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Previous research has revealed that 10.4% of breast cancer deaths in white women in the United States occurred in Appalachia (Yao et. al, 2012). Rates of unstaged breast cancer, cancer for which there is not enough medical evidence to classify the disease progression (National Cancer Institute, 2013), are higher in the rural regions compared to the urban regions of Appalachia (Lengerich et. al, 2005). In the United States, the rates of adherence to adjuvant hormone therapy, a standard therapy prescribed for estrogen receptor positive breast cancer cases, are between 70-80%, while the rate of discontinuation of this treatment is 20%. However, in Appalachia, there is a 69% adherence rate and a 30% discontinuation rate to the same adjuvant hormone therapy. A disparity in breast cancer diagnosis and care exists not only between Appalachia and the rest of the United States but also between urban and rural areas of Appalachia (Lengerich et. al, 2005). While biological or environmental differences may contribute to the increased rates in rural Appalachia, there may be psycho-social-cultural barriers that prevent women with breast cancer in Appalachia from receiving equitable diagnosis or care for their cancer. Women in the United States are benefiting from advances in medical treatment for breast cancer (Elkin & Hudis, 2015); however, women in rural Appalachia still seem to suffer from the burden of this disease (Lengerich et. al, 2005; Yao et. al, 2012). They are more likely to be diagnosed with unstaged cancer, more likely to discontinue using critical therapies, and more likely to die of breast cancer than their urban counterparts. To develop effective interventions to increase optimal care in Appalachia, we need to understand why some women receive diagnosis and care for their breast cancer, while some do not. This thesis explores a facet of this complex issue by considering: of women in Appalachia with breast cancer who did receive care, what positively influenced their pursuit of care and treatment? Using the theory of reasoned action (Ajzen & Fishbein, 1980) as a framework, I sought to understand the experiences of women in Appalachia who pursued care for their breast cancer, and how these experiences influenced their entrance and continuation of care. The results of this study revealed consistencies and inconsistencies with the theory of reasoned action, as well as the need for consideration of factors not address by the theory. These findings have practical implications for how cancer centers support and educate patients, and how physicians present treatment plans.
Delivering high-quality cancer care to all patients presents numerous challenges, including difficulties with care coordination and access. Patient navigation is a community-based service delivery intervention designed to promote access to timely diagnosis and treatment of cancer and other chronic diseases by eliminating barriers to care, and has often been proposed and implemented to address these challenges. However, unresolved questions include where patient navigation programs should be deployed, and which patients should be prioritized to receive navigation services when resources are limited. To address these issues and facilitate discussion on how to improve navigation services for patients with cancer, the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine held a workshop on November 13 and 14, 2017. At this workshop, a broad range of experts and stakeholders, including clinicians, navigators, researchers, and patients, explored which patients need navigation and who should serve as navigators, and the benefits of navigation and current gaps in the evidence base.
Mammography is an important tool for detecting breast cancer at an early stage. When coupled with appropriate treatment, early detection can reduce breast cancer mortality. At the request of Congress, the Food and Drug Administration (FDA) commissioned a study to examine the current practice of mammography and breast cancer detection, with a focus on the FDA's oversight via the Mammography Quality Standards Act (MQSA), to identify areas in need of improvement. Enacted in 1993, MQSA provides a general framework for ensuring national quality standards in facilities performing screening mammography, requires that each mammography facility be accredited and certified, and mandates that facilities will undergo annual inspections. This book recommends strategies for achieving continued progress in assuring mammography quality, including changes to MQSA regulation, as well as approaches that do not fall within the purview of MQSA. Specifically, this book provides recommendations aimed at improving mammography interpretation; revising MQSA regulations, inspections, and enforcement; ensuring an adequate workforce for breast cancer screening and diagnosis; and improving breast imaging quality beyond mammography.
Building on the innovative Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Quality Through Collaboration: The Future of Rural Health offers a strategy to address the quality challenges in rural communities. Rural America is a vital, diverse component of the American community, representing nearly 20% of the population of the United States. Rural communities are heterogeneous and differ in population density, remoteness from urban areas, and the cultural norms of the regions of which they are a part. As a result, rural communities range in their demographics and environmental, economic, and social characteristics. These differences influence the magnitude and types of health problems these communities face. Quality Through Collaboration: The Future of Rural Health assesses the quality of health care in rural areas and provides a framework for core set of services and essential infrastructure to deliver those services to rural communities. The book recommends: Adopting an integrated approach to addressing both personal and population health needs Establishing a stronger health care quality improvement support structure to assist rural health systems and professionals Enhancing the human resource capacity of health care professionals in rural communities and expanding the preparedness of rural residents to actively engage in improving their health and health care Assuring that rural health care systems are financially stable Investing in an information and communications technology infrastructure It is critical that existing and new resources be deployed strategically, recognizing the need to improve both the quality of individual-level care and the health of rural communities and populations.
Drug overdose, driven largely by overdose related to the use of opioids, is now the leading cause of unintentional injury death in the United States. The ongoing opioid crisis lies at the intersection of two public health challenges: reducing the burden of suffering from pain and containing the rising toll of the harms that can arise from the use of opioid medications. Chronic pain and opioid use disorder both represent complex human conditions affecting millions of Americans and causing untold disability and loss of function. In the context of the growing opioid problem, the U.S. Food and Drug Administration (FDA) launched an Opioids Action Plan in early 2016. As part of this plan, the FDA asked the National Academies of Sciences, Engineering, and Medicine to convene a committee to update the state of the science on pain research, care, and education and to identify actions the FDA and others can take to respond to the opioid epidemic, with a particular focus on informing FDA's development of a formal method for incorporating individual and societal considerations into its risk-benefit framework for opioid approval and monitoring.
Cancer has become a leading cause of death and disability and a serious yet unforeseen challenge to health systems in low-and middle-income countries. A protracted and polarized cancer transition is under way and fuels a concentration of preventable risk, illness, suffering, impoverishment from ill health, and death among poor populations. Closing this cancer divide is an equity imperative. The world faces a huge, unperceived cost of failure to take action that requires an immediate and large-scale global response. Closing the Cancer Divide presents strategies for innovation in delivery, pricing, procurement, finance, knowledge-building, and leadership that can be scaled up by applying a diagonal approach to health system strengthening. The chapters provide evidence-based recommendations for developing programs, local and global policy-making, and prioritizing research. The cases and frameworks provide a guide for developing responses to the challenge of cancer and other chronic illnesses. The book summarizes results of the Global Task Force on Expanding Access to Cancer Care and Control in Developing Countries, a collaboration among leaders from the global health and cancer care communities worldwide, originally convened by Harvard University. It includes contributions from civil society, global and national policy-makers, patients and practitioners, and academics representing an array of fields.
Diet and Health examines the many complex issues concerning diet and its role in increasing or decreasing the risk of chronic disease. It proposes dietary recommendations for reducing the risk of the major diseases and causes of death today: atherosclerotic cardiovascular diseases (including heart attack and stroke), cancer, high blood pressure, obesity, osteoporosis, diabetes mellitus, liver disease, and dental caries.
This volume provides an overview of the important health promotion and disease prevention theories, methods, and policy issues. Applications of these theories and methods are reviewed to promote health through a variety of channels, for a variety of disease outcomes, and among a variety of populations. It can be used as a text for introductory causes to the field of health promotion and disease prevention, as well as a reference for researchers and practitioner's actively working in this area.
In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health. Only part of an individual's health status depends on his or her behavior and choice; community-wide problems like poverty, unemployment, poor education, inadequate housing, poor public transportation, interpersonal violence, and decaying neighborhoods also contribute to health inequities, as well as the historic and ongoing interplay of structures, policies, and norms that shape lives. When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways. Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome.