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Wen KY, Dayaratna S, Slamon R, Granda-Cameron C, Tagai EK, Kohler RE, Hudson SV, Miller SM. Chatbot-interfaced and cognitive-affective barrier-driven messages to improve colposcopy adherence after abnormal Pap test results in underserved urban women: A feasibility pilot study. Transl Behav Med 2024; 14:1-12. [PMID: 38014626 PMCID: PMC10782901 DOI: 10.1093/tbm/ibad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Challenges in ensuring adherence to colposcopy and follow-up recommendations, particularly within underserved communities, hinder the delivery of appropriate care. Informed by our established evidence-based program, we sought to assess the feasibility and acceptability of a novel cognitive-affective intervention delivered through a Chatbot interface, aimed to enhance colposcopy adherence within an urban inner-city population. We developed the evidence-based intervention, CervixChat, to address comprehension of colposcopy's purpose, human papillomavirus (HPV) understanding, cancer-related fatalistic beliefs, procedural concerns, and disease progression, offered in both English and Spanish. Females aged 21-65, with colposcopy appointments at an urban OBGYN clinic, were invited to participate. Enrolled patients experienced real-time counseling messages tailored via a Chatbot-driven barriers assessment, dispatched via text one week before their scheduled colposcopy. Cognitive-affective measures were assessed at baseline and through a 1-month follow-up. Participants also engaged in a brief post-intervention satisfaction survey and interview to capture their acceptance and feedback on the intervention. The primary endpoints encompassed study adherence (CervixChat response rate and follow-up survey rate) and self-evaluated intervention acceptability, with predefined feasibility benchmarks of at least 70% adherence and 80% satisfaction. Among 48 eligible women scheduled for colposcopies, 27 (56.3%) agreed, consented, and completed baseline assessments. Participants had an average age of 34 years, with 14 (52%) identifying as non-Hispanic White. Of these, 21 (77.8%) engaged with the CervixChat intervention via mobile phones. Impressively, 26 participants (96.3%) attended their diagnostic colposcopy within the specified timeframe. Moreover, 22 (81.5%) completed the follow-up survey and a brief interview. Barriers assessment revealed notable encodings in the Affect and Values/Goals domains, highlighting concerns and understanding around HPV, as well as its impact on body image and sexual matters. Persistent and relatively high intrusive thoughts and lowered risk perceptions regarding cervical cancer were reported over time, unaffected by the intervention. Post-intervention evaluations documented high satisfaction and perceived usefulness, with recommendations for incorporating additional practical and educational content. Our findings underscore the robust satisfaction and practicality of the CervixChat intervention among a diverse underserved population. Moving forward, our next step involves evaluating the intervention's efficacy through a Sequential Multiple Assignment Randomized Trial (SMART) design. Enhanced by personalized health coaching, we aim to further bolster women's risk perception, address intrusive thoughts, and streamline resources to effectively improve colposcopy screening attendance.
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Affiliation(s)
- Kuang-Yi Wen
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Sandra Dayaratna
- Department of Obstetrics, Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, 833 Chestnut Street, Philadelphia, PA 19107, USA
| | - Rachel Slamon
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Clara Granda-Cameron
- Department of Graduate Program, College of Nursing, Thomas Jefferson University, 901 Walnut Street, Suite 703, Philadelphia, PA 19107, USA
| | - Erin K Tagai
- Department of Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Racquel E Kohler
- Cancer Health Equity Center, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Suzanne M Miller
- Department of Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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Kohler RE, Wagner RB, Careaga K, Btoush R, Greene K, Kantor L. Mothers' perceptions and attitudes about HPV vaccination initiation among 9- and 10-year-olds. Hum Vaccin Immunother 2023; 19:2270842. [PMID: 37955127 PMCID: PMC10653617 DOI: 10.1080/21645515.2023.2270842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
HPV vaccination has potential to prevent 90% of HPV-associated cancers. The Advisory Committee on Immunization Practices recommends HPV vaccination for 11- and 12-year-olds, but vaccine initiation can start at age 9. The purpose of this study was to explore perceptions about starting HPV vaccination at a younger age to inform future interventions that promote initiation at ages 9 and 10 years. This was part of a larger study about vaccine hesitancy among racially/ethnically diverse parents of adolescents in the Greater Newark Area of New Jersey. We thematically analyzed transcripts from 16 interviews with English- and Spanish-speaking mothers who had at least one child ≤ 10 years. Analyses focused on perceptions of HPV-related disease risk, attitudes toward HPV vaccination need, and vaccine confidence specifically for 9- and 10-year-olds. Few parents with young adolescents reported receiving vaccination recommendations, and only one reported series initiation before age 11. Mothers' hesitation about younger HPV vaccination initiation revolved around: 1) low perceived necessity among English-speaking mothers due to young adolescents not being sexually active, 2) concerns about potential side effects associated with vaccinating prepubescent adolescents, and 3) a desire for adolescents to be old enough to provide assent. Participants were not opposed to younger initiation but wanted and relied on pediatricians to inform them about vaccination for younger adolescents. These findings suggest mothers are willing to vaccinate at younger ages after clear provider recommendations. Equipping providers with evidence about vaccine safety and cancer prevention communication strategies may promote initiation and timely completion at younger ages.
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Affiliation(s)
- Racquel E. Kohler
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- School of Public Health, Rutgers University, New Brunswick, NJ, USA
| | - Rachel B. Wagner
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- School of Public Health, Rutgers University, New Brunswick, NJ, USA
| | - Katherine Careaga
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Rula Btoush
- School of Nursing, Rutgers University, New Brunswick, NJ, USA
| | - Kathryn Greene
- School of Communication & Information, Rutgers University, New Brunswick, NJ, USA
| | - Leslie Kantor
- School of Public Health, Rutgers University, New Brunswick, NJ, USA
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Satagopan JM, Dharamdasani T, Mathur S, Kohler RE, Bandera EV, Kinney AY. Experiences and lessons learned from community-engaged recruitment for the South Asian breast cancer study in New Jersey during the COVID-19 pandemic. PLoS One 2023; 18:e0294170. [PMID: 37956167 PMCID: PMC10642833 DOI: 10.1371/journal.pone.0294170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND South Asians are a rapidly growing population in the United States. Breast cancer is a major concern among South Asian American women, who are an understudied population. We established the South Asian Breast Cancer (SABCa) study in New Jersey during early 2020 to gain insights into their breast cancer-related health attitudes. Shortly after we started planning for the study, the COVID-19 disease spread throughout the world. In this paper, we describe our experiences and lessons learned from recruiting study participants by partnering with New Jersey's community organizations during the COVID-19 pandemic. METHODS We used a cross-sectional design. We contacted 12 community organizations and 7 (58%) disseminated our study information. However, these organizations became considerably busy with pandemic-related needs. Therefore, we had to pivot to alternative recruitment strategies through community radio, Rutgers Cancer Institute of New Jersey's Community Outreach and Engagement Program, and Rutgers Cooperative Extension's community health programs. We recruited participants through these alternative strategies, obtained written informed consent, and collected demographic information using a structured survey. RESULTS Twenty five women expressed interest in the study, of which 22 (88%) participated. Nine (41%) participants learned about the study through the radio, 5 (23%) through these participants, 1 (4.5%) through a non-radio community organization, and 7 (32%) through community health programs. Two (9%) participants heard about the study from their spouse. All participants were born outside the US, their average age was 52.4 years (range: 39-72 years), and they have lived in the US for an average of 26 years (range: 5-51 years). CONCLUSION Pivoting to alternative strategies were crucial for successful recruitment. Findings suggest the significant potential of broadcast media for community-based recruitment. Family dynamics and the community's trust in our partners also encouraged participation. Such strategies must be considered when working with understudied populations.
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Affiliation(s)
- Jaya M. Satagopan
- Department of Biostatistics and Epidemiology, School of Public Health, Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States of America
| | - Tina Dharamdasani
- Department of Biostatistics and Epidemiology, School of Public Health, Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States of America
| | - Shailja Mathur
- Department of Family and Community Health Sciences, Cooperative Extension, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States of America
| | - Racquel E. Kohler
- Department of Health Behavior, Society & Policy, School of Public Health, Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States of America
| | - Elisa V. Bandera
- Cancer Epidemiology and Health Outcomes, Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States of America
| | - Anita Y. Kinney
- Department of Biostatistics and Epidemiology, School of Public Health, Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States of America
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Rabin Y, Kohler RE. COVID-19 Vaccination Messengers, Communication Channels, and Messages Trusted Among Black Communities in the USA: a Review. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01858-1. [PMID: 37947953 DOI: 10.1007/s40615-023-01858-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
Black and African American adults exhibited higher levels of mistrust and vaccine hesitancy and lower levels of vaccination throughout the COVID-19 pandemic. Vaccination and booster uptake remains disproportionately low among Black adults. We conducted a systematic review of empirical research published between February 2021 and July 2022 from five electronic databases and the grey literature. We screened studies that assessed COVID-19 vaccination information needs and preferences as well as communication strategies among Black adults in the USA. We extracted data, then analyzed and synthesized results narratively. Twenty-two articles were included: 2 interventions, 3 experimental surveys, 7 observational surveys, 8 qualitative inquiries, and 2 mixed methods studies. Studies reported credible and preferred COVID-19 vaccination information sources/messengers, channels, and content. Commonly trusted messengers included personal health care providers, social network connections, and church/faith leaders. Electronic outreach (e.g., email, text messages), community events (e.g., forums, canvassing), and social media were popular. Black communities wanted hopeful, fact-based messages that address racism and mistrust; persuasive messages using collective appeals about protecting others may be more influential in changing behavior. Future communication strategies aiming to increase vaccine confidence and encourage COVID-19 booster vaccination among Black communities should be developed in partnership with community leaders and local health care providers to disseminate trauma-informed messages with transparent facts and collective action appeals across multiple in-person and electronic channels.
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Affiliation(s)
- Yael Rabin
- Department of Health Behavior Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Racquel E Kohler
- Department of Health Behavior Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA.
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
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Kohler RE, Hemler J, Wagner RB, Sullivan B, Macenat M, Tagai EK, Miller SM, Wen KY, Ayers C, Einstein MH, Hudson SV. Confusion and anxiety in between abnormal cervical cancer screening results and colposcopy: "The land of the unknown". Patient Educ Couns 2023; 114:107810. [PMID: 37244133 PMCID: PMC10527466 DOI: 10.1016/j.pec.2023.107810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Attendance to colposcopy after abnormal cervical cancer screening is essential to cervical cancer prevention. This qualitative study explored patients' understanding of screening results, their experiences of the time leading up to the colposcopy appointment, and colposcopy. METHODS We recruited women referred for colposcopy from two urban practices in an academic health system. Individual interviews (N = 15) with participants were conducted after colposcopy appointments about their cervical cancer screening histories, current results, and colposcopy experiences. A team analyzed and summarized interviews and coded transcripts in Atlas.ti. RESULTS We found that most women were confused about their screening results, did not know what a colposcopy was before being referred for one, and experienced anxiety in the interval between receiving their results and having their colposcopy. Most women searched for information online, but found "misinformation," "worst-case scenarios" and generic information that did not resolve their confusion. CONCLUSION Women had little understanding of their cervical cancer risk and experienced anxiety looking for information and waiting for the colposcopy. Educating patients about cervical precancer and colposcopy, providing tailored information about their abnormal screening test results and potential next steps, and helping women manage distress may alleviate uncertainty while waiting for follow-up appointments. PRACTICE IMPLICATIONS Interventions to manage uncertainty and distress in the interval between receiving an abnormal screening test result and attending colposcopy are needed, even among highly adherent patients.
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Affiliation(s)
- Racquel E Kohler
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA.
| | - Jennifer Hemler
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Rachel B Wagner
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Brittany Sullivan
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Myneka Macenat
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Erin K Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Suzanne M Miller
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Kuang-Yi Wen
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Charletta Ayers
- Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ 08901, USA
| | - Mark H Einstein
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, 185 South Orange Avenue, Newark, NJ 07103, USA
| | - Shawna V Hudson
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA; Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
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Paolino M, Sánchez Antelo V, Kohler RE, Viswanath K, Arrossi S. Implementation of an mHealth intervention to increase adherence to triage among HPV positive women with HPV-self-collection (ATICA study): post-implementation evaluation from the women's perspective. BMC Womens Health 2023; 23:332. [PMID: 37353835 PMCID: PMC10288763 DOI: 10.1186/s12905-023-02475-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 06/10/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Low adherence to triage after positive screening is a widespread problem for cervical cancer screening programs in Low- and Middle-income Countries. Adherence to cytology-based triage can be challenging, especially among women with self-collected tests. SMS-based interventions are accepted by women and can increase screening uptake. The ATICA study was an effectiveness-implementation hybrid type I trial, combining a cluster randomized controlled trial (RCT) with a mixed-methods implementation evaluation involving quantitative and qualitative methods. Although the RCT provided evidence regarding the effectiveness of the SMS-based intervention, less is known about its acceptability, relevance, and usefulness from the women´s perspective. METHODS We carried out a cross-sectional study based on a structured questionnaire among HPV-positive women who were enrolled in ATICA's intervention group. We measured acceptability, appropriateness, and message content comprehension. Also, we evaluated if the SMS message was considered a cue to encourage women to pick up their HPV test results and promote the triage. RESULTS We interviewed 370 HPV-positive women. Acceptability of SMS messages among women who had received at least one message was high (97%). We found high levels of agreement in all appropriateness dimensions. More than 77% of women showed high comprehension of the content. Among women who received at least one SMS message, 76% went to the health center to pick up their results. Among those who got their results, 90% reported that the SMS message had influenced them to go. We found no significant differences in acceptability, appropriateness or message comprehension between women who adhered to triage and those who did not adhere after receiving the SMS messages. CONCLUSION The intervention was highly acceptable, and women reported SMS was an appropriate channel to be informed about HPV test results availability. SMS was also a useful cue to go to the health center to pick up results. The implementation did not encounter barriers associated with the SMS message itself, suggesting the existence of other obstacles to triage adherence. Our results support the RCT findings that scaling up SMS is a highly acceptable intervention to promote cervical screening triage adherence.
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Affiliation(s)
- Melisa Paolino
- Centre for the Study of State and Society, National Council for Scientific and Technical Research AR, Buenos Aires, Argentina.
| | - Victoria Sánchez Antelo
- Centre for the Study of State and Society, National Council for Scientific and Technical Research AR, Buenos Aires, Argentina
| | - Racquel E Kohler
- Cancer Health Equity, Cancer Institute of New Jersey, Rutgers - the State University of New Jersey, New Jersey, USA
| | - Kasisomayajula Viswanath
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, USA
| | - Silvina Arrossi
- Centre for the Study of State and Society, National Council for Scientific and Technical Research AR, Buenos Aires, Argentina
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Kohler RE, Wagner RB, Careaga K, Vega J, Btoush R, Greene K, Kantor L. Parents' Intentions, Concerns and Information Needs about COVID-19 Vaccination in New Jersey: A Qualitative Analysis. Vaccines (Basel) 2023; 11:1096. [PMID: 37376485 DOI: 10.3390/vaccines11061096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/06/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND In 2019, the World Health Organization identified vaccine hesitancy as a top ten global health threat, which has been exacerbated by the COVID-19 pandemic. Despite local and nationwide public health efforts, adolescent COVID-19 vaccination uptake in the US remains low. This study explored parents' perceptions of the COVID-19 vaccine and factors influencing hesitancy to inform future outreach and education campaigns. METHODS We conducted two rounds of individual interviews via Zoom in May-September 2021 and January-February 2022, with parents of adolescents from the Greater Newark Area of New Jersey, a densely populated area with historically marginalized groups that had low COVID-19 vaccination uptake. Data collection and analysis was guided by the Increasing Vaccination Model and WHO Vaccine Hesitancy Matrix. Interview transcripts were double-coded and thematically analyzed in NVivo. RESULTS We interviewed 22 parents (17 in English, 5 in Spanish). Nearly half (45%) were Black and 41% were Hispanic. Over half (54%) were born outside of the US. Most of the parents described that their adolescents had received at least one dose of a COVID-19 vaccine. All but one parent had received the COVID-19 vaccine. Despite strong vaccination acceptance for themselves, parents remained hesitant about vaccinating their adolescents. They were mostly concerned about the safety and potential side effects due to the novelty of the vaccine. Parents sought information about the vaccines online, through healthcare providers and authorities, and at community spaces. Interpersonal communication exposed parents to misinformation, though some personal connections to severe COVID-19 illness motivated vaccination. Historical mistreatment by the healthcare system and politicization of the vaccine contributed to parents' mixed feelings about the trustworthiness of those involved with developing, promoting, and distributing COVID-19 vaccines. CONCLUSIONS We identified multilevel influences on COVID-19 vaccine-specific hesitancy among a racially/ethnically diverse sample of parents with adolescents that can inform future vaccination interventions. To increase vaccine confidence, future COVID booster campaigns and other vaccination efforts should disseminate information through trusted healthcare providers in clinical and also utilize community settings by addressing specific safety concerns and promoting vaccine effectiveness.
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Affiliation(s)
- Racquel E Kohler
- Center for Cancer Heath Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA
- School of Public Health, Rutgers University, Piscataway, NJ 08854, USA
| | - Rachel B Wagner
- Center for Cancer Heath Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA
- School of Public Health, Rutgers University, Piscataway, NJ 08854, USA
| | - Katherine Careaga
- Center for Cancer Heath Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA
| | - Jacqueline Vega
- Center for Cancer Heath Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA
- School of Public Health, Rutgers University, Piscataway, NJ 08854, USA
| | - Rula Btoush
- School of Nursing, Rutgers University, New Brunswick, NJ 08901, USA
| | - Kathryn Greene
- Center for Cancer Heath Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA
- School of Communication & Information, Rutgers University, New Brunswick, NJ 08901, USA
| | - Leslie Kantor
- School of Public Health, Rutgers University, Piscataway, NJ 08854, USA
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Mittal A, Neibart SS, Kulkarni A, Anderson T, Hudson SV, Beer NL, Einstein MH, Kohler RE. Barriers and facilitators to effective cervical cancer screening in Belize: a qualitative analysis. Cancer Causes Control 2023:10.1007/s10552-023-01703-0. [PMID: 37165111 DOI: 10.1007/s10552-023-01703-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 04/13/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Belize has among the highest cervical cancer incidence and mortality rates of Latin American and Caribbean countries. This study evaluates the perspectives of key stakeholders for cervical cancer screening in Belize and identifies the barriers and facilitators for providing equitable access to prevention services. METHODS Semi-structured interviews discussing cervical cancer screening were conducted with key stakeholders across the six districts of Belize in 2018. Interviews were transcribed, coded, and analyzed thematically; themes were organized by levels of the social-ecological model. RESULTS We conducted 47 interviews with health care providers (45%), administrators (17%), government officials (25%), and other stakeholders (13%). Majority (78%) of interviews were from the public sector. Perceived barriers to cervical cancer screening were identified across multiple levels: (1) Individual Patient: potential delays in Pap smear results and fear of a cancer diagnosis; (2) Provider: competing clinician responsibilities; (3) Organizational: insufficient space and training; (4) Community: reduced accessibility in rural areas; and (5) Policy: equipment and staffing budget limitations. The main facilitators we identified included the following: (1) at the Community level: resource-sharing between public and private sectors and dedicated rural outreach personnel; (2) at the Policy level: free public screening services and the establishment of population-based screening. CONCLUSION Despite free, publicly available cervical cancer screening in Belize, complex barriers affect access and completion of management when abnormal screening tests are identified. Provider workload, education outreach, and additional funding for training and facilities are potential areas for strengthening this program and increasing detection and management for cervical cancer control.
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Affiliation(s)
- Avni Mittal
- Department of Obstetrics and Reproductive Health and Gynecology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Shane S Neibart
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Abha Kulkarni
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Taylor Anderson
- University of Queensland Ochsner Clinical School, Brisbane, QLD, Australia
| | - Shawna V Hudson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Cancer Prevention and Control, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Mark H Einstein
- Department of Obstetrics and Reproductive Health and Gynecology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Racquel E Kohler
- Department of Cancer Prevention and Control, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health , Piscataway, NJ, USA
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Molebatsi K, Iyer HS, Kohler RE, Gabegwe K, Nkele I, Rabasha B, Botebele K, Barak T, Balosang S, Tapela NM, Dryden-Peterson SL. Improving identification of symptomatic cancer at primary care clinics: A predictive modeling analysis in Botswana. Int J Cancer 2022; 151:1663-1673. [PMID: 35716138 PMCID: PMC10286759 DOI: 10.1002/ijc.34178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/26/2022] [Accepted: 03/08/2022] [Indexed: 12/24/2022]
Abstract
In resource-limited settings, augmenting primary care provider (PCP)-based referrals with data-derived algorithms could direct scarce resources towards those patients most likely to have a cancer diagnosis and benefit from early treatment. Using data from Botswana, we compared accuracy of predictions of probable cancer using different approaches for identifying symptomatic cancer at primary clinics. We followed cancer suspects until they entered specialized care for cancer treatment (following pathologically confirmed diagnosis), exited from the study following noncancer diagnosis, or died. Routine symptom and demographic data included baseline cancer probability assessed by the primary care provider (low, intermediate, high), age, sex, performance status, baseline cancer probability by study physician, predominant symptom (lump, bleeding, pain or other) and HIV status. Logistic regression with 10-fold cross-validation was used to evaluate classification by different sets of predictors: (1) PCPs, (2) Algorithm-only, (3) External specialist physician review and (4) Primary clinician augmented by algorithm. Classification accuracy was assessed using c-statistics, sensitivity and specificity. Six hundred and twenty-three adult cancer suspects with complete data were retained, of whom 166 (27%) were diagnosed with cancer. Models using PCP augmented by algorithm (c-statistic: 77.2%, 95% CI: 73.4%, 81.0%) and external study physician assessment (77.6%, 95% CI: 73.6%, 81.7%) performed better than algorithm-only (74.9%, 95% CI: 71.0%, 78.9%) and PCP initial assessment (62.8%, 95% CI: 57.9%, 67.7%) in correctly classifying suspected cancer patients. Sensitivity and specificity statistics from models combining PCP classifications and routine data were comparable to physicians, suggesting that incorporating data-driven algorithms into referral systems could improve efficiency.
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Affiliation(s)
- Kesaobaka Molebatsi
- Department of Statistics, University of Botswana, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Hari S Iyer
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Racquel E Kohler
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA.,Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kemiso Gabegwe
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Isaac Nkele
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Bokang Rabasha
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Tomer Barak
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Neo M Tapela
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,Nuffield Department of Population Health, Oxford University, Oxford, UK
| | - Scott L Dryden-Peterson
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
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10
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Arrossi S, Paolino M, Sánchez Antelo V, Thouyaret L, Kohler RE, Cuberli M, Flores L, Serra V, Viswanath K, Orellana L. Effectiveness of an mHealth intervention to increase adherence to triage of HPV DNA positive women who have performed self-collection (the ATICA study): A hybrid type I cluster randomised effectiveness-implementation trial. The Lancet Regional Health - Americas 2022; 9. [PMID: 35655914 PMCID: PMC9159703 DOI: 10.1016/j.lana.2022.100199] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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11
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Anuforo B, McGee-Avila JK, Toler L, Xu B, Kohler RE, Manne S, Tsui J. Disparities in HPV vaccine knowledge and adolescent HPV vaccine uptake by parental nativity among diverse multiethnic parents in New Jersey. BMC Public Health 2022; 22:195. [PMID: 35093050 PMCID: PMC8800253 DOI: 10.1186/s12889-022-12573-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/11/2022] [Indexed: 12/20/2022] Open
Abstract
Background Suboptimal human papillomavirus (HPV) vaccination rates persist among adolescents in the United States (U.S.). New Jersey (NJ), among the top, most racially/ethnically diverse states in the U.S., had among the lowest HPV vaccine initiation rates, prior to 2018. This study examined parental HPV vaccine knowledge and adolescent HPV vaccine initiation among multiethnic parents in NJ, where access to language concordant HPV vaccine information and vaccination services may differ, for immigrant parents. Methods We surveyed parents of adolescents (ages 11–18) at community events in NJ to examine parental HPV vaccine knowledge and adolescent HPV vaccine uptake. Vaccine knowledge was assessed using an 11-item question stem that covered vaccine efficacy, gender recommendation, vaccine protection, and myths. Multivariable models assessed the association of parent nativity on HPV vaccine knowledge scores and adolescent HPV vaccine initiation, controlling for sociodemographic factors. Results Of the 77 parents, most parents (84%) were aware of the HPV vaccine. However, knowledge scores were low and differed by parent nativity. Non-U.S. born parents had significantly lower knowledge scores − 1.7 [− 3.1, − 0.4] and lower odds of adolescent children initiating the HPV vaccine 0.3 [0.1, 0.9] compared to U.S.-born parents after adjusting demographic characteristics. Conclusions Our findings reveal that parental HPV vaccine knowledge remains low among suburban dwelling, immigrant parents, even though they have higher education and access to health care. Multilevel strategies to reduce missed opportunities for HPV vaccine education among parents and HPV vaccination for adolescents are needed, including for suburban, immigrant communities. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12573-7.
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12
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Kohler RE, Roncarati JS, Aguiar A, Chatterjee P, Gaeta J, Viswanath K, Henry C. Trauma and cervical cancer screening among women experiencing homelessness: A call for trauma-informed care. Womens Health (Lond) 2021; 17:17455065211029238. [PMID: 34225506 PMCID: PMC8264729 DOI: 10.1177/17455065211029238] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/28/2021] [Accepted: 06/08/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Women experiencing homelessness are at increased risk of cervical cancer and have disproportionately low Pap screening behaviors compared to the general population. Prevalence of Pap refusals and multiple kinds of trauma, specifically sexual trauma, are high among homeless women. This qualitative study explored how trauma affects Pap screening experiences, behaviors, and provider practices in the context of homelessness. METHODS We conducted 29 in-depth interviews with patients and providers from multiple sites of a Federally Qualified Health Center as part of a study on barriers and facilitators to cervical cancer screening among urban women experiencing homelessness. The Health Belief Model and trauma-informed frameworks guided the analysis. RESULTS Trauma histories were common among the 18 patients we interviewed. Many women also had strong physical and psychological reactions to screening, which influenced current behaviors and future intentions. Although most women had screened at least once in their lifetime, many patients experienced anticipated anxiety and retraumatization which pushed them to delay or refuse Paps. We recruited 11 providers who identified strategies they used to encourage screening, including emphasizing safety and shared decision-making before and during the exam, building strong patient-provider trust and communication, and individually tailoring education and counseling to patients' needs. We outlined suggestions and implications from these findings as trauma-informed cervical cancer screening. CONCLUSION Discomfort with Pap screening was common among women experiencing homelessness, especially those with histories of sexual trauma. Applying a trauma-informed approach to cervical cancer screening may help address complex barriers among women experiencing homelessness, with histories of sexual trauma, or others who avoid, delay, or refuse the exam.
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Affiliation(s)
- Racquel E Kohler
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Jill S Roncarati
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | | | - Pritha Chatterjee
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jessie Gaeta
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Kasisomayajula Viswanath
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Cassis Henry
- Boston Health Care for the Homeless Program, Boston, MA, USA
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13
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Painschab MS, Kohler RE, Kasonkanji E, Zuze T, Kaimila B, Nyasosela R, Nyirenda R, Krysiak R, Gopal S. Microcosting Analysis of Diffuse Large B-Cell Lymphoma Treatment in Malawi. J Glob Oncol 2020; 5:1-10. [PMID: 31322992 PMCID: PMC6690619 DOI: 10.1200/jgo.19.00059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To describe the cost of treating diffuse large B-cell lymphoma (DLBCL) in Malawi under the following circumstances: (1) palliation only, (2) first-line cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), (3) salvage etoposide, ifosfamide, and cisplatin (EPIC), and (4) salvage gemcitabine and oxaliplatin (GEMOX). METHODS We conducted a microcosting analysis from the health system perspective in the context of a prospective cohort study at a national teaching hospital in Lilongwe, Malawi. Clinical outcomes data were derived from previously published literature from the cohort. Cost data were collected for treatment and 2-year follow-up, reflecting costs incurred by the research institution or referral hospital for goods and services. Costs were collected in Malawian kwacha, inflated and converted to 2017 US dollars. RESULTS On a per-patient basis, palliative care alone cost $728 per person. Total costs for first-line treatment with CHOP chemotherapy was $1,844, of which chemotherapy drugs made up 15%. Separate salvage EPIC and GEMOX cost $2,597 and $3,176, respectively. Chemotherapy drugs accounted for 30% of EPIC and 47% of GEMOX. CONCLUSION To our knowledge, this is among the first published efforts to characterize detailed costs of cancer treatment in sub-Saharan Africa. The per-patient cost of first-line treatment of DLBCL in Malawi is low relative to high-income countries, suggesting that investments in fixed-duration, curative-intent DLBCL treatment may be attractive in sub-Saharan Africa. Salvage treatment of relapsed/refractory DLBCL costs much more than first-line therapy. Formal cost-effectiveness modeling for CHOP and salvage treatment in the Malawian and other low-resource settings is needed to inform decision makers about optimal use of resources for cancer treatment.
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Affiliation(s)
- Matthew S Painschab
- The University of North Carolina Project-Malawi, Lilongwe, Malawi.,University of North Carolina, Chapel Hill, NC
| | | | | | - Takondwa Zuze
- The University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Bongani Kaimila
- The University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | | | - Robert Krysiak
- The University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Satish Gopal
- The University of North Carolina Project-Malawi, Lilongwe, Malawi.,University of North Carolina, Chapel Hill, NC.,University of Malawi College of Medicine, Blantyre, Malawi
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14
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Lancaster KE, Lungu T, Bula A, Shea JM, Shoben A, Hosseinipour MC, Kohler RE, Hoffman IF, Go VF, Golin CE, Wheeler SB, Miller WC. Preferences for Pre-exposure Prophylaxis Service Delivery Among Female Sex Workers in Malawi: A Discrete Choice Experiment. AIDS Behav 2020; 24:1294-1303. [PMID: 31720955 DOI: 10.1007/s10461-019-02705-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Female sex workers (FSW) in Malawi have among the highest HIV prevalence estimates worldwide. Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet preferences for PrEP delivery among FSW are lacking. Eight focus group discussions, a literature review, and cognitive interviews were conducted to identify modifiable PrEP delivery attributes and inform discrete-choice experiment (DCE) development for FSW in Lilongwe. Enrolled FSW received an interviewer-assisted DCE. Data were analyzed using mixed logit regression. Dispensing location was most preferred, followed by the provision of additional services. Women preferred receiving PrEP at family planning clinics or non-governmental organization run drop-in centers. Cervical cancer screening was the most preferred additional service, while pregnancy testing and partner risk reduction counseling were less valued. This study was the first study to examine PrEP delivery preferences in Malawi using DCE-a powerful elicitation tool to apply to other key populations at risk for HIV.
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Affiliation(s)
- Kathryn E Lancaster
- Division of Epidemiology, College of Public Health, The Ohio State University, 334 Cunz Hall, 1841 Neil Ave, Columbus, OH, USA.
| | - Thandie Lungu
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Agatha Bula
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Jaclyn M Shea
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Abigail Shoben
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Irving F Hoffman
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vivian F Go
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carol E Golin
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William C Miller
- Division of Epidemiology, College of Public Health, The Ohio State University, 334 Cunz Hall, 1841 Neil Ave, Columbus, OH, USA
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15
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Sanchez Antelo V, Kohler RE, Curotto M, Viswanath KV, Paolino M, Arrossi S. Developing SMS Content to Promote Papanicolaou Triage Among Women Who Performed HPV Self-collection Test: Qualitative Study. JMIR Form Res 2020; 4:e14652. [PMID: 32032940 PMCID: PMC7084289 DOI: 10.2196/14652] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 01/23/2020] [Accepted: 02/06/2020] [Indexed: 12/19/2022] Open
Abstract
Background SMS interventions are effective in promoting a variety of health behaviors; however, there is limited information regarding the use of SMS for cervical cancer screening and follow-up care. The Application of Communication and Information Technologies to Self-Collection study aims to evaluate a multicomponent mobile health intervention to increase triage adherence among women with human papillomavirus (HPV)–positive self-collected tests in Jujuy, Argentina. Here, we describe the formative results used to design the content of the SMS to be tested in the trial. Objective This study aimed to understand the cultural and contextual elements, women’s beliefs, and perceptions regarding the use of SMS by the health care system and women’s preferences about the message content. Methods We conducted five focus groups (FGs), stratified by rural or urban residence and age. All participants were aged 30 years or older and had performed HPV self-collection. Participatory techniques, including brainstorming, card-based classification, and discussions were used to debate the advantages and disadvantages of messages. We openly coded the discussions for agreements and preferences regarding the SMS content. Messages for both HPV-negative and HPV-positive women were validated through interviews with health authorities and 14 HPV-tested women. The final versions of the messages were pilot-tested. Results A total of 48 women participated in the FGs. Participants rejected receiving both negative and positive HPV results by SMS because, for them, the delivery of results should be done in a face-to-face interaction with health professionals. They stressed the importance of the SMS content informing them that results were available for pick up and reflecting the kind of relationship that they have with the community health workers and the nearest health center. Women considered that a personalized SMS was important, as was the use of a formal yet warm tone. Owing to confidentiality issues, not using the word “HPV” was also a key component of the desired SMS content; therefore, the final message included the term “self-collection” without the mention of HPV infection. Results from the validation stage and pilot test showed high acceptability of the final version of the message. Conclusions The results suggest that SMS is accepted when notifying women about the availability of the HPV test result, but it should not replace the delivery of results in face-to-face, doctor-patient encounters. In addition, messages must be tailored and must have a persuasive tone to motivate women to adhere to the triage.
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Affiliation(s)
| | - Racquel E Kohler
- Cancer Health Equity, Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Mariana Curotto
- Programa Nacional de Prevención de Cáncer Cervicouterino, Instituto Nacional del Cáncer, Buenos Aires, Argentina
| | - Kasisomayajula Vish Viswanath
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, United States.,McGraw-Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Melisa Paolino
- Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Silvina Arrossi
- Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
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16
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Kohler RE, Elliott T, Monare B, Moshashane N, Ramontshonyana K, Chatterjee P, Ramogola-Masire D, Morroni C. HPV self-sampling acceptability and preferences among women living with HIV in Botswana. Int J Gynaecol Obstet 2019; 147:332-338. [PMID: 31489627 DOI: 10.1002/ijgo.12963] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/24/2019] [Accepted: 09/03/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the acceptability and preferences of HPV screening with self-sampling and mobile phone results delivery among women living with HIV (WLWH) in Botswana, as an alternative to traditional speculum screening. METHODS WLWH aged 25 years or older attending an infectious disease clinic in Gaborone were enrolled in a cross-sectional study between March and April 2017. Women self-sampled with a flocked swab, had a speculum exam, and completed an interviewer-administered questionnaire about screening acceptability, experiences, and preferences. RESULTS Of the 104 WLWH recruited, 98 (94%) had a history of traditional screening. Over 90% agreed self-sampling was easy and comfortable. Ninety-five percent were willing to self-sample again; however, only 19% preferred self-sampling over speculum exam for future screening. Preferences differed by education and residence with self-sampling being considered more convenient, easier, less embarrassing, and less painful. Speculum exams were preferred because of trust in providers' skills and women's low self-efficacy to sample correctly. Almost half (47%) preferred to receive results via mobile phone call. Knowledge of cervical cancer did not affect preferences. CONCLUSION HPV self-sampling is acceptable among WLWH in Botswana; however, preferences vary. Although self-sampling is an important alternative to traditional speculum screening, education and support will be critical to address women's low self-efficacy to self-sample correctly.
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Affiliation(s)
- Racquel E Kohler
- Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | | | | | - Pritha Chatterjee
- Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Doreen Ramogola-Masire
- Botswana UPenn Partnership, Gaborone, Botswana.,Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Botswana UPenn Partnership, Gaborone, Botswana.,International Sexual and Reproductive Health, Liverpool School of Tropical Medicine, Liverpool, UK
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17
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Elliott T, Kohler RE, Monare B, Moshashane N, Ramontshonyana K, Muthoga C, Wynn A, Howett R, Luckett R, Morroni C, Ramogola-Masire D. Performance of vaginal self-sampling for human papillomavirus testing among women living with HIV in Botswana. Int J STD AIDS 2019; 30:1169-1176. [PMID: 31558129 PMCID: PMC7179768 DOI: 10.1177/0956462419868618] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: In Botswana, where HIV prevalence remains high, cervical cancer is the leading cause of cancer deaths in women. Multiple organizations recommend high-risk human papillomavirus (hr-HPV) testing as a screening tool, however, high coverage may not be feasible with provider-collected samples. We conducted the first assessment of self- versus provider-collected samples for hr-HPV testing in HIV-positive women in Botswana and report prevalence of hr-HPV and histological outcomes. Methods: We recruited HIV-positive women ≥25 years attending an HIV clinic in Gaborone. Self- and provider-collected samples from participants were tested for hr-HPV using Cepheid GeneXpert. Women testing positive for any hr-HPV returned for colposcopy. We used unweighted κ statistics to determine hr-HPV agreement. Results: Thirty-one (30%) of 103 women tested positive for any hr-HPV. The most common genotypes were HPV 31/33/35/52/58. Overall agreement between self- and provider-collected samples for any hr-HPV was 92% with a κ of 0.80. Ten of the 30 hr-HPV positive women attending colposcopy had CIN 2+ (33%). Conclusions: In this HIV-positive population, hr-HPV prevalence was 30%, with excellent agreement between self and provider samples. Self-sampling may play an important role in screening programs in high HIV burden settings with limited resources like Botswana.
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Affiliation(s)
| | - Racquel E Kohler
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
- Botswana Harvard Aids Institute Partnership, Gaborone, Botswana
| | | | | | | | | | - Adriane Wynn
- Botswana UPenn Partnership, Gaborone, Botswana
- University of California, San Diego, CA, USA
| | | | - Rebecca Luckett
- Botswana Harvard Aids Institute Partnership, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Chelsea Morroni
- Botswana UPenn Partnership, Gaborone, Botswana
- Botswana Harvard Aids Institute Partnership, Gaborone, Botswana
- Liverpool School of Tropical Medicine, Liverpool, UK
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18
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Iyer HS, Kohler RE, Ramogola-Masire D, Brown C, Molebatsi K, Grover S, Kablay I, Bvochora-Nsingo M, Efstathiou JA, Lockman S, Tapela N, Dryden-Peterson SL. Explaining disparities in oncology health systems delays and stage at diagnosis between men and women in Botswana: A cohort study. PLoS One 2019; 14:e0218094. [PMID: 31170274 PMCID: PMC6553768 DOI: 10.1371/journal.pone.0218094] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 05/24/2019] [Indexed: 01/04/2023] Open
Abstract
Purpose Men in Botswana present with more advanced cancer than women, leading to poorer outcomes. We sought to explain sex-specific differences in time to and stage at treatment initiation. Methods Cancer patients who initiated oncology treatment between October 2010 and June 2017 were recruited at four oncology centers in Botswana. Primary outcomes were time from first visit with cancer symptom to treatment initiation, and advanced cancer (stage III/IV). Sociodemographic and clinical covariates were obtained retrospectively through interviews and medical record review. We used accelerated failure time and logistic models to estimate standardized sex differences in treatment initiation time and risk differences for presentation with advanced stage. Results were stratified by cancer type (breast, cervix, non-Hodgkin’s lymphoma, anogenital, head and neck, esophageal, other). Results 1886 participants (70% female) were included. After covariate adjustment, men experienced longer excess time from first presentation to treatment initiation (8.4 months) than women (7.0 months) for all cancers combined (1.4 months, 95% CI: 0.30, 2.5). In analysis stratified by cancer type, we only found evidence of a sex disparity (Men: 8.2; Women: 6.8 months) among patients with other, non-common cancers (1.4 months, 95% CI: 0.01, 2.8). Men experienced an increased risk of advanced stage (Men: 67%; Women: 60%; aRD: 6.7%, 95% CI: -1.7%, 15.1%) for all cancers combined, but this disparity was only statistically significant among patients with anogenital cancers (Men: 72%; Women: 50%; aRD: 22.0%, 95% CI: 0.5%, 43.5%). Conclusions Accounting for the types of cancers experienced by men and women strongly attenuated disparities in time to treatment initiation and stage. Higher incidence of rarer cancers among men could explain these disparities.
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Affiliation(s)
- Hari S. Iyer
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Racquel E. Kohler
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Doreen Ramogola-Masire
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
- School of Medicine, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Carolyn Brown
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, United States of America
| | | | - Surbhi Grover
- Botswana University of Pennsylvania Partnership, Gaborone, Botswana
- School of Medicine, University of Botswana, Gaborone, Botswana
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Princess Marina Hospital, Gaborone, Botswana
| | | | | | - Jason A. Efstathiou
- Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Shahin Lockman
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Neo Tapela
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Botswana Ministry of Health and Wellness, Gaborone, Botswana
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Scott L. Dryden-Peterson
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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19
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Arrossi S, Paolino M, Orellana L, Thouyaret L, Kohler RE, Viswanath K. Mixed-methods approach to evaluate an mHealth intervention to increase adherence to triage of human papillomavirus-positive women who have performed self-collection (the ATICA study): study protocol for a hybrid type I cluster randomized effectiveness-implementation trial. Trials 2019; 20:148. [PMID: 30808379 PMCID: PMC6390557 DOI: 10.1186/s13063-019-3229-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 01/29/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cervical cancer is one of the leading causes of cancer death among women worldwide, with more than 85% of cases occurring in low- and middle-income countries. Human papillomavirus (HPV) screening allows for self-collection with the potential to increase coverage, but still requires triage to identify which HPV+ women need diagnostic and treatment procedures. However, achieving high levels of triage adherence can be challenging, especially among socially vulnerable women. This paper describes the ATICA protocol (Application of Communication and Information Technologies to Self-Collection, for its initials in Spanish), aimed at evaluating the implementation strategy and the effectiveness of a multi-component mobile health (mHealth) intervention to increase adherence to triage among women with HPV+ self-collected tests. METHODS We will use an effectiveness-implementation hybrid type I trial with a mixed-methods evaluation approach. A cluster randomized trial design including 200 community health workers (CHWs) will evaluate whether the mHealth intervention increases adherence to triage among HPV+ women who self-collected at home during a CHW visit within 120 days after a positive result. The intervention includes an initial mobile phone text message (SMS) alert and subsequent reminders sent to HPV+ women. For those who do not adhere to triage within 60 days of a positive HPV test, an email and SMS will be sent to the CHWs to promote contact with these women during home visits. We will use the Consolidated Framework for Implementation Research (CFIR) as an organizing and analytic framework to evaluate the implementation of the intervention while also drawing on Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM). We will conduct a self-administered, semi-structured survey of CHWs, semi-structured interviews with local health authorities, and a survey of HPV+ women. Combining both qualitative and quantitative data will provide rich insights into local implementation challenges and successes. DISCUSSION Findings from the implementation evaluation will be applicable to programs that use or are planning to incorporate HPV self-collection and/or mHealth interventions in different settings and countries. This innovative study will also serve as a model for using implementation science in the region. TRIAL REGISTRATION ClinicalTrials.gov, NCT03478397 . Registered on 20 March 2018.
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Affiliation(s)
- Silvina Arrossi
- Centro de Estudios de Estado y Sociedad/Consejo Nacional de Investigaciones Científicas y Técnicas Sociedad, Sánchez de Bustamante 27, 1193 Buenos Aires, Argentina
| | - Melisa Paolino
- Centro de Estudios de Estado y Sociedad/Consejo Nacional de Investigaciones Científicas y Técnicas, Sánchez de Bustamante 27, 1193 Buenos Aires, Argentina
| | - Liliana Orellana
- Biostatistics Unit, Faculty of Health, Deakin University, Geelong, Australia
| | - Laura Thouyaret
- Programa Nacional de Prevención de Cáncer Cervicouterino/Instituto Nacional del Cáncer (Argentina), Julio A. Roca 781, Piso 9, 1067 Buenos Aires, Argentina
| | - Racquel E. Kohler
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, USA
| | - Kasisomayajula Viswanath
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, USA
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20
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Brown CA, Kohler RE, John O, Motswetla G, Mmalane M, Tapela N, Grover S, Dryden-Peterson S, Lockman S, Dryden-Peterson SL. Multilevel Factors Affecting Time to Cancer Diagnosis and Care Quality in Botswana. Oncologist 2018; 23:1453-1460. [PMID: 30082488 DOI: 10.1634/theoncologist.2017-0643] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 04/20/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cancer incidence is increasing in Africa, and the majority of patients are diagnosed with advanced disease, limiting treatment options and survival. We sought to understand care patterns and factors contributing to delayed diagnosis and treatment initiation among patients with cancer in Botswana. PATIENTS AND METHODS We recruited 20 patients who were enrolled in a prospective cancer cohort in Botswana to a qualitative substudy that explored cancer care pathways and factors affecting cancer care access and quality. We conducted an in-depth interview with each participant between October 2014 and January 2015, using a a structured interview guide with questions about initial cancer symptoms, previous consultations, diagnosis, and care pathways. Medical records were used to confirm dates or treatment details when needed. RESULTS Individual and interpersonal factors such as cancer awareness and social support facilitated care-seeking behaviors. However, patients experienced multiple delays in diagnosis and treatment because of provider and health system barriers. Health system factors, such as misdiagnosis, understaffed facilities, poor referral communication and scheduling, and inadequate laboratory reporting systems, affected access to and quality of cancer care. CONCLUSION These findings highlight the need for interventions at the patient, provider, and health system levels to improve cancer care quality and outcomes in Botswana. Results also suggest that widespread cancer education has potential to promote early diagnosis through family and community networks. Identified barriers and facilitators suggest that interventions to improve community education and access to diagnostic technologies could help improve cancer outcomes in this setting. IMPLICATIONS FOR PRACTICE The majority (54%) of patients with cancer in Botswana present with advanced-stage cancer despite universal access to free health care, limiting the options for treatment and decreasing the likelihood of positive treatment outcomes. To reduce time from symptom onset to cancer treatment initiation, causes of delay in cancer care trajectories must be identified. The narratives of the patients interviewed for this study give insight into psychosocial factors, outlooks on disease, lower-level provider delays, and health system barriers that contribute to substantial delays for patients with cancer in Botswana. Identification of problems and barriers is essential for development of effective interventions to mitigate these factors, in order to improve cancer outcomes in this population.
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Affiliation(s)
- Carolyn A Brown
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - Racquel E Kohler
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Oaitse John
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Neo Tapela
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Ministry of Health Botswana, Gaborone, Botswana
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Surbhi Grover
- Department of Radiation Oncology, Botswana-UPENN Partnership, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Oncology, Princess Marina Hospital, Gaborone, Botswana
| | | | - Shahin Lockman
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Scott L Dryden-Peterson
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
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21
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Tapela NM, Peluso MJ, Kohler RE, Setlhako II, Botebele K, Gabegwe K, Nkele I, Narasimhamurthy M, Mmalane M, Grover S, Barak T, Shulman LN, Lockman S, Dryden-Peterson S. A Step Toward Timely Referral and Early Diagnosis of Cancer: Implementation and Impact on Knowledge of a Primary Care-Based Training Program in Botswana. Front Oncol 2018; 8:187. [PMID: 29896450 PMCID: PMC5986942 DOI: 10.3389/fonc.2018.00187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/11/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction Health system delays in diagnosis of cancer contribute to the glaring disparities in cancer mortality between high-income countries and low- and middle-income countries. In Botswana, approximately 70% of cancers are diagnosed at late stage and median time from first health facility visit for cancer-related symptoms to specialty cancer care was 160 days (IQR 59-653). We describe the implementation and early outcomes of training targeting primary care providers, which is a part of a multi-component implementation study in Kweneng-East district aiming to enhance timely diagnosis of cancers. Methods Health-care providers from all public facilities within the district were invited to participate in an 8-h intensive short-course program developed by a multidisciplinary team and adapted to the Botswana health system context. Participants' performance was assessed using a 25-multiple choice question tool, with pre- and post-assessments paired by anonymous identifier. Statistical analysis with Wilcoxon signed-rank test to compare performance at the two time points across eight sub-domains (pathophysiology, epidemiology, social context, symptoms, evaluation, treatment, documentation, follow-up). Linear regression and negative binomial modeling were used to determine change in performance. Participants' satisfaction with the program was measured on a separate survey using a 5-point Likert scale. Results 176 participants attended the training over 5 days in April 2016. Pooled linear regression controlling for test version showed an overall performance increase of 16.8% after participation (95% CI 15.2-18.4). Statistically significant improvement was observed for seven out of eight subdomains on test A and all eight subdomains on test B. Overall, 71 (40.3%) trainees achieved a score greater than 70% on the pretest, and 161 (91.5%) did so on the posttest. Participants reported a high degree of satisfaction with the training program's content and its relevance to their daily work. Conclusion We describe a successfully implemented primary health care provider-focused training component of an innovative intervention aiming to reduce health systems delays in cancer diagnosis in sub-Saharan Africa. The training achieved district-wide participation, and improvement in the knowledge of primary health-care providers in this setting. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT02752061.
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Affiliation(s)
- Neo M Tapela
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States
| | - Michael J Peluso
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States.,Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Racquel E Kohler
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Irene I Setlhako
- Princess Marina Hospital, Ministry of Health and Wellness, Gaborone, Botswana
| | | | - Kemiso Gabegwe
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Isaac Nkele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mohan Narasimhamurthy
- Department of Pathology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Surbhi Grover
- University of Pennsylvania, Philadelphia, PA, United States.,Botswana Upenn Partnership, Gaborone, Botswana
| | - Tomer Barak
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Lawrence N Shulman
- Center for Global Cancer Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, United States
| | - Shahin Lockman
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Harvard TH Chan School of Public Health, Boston, MA, United States.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, United States
| | - Scott Dryden-Peterson
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Harvard TH Chan School of Public Health, Boston, MA, United States.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, United States
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22
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Kohler RE, Gopal S, Lee CN, Weiner BJ, Reeve BB, Wheeler SB. Breast Cancer Knowledge, Behaviors, and Preferences in Malawi: Implications for Early Detection Interventions From a Discrete Choice Experiment. J Glob Oncol 2017; 3:480-489. [PMID: 29094086 PMCID: PMC5646878 DOI: 10.1200/jgo.2016.005371] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Breast cancer is the most common female cancer in Africa and leading cause of death resulting from cancer; however, many countries lack early detection services. In Malawi, women are frequently diagnosed with large tumors after long symptomatic periods. Little is known about local cancer knowledge. METHODS We administered a cross-sectional survey with a discrete choice experiment to a random sample in urban and rural areas of Lilongwe district. Bivariable and multivariable analyses determined factors associated with knowledge. Preference utilities for early detection interventions were estimated using a hierarchical Bayesian model in Sawtooth software. RESULTS Of 213 women recruited, fewer than half were aware of breast cancer. In multivariable analysis, electricity at home and knowing someone with cancer increased the odds of awareness. Women were more knowledgeable about symptoms than treatment or risk factors; more than 60% erroneously believed local misconceptions. Seventeen percent were aware of breast self-examination, and 20% were aware of clinical breast examination (CBE); few reported either behavior. Common barriers included not knowing where to access CBE and transportation difficulties. Discrete choice experiment results indicated the detection strategy (breast health awareness, CBE, or both) was the most important attribute of an intervention, followed by the encounter setting and travel time. CONCLUSION Addressing misconceptions in health messages and engaging survivors to promote early detection may help improve breast cancer knowledge in Malawi. Program designs accounting for women's preferences should provide breast health education and CBEs in convenient settings to address transportation barriers, particularly for women with low socioeconomic position.
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Affiliation(s)
- Racquel E. Kohler
- Racquel E. Kohler, Satish Gopal, Clara N. Lee, Bryan J. Weiner, Bryce B. Reeve, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Racquel E. Kohler and Satish Gopal, UNC Project Malawi, Lilongwe, Malawi
| | - Satish Gopal
- Racquel E. Kohler, Satish Gopal, Clara N. Lee, Bryan J. Weiner, Bryce B. Reeve, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Racquel E. Kohler and Satish Gopal, UNC Project Malawi, Lilongwe, Malawi
| | - Clara N. Lee
- Racquel E. Kohler, Satish Gopal, Clara N. Lee, Bryan J. Weiner, Bryce B. Reeve, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Racquel E. Kohler and Satish Gopal, UNC Project Malawi, Lilongwe, Malawi
| | - Bryan J. Weiner
- Racquel E. Kohler, Satish Gopal, Clara N. Lee, Bryan J. Weiner, Bryce B. Reeve, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Racquel E. Kohler and Satish Gopal, UNC Project Malawi, Lilongwe, Malawi
| | - Bryce B. Reeve
- Racquel E. Kohler, Satish Gopal, Clara N. Lee, Bryan J. Weiner, Bryce B. Reeve, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Racquel E. Kohler and Satish Gopal, UNC Project Malawi, Lilongwe, Malawi
| | - Stephanie B. Wheeler
- Racquel E. Kohler, Satish Gopal, Clara N. Lee, Bryan J. Weiner, Bryce B. Reeve, and Stephanie B. Wheeler, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Racquel E. Kohler and Satish Gopal, UNC Project Malawi, Lilongwe, Malawi
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23
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McCloud RF, Kohler RE, Viswanath K. Cancer Risk-Promoting Information: The Communication Environment of Young Adults. Am J Prev Med 2017; 53:S63-S72. [PMID: 28818248 DOI: 10.1016/j.amepre.2017.03.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 03/07/2017] [Accepted: 03/23/2017] [Indexed: 10/19/2022]
Abstract
Young adulthood represents a time of myriad transitions, which leave young adults (YAs) more susceptible to the influences of cancer risk-promoting information. The tobacco, alcohol, indoor tanning, and food and beverage industries engage in aggressive marketing strategies through both traditional and social media to target this age group to consume their products, which have known links to cancer. Despite this barrage of messaging, detailed data are lacking on the communication behaviors of subgroups of this diverse age group, particularly those from low SES. This paper explores the available data on media usage among YAs and describes the cancer risk-promoting information environment, with a focus on communication inequalities and their implications for cancer research and control. Nationally representative data on media consumption patterns indicate that the majority of YAs access a diverse range of traditional and social media platforms, but these data do not fully describe differences at the intersection of age and important factors such as SES, gender, race/ethnicity, or urban/rural residence. Meanwhile, risk-promoting information is heavily marketed to YAs across media, with an increasing focus on using social media sites to normalize products and evade marketing restrictions. Gaps in the available data on YAs' media consumption behaviors, coupled with aggressive risk-promoting marketing strategies toward YAs, may impede cancer control efforts. Relationships between exposure to various cancer risk-promoting information, concurrent risk behaviors, SES disparities, and communication inequalities should be investigated to develop innovative and effective control programs and policies to promote cancer control in this important group.
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Affiliation(s)
- Rachel F McCloud
- Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Racquel E Kohler
- Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - K Viswanath
- Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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24
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Kohler RE, Miller AR, Gutnik L, Lee CN, Gopal S. Experiences and perceptions regarding clinical breast exam screening by trained laywomen in Malawi. Cancer Causes Control 2017; 28:137-143. [PMID: 28097471 DOI: 10.1007/s10552-016-0844-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 12/20/2016] [Indexed: 12/27/2022]
Abstract
PURPOSE Despite the increasing burden, breast cancer control in sub-Saharan Africa is insufficient. Late diagnosis and lack of early detection and screening services contribute to high mortality. Clinical breast exam (CBE) screening can be valuable in low-income countries, including use of community health workers and non-health professionals to conduct exams. We assessed experiences of women who underwent CBE screening by trained laywomen in Lilongwe, Malawi, as part of a pilot program. METHODS The pilot study invited women attending urban health clinics to a breast cancer educational talk followed by CBE screening by trained laywomen. We purposively sampled participants from the pilot study and interviewed them about the screening experience and future cancer education programs and services. RESULTS Overall participants had positive experiences and were willing to undergo CBE screening by trained laywomen. Participants were motivated by the educational talk, shared newly acquired cancer knowledge with their social networks, and encouraged others to seek screening. Screened women suggested strategies for future interventions including combining breast and cervical cancer screening, using female providers, partnering with community leaders to increase uptake, and expanding services into the community. CONCLUSIONS Asymptomatic Malawian women accepted CBE screening by trained laywomen and considered breast cancer an important health issue. Women appreciated combined education and screening services and proposed further linkage of breast and cervical cancer screening. Based on our results, training laywomen to educate the public on breast cancer and conduct CBE is a feasible breast cancer control strategy in sub-Saharan Africa.
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Affiliation(s)
- Racquel E Kohler
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02115, USA.
| | - Anna R Miller
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, 130 Mason Farm Rd, Chapel Hill, NC, 27514, USA
| | - Lily Gutnik
- Department of Surgery, University of Utah, 30 North 1900 East, 3B 110 School of Medicine, Salt Lake City, UT, 84132, USA
| | - Clara N Lee
- Department of Surgery, University of North Carolina at Chapel Hill, 7041 Burnett-Womack, Chapel Hill, NC, 27599-7195, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Satish Gopal
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, 130 Mason Farm Rd, Chapel Hill, NC, 27514, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Project-Malawi, Lilongwe, Malawi
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25
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Kohler RE, Gopal S, Miller AR, Lee CN, Reeve BB, Weiner BJ, Wheeler SB. A framework for improving early detection of breast cancer in sub-Saharan Africa: A qualitative study of help-seeking behaviors among Malawian women. Patient Educ Couns 2017; 100:167-173. [PMID: 27528411 PMCID: PMC5301948 DOI: 10.1016/j.pec.2016.08.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 07/16/2016] [Accepted: 08/09/2016] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Many women in Africa are diagnosed with advanced breast cancer. We explored Malawian breast cancer patients' perspectives about their diagnosis and ability to access care to identify help-seeking behaviors and to describe factors influencing delay. METHODS We purposively sampled 20 Malawian breast cancer patients to conduct in-depth interviews. Transcripts were double coded to identify major themes of breast cancer help-seeking behaviors and what delayed or facilitated access to care. RESULTS We outlined a breast cancer help-seeking pathway describing decisions, behaviors, and interactions from symptom presentation to receipt of cancer care. Patients were largely unaware of breast cancer and did not immediately notice or interpret symptoms. As symptoms progressed, women inferred illness and sought help from social networks, traditional remedies, and medical care. Economic hardship, distance to the facility, provider knowledge, health system factors, and social norms often delayed reaching the facility, referrals, diagnosis, and receipt of care. CONCLUSIONS Social-contextual factors at the individual, interpersonal, health system, and societal levels delay decisions, behaviors, and access to breast cancer detection and appropriate care. PRACTICE IMPLICATIONS A comprehensive approach to improving breast cancer early detection must address public awareness and misconceptions, provider knowledge and communication, and cancer care delivery.
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Affiliation(s)
- Racquel E Kohler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA; UNC Project-Malawi, Lilongwe, Malawi.
| | - Satish Gopal
- UNC Project-Malawi, Lilongwe, Malawi; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Anna R Miller
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Clara N Lee
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Bryce B Reeve
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Bryan J Weiner
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
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26
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Kohler RE, Tomlinson J, Chilunjika TE, Young S, Hosseinipour M, Lee CN. "Life is at a standstill" Quality of life after lower extremity trauma in Malawi. Qual Life Res 2016; 26:1027-1035. [PMID: 27771822 DOI: 10.1007/s11136-016-1431-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE Low- and middle-income countries face a disproportionate burden of death and disability from injuries, many of which are due to road traffic accidents or falls. Lower extremity injuries in particular have implications not only for physical disabilities affecting work and school performance, but also for quality of life (QOL) of the individual. This qualitative study explores the psychosocial impact and QOL changes due to lower extremity injuries among trauma patients in central Malawi. METHODS We transcribed and translated interviews with 20 patients who received care for a trauma to the lower extremity at a tertiary hospital in Lilongwe. We used NVivo to organize and thematically analyze the data. RESULTS Participants reported limitations in physical functioning, activities of daily living, social roles, and vocational and social activities. Limited mobility led to unplanned long-term disruptions in work, personal financial loss, and household economic hardship. As a result, psychological distress, fears and worries about recovery, and poor perceptions of health and QOL were common. Several contextual factors influenced patient outcomes including socioeconomic status, religious beliefs, social networks, local landscape, housing structures, and transportation accessibility. CONCLUSION Lower extremity trauma led to physical suffering and ongoing social and economic costs among Malawians. Injuries affecting mobility have broad QOL and economic consequences for patients and affected family members. Interventions are needed to improve post-injury recovery and QOL. Better access to trauma surgery and social and welfare support services for people living with disabling conditions are needed to alleviate the consequences of injuries.
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Affiliation(s)
- Racquel E Kohler
- Harvard TH Chan School of Public Health; Dana Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02115, USA.
| | - Jared Tomlinson
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Sven Young
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi.,Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Mina Hosseinipour
- Department of Medicine, University of North Carolina at Chapel Hill, UNC Project, Lilongwe, Malawi
| | - Clara N Lee
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Cecil Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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27
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Gutnik LA, Matanje-Mwagomba B, Msosa V, Mzumara S, Khondowe B, Moses A, Kohler RE, Carey LA, Lee CN, Gopal S. Breast Cancer Screening in Low- and Middle-Income Countries: A Perspective From Malawi. J Glob Oncol 2016; 2:4-8. [PMID: 28717676 PMCID: PMC5497737 DOI: 10.1200/jgo.2015.000430] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Lily A. Gutnik
- Lily A. Gutnik, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Lily A. Gutnik, Blandina Khondowe, Agnes Moses, and Satish Gopal, UNC–Project Malawi; Beatrice Matanje-Mwagomba, Malawi Ministry of Health; Vanessa Msosa and Suzgo Mzumara, Kamuzu Central Hospital, Lilongwe; Suzgo Mzumara and Agnes Moses, University of Malawi College of Medicine, Blantyre, Malawi; Racquel E. Kohler, Gillings School of Global Public Health; Lisa A. Carey, Clara N. Lee, and Satish Gopal, Lineberger Comprehensive Cancer Center; and Satish Gopal, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Beatrice Matanje-Mwagomba
- Lily A. Gutnik, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Lily A. Gutnik, Blandina Khondowe, Agnes Moses, and Satish Gopal, UNC–Project Malawi; Beatrice Matanje-Mwagomba, Malawi Ministry of Health; Vanessa Msosa and Suzgo Mzumara, Kamuzu Central Hospital, Lilongwe; Suzgo Mzumara and Agnes Moses, University of Malawi College of Medicine, Blantyre, Malawi; Racquel E. Kohler, Gillings School of Global Public Health; Lisa A. Carey, Clara N. Lee, and Satish Gopal, Lineberger Comprehensive Cancer Center; and Satish Gopal, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Vanessa Msosa
- Lily A. Gutnik, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Lily A. Gutnik, Blandina Khondowe, Agnes Moses, and Satish Gopal, UNC–Project Malawi; Beatrice Matanje-Mwagomba, Malawi Ministry of Health; Vanessa Msosa and Suzgo Mzumara, Kamuzu Central Hospital, Lilongwe; Suzgo Mzumara and Agnes Moses, University of Malawi College of Medicine, Blantyre, Malawi; Racquel E. Kohler, Gillings School of Global Public Health; Lisa A. Carey, Clara N. Lee, and Satish Gopal, Lineberger Comprehensive Cancer Center; and Satish Gopal, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Suzgo Mzumara
- Lily A. Gutnik, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Lily A. Gutnik, Blandina Khondowe, Agnes Moses, and Satish Gopal, UNC–Project Malawi; Beatrice Matanje-Mwagomba, Malawi Ministry of Health; Vanessa Msosa and Suzgo Mzumara, Kamuzu Central Hospital, Lilongwe; Suzgo Mzumara and Agnes Moses, University of Malawi College of Medicine, Blantyre, Malawi; Racquel E. Kohler, Gillings School of Global Public Health; Lisa A. Carey, Clara N. Lee, and Satish Gopal, Lineberger Comprehensive Cancer Center; and Satish Gopal, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Blandina Khondowe
- Lily A. Gutnik, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Lily A. Gutnik, Blandina Khondowe, Agnes Moses, and Satish Gopal, UNC–Project Malawi; Beatrice Matanje-Mwagomba, Malawi Ministry of Health; Vanessa Msosa and Suzgo Mzumara, Kamuzu Central Hospital, Lilongwe; Suzgo Mzumara and Agnes Moses, University of Malawi College of Medicine, Blantyre, Malawi; Racquel E. Kohler, Gillings School of Global Public Health; Lisa A. Carey, Clara N. Lee, and Satish Gopal, Lineberger Comprehensive Cancer Center; and Satish Gopal, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Agnes Moses
- Lily A. Gutnik, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Lily A. Gutnik, Blandina Khondowe, Agnes Moses, and Satish Gopal, UNC–Project Malawi; Beatrice Matanje-Mwagomba, Malawi Ministry of Health; Vanessa Msosa and Suzgo Mzumara, Kamuzu Central Hospital, Lilongwe; Suzgo Mzumara and Agnes Moses, University of Malawi College of Medicine, Blantyre, Malawi; Racquel E. Kohler, Gillings School of Global Public Health; Lisa A. Carey, Clara N. Lee, and Satish Gopal, Lineberger Comprehensive Cancer Center; and Satish Gopal, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Racquel E. Kohler
- Lily A. Gutnik, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Lily A. Gutnik, Blandina Khondowe, Agnes Moses, and Satish Gopal, UNC–Project Malawi; Beatrice Matanje-Mwagomba, Malawi Ministry of Health; Vanessa Msosa and Suzgo Mzumara, Kamuzu Central Hospital, Lilongwe; Suzgo Mzumara and Agnes Moses, University of Malawi College of Medicine, Blantyre, Malawi; Racquel E. Kohler, Gillings School of Global Public Health; Lisa A. Carey, Clara N. Lee, and Satish Gopal, Lineberger Comprehensive Cancer Center; and Satish Gopal, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lisa A. Carey
- Lily A. Gutnik, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Lily A. Gutnik, Blandina Khondowe, Agnes Moses, and Satish Gopal, UNC–Project Malawi; Beatrice Matanje-Mwagomba, Malawi Ministry of Health; Vanessa Msosa and Suzgo Mzumara, Kamuzu Central Hospital, Lilongwe; Suzgo Mzumara and Agnes Moses, University of Malawi College of Medicine, Blantyre, Malawi; Racquel E. Kohler, Gillings School of Global Public Health; Lisa A. Carey, Clara N. Lee, and Satish Gopal, Lineberger Comprehensive Cancer Center; and Satish Gopal, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Clara N. Lee
- Lily A. Gutnik, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Lily A. Gutnik, Blandina Khondowe, Agnes Moses, and Satish Gopal, UNC–Project Malawi; Beatrice Matanje-Mwagomba, Malawi Ministry of Health; Vanessa Msosa and Suzgo Mzumara, Kamuzu Central Hospital, Lilongwe; Suzgo Mzumara and Agnes Moses, University of Malawi College of Medicine, Blantyre, Malawi; Racquel E. Kohler, Gillings School of Global Public Health; Lisa A. Carey, Clara N. Lee, and Satish Gopal, Lineberger Comprehensive Cancer Center; and Satish Gopal, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Satish Gopal
- Lily A. Gutnik, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY; Lily A. Gutnik, Blandina Khondowe, Agnes Moses, and Satish Gopal, UNC–Project Malawi; Beatrice Matanje-Mwagomba, Malawi Ministry of Health; Vanessa Msosa and Suzgo Mzumara, Kamuzu Central Hospital, Lilongwe; Suzgo Mzumara and Agnes Moses, University of Malawi College of Medicine, Blantyre, Malawi; Racquel E. Kohler, Gillings School of Global Public Health; Lisa A. Carey, Clara N. Lee, and Satish Gopal, Lineberger Comprehensive Cancer Center; and Satish Gopal, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Jaacks LM, Ali MK, Bartlett J, Bloomfield GS, Checkley W, Gaziano TA, Heimburger DC, Kishore SP, Kohler RE, Lipska KJ, Manders O, Ngaruiya C, Peck R, Pena MB, Watkins DA, Siegel KR, Narayan KV. Global Noncommunicable Disease Research: Opportunities and Challenges. Ann Intern Med 2015; 163:712-4. [PMID: 26301624 PMCID: PMC4850027 DOI: 10.7326/m15-1068] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Lindsay M. Jaacks
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Mohammed K. Ali
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - John Bartlett
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Gerald S. Bloomfield
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - William Checkley
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Thomas A. Gaziano
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Douglas C. Heimburger
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Sandeep P. Kishore
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Racquel E. Kohler
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Kasia J. Lipska
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Olivia Manders
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Christine Ngaruiya
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Robert Peck
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Melissa Burroughs Pena
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - David A. Watkins
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - Karen R. Siegel
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
| | - K.M. Venkat Narayan
- From Rollins School of Public Health, Emory University, Atlanta, Georgia; Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, North Carolina; School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Brigham and Women's Hospital and Young Professionals Chronic Disease Network, Boston, Massachusetts; Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee
- Yale School of Medicine, New Haven, Connecticut; University of North Carolina, Chapel Hill, North Carolina; Center for Global Health, Weill Cornell Medical College, New York, New York; and University of Washington, Seattle, Washington
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Kohler RE, Moses A, Krysiak R, Liomba NG, Gopal S. Pathologically confirmed breast cancer in Malawi: a descriptive study: Clinical profile of breast cancer. Malawi Med J 2015; 27:10-2. [PMID: 26137191 DOI: 10.4314/mmj.v27i1.3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Breast cancer is the most common female cancer in Africa, yet no published studies have investigated breast cancer in Malawi. Understanding the clinical profile of breast cancer is important to develop early diagnosis efforts. AIM To describe clinical and pathological characteristics of breast specimens from a pathology laboratory at a national teaching hospital. METHODS Secondary analysis of pathology reports from July 2011 to September 2013. RESULTS Among 85 breast cancer cases, 55% were < 50 years. Median tumor size was 4 cm and 49% were grade 3. Median symptom duration was eight months. CONCLUSIONS Malawian women with breast cancer commonly have long symptom durations prior to diagnosis, young age, and poorly differentiated tumors. Improved clinical and pathological characterization, including hormone receptor status, are urgently needed to better understand this disease in Malawi.
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Affiliation(s)
- R E Kohler
- Department of Health Policy and Management University of Chapel Hill at North Carolina
| | - A Moses
- University of North Carolina Project Malawi
| | - R Krysiak
- Department of Health Policy and Management University of Chapel Hill at North Carolina
| | - N G Liomba
- University of North Carolina Project Malawi
| | - S Gopal
- University of North Carolina Project Malawi
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Kohler RE, Goyal RK, Lich KH, Domino ME, Wheeler SB. Association between medical home enrollment and health care utilization and costs among breast cancer patients in a state Medicaid program. Cancer 2015; 121:3975-81. [PMID: 26287506 DOI: 10.1002/cncr.29596] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/11/2015] [Accepted: 06/22/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND The patient-centered medical home (PCMH) is increasingly being implemented in an effort to improve and coordinate primary care, but its effect on health care utilization among breast cancer patients remains unclear. The objective of this study was to examine health care utilization and expenditures as a function of PCMH enrollment among breast cancer patients in North Carolina's Medicaid program. METHODS North Carolina Medicaid claims linked to North Carolina Central Cancer Registry records (2003-2007) were used to examine monthly patterns of health care use and expenditures. Controlling for a selection bias for time-invariant characteristics, fixed effects regression models analyzed associations between PCMH enrollment and utilization of outpatient, inpatient, and emergency department (ED) services and Medicaid expenditures during the 15 months after the diagnosis of breast cancer. RESULTS Among 758 breast cancer patients, 381 (50%) were enrolled in a PCMH at some time in the 15 months after diagnosis. After controlling for individual fixed effects, PCMH enrollment was significantly associated with greater outpatient service use, but there was no difference in the probability of inpatient hospitalizations or ED visits. Enrollment in a PCMH was associated with increased average expenditures of $429 per month during the first 15 months. CONCLUSIONS Greater outpatient care utilization and increased average expenditures among breast cancer patients enrolled in a PCMH may suggest that these women have improved access to primary and specialty care. Expanding PCMHs may change patterns of service utilization for Medicaid breast cancer patients but may not be associated with lower costs.
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Affiliation(s)
- Racquel E Kohler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ravi K Goyal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,RTI Health Solutions, Research Triangle Park, North Carolina
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marisa Elena Domino
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Kohler RE, Tang J, Gopal S, Chinula L, Hosseinipour MC, Liomba NG, Chiudzu G. High rates of cervical cancer among HIV-infected women at a referral hospital in Malawi. Int J STD AIDS 2015; 27:753-60. [PMID: 26130691 DOI: 10.1177/0956462415592999] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/30/2015] [Indexed: 11/16/2022]
Abstract
Cervical cancer is the most common cancer among women in Malawi. National guidelines recommend screening women aged 30-45 years every five years; however, no specific recommendations exist for women with HIV. We aimed to assess the frequency of high-grade dysplasia (CIN 2 or CIN3) and cervical cancer among women in central Malawi and to examine associations with CIN2+ (CIN2/3 or cancer). We extracted cervical Pap smear, biopsy, loop electrosurgical excision procedure and uterine specimen reports from a hospital pathology database from November 2012 to November 2013. We used logistic regression to estimate associations with CIN2+. We reviewed specimens from 824 women; we excluded 194 with unknown HIV status, leaving 630 in the analytic sample. Twelve percent had high-grade dysplasia and 109 women (17%) had cancer. Twenty-five percent of high-grade dysplasia cases and 35% of cancers occurred among women outside recommended screening ages. The odds of having CIN2+ were 6.55 times (95% CI 4.44-9.67) greater for HIV+ women. High-grade dysplasia and cervical cancer are very common among Malawian women, especially HIV+ women. HIV infection was strongly associated with CIN2+. Expanding screening to women not covered by current guidelines could avert a substantial proportion of cervical cancer cases in Malawi.
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Affiliation(s)
- Racquel E Kohler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer Tang
- Division of Global Women's Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Satish Gopal
- Division of Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Mina C Hosseinipour
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Grace Chiudzu
- Department of Obstetrics and Gynecology, Kamuzu Central Hospital, Lilongwe, Malawi
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Kohler RE, Lee CN, Gopal S, Reeve BB, Weiner BJ, Wheeler SB. Developing a discrete choice experiment in Malawi: eliciting preferences for breast cancer early detection services. Patient Prefer Adherence 2015; 9:1459-72. [PMID: 26508842 PMCID: PMC4612134 DOI: 10.2147/ppa.s87341] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In Malawi, routine breast cancer screening is not available and little is known about women's preferences regarding early detection services. Discrete choice experiments are increasingly used to reveal preferences about new health services; however, selecting appropriate attributes that describe a new health service is imperative to ensure validity of the choice experiment. OBJECTIVE To identify important factors that are relevant to Malawian women's preferences for breast cancer detection services and to select attributes and levels for a discrete choice experiment in a setting where both breast cancer early detection and choice experiments are rare. METHODS We reviewed the literature to establish an initial list of potential attributes and levels for a discrete choice experiment and conducted qualitative interviews with health workers and community women to explore relevant local factors affecting decisions to use cancer detection services. We tested the design through cognitive interviews and refined the levels, descriptions, and designs. RESULTS Themes that emerged from interviews provided critical information about breast cancer detection services, specifically, that breast cancer interventions should be integrated into other health services because asymptomatic screening may not be practical as an individual service. Based on participants' responses, the final attributes of the choice experiment included travel time, health encounter, health worker type and sex, and breast cancer early detection strategy. Cognitive testing confirmed the acceptability of the final attributes, comprehension of choice tasks, and women's abilities to make trade-offs. CONCLUSION Applying a discrete choice experiment for breast cancer early detection was feasible with appropriate tailoring for a low-income, low-literacy African setting.
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Affiliation(s)
- Racquel E Kohler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Correspondence: Racquel E Kohler, University of North Carolina at Chapel Hill, 135 Dauer Drive, 1101 McGavran-Greenberg Hall, CB #7411, Chapel Hill, NC 27599-7411, USA, Tel +1 919 966 7374, Fax +1 919 966 3671, Email
| | - Clara N Lee
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Satish Gopal
- UNC Project-Malawi, Tidziwe Center, Lilongwe, Malawi
| | - Bryce B Reeve
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bryan J Weiner
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Goyal RK, Wheeler SB, Kohler RE, Lich KH, Lin CC, Reeder-Hayes K, Meyer AM, Mayer DK. Health care utilization from chemotherapy-related adverse events among low-income breast cancer patients: effect of enrollment in a medical home program. N C Med J 2014; 75:231-8. [PMID: 25046085 DOI: 10.18043/ncm.75.4.231] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chemotherapy-related health care utilization by breast cancer patients can be expensive for payers and patients. This study evaluated the patient-centered medical home program Community Care of North Carolina (CCNC) in terms of its potential to reduce health care utilization associated with chemotherapy-related adverse events (AEs). METHODS Early-stage breast cancer cases diagnosed during the 5-year period 2003-2007 were identified in the North Carolina Central Cancer Registry; these cases were then linked to North Carolina Medicaid claims data. We measured health care utilization associated with chemotherapy-related AEs by setting (inpatient, outpatient, or emergency department) during a 15-month postdiagnosis follow-up period. Descriptive and multivariate analyses were performed to examine associations between CCNC enrollment and health care utilization associated with chemotherapy-related AEs. RESULTS A large proportion of breast cancer patients had at least 1 health care visit associated with a chemotherapy-related AE (n = 412 [72.3%]). The mean numbers of AE-related visits occurring in inpatient, outpatient, and emergency department settings were 0.30 (standard deviation [SD] = 0.83), 6.92 (SD = 10.94), and 0.46 (SD = 1.26), respectively. CCNC enrollment was associated with significantly fewer inpatient admissions (marginal effect, -0.1421; 95% confidence interval, -0.280 to -0.004). LIMITATIONS In this observational study, we were unable to draw conclusions about the causality of these associations. CONCLUSIONS Patients enrolled in CCNC had fewer inpatient health care visits associated with chemotherapy-related AEs. Future research should continue to explore the extent to which patient-centered medical homes can monitor and help manage the effects of cancer treatments.
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Affiliation(s)
- Ravi K Goyal
- RTI Health Solutions, Research Triangle Park, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill; Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Racquel E Kohler
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kristen H Lich
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ching-Ching Lin
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Katherine Reeder-Hayes
- Division of Hematology and Oncology, UNC School of Medicine, University of North Carolina at Chapel Hill; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anne-Marie Meyer
- Integrated Cancer Information and Surveillance System (ICISS), Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Deborah K Mayer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill; UNC School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Salloum RG, Abbyad CW, Kohler RE, Kratka AK, Oh L, Wood KA. Assessing preferences for a university-based smoking cessation program in Lebanon: a discrete choice experiment. Nicotine Tob Res 2014; 17:580-5. [PMID: 25239962 DOI: 10.1093/ntr/ntu188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 09/03/2014] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Smoking prevalence rates in Lebanon are among the highest in the Eastern Mediterranean region. Few smoking cessation programs are offered in Lebanon and little is known about the preferences of Lebanese smokers for cessation treatment programs. OBJECTIVE To establish which attributes of smoking cessation programs are most important to Lebanese smokers. METHODS Smokers at the American University of Beirut were surveyed to elicit their preferences for, and tradeoffs between the attributes of a hypothetical university-based smoking cessation program. Preferences for medication type/mechanism, risk of benign side effects, availability of support, distance traveled to obtain medication, and price of complete treatment were assessed using the discrete choice experiment method. RESULTS The smokers' responses (N = 191) to changes in attributes were statistically significant. Smokers were willing to make trade-offs between attributes. On average, smokers were willing to pay LBP 103,000 (USD 69) for cessation support. Respondents were willing to give up LBP 105,000 (USD 70) to avoid an additional 10% risk of minor side effects and LBP 18,000 (USD 12) to avoid an addition kilometer of travel to the nearest pharmacy. Heavy smokers were the least responsive group and had the lowest demand elasticities. CONCLUSIONS Student smokers were willing to participate in a relatively complex exercise that weighs the advantages and disadvantages of a hypothetical smoking cessation program. Overall they were less interested in the pill form of smoking cessation treatment, but they were willing to make tradeoffs to be smoke-free.
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Affiliation(s)
- Ramzi G Salloum
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC;
| | - Christine W Abbyad
- Hariri School of Nursing, American University of Beirut, Beirut, Lebanon
| | - Racquel E Kohler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Leighanne Oh
- Department of Biomedical Engineering, Duke University, Durham, NC
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Salloum RG, Kohler RE, Jensen GA, Sheridan SL, Carpenter WR, Biddle AK. U.S. Preventive Services Task Force recommendations and cancer screening among female Medicare beneficiaries. J Womens Health (Larchmt) 2014; 23:211-7. [PMID: 24195774 PMCID: PMC3952589 DOI: 10.1089/jwh.2013.4421] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Medicare covers several cancer screening tests not currently recommended by the U.S. Preventive Services Task Force (Task Force). In September 2002, the Task Force relaxed the upper age limit of 70 years for breast cancer screening recommendations, and in March 2003 an upper age limit of 65 years was introduced for cervical cancer screening recommendations. We assessed whether mammogram and Pap test utilization among women with Medicare coverage is influenced by changes in the Task Force's recommendations for screening. METHODS We identified female Medicare beneficiaries aged 66-80 years and used bivariate probit regression to examine the receipt of breast (mammogram) and cervical (Pap test) cancer screening reflecting changes in the Task Force recommendations. We analyzed 9,760 Medicare Current Beneficiary Survey responses from 2001 to 2007. RESULTS More than two-thirds reported receiving a mammogram and more than one-third a Pap test in the previous 2 years. Lack of recommendation was given as a reason for not getting screened among the majority (51% for mammogram and 75% for Pap). After controlling for beneficiary-level socioeconomic characteristics and access to care factors, we did not observe a significant change in breast and cervical cancer screening patterns following the changes in Task Force recommendations. CONCLUSIONS Although there is evidence that many Medicare beneficiaries adhere to screening guidelines, some women may be receiving non-recommended screening services covered by Medicare.
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Affiliation(s)
- Ramzi G. Salloum
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Racquel E. Kohler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gail A. Jensen
- Institute of Gerontology and Department of Economics, Wayne State University, Detroit, Michigan
| | - Stacey L. Sheridan
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - William R. Carpenter
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Andrea K. Biddle
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Kohler RE, Sheets NC, Wheeler SB, Nutting C, Hall E, Chera BS. Two-year and lifetime cost-effectiveness of intensity modulated radiation therapy versus 3-dimensional conformal radiation therapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys 2013; 87:683-9. [PMID: 24138916 DOI: 10.1016/j.ijrobp.2013.08.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess the cost-effectiveness of intensity modulated radiation therapy (IMRT) versus 3-dimensional conformal radiation therapy (3D-CRT) in the treatment of head-and neck-cancer (HNC). METHODS AND MATERIALS We used a Markov model to simulate radiation therapy-induced xerostomia and dysphagia in a hypothetical cohort of 65-year-old HNC patients. Model input parameters were derived from PARSPORT (CRUK/03/005) patient-level trial data and quality-of-life and Medicare cost data from published literature. We calculated average incremental cost-effectiveness ratios (ICERs) from the US health care perspective as cost per quality-adjusted life-year (QALY) gained and compared our ICERs with current cost-effectiveness standards whereby treatment comparators less than $50,000 per QALY gained are considered cost-effective. RESULTS In the first 2 years after initial treatment, IMRT is not cost-effective compared with 3D-CRT, given an average ICER of $101,100 per QALY gained. However, over 15 years (remaining lifetime on the basis of average life expectancy of a 65-year-old), IMRT is more cost-effective at $34,523 per QALY gained. CONCLUSION Although HNC patients receiving IMRT will likely experience reduced xerostomia and dysphagia symptoms, the small quality-of-life benefit associated with IMRT is not cost-effective in the short term but may be cost-effective over a patient's lifetime, assuming benefits persist over time and patients are healthy and likely to live for a sustained period. Additional data quantifying the long-term benefits of IMRT, however, are needed.
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Affiliation(s)
- Racquel E Kohler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Kohler RE. Subcultures in Genetics:
Styles of Scientific Thought
. The German Genetics Community, 1900-1933. Jonathan Harwood. University of Chicago Press, Chicago, 1993. xx, 423 pp., illus. $65 or £51.95; paper, $23.95 or £19.25. Science and Its Conceptual Foundations. Science 1993; 261:1061-2. [PMID: 17739629 DOI: 10.1126/science.261.5124.1061] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Kohler RE. Sanitarians, engineers and public science in the gilded age. Minerva 1993; 31:184-210. [PMID: 11613060 DOI: 10.1007/bf01125434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Kohler RE. Drosophila and evolutionary genetics: the moral economy of scientific practice. Hist Sci 1991; 29:335-375. [PMID: 11622999 DOI: 10.1177/007327539102900401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Kohler RE. Science, foundations, and American universities in the 1920s. Osiris 1987; 3:135-164. [PMID: 11621657 DOI: 10.1086/368664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Kohler RE. Philanthropy and science. Proc Am Philos Soc 1985; 129:9-13. [PMID: 11611743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Kohler RE. Science and philanthropy: Wickliffe Rose and the International Education Board. Minerva 1985; 23:75-95. [PMID: 11620725 DOI: 10.1007/bf01097841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Kohler RE. History of Science: Perceptions. Science 1980; 207:934-5. [PMID: 17830443 DOI: 10.1126/science.207.4434.934-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Kohler RE. Research Specialties:
Perspectives on the Emergence of Scientific Disciplines
. Papers from two meetings, Paris, Dec. 1973, and York, June 1974. Gerard Lemaine, Roy MacLeod, Michael Mulkay, and Peter WeingarT, Eds. Mouton, The Hague, and Aldine, Chicago, 1977. xii, 282 pp. $18.50. Maison des Sciences de l'Homme, Paris, Publications, 4. Science 1978; 199:1196-7. [PMID: 17745603 DOI: 10.1126/science.199.4334.1196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Kohler RE. The management of science: the experience of Warren Weaver and the Rockefeller Foundation programme in molecular biology. Minerva 1976; 14:279-306. [PMID: 11615683 DOI: 10.1007/bf01096274] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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