A health care labyrinth: perspectives of caregivers on the journey to accessing timely cancer diagnosis and treatment for children in India

Background

Cure rates for children with cancer in India lag behind that of high-income countries. Various disease, treatment and socio-economic related factors contribute to this gap including barriers in timely access of diagnostic and therapeutic care. This study investigated barriers to accessing care from symptom onset to beginning of treatment, from perspectives of caregivers of children with cancer in India.

Methods

Semi-structured in-depth interviews were conducted with caregivers of children (< 18 years) diagnosed with cancer in seven tertiary care hospitals across New Delhi and Hyderabad. Purposive sampling to saturation was used to ensure adequate representation of the child’s gender, age, cancer type, geographical location and socioeconomic status. Interviews were audio recorded after obtaining informed consent. Thematic content analysis was conducted and organised using NVivo 11.

Results

Thirty-nine caregivers were interviewed, where three key themes emerged from the narratives: time intervals to definitive diagnosis and treatment, the importance of social supportive care and the overall accumulative impacts of the journey. There were two phases encapsulating the experiences of the family: referral pathways taken to reach the hospital and after reaching the hospital. Most caregivers, especially those from distant geographical areas had variable and inconsistent referral pathways partly due to poor availability of specialist doctors and diagnostic facilities outside major cities, influence from family or friends, and long travel times. Upon reaching the hospital, families mostly from public hospitals faced challenges navigating the hospital facilities, finding accommodation, and comprehending the diagnosis and treatment pathway. Throughout both phases, financial constraint was a recurring issue amongst low-income families. The caregiver’s knowledge and awareness of the disease and health system, religious and social factors were also common barriers.

Conclusion

This qualitative study highlights and explores some of the barriers to childhood cancer care in India. Our findings show that referral pathways are intrinsically linked to the treatment experience and there should be better recognition of the financial and emotional challenges faced by the family that occur prior to definitive diagnosis and treatment. This information would help inform various stakeholders and contribute to improved interventions addressing these barriers.

The medium, the message and the measure: a theory-driven review on the value of telehealth as a patient-facing digital health innovation

By what measure should a policy maker choose between two mediums that deliver the same or similar message or service? Between, say, video consultation or a remote patient monitoring application (i.e. patient-facing digital health innovations) and in-person consultation? To answer this question, we sought to identify measures which are used in randomised controlled trials. But first we used two theories to frame the effects of patient-facing digital health innovations on - 1) transaction costs (i.e. the effort, time and costs required to complete a clinical interaction); and 2) process outcomes and clinical outcomes along the care cascade or information value chain, such that the 'value of information' (VoI) is different at each point in the care cascade or value chain. From the trials, we identified three categories of measures: outcome (process or clinical), satisfaction, and cost. We found that although patient-facing digital health innovations tend to confer much of their value by altering process outcomes, satisfaction, and transaction costs, these measures are inconsistently assessed. Efforts to determine the relative value of and choose between mediums of service delivery should adopt a metric (i.e. mathematical combination of measures) that capture all dimensions of value. We argue that 'value of information' (VoI) is such a metric - it is calculated as the difference between the 'expected utility' (EU) of alternative options. But for patient-facing digital health innovations, 'expected utility' (EU) should incorporate the probability of achieving not only a clinical outcome, but also process outcomes (depending on the innovation under consideration); and the measures of utility should include satisfaction and transaction costs; and also changes in population access to services, and health system capacity to deliver more services, which may result from reduction in transaction costs.

Evaluating access to essential medicines for treating childhood cancers: a medicines availability, price and affordability study in New Delhi, India

Introduction

Limited access to essential medicines (EMs) for treating chronic diseases is a major challenge in low-income and middle-income countries. Although India is the largest manufacturer of generic medicines, there is a paucity of information on availability, price and affordability of anti-neoplastic EMs, which this study evaluates.

Methods

Using a modified WHO/Health Action International methodology, data were collected on availability and price of 33 strength-specific anti-neoplastic EMs and 4 non-cancer EMs. Seven 'survey anchor' hospitals (4 public and 3 private) and 32 private-sector retail pharmacies were surveyed. Median price ratios (MPRs) were calculated by comparing consumer prices with international reference prices (IRPs).

Results

On average, across survey anchor areas (hospital and private-sector retail pharmacies combined), the mean availability of anti-neoplastic EMs and non-cancer medicines was 70% and 100%, respectively. Mean availability of anti-neoplastic EMs was 38% in private-sector retail pharmacies, 43% in public hospital pharmacies and 71% in private hospital pharmacies. Median MPR of lowest-priced generic versions was 0.71 in retail pharmacies. The estimated cost of chemotherapy medicines needed for treating a 30 kg child with standard-risk leukaemia was INR 27 850 (US$442) and INR 17 500 (US$278) for Hodgkin's lymphoma, requiring 88 and 55 days' wages, respectively, for the lowest paid government worker.

Conclusion

Most anti-neoplastic EMs are found in survey anchor areas, however, mean availability was less than non-cancer medicines; not meeting the WHO target of 80%. Medicine prices were relatively low in New Delhi compared with IRPs. However, the cost of chemotherapy medicines seems unaffordable in the local context.

On the same page: Co-designing the logic model of a telehealth service for children in rural and remote Australia

The value of programme logic models as a tool for planning, evaluation, and communication is well recognised. However, the value of its development process is less discussed. In this paper, we describe how we used a combination of literature review and organisational stakeholder consultations to develop a logic model for a telehealth programme for children in rural and remote Australia. Our aim was to use this process to further embed the programme within its implementing organisation, and by so doing to promote its sustainability and scale-up; a major challenge of telehealth programmes, especially those involving reorganisation of processes. Our efforts to describe the components of this complex intervention on the one-page logic model allowed for debates and discussions within the implementing organisation which then facilitated an improved cross-organisational understanding of the telehealth programme; a real time face-to-face (video-link) service which requires the reorganisation of existing service delivery platforms. The process helped to embed the telehealth programme within existing services. We conclude that stakeholder engagement in developing logic models can transform them from being only a tool that provides the picture of why and how a programme works, to one that plays a role in embedding programmes within implementing organisations.

Defining and measuring health equity in research on task shifting in high-income countries: A systematic review

Introduction

Task shifting interventions have been implemented to improve health and address health inequities. Little is known about how inequity and vulnerability are defined and measured in research on task shifting. We conducted a systematic review to identify how inequity and vulnerability are identified, defined and measured in task shifting research from high-income countries.

Methods and analysis

We implemented a novel search process to identify programs of research concerning task shifting interventions in high-income countries. We searched MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and CENTRAL to identify articles published from 2004 to 2016. Each program of research incorporated a "parent" randomized trial and "child" publications or sub-studies arising from the same research group. Two investigators extracted (1) study details, (2) definitions and measures of health equity or population vulnerability, and (3) assessed the quality of the reporting and measurement of health equity and vulnerability using a five-point scale developed for this study. We summarized the findings using a narrative approach.

Results

Fifteen programs of research met inclusion criteria, involving 15 parent randomized trials and 62 child publications. Included programs of research were all undertaken in the United States, among Hispanic- (5/15), African- (2/15), and Korean-Americans (1/15), and low socioeconomic status (2/15), rural (2/15) and older adult populations (2/15). Task shifting interventions included community health workers, peers, and a variety of other non-professional and lay workers to address a range of non-communicable diseases. Some research provided robust analyses of the affected populations' health inequities and demonstrated how a task shifting intervention redressed those concerns. Other studies provided no such definitions and measured only biomedical endpoints.

Conclusion

Included studies vary substantially in the definition and measurement of health inequity and vulnerability. A more precise theoretical and evaluative framework for task shifting is recommended to effectively achieve the goal of equitable health.

Families of Children Newly Diagnosed With Cancer Incur Significant Out-of-Pocket Expenditure for Treatment: Report of a Multi-Site Prospective Longitudinal Study From India (INPOG-ACC-16-01)

Background: Diagnosis of cancer in a child places considerable economic burden on families. The health expenditures are more catastrophic in resource limited countries like India where GDP spend on health is just over 1% and financing of treatment is usually out-of-pocket (OOP). Consequently parents may abandon their child's cancer treatment to ensure financial sustainability of the family. Research in this area is mostly from resource rich countries and OOP expenditure burden remains unknown in India. Aim: The objective of this study is to describe the OOP expenditure incurred by families of children (< 18 years age) with cancer being treated in India prior to and during cancer directed treatment. Methods: A prospective cost of illness study from a family household perspective was conducted in 14 centers (5 public, 5 private and 4 charitable trust sector) in 4 cities in India from 2016-2018. Baseline family demographic and socioeconomic data were collected followed by OOP expenditure incurred prior to start of treatment. For the duration of the child's treatment, a social worker contacted parents at regular intervals to record their expenditure on cancer directed treatment. Data collection was stopped when one of these happened - completion of treatment or death or progression/relapse or abandonment or transfer. Data were described descriptively and a univariate/multivariate analysis using logistic regression was done to detect factors associated with OOP expenditure. Results: 394 children (63% male, median age 5 years) with cancer (64% leukemia/lymphoma, 33% solid tumors, 3% CNS tumors) were enrolled from public (45%), charitable trust (28%) and private (27%) sector hospitals. They were symptomatic for a median duration of 6 weeks (range 0 to 104 weeks). 88% had no insurance and 73% were from families with monthly income of ≤ 10,000 rupees (≤ 159 US$). Mean OOP expenditure was Rs 209,500 (3325 US$) which is 195% of per capita income (1706 US$) of India. OOP expenditure from onset of symptoms to start of treatment was Rs 53,104 (843 US$) of which 77% was medical (15% laboratory tests, 11% medicines, 9% hospital bed costs) and 23% nonmedical (12% travel, 6% food, 3% lodging). OOP expenditure on cancer directed treatment was Rs 156,396 (2482 US$) of which 64% was medical (9% hospital bed costs, 9% supportive care drugs, 8% laboratory tests) and 36% nonmedical (19% food, 9% travel, 6% lodging). On univariate analysis age, gender, city, type of treatment facility, insurance, type of cancer, driving time and distance were significantly associated with OOP expenditure but only insurance and type of treatment facility were found significant on multivariate analysis. Conclusion: Families of children with cancer incur significant OOP expenditure prior to and during cancer directed treatment, which includes a significant portion on nonmedical expenses. Expenditure varied significantly by insurance and type of treatment facility.

Defining and measuring health equity effects in research on task shifting interventions in high-income countries: a systematic review protocol

INTRODUCTION

Task shifting interventions are intended to both deliver clinically effective treatments to reduce disease burden and address health inequities or population vulnerability. Little is known about how health equity and population vulnerability are defined and measured in research focused on task shifting. This systematic review will address the following questions: Among task shifting interventions in high-income settings that have been studied using randomised controlled trials or variants, how are health inequity or population vulnerability identified and defined? What methods and indicators are used to describe, characterise and measure the population's baseline status and the intervention's impacts on inequity and vulnerability?

METHODS AND ANALYSIS

Studies were identified through database searches (MEDLINE, Embase, CINAHL, PsycINFO and Web of Science). Eligible studies will be randomised controlled trials published since 2004, conducted in high-income countries, concerning task shifting interventions to treat any disease, in any population that may face health disadvantage as defined by the PROGRESS-Plus framework (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, social capital, socioeconomic position, age, disability, sexual orientation, other vulnerable groups). We will conduct independent and duplicate title and abstract screening, then identify related papers from the same programme of research through further database and manual searching. From each programme of research, we will extract study details, and definitions and measures of health equity or population vulnerability based on the PROGRESS-Plus framework. Two investigators will assess the quality of reporting and measurement related to health equity and vulnerability using a scale developed for this study. A narrative synthesis will highlight similarities and differences between the gathered studies and offer critical analyses and implications.

ETHICS AND DISSEMINATION

This review does not involve primary data collection, does not constitute research on human subjects and is not subject to additional institutional ethics review or informed consent procedures. Dissemination will include open-access peer-reviewed publication and academic conference presentations.PROSPERO Registration Number CRD42017049959.

Cancer in the Solomon Islands

INTRODUCTION

The Solomon Islands, with a population of 550,000, has significant challenges in addressing non-communicable diseases, including cancer, in the face of significant economic, cultural, general awareness and health system challenges.

OBJECTIVES

To summarise the existing knowledge regarding cancer in the Solomon Islands, to gather new data and make recommendations.

METHODS

A literature review was undertaken and cancer data from the National Referral Hospital, Honiara were analysed and are presented. Key stakeholders were interviewed for their perspectives including areas to target for ongoing, incremental improvements. Last, a health services audit for cancer using the WHO SARA tool was undertaken.

RESULTS

Breast and cervical cancer remain the first and second most commonly identified cancers in the Solomon Islands. The Solomons cancer registry is hospital based and suffers from incomplete data collection due to its passive nature, lack of resources for data entry and processing resulting in weak data which is rarely used for decision-making. The health system audit revealed system and individual reasons for delayed diagnosis or lack of cancer treatment or palliation in the Solomon Islands. Reasons included lack of patient knowledge regarding symptoms, late referrals to the National Referral Hospital and inability of health care workers to detect cancers either due to lack of skills to do so, or lack of diagnostic capabilities, and an overall lack of access to any health care, due to geographical barriers and overall national economic fragility.

CONCLUSION

The Solomon Islands is challenged in preventing, diagnosing, treating and palliating cancer. Stakeholders recommend establishing specialty expertise (in the form of a cancer unit), improved registry processes and increased collaboration between the sole tertiary hospital nationwide and other Solomon health services as important targets for incremental improvement.

Frequency and predictors of psychological distress after a diagnosis of epilepsy: A community-based study

OBJECTIVE

The objective of the study was to determine the frequency and predictors of psychological distress after a diagnosis of epilepsy.

METHODS

The Sydney Epilepsy Incidence Study to Measure Illness Consequences (SEISMIC) was a prospective, multicenter, community-based study of people of all ages with newly diagnosed epilepsy in Sydney, Australia. Analyses involved multivariate logistic regression and multinomial logit regression to identify predictors of psychological distress, assessed using the Hospital Anxiety and Depression Scale (HADS) and the Strengths and Difficulties Questionnaire (SDQ), as part of structured interviews.

RESULTS

Psychological distress occurred in 33% (95% confidence interval [CI] 26 to 40%) and 24% (95% CI 18 to 31%) of 180 adults at baseline and 12months, respectively, and 23% (95% CI 14 to 33%) of 77 children at both time points. Thirty adults and 7 children had distress at baseline who recovered at 12months, while 15 adults and 7 children had new onset of distress during this period. History of psychiatric or behavioral disorder (for adults, odds ratio [OR] 6.82, 95% CI 3.08 to 15.10; for children, OR 28.85, 95% CI 2.88 to 288.60) and higher psychosocial disability (adults, OR 1.17, 95% CI 1.07 to 1.27) or lower family functioning (children, OR 1.80, 95% CI 1.08 to 3.02) were associated with psychological distress (C statistics 0.80 and 0.78).

CONCLUSIONS

Psychological distress is common and fluctuates in frequency after a diagnosis of epilepsy. Those with premorbid psychological, psychosocial, and family problems are at high risk of this adverse outcome.

Positional plagiocephaly reduces parental adherence to SIDS Guidelines and inundates the health system

BACKGROUND

This study sought to better understand parent, grandparent and clinician views of prevention, treatment and costs of plagiocephaly.

METHODS

A qualitative study was conducted using focus groups and semi-structured interviews. A grounded theory approach was taken to build theories from the qualitative data collected. A subjectivist epistemological orientation was taken under the paradigm of positivism.

RESULTS

Ninety-one parents, 6 grandparents and 24 clinicians were recruited from the community as well as primary and tertiary care clinics. Plagiocephaly worried most parents because it could permanently affect their child's 'looks' and some thought it would affect a child's development. Parents were 'willing to do anything' to prevent plagiocephaly including using products or sleeping positions that are contraindicated under sudden infant death syndrome guidelines. Parents found the care pathway convoluted and inconsistent messages were given from different health providers. For clinicians, the high prevalence of flat head is 'clogging up their patient pool', taking up time they used to spend with children with more severe conditions.

CONCLUSION

There is a need to re-emphasize sudden infant death syndrome guidelines for families when they present with an infant with plagiocephaly. Stronger messaging regarding the lack of safety of current pillows marketed to prevent flat head may be useful to decrease their use. Increasing education for all health professionals including general practitioners, allied health and complementary health providers and standardizing assessment and referral criteria may allow the majority of diagnosis and treatment of positional plagiocephaly to occur at points of first contact (e.g. general practitioners, community nurse) and may prevent further burden on the health care system.

Towards people-centred health systems: a multi-level framework for analysing primary health care governance in low- and middle-income countries

Although there is evidence that non-government health system actors can individually or collectively develop practical strategies to address primary health care (PHC) challenges in the community, existing frameworks for analysing health system governance largely focus on the role of governments, and do not sufficiently account for the broad range of contribution to PHC governance. This is important because of the tendency for weak governments in low- and middle-income countries (LMICs). We present a multi-level governance framework for use as a thinking guide in analysing PHC governance in LMICs. This framework has previously been used to analyse the governance of common-pool resources such as community fisheries and irrigation systems. We apply the framework to PHC because, like common-pool resources, PHC facilities in LMICs tend to be commonly owned by the community such that individual and collective action is often required to avoid the ‘tragedy of the commons’—destruction and degradation of the resource resulting from lack of concern for its continuous supply. In the multi-level framework, PHC governance is conceptualized at three levels, depending on who influences the supply and demand of PHC services in a community and how: operational governance (individuals and providers within the local health market), collective governance (community coalitions) and constitutional governance (governments at different levels and other distant but influential actors). Using the example of PHC governance in Nigeria, we illustrate how the multi-level governance framework offers a people-centred lens on the governance of PHC in LMICs, with a focus on relations among health system actors within and between levels of governance. We demonstrate the potential impact of health system actors functioning at different levels of governance on PHC delivery, and how governance failure at one level can be assuaged by governance at another level.

A multisite evaluation of summer camps for children with cancer and their siblings

Summer camps for pediatric cancer patients and their families are ubiquitous. However, there is relatively little research, particularly studies including more than one camp, documenting outcomes associated with children's participation in summer camp. The current cross-sectional study used a standardized measure to examine the role of demographic, illness, and camp factors in predicting children's oncology camp-related outcomes. In total, 2,114 children at 19 camps participated. Campers were asked to complete the pediatric camp outcome measure, which assesses camp-specific self-esteem, emotional, physical, and social functioning. Campers reported high levels of emotional, physical, social, and self-esteem functioning. There were differences in functioning based on demographic and illness characteristics, including gender, whether campers/siblings were on or off active cancer treatment, age, and number of prior years attending camp. Results indicated that summer camps can be beneficial for pediatric oncology patients and their siblings, regardless of demographic factors (e.g., gender, treatment status) and camp factors (e.g., whether camp sessions included patients only, siblings only, or both). Future work could advance the oncology summer camp literature by examining other outcomes linked to summer camp attendance, using longitudinal designs, and including comparison groups.

Driver licensing: descriptive epidemiology of a social determinant of Aboriginal and Torres Strait Islander health

OBJECTIVE

Education, employment and equitable access to services are commonly accepted as important underlying social determinants of health. For most Australians, access to health, education and other services is facilitated by private transport and a driver licence. This study aimed to examine licensing rates and predictors of licensing in a sample of Aboriginal and Torres Strait Islander people, as these have previously been poorly described.

METHODS

Interviewer-administered surveys were conducted with 625 people 16 years or older in four Aboriginal Community Controlled Health Services in New South Wales and South Australia over a two-week period in 2012-2013.

RESULTS

Licensing rates varied from 51% to 77% by site. Compared to not having a licence, having a driver licence was significantly associated with higher odds of full-time employment (adjusted OR 4.0, 95%CI 2.5-6.3) and educational attainment (adjusted OR 1.9, 95%CI 1.2-2.8 for trade or certificate; adjusted OR 4.0, 95%CI 1.6-9.5 for degree qualification).

CONCLUSIONS

Variation in driver licensing rates suggests different yet pervasive barriers to access. There is a strong association between driver licensing, education and employment.

IMPLICATIONS

Licensing inequality has far-reaching impacts on the broader health and wellbeing of Aboriginal and Torres Strait Islander people, reinforcing the need for appropriate and accessible pathways to achieving and maintaining driver licensing.

Cost and impoverishment 1 year after hospitalisation due to injuries: a cohort study in Thái Bình, Vietnam

BACKGROUND

Evidence on the economic impact on individuals and their families following an injury in Vietnam is limited. This study examines the costs and the risk of impoverishment due to hospitalised injuries at 12 months following hospital discharge and associated factors.

METHOD

Employing a prospective cohort design, 892 people hospitalised for injury were recruited from Thái Bình General Hospital in Vietnam in 2010 and followed up for 12 months. All out-of-pocket costs incurred and income lost by injured persons and their caregivers associated with care and treatment of their injuries were reported. To examine associated factors, we used generalised estimating equation models for costs and modified Poisson regression for the risk of impoverishment.

RESULTS

The mean total costs by 12 months postdischarge were US$804, nearly 1.2 times the annual average income. Injuries that incurred highest costs were falls (US$950) and road traffic injuries (RTIs) (US$794). At 12-month follow-up, 181 persons (26.9%) became impoverished, with those injured in RTIs and falls at highest risk (26.1% and 35.4%, respectively). Factors associated with higher costs were also those associated with higher risk of impoverishment. These include those injured in RTIs or falls; having higher severity level; principal injured region as upper extremities, lower extremities or head; physical nature of injuries as fracture or concussion injuries; and longer hospitalisation.

CONCLUSIONS

Injuries impose significant economic burden on injured persons and their families during and beyond hospitalisation. In addition to prevention, there is a need to reform health financing system to protect injured persons from significant out-of-pocket expense for healthcare services.

How decentralisation influences the retention of primary health care workers in rural Nigeria

BACKGROUND

In Nigeria, the shortage of health workers is worst at the primary health care (PHC) level, especially in rural communities. And the responsibility for PHC - usually the only form of formal health service available in rural communities - is shared among the three tiers of government (federal, state, and local governments). In addition, the responsibility for community engagement in PHC is delegated to community health committees.

OBJECTIVE

This study examines how the decentralisation of health system governance influences retention of health workers in rural communities in Nigeria from the perspective of health managers, health workers, and people living in rural communities.

DESIGN

The study adopted a qualitative approach, and data were collected using semi-structured in-depth interviews and focus group discussions. The multi-stakeholder data were analysed for themes related to health system decentralisation.

RESULTS

The results showed that decentralisation influences the retention of rural health workers in two ways: 1) The salary of PHC workers is often delayed and irregular as a result of delays in transfer of funds from the national to sub-national governments and because one tier of government can blame failure on another tier of government. Further, the primary responsibility for PHC is often left to the weakest tier of government (local governments). And the result is that rural PHC workers are attracted to working at levels of care where salaries are higher and more regular - in secondary care (run by state governments) and tertiary care (run by the federal government), which are also usually in urban areas. 2) Through community health committees, rural communities influence the retention of health workers by working to increase the uptake of PHC services. Community efforts to retain health workers also include providing social, financial, and accommodation support to health workers. To encourage health workers to stay, communities also take the initiative to co-finance and co-manage PHC services in order to ensure that PHC facilities are functional.

CONCLUSIONS

In Nigeria and other low- and middle-income countries with decentralised health systems, intervention to increase the retention of health workers in rural communities should seek to reform and strengthen governance mechanisms, using both top-down and bottom-up strategies to improve the remuneration and support for health workers in rural communities.

Task-shifting and prioritization: a situational analysis examining the role and experiences of community health workers in Malawi

BACKGROUND

As low- and middle-income countries face continued shortages of human resources for health and the double burden of infectious and chronic diseases, there is renewed international interest in the potential for community health workers to assume a growing role in strengthening health systems. A growing list of tasks, some of them complex, is being shifted to community health workers' job descriptions. Health Surveillance Assistants (HSAs) - as the community health worker cadre in Malawi is known - play a vital role in providing essential health services and connecting the community with the formal health care sector. The objective of this study was to understand the performed versus documented roles of the HSAs, to examine how tasks were prioritized, and to understand HSAs' perspectives on their roles and responsibilities.

METHODS

A situational analysis of the HSA cadre and its contribution to the delivery of health services in Zomba district, Malawi was conducted. Focus groups and interviews were conducted with 70 HSAs. Observations of three HSAs performing duties and work diaries from five HSAs were collected. Lastly, six policy-maker and seven HSA supervisor interviews and a document review were used to further understand the cadre's role and to triangulate collected data.

RESULTS

HSAs performed a variety of tasks in addition to those outlined in the job description resulting in issues of overloading, specialization and competing demands existing in the context of task-shifting and prioritization. Not all HSAs were resistant to the expansion of their role despite role confusion and HSAs feeling they lacked adequate training, remuneration and supervision. HSAs also said that increasing workload was making completing their primary duties challenging. Considerations for policy-makers include the division of roles of HSAs in prevention versus curative care; community versus centre-based activities; and the potential specialization of HSAs.

CONCLUSION

This study provides insights into HSAs' perceptions of their work, their expanding role and their willingness to change the scope of their practice. There are clear decision points for policy-makers regarding future direction in policy and planning in order to maximize the cadre's effectiveness in addressing the country's health priorities.

Camp programs for children with cancer and their families: review of research progress over the past decade

A systematic review was conducted of studies (2001-2013) about therapeutic recreation/camp for children with cancer and/or their family which measured either process or outcome variables qualitatively or quantitatively. Of 581 titles, 20 met the inclusion criteria. Research demonstrates positive impacts of camp on: cancer knowledge, mood, self-concept, empathy, and friendship, quality of life, and emotional well-being. This recent decade of research illuminates nuances in camp outcomes, which previously were unexplored. For instance, changes following camp do not necessarily occur in a linear, positive fashion and varying outcomes were observed by camper subgroup depending on age, culture, and treatment status.