to a unique target population, in its entirety, this work seeks to answer the following cross-cutting questions: (i) what are the factors that encourage and challenge utilization of health services, (ii) under which moderating conditions and through which channels is improved utilization supported, and (iii) how can a better understanding of the antecedents of improved utilization contribute to the design of well-targeted health interventions. In Chapter 1, we show that participation in health insurance increases the probability of meeting medical needs while decreasing the probability of incurring catastrophic out-of-pocket health payments in Ghana. Drawing on nationally representative survey data from India, Chapter 2 offers causal insight into the effect of female empowerment, in the form of marital age, on women’s utilization of cervical and breast screening. Our findings suggest that losses in female empowerment attributed to early marriage partly explain Indian women’s low cervical and breast screening participation. Aiming to contribute a better understanding of health utilization among hard-to-reach groups, Chapter 3 investigates the factors that determine the extent of thought given to screening in a sample of high-risk heavy smokers who attended the first free lung cancer screening program in Italy. We show that individuals with greater life-time smoking exposure, and therefore at higher risk of developing lung cancer, tend to contemplate screening less. Finally, Chapter 4 evaluates the cost-effectiveness of a population-based lung cancer screening program targeting high-risk prior and current heavy smokers (≥20 pack-years) aged between 55 and 74 years, in Italy. In doing so, we explore the economic relevance of programs designed with a view towards improving screening participation within hard-to-reach target populations. We offer evidence that rendering an annual LDCT-based screening – with three varying screening invitation strategies – available to the Italian heavy smoker population is more effective, yet more costly, than current clinical practice from the perspective of the national budget holder. Thus, in seeking to offer insight into the factors that encourage and challenge utilization, the conditions and channels that sustain it, and the design of programs that may, in turn, be sustained by it, this dissertation positions health utilization at centre stage

Health beliefs and personality correlates of breast cancer: from screening to mastectomy adjustment - a cross-cultural study between Scotland and Greece

The present thesis consists of three thematic parts in relation to breast cancer: (a) practice of breast self - examination (BSE), (b) screening mammography attendance and (c) adjustment to breast cancer surgery / mastectomy. The aims of the respective studies are (a) to examine attitudes, beliefs and practices regarding BSE in younger (30 years old or under) and older women (over 30 years old), (b) to explore attitudes and beliefs regarding mammography and identify factors associated with screening mammography attendance and (c) to explore factors associated with adjustment to breast cancer surgery. The above aims are explored in two different cultural contexts, by comparing samples from Scotland and Greece. Samples consisted (a) of 205 younger and 258 older women, university staff and students in Scotland and 85 younger women, university students in Greece, (b) 283 women who attended and 72 women who did not attend the National Breast Screening in Scotland, and 72 women undergoing mammography in Greece and (c) 19 women in Scotland and 27 women in Greece, who have undergone surgery for breast cancer. All participants were assessed on a variety of measures. These included demographics, health history, health beliefs and health - related personality variables. Results indicated that: 1. BSE was predicted by different variables across age and cultural groups. 2. In particular, practice of BSE in younger women was predicted by knowledge about breast cancer, perceived barriers, health motivation and cues for action, whereas practice in older women was predicted by knowledge about BSE, perceived barriers and cues for action. 3. BSE rates in both countries were higher than previously reported but did not differ between women in Scotland and Greece. However, the two groups differed in knowledge and attitudes, regarding BSE, and in personality. Women in Scotland appeared more knowledgeable regarding BSE, felt less susceptible to breast cancer and were less active in coping with health issues than women in Greece. Women in Greece valued their health more and scored higher in chance health locus of control beliefs than women in Scotland. 4. The best predictor of breast screening mammography attendance in Scotland was knowledge about mammography. Attenders appeared to have more knowledge about breast cancer and about mammography and to focus more on emotional coping, in order to deal with health stresses. 5. The two cultural groups differed in health-related decision making and health - related coping styles. Attenders in Scotland were more knowledgeable about risk factors related to breast cancer and about mammograms and perceived significantly more pain/discomfort associated with the procedure, than attenders in Greece. Attenders in Greece resorted more to acceptance and denial and were more likely to seek emotional support, in order to cope with health stressors than attenders in Scotland. 6. Health beliefs of breast cancer patients, in relation to their condition, and their style of coping with threatening information, concerning their breast problem, are highlighted as important factors to their adjustment in both cultures. However, adjustment to breast cancer surgery appears culture-specific, as different factors seem to determine it in different cultural contexts. 7. Patients in Scotland and Greece did not differ in their overall adjustment. However, Greek patients were significantly less well adjusted sexually postoperatively than patients in Scotland. Findings are discussed in relation to theoretical and practical implications

Shared Decision-making in breast cancer screening programmes: Contributions to its implementations

A mesura que els pacients prenen consciència de ser usuaris del Sistema Nacional de Salut, demanen una prestació no relacionada només en resoldre el seu problema de salut de manera oportuna, sinó que també inclogui un bon acompanyament per part dels professionals, de manera que aconsegueixin un millor benestar. És a dir, sentir-se escoltat, rebre informació comprensible, ser tractat amb empatia i poder-se involucrar en les decisions que afecten la seva salut, sembla que són elements importants a considerar. Així ho han entès els diferents sistemes de salut, que han declarat com a centre del model els pacients, encara que de vegades sigui un desafiament portar-lo a la pràctica diària. La Presa de Decisions Compartides (TDC) pot ser una alternativa per concretar una atenció més participativa i centrada en el pacient, i models com "The Three-talk" faciliten la seva aplicació en situacions específiques de salut o malaltia. En aquest context, en el cribratge de càncer de mama, les dones tenen una baixa implicació a l'hora de decidir la seva participació, ja que no tenen ni un espai ni un temps específic on poder expressar els seus temors, dubtes o preferències a un professional de la salut, i moltes vegades manca informació sobre els beneficis i efectes adversos de participar en el cribratge. Més encara, elles no visualitzen aquestes mancances com una necessitat, perquè està molt interioritzat el benefici d'una detecció precoç com l'únic resultat possible i desconeixen o minimitzen els efectes adversos que coexisteixen amb el cribratge: falsos positius, falsos negatius o sobrediagnòstic. Aquesta tesi té per finalitat contribuir al desenvolupament d'una salut més participativa en l'àmbit del cribratge de càncer de mama, en un context de Sistema Nacional de Salut, utilitzant el model de TDC. Així, els resultats de tres estudis han permès: 1) conèixer les barreres i facilitadors per a l'aplicació de la TDC des de la perspectiva dels professionals de la salut, 2) crear dos documents –manual i guia– que ofereixen suport empíric als professionals de la salut per involucrar les dones en la presa de decisions del cribratge; 3) entendre les preferències de les dones comparant la significació dels atributs que defineixen el model de salut convencional i un amb incorporació d'una TDC.A medida que los pacientes toman conciencia como usuarios del Sistema Nacional de Salud, demandan prestaciones relacionadas no sólo con la resolución óptima de su problema de salud, sino una atención que también incluya un buen acompañamiento por parte de los profesionales, de forma que consigan un mejor bienestar. Es decir, sentirse escuchado, recibir información comprensible, ser tratado con empatía y poder involucrarse en las decisiones que afectan a su salud parecen ser elementos importantes que considerar. Así lo han entendido los diferentes sistemas de salud, que han declarado, como centro del modelo, a los pacientes, aunque en ocasiones sea un desafío llevarlo a la práctica diaria. La Toma de Decisiones Compartidas (TDC) puede ser una alternativa para concretar una atención más participativa y centrada en el paciente, y modelos como “The Three-talk model” facilitan su aplicación en situaciones específicas de salud o enfermedad. En este contexto, en el cribado de cáncer de mama, las mujeres tienen una baja implicación a la hora de decidir su participación, puesto que no tienen ni un espacio ni un tiempo específico donde poder expresar sus temores, dudas o preferencias a un profesional sanitario, y muchas veces carece de información sobre los beneficios y efectos adversos de participar en el cribado. Más aún, ellas no visualizan estas carencias como una necesidad, porque está muy interiorizado el beneficio de una detección precoz como el único resultado posible y desconocen o minimizan los efectos adversos que coexisten con el cribado: falsos positivos, falsos negativos o sobrediagnóstico. Esta tesis tiene por finalidad contribuir al desarrollo de una salud más participativa en el ámbito del cribado de cáncer de mama, en un contexto de Sistema Nacional de Salud, utilizando el modelo de TDC. Se realizaron tres estudios que han permitido: 1) conocer las barreras y facilitadores para la aplicación de la TDC desde la perspectiva de los profesionales de la salud, 2) crear dos documentos –manual y guía– que ofrecen soporte empírico a los profesionales sanitarios para involucrar a las mujeres en la toma de decisiones del cribado; 3) entender las preferencias de las mujeres comparando la significación de los atributos que definen el modelo de salud convencional y uno con incorporación de una TDC.As the awareness of patients as users of the national health system increases, they demand more well-being, which is not only related to solving their problem, but also a good accompaniment by health professionals. That is, feeling heard, receiving understandable information, being treated with empathy, and getting involved in decisions that affect your health seem to be important elements to consider. This has been understood by the different health systems, which have declared patients as the center of the model, although it is sometimes a challenge to put it into routine practice. Shared Decision-making (SDM) could be an alternative for more participatory and patient-centered care, as well as “The Three-talk” model would simplify its application in specific health or disease situations. In this context, women in breast cancer screening have a low involvement in the decision to participate, since they do not have a space in which to express their fears, doubts, or preferences to a health professional, and do not have sufficient information on the benefits and adverse effects of participating in screening. Even worse, they do not see these deficiencies as a necessity, since the benefit of early detection is very much internalized as the only possible result and they do not know or minimize the adverse effects they may suffer due to screening: false positives, false negatives or overdiagnosis. This thesis aims to contribute to the development of a more participatory health in the context of breast cancer screening in a context of the National Health System, using the SDM model. Three studies were carried out: 1) to know the barriers and facilitators for the application of the SDM from the perspective of health professionals, 2) create two documents, manual and guide, to give practical support to health professionals to involve women in the screening decision, 3) to know the preferences of women by comparing the attributes of the conventional health model and one with the incorporation of an SDM

Psychological Impact of Testing Positive for Human Papillomavirus at Cervical Cancer Screening

In the UK and elsewhere, cervical cancer screening has changed to incorporate primary human papillomavirus (HPV) testing. This means all women who attend screening are told whether they test positive or negative for high-risk HPV. Testing positive for HPV has been associated with elevated anxiety and distress; and can also carry a negative label due to its sexually transmitted nature. Prior to this PhD, there had been no major studies assessing the psychological impact of routine HPV primary screening, or the impact of testing HPV-positive with normal cytology, a result unique to these screening methods. Four studies were conducted: 1) mixed-method systematic review to synthesise emotional response to testing HPV-positive at cervical cancer screening (33 studies); 2) cross-sectional survey comparing anxiety and distress between different test result groups at routine HPV primary screening (n=1127); 3) cross-sectional survey exploring distinct illness representation profiles and anxiety in women testing HPV-positive with normal cytology (n=646); and 4) comparative qualitative interview study to explore reasons for variations in anxiety in women testing HPV-positive with normal cytology (n=30). Overall, testing HPV-positive at cervical screening was sometimes associated with adverse emotional, cognitive, behavioural, and physiological sequelae. These impacts appeared to differentially affect subgroups of the population in terms of intensity, duration, and clinical significance. For women testing HPV-positive with normal cytology, maladaptive illness representations may partially account for clinically significant anxiety. Highly anxious women primarily expressed fear of developing cervical cancer and had concerns about potential relationship infidelity and fertility issues. Cognitive Behavioural Theory and Leventhal’s Common-Sense Model of Self-Regulation were used to formulate overarching findings, providing a preliminary theoretical literature in an otherwise atheoretical domain. The findings of this PhD begin to develop an evidence-base for specific messages which could be used by policymakers in routine patient communication materials, to alleviate unnecessary anxiety at HPV primary screening