76 research outputs found

    Analyzing Physician and Patient factors in optimizing Cervical Cancer Screening in Alberta: Progress, Barriers, and Enablers

    Get PDF
    Cervical cancer screening (CCS) program effectiveness is well-accepted; however, inappropriate CCS results in either a woman being tested too often or not being tested at the recommended intervals. Widespread disparities in CCS uptake also exist, even when screening is offered without cost through a publicly funded and organized CCS in Alberta. This thesis has three main objectives: Study 1.To describe temporal trends in screening and outcomes for women, after changes in guidelines in Alberta, Canada, that raised the starting age for screening to 21, then to 25 years of age, and reduced frequency to 3-yearly Study 2. To identify family physicians’ (FP) characteristics that are associated with over- and under-screening for 25-69-year-old women in Calgary, Alberta. Study 3. To study spatial and temporal associations of CCS and sociodemographic variables in Calgary, Canada using Census Canada datasets (2006, 2011, 2016). Methods Study 1: Calgary Laboratory Information System data were used to examine CCS, follow-up procedures, and cancer among women 10 to 29 years from 2007 to 2016 in the whole population of Calgary. Interrupted time-series analyses were used to assess changes in screening and subsequent diagnostic procedures over the ten-year period. Study 2: A population-based retrospective observational study was performed by linking the College of Physicians and Surgeons Alberta physicians’ database of FPs practicing in Calgary with the Calgary Laboratory Services database. We matched physicians’ sex, country and year of medical school graduation, years since medical school graduation, city quadrant of practice, and their estimated patient panel size. Logistic regression models were applied to analyze the over-screening and under-screening patterns. Study 3: CCS rates were obtained from a population-wide laboratory administrative database for Calgary, Alberta for the years 2006, 2011, and 2016 for women 25-69 years of age. These years coincide with Census Canada years, allowing comparison with sociodemographic factors Ordinary Least Square regression (OLS) and geographically weighted regression models (GWR) were used to examine sociodemographic variables associated with CCS rates. Results Study 1: Annual Screening rates dropped by around 10% for all ages over 15 after the 2009 Alberta cervical cancer screening guidelines, followed by a steady decrease. The rates of abnormal test results and biopsies did not increase with decreased screening. Likewise, no increases in Cervical intra-epithelial neoplasias (CIN I, CIN II/III), or invasive cervical cancer rates were observed after reduced testing. Study 2: Among 807 physicians included in the over-screening analysis, 43% of physicians had over-screened their screen-eligible patients. Among the 317 physicians included in the underscreening analysis, 42% had under-screened during the three-year study period. Physician characteristics significantly associated with over-screening included more years of practice and having more female patients in the practice. Female physicians were less likely to under-screen their eligible female patients. Physicians practicing in the Northeast quadrant of the city also had lower odds of screening. Study 3: We analyzed approximately 200,000 cervical cancer screening tests for each year and noted a considerable decrease in screening rates between 2006 and 2011, consistent with changes in screening guidelines. The OLS results showed that a high median household income and university education were strongly associated with higher screening rates in all three census years. 2006 and 2011 OLS models showed negative associations with screening of Aboriginals, Blacks, and recent immigrant women. Conclusions Study 1: The largest decrease in screening and follow-up procedures occurred in the period immediately following the implementation of 2009 Alberta screening guidelines. The number of consequent procedures also decreased in proportion to decreased screening, but there was no increase in cancer rates. Starting screening at age 25 and reducing intervals appears to be safe. Study 2: Screening patterns of family physicians indicate both overuse and underuse, which indicates inconsistencies in adherence to screening guideline recommendations. Identifying strategies and addressing disparities to improve guideline adherence among different physician demographic groups is critical for the success of screening programs. More education and guideline publicity are required to encourage compliance with screening guidelines. Study 3: There were significant sociodemographic differences associated with cervical cancer screening in Calgary. Understanding these sociodemographic associations could form the basis of future education or outreach screening programs, targeting underserved populations, such as women with low income and education

    Do we really care?:An exploration of patient’s perspectives on healthcare for chronic conditions in children and adolescents

    Get PDF
    In the past few years there has been a major shift in health care policies, clinical decision making and research toward greater patient centeredness and optimizing quality of care (partly driven by value-based healthcare). A fundamental principle of patient-centered care is to respect the needs, values and preferences of patients in clinic and clinical decision making. The general aim of this thesis was to analyze to what extend current care in chronic disease, particularly chronic kidney disease in young patients, meets the needs and wishes for these patients. What are potential obstacles? And what is the impact of the chronic disease on daily life for these patients?The first part of the thesis focusses on current experiences with shared-care, particularly on to what extent valid outcomes for patients are integrated in research and care for young patients with CKD and in how clinicians experience shared-care decision making. We also explore to what extent the current care system meets the special needs for health-care in transgender youth in terms of shared-decision making.In part II of the thesis we focused on the determinants and impact of an impaired adaptive functioning and life participation for children and (young) adults with CKD. We aim to focus on patient perspectives on life participation and daily life functioning/ adaptive functioning in children with CKD. Previously, it has been found that ‘life participation’ is the most important outcome for children with CKD. Yet, what does life participation mean for this group of patients? Which topics should healthcare workers keep in mind and pay attention to? How can life participation be disturbed and what is the impact of this on the patient

    Examining men’s experiences of antiretroviral-based HIV treatment and prevention in Malawi and Eswatini with a focus on enablers, barriers and opportunities – a mixed methods study highlighting the intersectionality of stigma, masculinity and the life-course

    Get PDF
    Trotz ihrer selteneren Nutzung von HIV-Diensten wurden MĂ€nner, die Geschlechtsverkehr mit Frauen haben (der Begriff MĂ€nner wird hier auf diese Gruppe bezogen) erst in den letzten Jahren als eigenstĂ€ndige Zielgruppe fĂŒr die Erreichung der globalen HIV Behandlungs- und PrĂ€ventionsziele wahrgenommen. Antiretrovirale Therapie (ART) und PrĂ€-Expositions-Prophylaxe (PrEP) erfordern einen HIV-Test und (im Untersuchungszeitraum) die tĂ€gliche und potenziell stigmatisierende Einnahme von antiretroviralen Medikamenten (ARVs). Die Dissertationsstudie leistet einen Beitrag zur Schließung der GenderlĂŒcke fĂŒr HIV-PrĂ€vention und Behandlung und ist meines Wissens die erste Studie, die die Erfahrungen von MĂ€nnern mit ART und PrEP in zwei HochprĂ€valenzgebieten im sĂŒdlichen Afrika vergleicht: ART am Umodzi Family Centre (UFC), in Blantyre, Malawi, 2019 und PrEP an sechs lokalen Kliniken im Nordwesten Eswatinis, 2017-2018. Das multi-methodische Studiendesign umfasst klinikbezogene Daten, Interviews (n=72 in Malawi und n=114 in Eswatini) mit Klienten, Gesundheitspersonal und anderen Interessengruppen inklusive Gemeindevorsteher/-mitglieder, Policy-Dokumente und vier Fokusgruppendiskussionen unter Beteiligung von MĂ€nnern in Eswatini. Der Fokus lag dabei auf Faktoren, die die ART- und PrEP-Einnahme fördern oder hindern und zu besser geeigneten Gesundheitsdiensten fĂŒr MĂ€nner beitragen. Die Studie sollte darĂŒber hinaus aufweisen, welche Charakteristika von UFC-Klienten in Malawi mit Viruslastsuppression (VLS) und welche Charakteristika von Klienten in Eswatini mit einem HIV-Risiko und der PrEP-Einnahme im Zeitraum 2017-2019 assoziiert sind. Labordaten des UFC in Malawi wiesen eine VLS von 94% auf, fĂŒr Klienten auf einer Dolutegravir basierten Behandlung sogar eine VLS von ĂŒber 97%. FĂŒr Klienten <34 Jahre, auf der zweiten oder einer nicht-standardmĂ€ĂŸigen Therapielinie wurde eine VLS von unter 90% konstatiert. Poisson Regressionen zeigten folgende Assoziationen mit VLS: das relative Risiko einer VLS nahm mit Alter zu und war höher in MĂ€nnern mit BehandlungsunterstĂŒtzung. Die zweite und eine nicht-standardmĂ€ĂŸige Therapielinie war negativ mit VLS assoziiert. In Eswatini stellten MĂ€nner eine Minderheit der PrEP-KlientInnen dar (<30%), und 50% brachen die PrEP innerhalb von 30 Tagen ab. Poisson-Regressionen zeigten Alter <35 Jahre, Beziehungsstatus, Mitglied einer PrEP-Zielgruppe und PrEP als Grund des Klinikbesuchs signifikant mit einem HIV-Risiko assoziiert. Die letzteren beiden Variablen waren positiv mit PrEP-Einnahme fĂŒr mĂ€nnliche Klienten assoziiert. MĂ€nner mit mehreren Sexualpartnerinnen hatten ein höheres relatives Risiko, PrEP zu initiieren. Nach Aussagen der MĂ€nner motivierten sie Angst vor HIV, mehrere Sexualpartnerschaften und der unbekannte oder HIV-positive Status der Partnerin zur PrEP Einnahme. HauptgrĂŒnde fĂŒr die Ablehnung von PrEP waren, genauer ĂŒber PrEP nachdenken zu mĂŒssen, das eigene HIV-Risiko gering einzuschĂ€tzen und die Notwendigkeit, tĂ€glich Medikamente einzunehmen. Qualitative Ergebnisse aus Malawi und Eswatini kontextualisierten die quantitativen Ergebnisse. Gesellschaftliche Erwartungen, Stigma, Alter und Lebensphase, Beziehungsstatus mit Serokonkordanz oder -diskordanz, soziale Referenzgruppen, tĂ€gliche Pilleneinnahme, eigene Klinikerfahrung, Arbeitssituation vis-Ă -vis Klinikbesuche, moralische Überzeugungen und das VerstĂ€ndnis von ART oder PrEP hatten Auswirkungen auf Behandlungs- und PrĂ€ventionsentscheidungen und -erfahrungen von MĂ€nnern und bezogen sich auf alle Ebenen des sozio-ökologischen Modells, das die Dissertationsstudie untermauerte. Förder- und hinderliche Faktoren fĂŒr PrEP und ART konnten identisch sein oder divergieren. Die freie Entscheidung fĂŒr PrEP in Risikosituationen gegenĂŒber keiner wirklichen Alternative zu ART wirkten sich auf das Testen, die Erfahrung von Nebenwirkungen und die BehandlungslĂ€nge aus und zeigten Intra- und Intergruppenunterschiede. MaskulinitĂ€t spielte fĂŒr MĂ€nner in beiden Studien eine große Rolle: sie wollten gesund wirken and Ă€ußerten Hoffnungen und Ängste bezĂŒglich der Auswirkungen von ART und PrEP auf ihre VirilitĂ€t, was RĂŒckwirkungen auf die Medikamenteneinnahme hatte. Der Grad des anhaltenden HIV-Stigmas an beiden Studienorten ĂŒberraschte. MĂ€nner hatten Angst davor, als HIV-positiv gesehen zu werden, was in Eswatini zum Wunsch nach separaten PrEP-Einrichtungen fĂŒhrte. Die IntersektionalitĂ€t von Stigma, MaskulinitĂ€t und dem Lebensverlauf spiegelte sich in Malawi in stĂ€rker empfundenem Stigma bei jĂŒngeren MĂ€nnern wider, die mit ART behandelt wurden und konnte zu AdhĂ€renzproblemen fĂŒhren. Ältere HIV-positive MĂ€nner wurden aufgrund ihrer sozialen Stellung nachsichtiger beurteilt und handelten unabhĂ€ngiger. In Eswatini wurden junge MĂ€nner aufgrund ihrer sexuellen Experimentierfreudigkeit als Hauptzielgruppe fĂŒr PrEP betrachtet. Vertrauen und Misstrauen kristallisierten sich als wichtige Beziehungsthemen heraus: In Malawi spielten Verwandte eine SchlĂŒsselrolle in der praktischen und moralischen BehandlungsunterstĂŒtzung, wĂ€hrend anderen Personen weniger vertraut wurde. Serodiskordanz, Probleme mit Kondomen, der Wille, HIV-negativ zu bleiben und Misstrauen gegenĂŒber der Partnerin schufen Anreize fĂŒr die PrEP-Einnahme; Vertrauen hinderte die PrEP-Einnahme, die dann jedoch vornehmlich der Partnerin mitgeteilt wurde. An beiden Studienorten informierten MĂ€nner signifikante Andere und nahmen somit eine Rolle als „Peer-Educators“ ein, die im Rahmen von ART und PrEP-Programmen fĂŒr MĂ€nner gefördert werden sollte. Die HeterogenitĂ€t, MĂ€nnlichkeit zu leben, die in beiden Studien zum Vorschein kam, wies eine Bandbreite auf, die von Autonomie, VirilitĂ€t, Entscheidungsmacht, Scheu, Treue, FĂŒrsorge fĂŒr Partnerin(nen), Freunde und Familie, Vertrauen, Misstrauen, Geheimhaltung, Offenlegung des HIV-Status oder der PrEP-Einnahme bis zum Motivieren anderer reichte. Diese HeterogenitĂ€t stellte ein Streben nach einem hegemonialen MaskulinitĂ€tsideal wie auch das Ausleben einer untergeordneten MaskulinitĂ€t in Frage. Als alternatives Modell zum VerstĂ€ndnis von MaskulinitĂ€t und zur Transformation von mĂ€nnlichem Verhalten sollte das Konzept eines kulturellen Repertoires, aus dem situationsspezifische Aktionsstrategien gewĂ€hlt werden können, genauer untersucht werden. Die Dissertationsstudie unterstreicht die Wichtigkeit, MĂ€nner als eigene Zielgruppe wahrzunehmen und die HIV-bezogenen Dienste auf ihre BedĂŒrfnisse anzupassen. An beiden Studienorten zeigten MĂ€nner eine PrĂ€ferenz fĂŒr lĂ€nger anhaltende Wirkstoffe, fĂŒr die Verschreibung von Medikamenten fĂŒr mehrere Monate, um Klinikbesuche zu reduzieren und fĂŒr mĂ€nnerfreundliche Kliniken, GesundheitsaufklĂ€rung und -dienste in lokalen Gemeinschaften mit Sport- und Verpflegungsanreizen. FĂŒr ART beinhaltete dies neue Zugangsoptionen wie ARV-Automaten, Viruslastselbsttests und lokale Personen, ĂŒber die man ARVs beziehen kann; fĂŒr PrEP bestand Bedarf fĂŒr mehr gemeindeorientierte Informationen, z.B. zum Unterschied von ART und PrEP. HIV-Behandlung als PrĂ€vention schien MĂ€nnern an beiden Studienorten unbekannt zu sein. Fundiertere AufklĂ€rung könnte Stigma reduzieren und die Situation von serodiskordanten Paaren verbessern. Die verschiedenen VorschlĂ€ge sollten zusammen mit MĂ€nnern konkreter ausgearbeitet und in Pilotstudien getestet werden, um maskulinitĂ€tsbezogene ART- und PrEP-Barrieren zu ĂŒberwinden und zur beschleunigten Überwindung der AIDS-Epidemie fĂŒr alle beizutragen

    FACILITATORS ENABLING SUSTAINABLE CERVICAL CANCER CONTROL PROGRAMS IN LOW- AND MIDDLE-INCOME COUNTRIES: STRENGTHENING HEALTH SYSTEMS IN ZAMBIA

    Get PDF
    By 2030, an estimated 75% of cancer deaths will occur in low- and middle-income countries (LMICs) (Bray et al., 2018). Health systems in LMICs will need sustainable strengthening to meet the growing burden. In 2020, the World Health Organization (WHO) launched the 2020-2030 Global Strategy Towards the Global Elimination of Cervical Cancer (WHO, 2019). Screening, treatment, and early detection have proven effective in controlling cervical cancer. While sustainability of these interventions has not been extensively studied, identified barriers and facilitators to sustainability map closely to the six WHO building blocks for health systems strengthening. This linkage suggests that designing sustainable cervical cancer programs may help strengthen the broader health system. This study strives to identify the facilitators of sustainable cervical cancer screening and treatment programs that strengthen healthcare systems in an LMIC. Using a sequential mixed methods qualitative approach, the study’s aims and methods included: 1) describe the barriers and facilitators to sustaining cervical cancer programs in LMICs using a literature review and key informant interviews; 2) conduct a qualitative case study in Zambia, a country with a demonstrated sustainable cervical cancer program, using key informant interviews, document review and triangulation of data sources, to determine how the cervical cancer program strengthens the Zambian health system; and 3) develop a conceptual framework that links the identified facilitators to sustainable cervical cancer screening programs in LMICs (results from Aims 1-3) to the WHO health systems framework using a synthesis of results from aims 1 and 2. The results of this study provide insights into the facilitators and barriers of cervical cancer program sustainability, and ways that the cervical cancer program in Zambia strengthens the local health system. The findings build on the available evidence and inform a framework that provides guidance to countries as they are implementing cervical cancer screening and treatment programs. This research further highlights the need for future research, specifically implementation science, to inform future scale-up and sustainability of cervical cancer interventions.Doctor of Public Healt

    Cancer Biomarker Research and Personalized Medicine

    Get PDF
    Biomarkers are measures of a biological state. The treatment of individual patients based on particular factors, such as biomarkers, distinguishes standard, generalized treatment plans from personalized medicine. Even though personalized medicine is applicable to most branches of medicine, the field of oncology is perhaps where it is most easily employed. Cancer is a heterogeneous disease; although patients may be diagnosed histologically with the same cancer type, their tumors can comprise varying tumor microenvironments and molecular characteristics that can impact treatment response and prognosis. There has been a major drive over the past decade to try and realize personalized cancer medicine through the discovery and use of disease-specific biomarkers. This book, entitled “Cancer Biomarker Research and Personalized Medicine”, encompasses 22 publications from colleagues working on a diverse range of cancers, including prostate, breast, ovarian, head and neck, liver, gastric, bladder, colorectal, and kidney. The biomarkers assessed in these studies include genes, intracellular or secreted proteins, exosomes, DNA, RNA, miRNA, circulating tumor cells, circulating immune cells, in addition to radiomic features

    Neuromuscular Disorders in Children and Adolescents

    Get PDF
    Significant scientific and therapeutic advances have been made in recent decades, particularly in hereditary but also in acquired neuromuscular diseases. As a result of our increasing etiological understanding, the classification of these diseases has changed from a clinical–descriptive and formal–genetic to a molecular–genetic and pathophysiological one. This has led to an intensification of research into the diagnosis and treatment of these diseases, resulting in the first effective gene-modifying treatments for DMD and SMA in recent years and, more recently, gene replacement therapy for the most severe form of SMA. In addition, great strides have been made in symptomatic and rehabilitative treatment, making it possible to improve the functioning and quality of life of those affected and their families. This Special Issue of Children contains a collection of 12 studies and reviews dealing with genetic and acquired peripheral nerve and muscle disorders

    Extracellular Vesicles: Biology and Potentials in Cancer Therapeutics

    Get PDF
    Extracellular vesicles (EVs) are particles wrapped in a lipid bilayer membrane and are naturally released from cells. This kind of cargo vessel is a nanostructure that mainly transfers lipids, proteins, various nucleic acid fragments, and metabolic components to neighboring cells or distant parts of the body through the circulatory system. EVs are of great significance to the communication mechanism between cells. This book collects feature articles to enhance our understanding of the biological characteristics of EVs and their potential applications

    Phytochemical Omics in Medicinal Plants

    Get PDF
    Medicinal plants are used to treat diseases and provide health benefits, and their applications are increasing around the world. A huge array of phytochemicals have been identified from medicinal plants, belonging to carotenoids, flavonoids, lignans, and phenolic acids, and so on, with a wide range of biological activities. In order to explore our knowledge of phytochemicals with the assistance of modern molecular tools and high-throughput technologies, this book collects recent innovative original research and review articles on subtopics of mechanistic insights into bioactivities, treatment of diseases, profiling, extraction and identification, and biotechnology
    • 

    corecore