Receipt of mastectomy and adjuvant radiotherapy following breast conserving surgery (BCS) in New Zealand women with BCS-eligible breast cancer, 2010-2015: an observational study focusing on ethnic differences

BACKGROUND

Women with early breast cancer who meet guideline-based criteria should be offered breast conserving surgery (BCS) with adjuvant radiotherapy as an alternative to mastectomy. New Zealand (NZ) has documented ethnic disparities in screening access and in breast cancer treatment pathways. This study aimed to determine whether, among BCS-eligible women, rates of receipt of mastectomy or radiotherapy differed by ethnicity and other factors.

METHODS

The study assessed management of women with early breast cancer (ductal carcinoma in situ [DCIS] and invasive stages I-IIIA) registered between 2010 and 2015, extracted from the recently consolidated New Zealand Breast Cancer Registry (now Te Rēhita Mate Ūtaetae NZBCF National Breast Cancer Register). Specific criteria were applied to determine women eligible for BCS. Uni- and multivariable analyses were undertaken to examine differences by demographic and clinicopathological factors with a primary focus on ethnicity (Māori, Pacific, Asian, and Other; the latter is defined as NZ European, Other European, and Middle Eastern Latin American and African).

RESULTS

Overall 22.2% of 5520 BCS-eligible women were treated with mastectomy, and 91.1% of 3807 women who undertook BCS received adjuvant radiotherapy (93.5% for invasive cancer, and 78.3% for DCIS). Asian ethnicity was associated with a higher mastectomy rate in the invasive cancer group (OR 2.18; 95%CI 1.72-2.75), compared to Other ethnicity, along with older age, symptomatic diagnosis, advanced stage, larger tumour, HER2-positive, and hormone receptor-negative groups. Pacific ethnicity was associated with a lower adjuvant radiotherapy rate, compared to Other ethnicity, in both invasive and DCIS groups, along with older age, symptomatic diagnosis, and lower grade tumour in the invasive group. Both mastectomy and adjuvant radiotherapy rates decreased over time. For those who did not receive radiotherapy, non-referral by a clinician was the most common documented reason (8%), followed by patient decline after being referred (5%).

CONCLUSION

Rates of radiotherapy use are high by international standards. Further research is required to understand differences by ethnicity in both rates of mastectomy and lower rates of radiotherapy after BCS for Pacific women, and the reasons for non-referral by clinicians.

Mental health support across the sight loss pathway: a qualitative exploration of eye care patients, optometrists, and ECLOs

BACKGROUND

The process of becoming visually impaired or blind is undoubtedly a highly emotional experience, requiring practical and psychological support. Information on mental health support provision in the UK across the sight-loss pathway, however, is largely unknown, especially amongst healthcare practitioners that are often sought after for advice: the referring optometrist and eye clinic liaison officer (ECLO). This study aims to ascertain the perceived accessibility and quality of mental health support across the sight-loss pathway.

METHODS

Semi-structured individual interviews were conducted with patients with a diagnosed eye condition who had received care from a hospital eye service, referring optometrists, and ECLOs. Following interview transcription, results were synthesised in a narrative analysis.

RESULTS

A total of 28 participants were included in the analysis, of which 17 were participants with various eye conditions, five were referring optometrists, and five were ECLOs. After analysis, three broad themes emerged: (1) The emotional trauma of diagnosis (2) Availability of mental health support; (3) The point where mental health support is most needed across the sight-loss pathway. Several patients reporting that they had received no offer of support nor were they signposted to any possible sources. Referring optometrists and ECLO's agreed.

CONCLUSION

It is important that referring optometrists are aware of the need for mental health support services and can signpost to local support services including the third sector anytime during the referral process. Future large-scale, UK-wide research into referral practice and signposting for mental health support for patients is warranted, to identify how services can be improved in order to ensure that the wellbeing of patients is maintained.

Using vignettes about racism from health practice in Aotearoa to generate anti-racism interventions

Racism is a key modifiable determinant of health that contributes to health inequities in Aotearoa and elsewhere. Experiences of racism occur within the health sector for workers, patients and their whānau (extended family) every day. This paper uses stories of racism from nurses - reworked into vignettes - to examine the dynamics of racism to generate possible micro, meso and macro anti-racism interventions. A critical qualitative design was utilised, informed by kaupapa Māori approaches. The five vignettes in this paper were sourced from a pair of caucused focus groups with nine senior Māori (Indigenous peoples of Aotearoa) and Tauiwi (non-Māori) nurses held in Auckland Aotearoa in 2019. The vignettes were lightly edited and then critically analysed by both authors to identify sites of racism and generate ideas for anti-racism interventions. The vignettes illustrate five key themes in relation to racism. These include (i) mono-cultural practice, (ii) everyday micro-aggressions; (iii) complexity and the costs of racism, (iv) Pākehā (white settler) privilege and (v) employment discrimination. From analysing these themes, a range of evidence-based micro, meso and macro-level anti-racism interventions were derived. These ranged from engaging in reflective practice, education initiatives, monitoring, through to collective advocacy. Vignettes are a novel way to reveal sites of racism to create teachable moments and spark reflective practice and more active engagement in anti-racism interventions. When systematically analysed vignettes can be utilised to inform and refine anti-racist interventions. Being able to identify racism is essential to being able to effectively counter racism.

Patient-reported diagnostic intervals to colorectal cancer diagnosis in the Midland region of New Zealand: a prospective cohort study

BACKGROUND AND OBJECTIVES

New Zealand (NZ) has high rates of colorectal cancer (CRC) but low rates of early detection. The majority of CRC is diagnosed through general practice, where lengthy diagnostic intervals are common. We investigated factors contributing to diagnostic delay in a cohort of patients newly diagnosed with CRC.

METHODS

Patients were recruited from the Midland region and interviewed about their diagnostic experience using a questionnaire based on a modified Model of Pathways to Treatment framework and SYMPTOM questionnaire. Descriptive statistics were used to describe the population characteristics. Chi-square analysis and logistic regression were used to analyse factors influencing diagnostic intervals.

RESULTS

Data from 176 patients were analysed, of which 65 (36.9%) experienced a general practitioner (GP) diagnostic interval of >120 days and 96 (54.5%) experienced a total diagnostic interval (TDI) > 120 days. Patients reporting rectal bleeding were less likely to experience a long TDI (odds ratio [OR] 0.34, 95% confidence interval [CI]: 0.14-0.78) and appraisal/help-seeking interval (OR, 0.19, 95% CI: 0.06-0.59). Patients <60 were more likely to report a longer appraisal/help-seeking interval (OR, 3.32, 95% CI: 1.17-9.46). Female (OR, 2.19, 95% CI: 1.08-4.44) and Māori patients (OR, 3.18, 95% CI: 1.04-9.78) were more likely to experience a long GP diagnostic interval.

CONCLUSION

NZ patients with CRC can experience long diagnostic intervals, attributed to patient and health system factors. Young patients, Māori, females, and patients experiencing change of bowel habit may be at particular risk. We need to increase symptom awareness of CRC for patients and GPs. Concentrated efforts are needed to ensure equity for Māori in access to screening, diagnostics, and treatment.

Indigenous Cultural Identity of Research Authors Standard: research and reconciliation with Indigenous Peoples in rural health journals

The Indigenous Cultural Identity of Research Authors Standard (ICIRAS) is based on a gap in research publishing practice where Indigenous peoples' identity is not systematically and rigorously recognised in rural health research publications. There are widespread reforms, in different research areas, to counter the reputation of scientific research as a vehicle of racism and discrimination. Reflecting on these broader movements, the editorial teams of three rural health journals - Rural and Remote Health, the Australian Journal of Rural Health, and the Canadian Journal of Rural Medicine - adopted a policy of 'Nothing about Indigenous Peoples, without Indigenous Peoples'. This meant changing practices so that Indigenous Peoples' identity could be embedded in authorship credentials - such as in the byline. An environmental scan of literature about the inclusion of Indigenous Peoples in research revealed many ways in which editorial boards of journals could improve their process to signal to readers that Indigenous voices are included in rural health research publication governance. Improving the health and wellbeing of Indigenous peoples worldwide requires high-quality research evidence. This quality benchmark needs to explicitly signal the inclusion of Indigenous authors. The ICIRAS is a call to action for research journals and institutions to rigorously improve research governance and leadership to amplify the cultural identity of Indigenous peoples in rural health research.

Re-imagining anti-racist theory for the health sector

Ethnic health inequities between Māori and other New Zealanders continue to manifest systemically across the health sector. They are unjust, unfair, and are a breach of Te Tiriti o Waitangi. Institutional racism is a key modifiable driver of these disparities. Historically, health sector responses to racism could be characterised as ad hoc or in-action. Efforts have included investment in Māori health providers, Māori representation in governance, equity initiatives, kawa whakaruruhau-cultural safety and Te Tiriti training. Most anti-racist interventions have been educational and focused on individual change-especially for operational staff and students, rather than decision-makers. These historic contributions have been insufficient to address entrenched problems of systemic and societal racism.This paper examines three anti-racism initiatives currently occurring across Aotearoa; i) the Matike Mai Constitutional Transformation report/movement, ii) the development of the National Action Plan Against Racism, and iii) Ao Mai Te Rā currently being developed within the health sector.Drawing on long-time involvement in anti-racism praxis and scholarship, the Māori and non-Māori authors of this paper are making the case to re-imagine anti-racism theory. Such re-imagining needs to centre engagement with Te Tiriti. In addition, we argue it needs to involve both tangata whenua and Tauiwi.

A critical analysis of te Tiriti o Waitangi application in primary health organisations in Aotearoa New Zealand: Findings from a nationwide survey

Primary health is at the forefront of efforts to address health inequities. Effective primary health care keeps people well and improves longevity and quality of life. The persistence of health inequities, particularly between Indigenous peoples and non-Indigenous peoples globally, suggests that there is a need to strengthen policy and practise. Unique to Aotearoa (New Zealand) is te Tiriti o Waitangi, a treaty negotiated in 1840 between the British Crown and hapū (Māori [Indigenous] subtribes). This treaty is foundational to public policy in Aotearoa and requires the Crown (New Zealand government) to uphold a set of responsibilities around protecting and promoting Māori health. This paper examines to what extent Primary Health Organisations are upholding te Tiriti o Waitangi. The study utilises data from a nationwide telephone survey of public health providers conducted in 2019-2020 recruited from a list on the Ministry of Health website. This paper focuses on data about te Tiriti application from 21 Primary Health Organisations from a sample size of thirty. Critical te Tiriti analysis, an emerging methodology, was used to assess to what extent the participating primary health organisations were te Tiriti compliant. The critical te Tiriti analysis found poor to fair compliance with most elements of te Tiriti but good engagement with equity. Suggestions for strengthening practise included examining relationships with Māori, utilising a planned approach, structural mechanisms, normalising Māori world views and consistency in application. The onus needs to be on non-Māori to contribute to the cultural change and power-sharing required to uphold te Tiriti. Critical te Tiriti analysis is a useful methodology to review te Tiriti compliance and could be used in other contexts to review alignment with Indigenous rights and aspirations.

Outcomes from colonoscopy following referral from New Zealand general practice: a retrospective analysis

Background

New Zealand has high rates of colorectal cancer (CRC) but poor outcomes. Most patients with CRC are diagnosed following referral from general practice, where a general practitioner (GP) assesses symptoms according to national guidelines. All referred patients are then re-prioritised by the hospital system. The first objective of this study was to identify what proportion of patients referred by general practice to surgical/gastroenterology at Waikato District Health Board (DHB) had a colonoscopy. The second objective was to determine what proportion of these referrals have an underlying CRC and the factors associated with the likelihood of this diagnosis.

Methods

This study is a retrospective analysis of e-referral data for patients aged 30–70+ who were referred from 75 general practices to general surgery, gastroenterology or direct to colonoscopy at Waikato DHB, 01 January 2015–31 December 2017. Primary and secondary outcome measures included the proportion and characteristics of patients who were having colonoscopy, and of those, who were diagnosed with CRC. Data were analysed using chi square and logistic regression.

Results

6718/20648 (32.5%) patients had a colonoscopy and 372 (5.5%) of these were diagnosed with CRC. The probability of having CRC following a colonoscopy increased with age (p value < 0.001). Females (p value < 0.001), non-Māori (p value < 0.001), and patients with a high suspicion of cancer (HSCan) label originating from their GP were more likely to have a colonoscopy, while the odds ratio of Māori having a colonoscopy was 0.66 (95% CI 0.60–0.73). The odds ratio of a CRC diagnosis following colonoscopy was 1.67 (95% CI 1.35–2.07) for men compared to women, and 2.34 (95% CI 1.70–3.22) for those with a GP HSCan label. Of the 585 patients referred with a GP HSCan, 423 (72.3%) were reprioritised by the hospital and 55 patients had their diagnosis unnecessarily delayed.

Conclusions

If a GP refers a patient with an HSCan, and the patient receives a colonoscopy, then the likelihood of having CRC is almost 15.0%. This would suggest that these patients should be routinely prioritised without further triage by the hospital. Further research is needed to understand why Māori are less likely to receive a colonoscopy following referral from general practice.

Smashing the patriarchy to address gender health inequities: Past, present and future perspectives from Aotearoa (New Zealand)

The second wave feminist dream of smashing the patriarchy remains a task yet to be completed on a complex to do list. Women, particularly able-bodied cis-gendered white women however do enjoy the privilege of living longer than men. But our longer lives take place within patriarchal-capitalist systems where many women's social and cultural rights continue to be compromised. How do we ensure that all women can exercise our right to health and wellbeing? In this paper, the authors examine, critique, review and re-vision the dynamics of power and patriarchy over three distinct time periods - 1999, 2019 and 2039. We look to the past to track progress; we look to the present to see what we have achieved and look to the future for what might be. This conceptual paper is informed by the authors' expert knowledge, a review of the literature and the novel use of speculative ethnography. The authors conclude that patriarchy remains not only a negative determinant of women's health that needs to be smashed, but is also a threat to all people and to planetary health.

Te Tiriti o Waitangi compliance in regulated health practitioner competency documents in Aotearoa

Within Aotearoa (New Zealand) there are systemic health inequities between Māori (the Indigenous people of Aotearoa) and other New Zealanders. These inequities are enabled in part by the failure of the health providers, policy and practitioners to fulfil treaty obligations to Māori as outlined in our foundational document, te Tiriti o Waitangi (te Tiriti). Regulated health professionals have the potential to play a central role in upholding te Tiriti and addressing inequities. Competency documents define health professionals' scope of practice and inform curriculum in health faculties. In this novel study, we critically examine 18 regulated health practitioners' competency documents, which were sourced from the websites of their respective professional bodies. The competencies were reviewed using an adapted criterion from Critical te Tiriti Analysis, a five-phase analysis process, to determine their compliance with te Tiriti. There was considerable variation in the quality of the competency documents reviewed. Most were not te Tiriti compliant. We identified a range of alternative competencies that could strengthen te Tiriti engagement. They focussed on (i) the importance of whanaungatanga (the active making of relationships with Māori), (ii) non-Māori consciously becoming an ally with Māori in the pursuit of racial justice and (iii) actively engaging in decolonisation or power-sharing. In the context of Aotearoa, competency documents need to be te Tiriti compliant to fulfil treaty obligations and policy expectations about health equity. An adapted version of Critical te Tiriti Analysis might be useful for those interested in racial justice who want to review health competencies in other colonial settings.

How do colorectal cancer patients rate their GP: a mixed methods study

BACKGROUND

New Zealand (NZ) has a high incidence of colorectal cancer (CRC) and low rates of early diagnosis. With screening not yet nationwide, the majority of CRC is diagnosed through general practice. A good patient-general practitioner (GP) relationship can facilitate prompt diagnosis, but when there is a breakdown in this relationship, delays can occur. Delayed diagnosis of CRC in NZ receives a disproportionally high number of complaints directed against GPs, suggesting deficits in the patient-GP connection. We aimed to investigate patient-reported confidence and ratings of their GP following the diagnostic process.

METHODS

This study is a mixed methods analysis of responses to a structured questionnaire and free text comments from patients newly diagnosed with CRC in the Midland region of NZ. A total of 195 patients responded to the structured questionnaire, and 113 patients provided additional free text comments. Descriptive statistics were used to describe the study population and chi square analysis determined the statistical significance of factors possibly linked to delay. Free text comments were analysed using a thematic framework.

RESULTS

Most participants rated their GP as 'Very good/Good' at communication with patients about their health conditions and involving them in decisions about their care, and 6.7% of participants rated their overall level of confidence and trust in their GP as 'Not at all'. Age, gender, ethnicity and a longer diagnostic interval were associated with lower confidence and trust. Free text comments were grouped in to three themes: 1. GP Interpersonal skills; (communication, listening, taking patient symptoms seriously), 2. Technical competence; (speed of referral, misdiagnoses, lack of physical examination), and 3. Organisation of general practice care; (appointment length, getting an appointment, continuity of care).

CONCLUSIONS

Māori, females, and younger participants were more likely to report low confidence and trust in their GP. Participants associate a poor diagnostic experience with deficits in the interpersonal and technical skills of their GP, and health system factors within general practice. Short appointment times, access to appointments and poor GP continuity are important components of how patients assess their experience and are particularly important to ensure equal access for Māori patients.

The Simpson-led health sector review: a failure to uphold te Tiriti o Waitangi

The Health and Disability System Review (the 'Simpson Review') was an opportunity for health sector transformation, particularly in light of the recent damning WAI 2575 Waitangi Tribunal report released during the review process. There appears to have been a concerted effort to engage with the sector, an impressive Māori Expert Advisory Group and an extensive body of available scholarship documenting where improvements could be made. In this viewpoint, the authors, tangata whenua (Indigenous people of the land) and tangata Tiriti (people of te Tiriti) and health scholars and leaders undertook a high-level review of the Simpson Review report and analysed it against key elements of te Tiriti o Waitangi. The Simpson Review was an opportunity to share power, commit to Māori health and embed structural mechanisms, such as the proposed Māori health authority, to uphold te Tiriti o Waitangi. It was also an opportunity to recommit to health equity and eliminate institutional racism. We conclude that the Simpson Review did not take up these opportunities, but instead perpetuated further breaches of te Tiriti.

Hā Ora: secondary care barriers and enablers to early diagnosis of lung cancer for Māori communities

Background

Lung Cancer is the leading cause of cancer deaths in Aotearoa New Zealand. Māori communities in particular have higher incidence and mortality rates from Lung Cancer. Diagnosis of lung cancer at an early stage can allow for curative treatment. This project aimed to document the barriers to early diagnosis and treatment of lung cancer in secondary care for Māori communities.

Methods

This project used a kaupapa Māori approach. Nine community hui (focus groups) and nine primary healthcare provider hui were carried out in five rural localities in the Midland region. Community hui included cancer patients, whānau (families), and other community members. Healthcare provider hui comprised staff members at the local primary healthcare centre, including General Practitioners and nurses. Hui data were thematically analysed.

Results

Barriers and enablers to early diagnosis of lung cancer were categorised into two broad themes: Specialist services and treatment, and whānau journey. The barriers and enablers that participants experienced in specialist services and treatment related to access to care, engagement with specialists, communication with specialist services and cultural values and respect, whereas barriers and enablers relating to the whānau journey focused on agency and the impact on whānau.

Conclusions

The study highlighted the need to improve communication within and across healthcare services, the importance of understanding the cultural needs of patients and whānau and a health system strategy that meets these needs. Findings also demonstrated the resilience of Māori and the active efforts of whānau as carers to foster health literacy in future generations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07862-0.

Hā Ora: Reflecting on a Kaupapa Māori Community-Engaged Co-design Approach to Lung Cancer Research

Co-designed research is gaining prominence within the health care space. Community engagement is a key premise of co-design and is also particularly vital when carrying out kaupapa Māori research. Kaupapa Māori describes a “by Māori, for Māori” approach to research in Aotearoa/New Zealand. This article discusses the research process of Hā Ora: a co-design project underpinned by a kaupapa Māori approach. The objective was to explore the barriers to early presentation and diagnosis of lung cancer, barriers identified by Māori. The team worked with four rural Māori communities, with whom we aimed to co-design local interventions that would promote earlier diagnosis of lung cancer. This article highlights and unpacks the complexities of carrying out community- engaged co-design with Māori who live in rural communities. In particular, we draw attention to the importance of flexibility and adaptability in the research process. We highlight issues pertaining to timelines and budgets, and also the intricacies of involving co-governance and advisory groups. Overall, through this article, we argue that health researchers need to prioritise working with and for participants, rather than on them, especially when working with Māori communities.

Indigenous perspectives on breaking bad news: ethical considerations for healthcare providers

Most healthcare providers (HCPs) work from ethical principles based on a Western model of practice that may not adhere to the cultural values intrinsic to Indigenous peoples. Breaking bad news (BBN) is an important topic of ethical concern in health research. While much has been documented on BBN globally, the ethical implications of receiving bad news, from an Indigenous patient perspective in particular, is an area that requires further inquiry. This article discusses the experiences of Māori (Indigenous peoples of New Zealand) lung cancer patients and their families, in order to investigate the ethical implications of receiving bad news. Data collection occurred through 23 semistructured interviews and nine focus groups with Māori lung cancer patients and their families in four districts in the Midland Region of New Zealand: Waikato, Bay of Plenty, Lakes and Tairāwhiti. The findings of this study were categorised into two key themes: communication and context. Avenues for best practice include understanding the centrality of the HCP-patient relationship and family ties in the healthcare journey, and providing patients with the full range of viable treatment options including hope, clear advice and guidance when the situation calls for it. Overall, the findings of this study hold implications for providing culturally safe and humanistic cancer care when BBN to Māori and Indigenous patients.

The nature of police shootings in New Zealand: A comparison of mental health and non-mental health events

The use of firearms by police in mental health-related events has not been previously researched in New Zealand. This study analysed reports of investigations carried out by the Independent Police Conduct Authority between 1995 and 2019. We extracted data relating to mental health state, demographics, setting, police response, outcome of shooting, and whether the individual was known to police, mental health services, and with a history of mental distress or drug use. Of the 258 reports analysed, 47 (18%) involved mental health-related events compared to 211 (82%) classified as non-mental health events. Nineteen (40.4%) of the 47 mental health events resulted in shootings, compared to 31 (14.8%) of the 211 non-mental health events. Of the 50 cases that involved shootings 38% (n = 19) were identified as mental health events compared to 62% (n = 31) non-mental health events. Over half of the mental health events (n = 11, 57.9%) resulted in fatalities, compared to 35.5% (n = 11) of the non-mental health events. Cases predominantly involved young males. We could not ascertain the ethnicity of individuals from the IPCA reports. Across all shooting events, a high proportion of individuals possessed a weapon, predominantly either a firearm or a knife, and just under half were known to police and had known substance use. Of the 19 mental health events, 47.4% (n = 9) of individuals were known to mental health services and in 89.5% (n = 17) of cases whānau (family) were aware of the individual's current (at the time of the event) mental health distress and/or history. These findings suggest opportunities to prevent the escalation of events to the point where they involve shootings. Lack of ethnicity data limits the accountability of the IPCA and is an impediment to informed discussion of police response to people of different ethnicities, and Māori in particular, in New Zealand.

Hā Ora: Barriers and enablers to early diagnosis of lung cancer in primary healthcare for Māori communities

OBJECTIVE

The objective of this research was to document the barriers to early presentation and diagnosis of lung cancer within primary healthcare, identified by Māori whānau (families) and primary healthcare providers in the Midland region of Aotearoa New Zealand.

METHODS

This project used a kaupapa Māori approach. Nine community hui (focus groups) and nine primary healthcare provider hui were carried out in five rural localities in the Midland region. Each community hui included cancer patients, whānau, and other community members. Each healthcare provider hui comprised staff members at the local primary healthcare centre, including General Practitioners and nurses. Hui data were thematically analysed.

RESULTS

Barriers and enablers to early diagnosis of lung cancer were categorised into three key themes: GP relationship and position in the community, health literacy and pathways to diagnosis.

CONCLUSION

This study demonstrates that culturally responsive, patient-centred healthcare, and positive GP-patient relationships are significant factors for Māori patients and whānau serving as barriers and enablers to early diagnosis of lung cancer.

Barriers and facilitators to colorectal cancer diagnosis in New Zealand: a qualitative study

Background

New Zealand (NZ) has high rates of colorectal cancer but low rates of early diagnosis. Due to a lack of understanding of the pre-diagnostic experience from the patient’s perspective, it is necessary to investigate potential patient and health system factors that contribute to longer diagnostic intervals. Previous qualitative studies have discussed delays using The Model of Pathways to Treatment, but this has not been explored in the NZ context. This study aimed to understand the patient experience and perception of their general practitioner (GP) through the diagnostic process in the Waikato region of NZ. In particular, we sought to investigate potential barriers and facilitators that contribute to longer diagnostic intervals.

Methods

Ethical approval for this study was granted by the New Zealand Health and Disability Ethics Committee. Twenty-eight participants, diagnosed with colorectal cancer, were interviewed about their experience. Semi-structured interviews were audio recorded, transcribed verbatim and analysed thematically using The Model of Pathways to Treatment framework (intervals: appraisal, help-seeking, diagnostic).

Results

Participant appraisal of symptoms was a barrier to prompt diagnosis, particularly if symptoms were normalised, intermittent, or isolated in occurrence. Successful self-management techniques also resulted in delayed help-seeking. However if symptoms worsened, disruption to work and daily routines were important facilitators to seeking a GP consultation. Participants positively appraised GPs if they showed good technical competence and were proactive in investigating symptoms. Negative GP appraisals were associated with a lack of physical examinations and misdiagnosis, and left participants feeling dehumanised during the diagnostic process. However high levels of GP interpersonal competence could override poor technical competence, resulting in an overall positive experience, even if the cancer was diagnosed at an advanced stage. Māori participants often appraised symptoms inclusive of their sociocultural environment and considered the impact of their symptoms in relation to family.

Conclusions

The findings of this study highlight the importance of tailored colorectal cancer symptom communication in health campaigns, and indicate the significance of the interpersonal competence aspect of GP-patient interactions. These findings suggest that interpersonal competence be overtly displayed in all GP interactions to ensure a higher likelihood of a positive experience for the patient.

Inequalities between Māori and non-Māori men with prostate cancer in Aotearoa New Zealand

Māori experience poorer health statistics in terms of cancer incidence and mortality compared to non-Māori. For prostate cancer, Māori men are less likely than non-Māori men to be diagnosed with prostate cancer, but those that are diagnosed are much more likely to die of the disease than non-Māori men resulting in an excess mortality rate in Māori men compared with non-Māori. A review of the literature included a review of the epidemiology of prostate cancer; of screening; of access to healthcare and of treatment modalities. Our conclusion was that there are a number of reasons for the disparity in outcomes for Māori including differences in staging and characteristics at diagnosis; differences in screening and treatment offered to Māori men; and general barriers to healthcare that exist for Māori men in New Zealand. We conclude that there is a need for more culturally appropriate care to be available to Māori men.

Re-imagining anti-racism in the health sector in Aotearoa New Zealand

Background

Racism and dishonouring of te Tiriti o Waitangi are significant contributors to ethnic health inequities in Aotearoa. It is unclear how health professionals can contribute to the disruption of racism.

Methods

This multi-disciplinary study draws on systems change tools, evidence from the health kaupapa Waitangi Tribunal claim (WAI 2575), a review of professional competencies documents, and focus groups with Māori and non-Māori health practitioners to identify how to strengthen anti-racism praxis in health services. The preliminary data collected in 2019 has undergone a thematic analysis and is being synthesised collaboratively with stakeholders to generate a complex continuum of anti-racism praxis. This will be applied via two site-specific action research projects.

Results

The pilot study has been completed but data collection is still underway on the main study. The initial cut of a continuum of practice grouped behaviours into i) problematic, ii) variable to iii) proactive. Problematic behaviors included examples of cultural and institutional racism, Variable behavior included engagement with Te Reo me ona tikanga (Māori language and protocols), and professional development and compliance. The proactive grouping included Māori leadership and workforce, responding to Māori realities, reflective practice and critical consciousness.

Conclusions

Initial findings suggest anti-racism continuum of practice may be useful to strengthen competency documents, curricula, policy and discipline-specific professional development planning.

Key messages

With the persistence of institutional racism in colonial settings like Aotearoa we need to imagine new ways to pursue anti-racism. Mapping anti-racism praxis is a useful way to identify variations in practice with a view to strengthening curriculum, competencies and ultimately practice.

The Waitangi Tribunal's WAI 2575 Report: Implications for Decolonizing Health Systems

Te Tiriti o Waitangi, a treaty negotiated between Māori (the Indigenous peoples of Aotearoa) and the British Crown, affirmed Māori sovereignty and guaranteed the protection of hauora (health). The Waitangi Tribunal, established in 1975 to investigate alleged breaches of the agreement, released a major report in 2019 (registered as WAI 2575) about breaches of te Tiriti within the health sector in relation to primary care, legislation, and health policy. This article explores the implications of this report for the New Zealand health sector and the decolonial transformation of health systems. The tribunal found that the Crown has systematically contravened obligations under te Tiriti across the health sector. We complement the tribunal's findings, through critical analysis, to make five substantive recommendations: (1) the adoption of Tiriti-compliant legislation and policy; (2) recognition of extant Māori political authority (tino rangatiratanga); (3) strengthening of accountability mechanisms; (4) investment in Māori health; and (5) embedding equity and anti-racism within the health sector. These recommendations are critical for upholding te Tiriti obligations. We see these requirements as making significant contributions to decolonizing health systems and policy in Aotearoa and thereby contributing to aspirations for health equity as a transformative concept.

Patient and carer perceived barriers to early presentation and diagnosis of lung cancer: a systematic review

Background

Lung cancer is typically diagnosed at a late stage. Early presentation and detection of lung cancer symptoms is critical to improving survival but can be clinically complicated and as yet a robust screening method for diagnosis is not available in routine practice. Accordingly, the barriers to help-seeking behaviour and diagnosis need to be considered. This review aimed to document the barriers to early presentation and diagnosis of lung cancer, based on patient and carer perspectives.

Methods

A systematic review of databases was performed for original, English language articles discussing qualitative research on patient perceived barriers to early presentation and diagnosis of lung cancer. Three major databases were searched: Scopus, PubMed and EBSCOhost. References cited in the selected studies were searched for further relevant articles.

Results

Fourteen studies met inclusion criteria for review. Barriers were grouped into three categories: healthcare provider and system factors, patient factors and disease factors.

Conclusions

Studies showed that the most frequently reported barriers to early presentation and diagnosis of lung cancer reported by patients and carers related to poor relationships between GPs and patients, a lack of access to services and care for patients, and a lack of awareness of lung cancer symptoms and treatment. Addressing these barriers offers opportunities by which rates of early diagnosis of lung cancer may be improved.

Health service provider responses to indigenous peoples with cancer: An integrative review

Indigenous populations around the world have a higher burden of cancer incidence, severity and mortality. This integrative review aims to identify and appraise the evidence of health providers' responses to the issue of indigenous peoples with cancer. A surprisingly small number of studies were found (n = 9) that reported on programmes and interventions for indigenous people with cancer, the majority of which were from the USA. Our review shows that a service delivery approach that is focused on the indigenous population and includes culturally appropriate activities, resources and environments resulted in an increase in cancer knowledge, reduction in treatment interruption, improved access to cancer care and enrolment in clinical cancer trials, and increased satisfaction with health care. However, the question of why there are so few published studies needs further consideration.

Cultural health literacy: the experiences of Māori in palliative care

Health literacy is a concept that is frequently applied to the patient's ability to find and comprehend health information. However, recent literature has included the skill of the health professional and the accessibility of health resources as important factors in the level of health literacy achieved by individuals and populations. In 2014 a qualitative study undertaken in Aotearoa New Zealand, investigated the context of health literacy for Māori in a palliative care setting (Māori are the indigenous people of Aotearoa New Zealand). The study included the experiences of patients, whānau (families), and health professionals.

METHOD

Individual semi-structured interviews were held with 21 patients, whānau and six key informants: a medical specialist, a service leader involved in developing culturally specific responses to patients, two Māori service managers, and two Māori health team leaders. Focus groups were held with a total of 54 health professionals providing palliative care services.

DATA ANALYSIS

A thematic analysis was undertaken using a general inductive approach. The trustworthiness and reliability of the analysis was supported by sharing analysis of the transcripts among the research team. Member checking or respondent validation was used in seeking confirmation of the interim findings at five hui (meetings) with the research communities involved.

FINDINGS

This study found that the shock and grief that attends a life-limiting illness made hearing and processing health information very difficult for patients and whānau. Further, 'hard conversations' about moving from active treatment to palliative care were often avoided by health professionals, leaving patients and whānau distressed and confused about their choices and prognosis. Finally, poor cultural health literacy on the part of organisations has likely impacted on late access to or avoidance of palliative care for Māori.

Characteristics of and differences between Pasifika women and New Zealand European women diagnosed with breast cancer in New Zealand

AIM

Breast cancer in New Zealand-based Pasifika women is a significant issue. Although Pasifika women have a lower incidence of breast cancer compared to New Zealand European women, they have higher breast cancer mortality and lower five-year survival. The aim of this study was to describe the characteristics and tumour biology of Pasifika women and to compare New Zealand European women to identify what factors impact on early (Stage 1 and 2) vs advanced stage (Stage 3 and 4) at diagnosis.

METHOD

Data on all Pasifika and New Zealand European women diagnosed with breast cancer (C50) during the period 1 June 2000 to 31 May 2013 was extracted from the Auckland and Waikato Breast Cancer Registries. Descriptive tables and Chi-square test were used to examine differences in characteristics and tumour biology between Pasifika and New Zealand European women. Logistic regression was used to identify factors that contributed to an increased risk of advanced stage at diagnosis.

RESULTS

A significantly higher proportion of Pasifika women had advanced disease at diagnosis compared to New Zealand European women (33.3% and 18.3%, respectively). Cancer biology in Pasifika women was more likely to be: 1) HER2+, 2) ER/PR negative and 3) have a tumour size of ≥50mm. Pasifika women live in higher deprivation areas of 9-10 compared to New Zealand European women (55% vs 14%, respectively) and were less likely to have their cancer identified through screening. Logistic regression showed that if Pasifika women were on the screen-detected pathway they had similar odds (not sig.) of having advanced disease at diagnosis to New Zealand European women.

CONCLUSION

Mode of detection, deprivation, age and some biological factors contributed to the difference in odds ratio between Pasifika and New Zealand European women. For those of screening age, adherence to the screening programme and improvements in access to earlier diagnosis for Pasifika women under the current screening age have the potential to make a substantial difference in the number of Pasifika women presenting with late-stage disease.

Abstract P3-08-04: Trends in age of breast cancer diagnosis for women with pathogenic variants in genes associated with increased breast cancer risk

Background: The National Comprehensive Cancer Network (NCCN) currently recommends consideration of genetic testing for appropriate, high risk individuals when it will impact medical management of the individual or at-risk family members. Established NCCN testing criteria are based on family history, the presence of multiple primary cancers, and age of diagnosis. For breast cancer, women diagnosed before age 50 are eligible for genetic testing with limited family history; however, these criteria were developed based on high-risk breast cancer genes, such as BRCA1 and BRCA2. The growing use of gene panels has extended testing to include genes associated with a 2- to 4-fold increased risk for breast cancer. Although NCCN guidelines now include medical management recommendations for these genes, it is unclear whether current criteria appropriately identify candidates for testing who have pathogenic variants (PVs) in genes with moderate breast cancer risk. Here, we investigated the age of breast cancer diagnosis in women carrying PVs in genes with high or moderate breast cancer risk.

Methods: Clinical testing was performed for 68,239 women with a personal diagnosis of breast cancer using a 25-gene hereditary cancer panel that includes genes with a high (BRCA1, BRCA2, PTEN, TP53) or moderate (PALB2, CHEK2, ATM, STK11, CDH1, NBN, BARD1) risk of breast cancer. The majority of women tested met current NCCN criteria for testing based on their personal and/or family cancer history. The proportion of women with a PV who were diagnosed &lt;50 and &lt;60 years of age was evaluated.

Results: Overall, 5,231 women diagnosed with breast cancer were found to carry a PV in a gene with high or moderate breast cancer risk. 70.2% of women with PVs in genes with a high breast cancer risk were diagnosed with breast cancer before age 50, compared to only 55.5% of patients with PVs in genes with moderate breast cancer risk (see Table). However, similar proportions of women with PVs in genes with a high (89.3%) and moderate (80.2%) breast cancer risk were diagnosed before age 60 (see Table).

GeneDiagnosed &lt;50Diagnosed &lt;60Moderate Breast Cancer RiskCHEK2458 (59.3%)629 (81.5%)PALB2337 (54.7%)507 (82.3%)ATM315 (52.4%)452 (75.2%)BARD168 (51.5%)111 (84.1%)NBN56 (52.3%)86 (80.4%)CDH124 (58.5%)33 (80.5%)STK114 (66.7%)6 (100%)Total1262 (55.5%)1824 (80.2%)High Breast Cancer RiskBRCA11086 (76.4%)1314 (92.4%)BRCA2901 (63.0%)1227 (85.8%)TP5361 (83.6%)68 (93.2%)PTEN28 (90.3%)31 (100%)Total2076 (70.2%)2640 (89.3%)

Conclusions: Approximately half of the women with a PV in a moderate breast cancer risk gene identified here were diagnosed before age 50. This likely overestimates the proportion of moderate-risk PV carriers with early onset breast cancers, as current testing criteria are weighted towards diagnoses at young ages. Given that there are now medical management guidelines for patients who carry PVs in most of the moderate-risk breast cancer genes, it is important to consider whether current testing criteria developed for genes with a high breast cancer risk effectively identify women with PVs in moderate-risk genes.

Citation Format: Gorringe H, Rosenthal E, Kidd J, Brown K, Manley S. Trends in age of breast cancer diagnosis for women with pathogenic variants in genes associated with increased breast cancer risk [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-08-04.

Abstract P3-10-06: Genetic testing for HBOC among women with a personal diagnosis of breast cancer in patients with Medicaid as compared to patients with private insurance

Introduction: National guidelines recommend that women diagnosed with early-onset breast cancer and/or a strong family history receive BRCA1/2 testing to guide treatment decisions. Among newly diagnosed patients, a positive test result will often prompt more aggressive surgical treatment to minimize the risk of second primary cancers. Currently, coverage for genetic counseling and testing for Hereditary Breast and Ovarian Cancer (HBOC) under the Medicaid expansion program of the Affordable Care Act has varied by state, where some states require a copayment for this service. Similarly, there is no mandate to cover risk-reducing surgery for patients found to carry a genetic mutation despite research showing cost-effectiveness. This analysis sought to determine whether genetic testing for HBOC among patients with breast cancer is different for those with Medicaid compared to those with private insurance.

Methods: A commercial laboratory database was analyzed for patients with a personal history of breast cancer who underwent testing with a 25-gene hereditary cancer panel from September 2013-February 2016. Patients were eligible for inclusion if they were between ages 18 and 64 at the time of testing and had not undergone previous genetic testing. A total of 17,020 patients with either Medicaid (N=4,313) or one of 5 private payers (N=12,707) were tested during this period. Descriptive statistics, including means for continuous variables and proportions for categorical variables, were calculated. Chi-square tests were used to test associations and differences of positive rates between insurance provider category. Two-tailed p-values are reported, and any p-value less than 0.05 is considered statistically significant.

Results: Medicaid patients had a median age of breast cancer diagnosis of 45 compared to 47 for patient with private insurance. Among women with Medicaid insurance, a higher proportion were of African (13.3% vs 6.4%) and Latin American ancestry (16.4% vs 5.3%). The mutation positive rate among patients with Medicaid was 13.0%, which was statistically higher than patients with private insurance (9.5%) (p&lt;0.001). The positive rate was higher among Medicaid patients of all ancestries suggesting that this discrepancy was not due to ancestry difference among the two testing populations.

Positive rate by ancestry MedicaidPrivateOverallAfrican80 (13.9%)72 (8.9%)152 (11.0%)Ashkenazi3 (17.6%)20 (15.3%)23 (15.5%)Asian26 (13.3%)40 (7.5%)66 (9.1%)Caucasian201 (12.9%)171 (9.9%)918 (10.4%)Latin American/Caribbean98 (13.8%)65 (9.6%)163 (11.8%)Native American7 (13.7%)9 (7.9%)16 (9.7%)Neareast/Mideast10 (17.9%)8 (9.3%)18 (12.7%)Multiple49 (12.3%)77 (9.0%)126 (10.0%)None Specified85 (11.3%)199 (8.8%)284 (9.4%)Total559 (13.0%)1207 (9.5%)1766 (10.4%)

Conclusions: Overall, the positive mutation rate among individuals with Medicaid insurance was higher than those with private insurance, suggesting the testing requirements applied to this population may be more stringent than those applied to the private insurance population. Consistent genetic testing insurance criteria are necessary for all patients to receive care in line with guidelines following a breast cancer diagnosis.

Citation Format: Baron P, Johnson-Isidore K, Miller L, Brown K, Kidd J, Saam J, Lancaster J. Genetic testing for HBOC among women with a personal diagnosis of breast cancer in patients with Medicaid as compared to patients with private insurance [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-10-06.

Abstract P5-03-05: Development of a panel of serum-based protein biomarkers for the non-invasive detection of breast cancer in BI-RADS category 4 patients

Background: Current breast cancer screening guidelines call for annual mammography for asymptomatic women age 45 to 54 and once every two years for women age 55 and older. Women with suspicious screening mammograms are recommended for a diagnostic mammogram and may also undergo MRI or ultrasound. Ultimately, suspicious findings unresolved by imaging typically result in the recommendation of a breast biopsy. Approximately 10% of suspicious diagnostic mammograms are recommended for breast biopsies and 67% to 95% of these biopsies yield negative results. With the goal of reducing the number of patients with benign pathology undergoing invasive biopsies, we conducted a screen for serum protein biomarkers and identified a novel panel for the non-invasive detection of breast cancer.

Methods: Serum samples were collected at two sites from women with suspicious diagnostic mammogram findings (primarily BI-RADS category 4) undergoing biopsy for the evaluation of a potential malignancy. Serum samples from 100-patients (50 benign pathology and 50 malignant pathology) were evaluated on the SOMAscan Assay 1.3k, which measures levels of 1,310 different protein analytes. Statistical screening methodologies, such as individual t-tests with control for false discovery, were used to identify markers with the potential to distinguish benign from malignant pathology. The candidate markers were further studied and combined using generalized linear modeling to develop three potential diagnostic models. K-fold cross validation was used to guard against over fitting of the models.

Results: A 15-marker model resulted in an AUC of 0.92 with a sensitivity of 90% and specificity of 76%. Two 6-marker models (with 4 markers in common) each resulted in AUC of 0.85, yielding a sensitivity of 90% with a specificity of 56% or 64%.

Conclusions: This study reveals a novel panel of serum protein biomarkers that may allow for the non-invasive and sensitive detection of breast cancer in BI-RADS category 4 patients. A multicenter study is underway to further refine and validate this panel in a larger set of prospectively collected patient samples.

Citation Format: Chapman KB, Copeland K, Kidd J, Qiu L, Sheibani N, Tam O, Friedman L, Korn R, Fiorica J, Lourenco A, Suthers S, Hesterberg L. Development of a panel of serum-based protein biomarkers for the non-invasive detection of breast cancer in BI-RADS category 4 patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-03-05.

Abstract PD7-03: Characterization of Li-Fraumeni syndrome diagnosed using a 25-gene hereditary cancer panel

Background: Clinical diagnostic criteria for Li-Fraumeni syndrome (LFS) have evolved with increased utilization of TP53 germline testing and subsequent improved understanding of the diversity of the associated cancer phenotypes. However, data on LFS still suffer from ascertainment bias as patients are typically selected to undergo TP53 testing based on the presence of hallmark features of LFS. Analyzing TP53 mutation carriers identified from multi-gene panel testing, for which the diagnosis of LFS may not have been suspected or was included in a longer differential diagnosis, affords an opportunity to characterize additional TP53 carriers who might not otherwise have been ascertained.

Methods: Patients with a deleterious or suspected deleterious germline TP53 mutation were identified from 80,748 consecutive cases that underwent a 25-gene hereditary cancer panel test between September 2013 and March 2015 at a commercial diagnostic laboratory. Patient clinical data were obtained by healthcare provider report on test requisition forms. Each TP53 mutation carrier was evaluated to determine whether the National Comprehensive Cancer Network's (NCCN) guidelines were met for TP53 testing.

Results: Eighty-one TP53 mutation carriers were identified and had a total of 115 cancers (0.1% overall prevalence). Among the 76 carriers with at least one cancer, the average age at first diagnosis was 42 years (range 11-76 years) and 24% were first diagnosed older than age 50 years. The most common first cancers were of the breast (n=45), ovary (n=9), and gastrointestinal tract (n=8). Fifty-two of the 75 (69%) women had breast cancer, 44% of which were first diagnosed at 35 years or younger, and 21% were first diagnosed at 50 years or older. Only 27 TP53 carriers met NCCN criteria for TP53 testing, 14 of whom only met based on having early-onset breast cancer. An additional 8 did not meet criteria themselves but had a first- or second-degree relative who did. Among the 28 individuals with more than one primary cancer, 21 (75%) developed their second primary at a site for which increased surveillance is recommended in LFS, but only 4 would have met NCCN criteria for TP53 testing at their first cancer diagnosis. The most common second cancers were of the breast (n=16), gastrointestinal tract (n=4), or kidney (n=2) and occurred an average of 11 years after the first cancer (range 0-36 years).

Conclusion: In this analysis, a large proportion of carriers would not have been identified as TP53 testing candidates based on NCCN guidelines. Our data are consistent with other studies demonstrating high second primary cancer risks in LFS, and highlight the value of multigene panel testing in identifying individuals who may be candidates for increased surveillance and/or cancer risk-reducing management options.

Citation Format: Rich T, Lotito M, Kidd J, Saam J, Lancaster J. Characterization of Li-Fraumeni syndrome diagnosed using a 25-gene hereditary cancer panel. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD7-03.

Peer support workers: an untapped resource in primary mental health care

The treatment of moderate to severe mental illness in a primary health care setting is an area under development and can be contentious. The capacity, capability, resourcing and willingness of staff and organisations all feature in the discussions among specialist services and primary health care providers about the opportunities and barriers associated with primary mental health care. This paper presents the peer support worker as an untapped resource that has the potential to support the patient, primary health care staff, and general practitioner in the care of people who fall outside the current understanding of "mild" mental health problems, but who would nonetheless benefit from receiving their care in a primary health care setting.

Viewpoint: Peer support workers: an untapped resource in primary mental health care

The treatment of moderate to severe mental illness in a primary health care setting is an area under development and can be contentious. The capacity, capability, resourcing and willingness of staff and organisations all feature in the discussions among specialist services and primary health care providers about the opportunities and barriers associated with primary mental health care. This paper presents the peer support worker as an untapped resource that has the potential to support the patient, primary health care staff, and general practitioner in the care of people who fall outside the current understanding of 'mild' mental health problems, but who would nonetheless benefit from receiving their care in a primary health care setting. KEYWORDS: General practice; mental health; mental health services, community; primary health care

Implementing and maintaining nurse-led healthy living programs in forensic inpatient settings: an illustrative case study

BACKGROUND

Healthy living programs (HLPs) within the context of mental health units are an applied response to the concerns of metabolic syndrome and the associated physical illnesses to which people with serious mental illness are susceptible.

OBJECTIVE

To illustrate how nurses, with other health professionals and service users, have established and maintained HLPs in two locked forensic mental health units in New Zealand.

DESIGN

This illustrative case study adopts a multimodal approach to data collection and analysis. Across two programs, interviews were undertaken with service users (n = 15) and staff (n = 17), minutes of meetings were analyzed for major decision points, and clinical notes were reviewed to identify which service-user health status measures (body mass index, glucose tolerance test results, blood pressure, and medication use) were recorded.

RESULTS

Similarities were identified in the way the HLPs were implemented and maintained by champions who advocated for change, challenged staff attitudes, secured funding, and established new systems and protocols. Successful implementation depended on involvement of the multidisciplinary team. Each program operated within a different physical environment and adopted its own philosophical approach that shaped the style of the program. The HLPs had an impact on nurses, other staff, and on the culture of the institutions. The programs raised dilemmas about restrictions and risk versus autonomy and self-management.

CONCLUSION

Understanding the effects of the clinical and philosophical contexts in which HLPs are established and the way challenges and benefits are affected by context has practical significance for the future development of health programs in forensic settings, prisons, and general mental health units.

Child involvement in the paediatric consultation: a qualitative study of children and carers' views

BACKGROUND

This study aimed to investigate child and carers' attitudes towards child involvement in paediatric consultations.

METHODS

Semi-structured qualitative interviews explored child and carers' attitudes towards child involvement at different stages of the paediatric consultation process. Twenty families (21 children, 17 mothers and 5 fathers) were interviewed following a paediatric (index) consultation in two UK paediatric inpatient and outpatient departments.

RESULTS

All but one family felt the child should be involved at some stage of the consultation process but the desired extent and nature of involvement depended on child, family and illness characteristics, as well as on the stages of the consultation. During history gathering, some parents and children felt it was the decision and responsibility of the parent to facilitate communication between the child and the doctor. Others expected the doctor to decide when and how to facilitate this process. At diagnosis the desired amount of information given to the child increased with increasing maturity in the child. Some felt making a diagnosis should be a collaborative process; others felt it was solely the domain of the doctor. In discussing and making a treatment plan, some children wanted to be given the choice of being involved and some wanted their parents to be responsible for implementing the plan. Some families with a seriously ill child, however, wanted the burden of involvement in the management plan taken away from them.

CONCLUSIONS

Families vary in their views about involvement of children in paediatric consultations in a way that may be unique to each child, family and illness. Moreover, different views were expressed about involvement in each stage of the consultative process and in management of the child's health. The challenge for doctors is to determine the level of involvement and information exchange favoured by a particular parent and child. Good practice recommendations emerging from the analysis are described.

Hemoglobin Hakkari: an autosomal dominant form of beta thalassemia with inclusion bodies arising from de novo mutation in exon 2 of beta globin gene

Certain beta globin gene mutations produce a thalassemia major phenotype in the heterozygous state. While most such patients have thalassemia intermedia, we describe a young Guatemalan child with a de novo mutation in the beta globin gene, codon 31 T --> G (Hemoglobin Hakkari), who developed severe anemia at the age of 10 months and remains transfusion-dependent. The substitution of B13 leucine with arginine in the beta globin results in alteration of a critical heme contact point resulting in an extremely unstable variant hemoglobin and a clinical picture that is characterized by ineffective erythropoiesis and numerous intracytoplasmic inclusions within the erythrocyte precursors of the bone marrow. .