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PURPOSE Cancer disparities persist among medically underserved populations despite widespread efforts to address them. We describe the development of a framework for addressing cancer care disparities across the cancer care continuum (CCC), guided by the CCC domains established by the Institute of Medicine/National Academies of Sciences, Engineering, and Medicine (IOM/NAS). MATERIALS AND METHODS An environmental scan was conducted to identify strategies and associated experts who are providing or have successfully provided community- and/or patient-centric IOM/NAS-defined domain standards to our target populations. A multistakeholder expert roundtable working group was convened for framework development. A premeeting survey informed agenda development, documented expert practices for target populations, and identified priority areas for meeting focus. RESULTS The environmental scan identified 84 unique experts across 8 stakeholder groups and 44 patient organizations; 50 were invited to the roundtable and 33 participated. They broadly represented disease sites, geography, and experience with target populations and all CCC domains. The premeeting survey (16 responses) identified coordination of care or patient navigation (66.7%), community engagement (60.0%), and healthcare system changes (53.3%) as priority focus areas. The experts identified access and treatment barriers or gaps within and between CCC domains, specified key notable practices to address these, and developed an actionable framework and recommendations for each priority focus area. CONCLUSION The framework and recommendations are intended to guide researchers, healthcare leaders, advocates, community- and patient-focused service organizations, and policy leaders to address and promote health equity in cancer care access and treatment outcomes. [ABSTRACT FROM AUTHOR]

Background: Exercise effectively reduces symptoms of depression. However, correlates of regular exercise in depressed women are unknown. This study assessed psychosocial determinants of exercise in a sample of women with depressive symptoms. Methods: Sixty-one women completed demographic, depression, and exercise-related questionnaires. Results: The average Primary Health Questionnaire- 9 (PHQ-9) depression score was 12.1 (SD = 5.0), indicating moderate depressive symptoms. In the previous week, the women reported 12.8 metabolic equivalents (METs) of exercise. Low levels of self-efficacy and social support for exercise were also reported. Depressive symptoms were positively associated with barriers to exercise (r = .35, P < .01), and barriers were inversely related to exercise METs (r = -.37, P < .05). Barriers to activity and education level were significant determinants of exercise. Conclusions: Women with depressive symptoms report minimal exercise involvement, numerous barriers to exercise, and low exercise self-efficacy and social support for exercise. [ABSTRACT FROM AUTHOR]

Given the momentum in adopting patient navigation into cancer care, there is a need to understand the contribution of specific navigator activities to improved clinical outcomes. A mixed-methods study combined direct observations of patient navigators within the Patient Navigation Research Program and outcome data from the trial. We correlated the frequency of navigator tasks with the outcome of rate of diagnostic resolution within 365 days among patients who received the intervention relative to controls. A focused content analysis examined those tasks with the strongest correlations between navigator tasks and patient outcomes. Navigating directly with specific patients (r = 0.679), working with clinical providers to facilitate patient care (r = 0.643), and performing tasks not directly related to their diagnostic evaluation for patients were positively associated with more timely diagnosis (r = 0.714). Using medical records for non-navigation tasks had a negative association (r = -0.643). Content analysis revealed service provision directed at specific patients improved care while systems-focused activities did not. [ABSTRACT FROM AUTHOR]

Adverse social determinants of health (SDOH) are associated with poor health.[1] Cumulative social risk factors, such as food insecurity and social isolation, have a higher correlation with poor health outcomes than single social risk factors.[2] New health policy incentives encourage implementation of social and behavioral risk screening and referral models into health care delivery.[3] Understanding patient variation in facing adverse SDOH will allow policy makers and health care systems to prioritize screening for those most at risk, and develop targeted SDOH interventions. We applied survey weights to estimate nationally representative proportions by gender, which NHANES collects as a self-reported variable, for each risk factor and cumulative risk factors. Tailoring and targeting SDOH screening for women in clinical settings, especially for older women where the prevalence of multiple risk factors is highest, could increase the impact of SDOH interventions, and subsequently improve women's health and quality of life. [Extracted from the article]

Background Patient navigation is a promising intervention to address cancer disparities but requires a multisite controlled trial to assess its effectiveness. Methods The Patient Navigation Research Program compared patient navigation with usual care on time to diagnosis or treatment for participants with breast, cervical, colorectal, or prostate screening abnormalities and/or cancers between 2007 and 2010. Patient navigators developed individualized strategies to address barriers to care, with the focus on preventing delays in care. To assess timeliness of diagnostic resolution, we conducted a meta-analysis of center- and cancer-specific adjusted hazard ratios (aHRs) comparing patient navigation vs usual care. To assess initiation of cancer therapy, we calculated a single aHR, pooling data across all centers and cancer types. We conducted a metaregression to evaluate variability across centers. All statistical tests were two-sided. Results The 10521 participants with abnormal screening tests and 2105 with a cancer or precancer diagnosis were predominantly from racial/ethnic minority groups (73%) and publically insured (40%) or uninsured (31%). There was no benefit during the first 90 days of care, but a benefit of navigation was seen from 91 to 365 days for both diagnostic resolution (aHR = 1.51; 95% confidence interval [CI] = 1.23 to 1.84; P < .001)) and treatment initiation (aHR = 1.43; 95% CI = 1.10 to 1.86; P < .007). Metaregression revealed that navigation had its greatest benefits within centers with the greatest delays in follow-up under usual care. Conclusions Patient navigation demonstrated a moderate benefit in improving timely cancer care. These results support adoption of patient navigation in settings that serve populations at risk of being lost to follow-up. [ABSTRACT FROM AUTHOR]

Objective: Following the initial wave of federal support to address women's health, there is a need to assess successes and determine the next priorities to advance the health of women. The objective of this study was to systematically collect expert opinion on the major advances in women's health in the past decade and priorities for women's health research and service in the coming decade. Methods: We utilized a Delphi method to query the leadership from academic and community Centers of Excellence in Women's Health, as designated by the Department of Health and Human Services. Leaders from 36 of the 48 centers responded to a series of questions about the major advances and critical indicators to evaluate future needs in women's health. We utilized a social ecology model framework to organize the responses to each question. Results: The experts identified increased health education for women and increased empowerment of women across multiple spheres as the major advances positively impacting the health of women. The experts selected the following areas as the most important indicators to measure the status of the health of women in the future: health education and promotion, rates and impact of interpersonal violence against women, and access to healthcare. The major advances and measures of the health of women did not focus on specific changes to individual women in illness management, clinical care, or individual behavioral change. Conclusions: As we move to address health reform, we must be able to recognize and incorporate a broad perspective on public health and policy initiatives critical to the health and wellness of women and girls and, therefore, central to the well-being of the nation. [ABSTRACT FROM AUTHOR]

Objective. To develop a structured protocol for observing patient navigators at work, describing and characterizing specific activities related to their goals. Data Sources/Setting. Fourteen extended observations of navigators at three programs within a national trial of patient navigation. Study Design. Preliminary observations were guided by a conceptual model derived from the literature and expert consensus, then coded to develop and refine observation categories. These findings were then used to develop the protocol. Methods. Observation fieldnotes were coded, using both a priori codes and new codes based on emergent themes. Using these codes, the team refined the model and constructed an observation tool that enables consistent categorization of the observed range of navigator actions. Findings. Navigator actions across a wide variety of settings can be categorized in a matrix with two dimensions. One dimension categorizes the individuals and organizational entities with whom the navigator interacts; the other characterizes the types of tasks carried out by the navigators in support of their patients. Conclusions. Use of this protocol will enable researchers to systematically characterize and compare navigator activities within and across programs. [ABSTRACT FROM AUTHOR]

Background: Patient, provider, and systems barriers contribute to delays in cancer care, a lower quality of care, and poorer outcomes in vulnerable populations, including low-income, underinsured, and racial/ethnic minority populations. Patient navigation is emerging as an intervention to address this problem, but navigation requires a clear definition and a rigorous testing of its effectiveness. Pilot programs have provided some evidence of benefit, but have been limited by evaluation of single-site interventions and varying definitions of navigation. To overcome these limitations, a 9-site National Cancer Institute Patient Navigation Research Program (PNRP) was initiated.Methods: The PNRP is charged with designing, implementing, and evaluating a generalizable patient navigation program targeting vulnerable populations. Through a formal committee structure, the PNRP has developed a definition of patient navigation and metrics to assess the process and outcomes of patient navigation in diverse settings, compared with concurrent continuous control groups.Results: The PNRP defines patient navigation as support and guidance offered to vulnerable persons with abnormal cancer screening or a cancer diagnosis, with the goal of overcoming barriers to timely, quality care. Primary outcomes of the PNRP are 1) time to diagnostic resolution; 2) time to initiation of cancer treatment; 3) patient satisfaction with care; and 4) cost effectiveness, for breast, cervical, colon/rectum, and/or prostate cancer.Conclusions: The metrics to assess the processes and outcomes of patient navigation have been developed for the NCI-sponsored PNRP. If the metrics are found to be valid and reliable, they may prove useful to other investigators. [ABSTRACT FROM AUTHOR]

Background: Medical care at the end of life is often expensive and ineffective.Objective: To explore associations between primary care and hospital utilization at the end of life.Design: Retrospective analysis of Medicare data. We measured hospital utilization during the final 6 months of life and the number of primary care physician visits in the 12 preceding months. Multivariate cluster analysis adjusted for the effects of demographics, comorbidities, and geography in end-of-life healthcare utilization.Subjects: National random sample of 78,356 Medicare beneficiaries aged 66+ who died in 2001. Non-whites were over-sampled. All subjects with complete Medicare data for 18 months prior to death were retained, except for those in the End Stage Renal Disease program.Measurements: Hospital days, costs, in-hospital death, and presence of two types of preventable hospital admissions (Ambulatory Care Sensitive Conditions) during the final 6 months of life.Results: Sample characteristics: 38% had 0 primary care visits; 22%, 1-2; 19%, 3-5; 10%, 6-8; and 11%, 9+ visits. More primary care visits in the preceding year were associated with fewer hospital days at end of life (15.3 days for those with no primary care visits vs. 13.4 for those with > or = 9 visits, P < 0.001), lower costs ($24,400 vs. $23,400, P < 0.05), less in-hospital death (44% vs. 40%, P < 0.01), and fewer preventable hospitalizations for those with congestive heart failure (adjusted odds ratio, aOR = 0.82, P < 0.001) and chronic obstructive pulmonary disease (aOR = 0.81, P = 0.02).Conclusions: Primary care visits in the preceding year are associated with less, and less costly, end-of-life hospital utilization. Increased primary care access for Medicare beneficiaries may decrease costs and improve quality at the end of life. [ABSTRACT FROM AUTHOR]

Objective: The healthcare needs of lesbians are not well understood. We sought to characterize lesbians' experiences with, and preferences for, women's healthcare. Methods: We conducted three age-stratified focus groups (1829, 3050, and >50 years) with a total of 22 participants using a semistructured interview guide to elicit lesbians' experiences and preferences. We analyzed transcripts of these audiotaped sessions using the constant comparative method of grounded theory. Community-dwelling women who self-identified as lesbian and responded to advertisements were selected on first-come basis. Results: Participants voiced experiences and preferences for healthcare that emerged into three themes: desired models of care, desired processes of care, and desired patient-provider relationship. Each theme was further developed into multiple subthemes. Within the subthemes we identified issues that were specific to lesbians and those that were general women's health issues. Participants preferred, but did not always receive, care that is comprehensive in scope, person centered, nondiscriminatory, and inclusive of them as lesbians. Conclusions: Healthcare providers, institutions, and society should adopt an inviting, person-centered approach toward lesbians seeking healthcare, assure them access to healthcare information, and establish healthcare delivery systems that take all aspects of health into account. [ABSTRACT FROM AUTHOR]

Background and objectives: Clinical depression affects millions of women annually. Exercise has been studied as a potential antidepressant, with most studies supporting its efficacy. Exercise also has the potential to reduce the risk for physical comorbidities that occur with depression. However, less is known about the types of exercise programs to which women with depressive symptoms will adhere. Our objectives were to (1) compare two exercise programs, varying in their degree of structure, on improvements in physical activity and (2) compare the two exercise interventions on depressive symptoms, body composition, and fitness. Methods: Women with depressive symptoms (physician diagnosed and confirmed with the Beck Depression Inventory) residing in the greater Boston area were recruited for this 3-month intervention study. Continuous enrollment took place between November 2005 and November 2006. Women were randomly assigned to either a clinic-based or home-based exercise intervention, with assessments at baseline and 3-months. Results: Participants ( n = 32) were predominantly minority (81.4%) and, at baseline, had moderate symptoms of depression (Beck Depression Inventory [BDI], mean = 25.6, SD = 9.3), and were sedentary (mean = 35.8 min/week of moderate and vigorous activity, SD = 31.4). Gain scores for depressive symptoms (clinic-based mean = −11.7, home-based mean = − 9.7) and physical activity (clinic-based mean = 65.4, home-based mean = 39.0) indicate strong improvements across time. Intent-to-treat analyses on 3-month data show that both interventions were associated with improvements in time spent in physical activity and depressive symptoms. Neither intervention impacted body composition or fitness. Conclusions: Both exercise programs were associated with reductions in depressive symptoms and increased physical activity participation, suggesting that even a home-based program can benefit women with depressive symptoms. [ABSTRACT FROM AUTHOR]

From 1996 through 1998, 18 National Centers of Excellence in Women's Health (CoEs) were designated by the Office on Women's Health (OWH) of the U.S. Department of Health and Human Services (DHHS). These CoEs were charged with developing standards for comprehensive, multidisciplinary, and culturally competent approaches to women's health. One specific mandate to the CoEs was to address the needs of underserved women. This paper presents the efforts of the CoE Racial and Ethnic Minority and Underserved Women Working Group to describe the work done within the CoEs to meet this mandate. One method of defining underserved populations is the seven-point definition used in the current "Index for Primary Care Shortage," which categorizes underserved populations based on characteristics including race, ethnicity, geography, and health outcomes. The definition allows the local identification of underserved communities based on this group of variables. The analysis included in this paper focuses specifically on the CoEs' efforts to operationalize this definition in order to meet the clinical care needs of women who are of low socioeconomic status (SES), racial or ethnic minorities, or non-English speaking. A brief review of the literature linking these characteristics to being underserved is provided, followed by examples of ongoing activities at the 15 currently funded CoEs, to understand the needs of diverse women, to improve the quality of care provided to women, and to address healthcare needs of underserved women who meet this definition. Efforts to serve three additional underserved populations defined by age, sexual orientation, and disability status are also presented. [ABSTRACT FROM AUTHOR]

New models of care delivery have been developed to better coordinate and integrate healthcare for women. In the United States, one of the challenges is to incorporate the needs of racial and ethnic minority populations into these newer care paradigms. This paper begins with a brief historical review of the experience of racial and ethnic minorities in the American healthcare system to provide a context for discussing barriers and limitations of more traditional models of women's healthcare. Specific approaches used by National Centers of Excellence in Women's Health are presented as examples of strategies that may be implemented by other communities to address these barriers. [ABSTRACT FROM AUTHOR]

The article presents a study that compared women's health practice and general internal medicine practice on issues of care during menopause. Menopause was selected in the study because of the potential variability in physician and patient expectation, and diverse views on the roles of various preventive and therapeutic strategies. The study surveyed female patients and their physicians in a women's health practice and a general internal medicine practice, comparing (1) patient characteristics and health behaviours, (2) symptoms of and attitudes toward the menopause, and (3) physicians' awareness of their own patients' attitudes and health beliefs on menopausal issues. Three self-administered questionnaires were deigned for use in this study, one patient questionnaire and two physician questionnaires. The patient questionnaire contained questions to assess age, education and race. Findings of the study suggest that there are differences in the patients who seek primary care in women's health centers relative to those receiving care in traditional general internal medicine practices. The study does not provide evidence of differences in care related to menopause but rather suggests that physician gender may be associated with physicians' awareness of patients' menopausal attitudes.

The article focuses on patient navigation, a care management system used to address cancer disparities. Patient navigation is a model to improve the healthcare being delivered to vulnerable populations which focuses on improved cancer outcomes. Patient navigation is a logistic and emotional support offered through cancer care continuum including screening, diagnostic evaluation and cancer treatment. Furthermore, patient navigation shares several attributes with other care management models.

The article discusses the health care issues of women in developed countries. In the developed world, women can expect that they will live beyond their childbearing years and into old age. There has been a shift in attention and resources from maternal mortality and infectious diseases to the prevention and management of chronic disease. Chemoprevention has also gained much attention with regard to women's health. International trials on breast-cancer prevention using selective oestrogen-receptor modulators in women at high risk of cancer is one example of such an initiative. In contrast to the advances in screening and prevention, a second face of women's health, is characterised by poorer health outcomes in women with low socioeconomic status. Even in those countries with broad health-care coverage and organised screening campaigns, women with low incomes, or little education continue to have poorer health outcomes. In the United States, African American women have a life expectancy 5 years shorter than that of white women. A study of several European countries found that markers of morbidity are consistently less favourable among women with lower income and education. Women with low incomes and from ethnic minorities are more likely to have low birthweight infants, cervical cancer, and HIV disease, all of which are usually associated with developing countries.