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1.  Prehabilitation for men undergoing radical prostatectomy: a multi-centre, pilot randomized controlled trial 
BMC Surgery  2014;14(1):89.
An emerging field of research describes the role of preoperative health behaviours, known as prehabilitation. The preoperative period may be a more physically and emotionally salient time to introduce and foster chronic adherence to health behaviours, such as exercise, in patients compared to post-treatment during recovery. Moreover, physical and psychosocial improvements during the preoperative period may translate into an enhanced recovery trajectory with reduced operative complications and postoperative adverse effects. No studies have assessed prehabilitation for men with prostate cancer undergoing radical prostatectomy.
This is a multi-centre, pilot randomized control trial conducted at two Canadian urban teaching hospitals. 100 men undergoing radical prostatectomy for prostate cancer with no contraindications to exercise will be recruited and randomized to the prehabiliation program or usual care. Prehabilitation participants will engage in a preoperative, individualized exercise program including pelvic floor muscle strengthening instructions and a healthy lifestyle guide for men with prostate cancer. These participants will be asked to engage in 60 minutes of home-based, unsupervised, moderate-intensity exercise on 3–4 days per week. Usual care participants will receive the same pelvic floor muscle strengthening instructions and healthy lifestyle guide only. We will assess the feasibility of conducting an adequately powered trial of the same design via recruitment rate, programmatic adherence/contamination, attrition, and safety. Estimates of intervention efficacy will be captured through measurements at baseline (4–8 weeks preoperatively), within 1 week prior to surgery, and postoperatively at 4, 12, and 26 weeks. Efficacy outcomes include: fatigue, quality of life, urinary incontinence, physical fitness, body composition, aerobic fitness, pain, and physical activity volume.
The primary outcome of this study is to determine the feasibility of conducting a full-scale, randomized controlled trial of prehabilitation versus usual care and to estimate effect sizes that will inform sample size determinations for subsequent trials in this field. To our knowledge, this is the first study to examine a structured presurgical exercise program for men undergoing radical prostatectomy for prostate cancer. This trial will advance our understanding of strategies to efficiently and effectively use the preoperative period to optimize postoperative recovery.
Trial registration Identifier: NCT02036684
PMCID: PMC4246547  PMID: 25394949
Prehabilitation; Prostate cancer; Exercise; Randomized controlled trial; Rehabilitation
2.  The MOBI-Kids Study Protocol: Challenges in Assessing Childhood and Adolescent Exposure to Electromagnetic Fields from Wireless Telecommunication Technologies and Possible Association with Brain Tumor Risk 
The rapid increase in mobile phone use in young people has generated concern about possible health effects of exposure to radiofrequency (RF) and extremely low frequency (ELF) electromagnetic fields (EMF). MOBI-Kids, a multinational case–control study, investigates the potential effects of childhood and adolescent exposure to EMF from mobile communications technologies on brain tumor risk in 14 countries. The study, which aims to include approximately 1,000 brain tumor cases aged 10–24 years and two individually matched controls for each case, follows a common protocol and builds upon the methodological experience of the INTERPHONE study. The design and conduct of a study on EMF exposure and brain tumor risk in young people in a large number of countries is complex and poses methodological challenges. This manuscript discusses the design of MOBI-Kids and describes the challenges and approaches chosen to address them, including: (1) the choice of controls operated for suspected appendicitis, to reduce potential selection bias related to low response rates among population controls; (2) investigating a young study population spanning a relatively wide age range; (3) conducting a large, multinational epidemiological study, while adhering to increasingly stricter ethics requirements; (4) investigating a rare and potentially fatal disease; and (5) assessing exposure to EMF from communication technologies. Our experience in thus far developing and implementing the study protocol indicates that MOBI-Kids is feasible and will generate results that will contribute to the understanding of potential brain tumor risks associated with use of mobile phones and other wireless communications technologies among young people.
PMCID: PMC4172002  PMID: 25295243
children; adolescents; brain tumors; ELF–EMF; mobile phones; RF-EMF
3.  Smartphone-Enabled Health Coach Intervention for People With Diabetes From a Modest Socioeconomic Strata Community: Single-Arm Longitudinal Feasibility Study 
Lower socioeconomic strata (SES) populations have higher chronic disease risks. Smartphone-based interventions can support adoption of health behaviors that may, in turn, reduce the risks of type 2 diabetes-related complications, overcoming the obstacles that some patients may have with regular clinical contact (eg, shiftwork, travel difficulties, miscommunication).
The intent of the study was to develop and test a smartphone-assisted intervention that improves behavioral management of type 2 diabetes in an ethnically diverse, lower SES population within an urban community health setting.
This single-arm pilot study assessed a smartphone application developed with investigator assistance and delivered by health coaches. Participants were recruited from the Black Creek Community Health Centre in Toronto and had minimal prior experience with smartphones.
A total of 21 subjects consented and 19 participants completed the 6-month trial; 12 had baseline glycosylated hemoglobin (HbA1c) levels >7.0% and these subjects demonstrated a mean reduction of 0.43% (SD 0.63) (P<.05) with minimal changes in medication.
This project supported the feasibility of smartphone-based health coaching for individuals from lower SES with minimal prior smartphone experience.
PMCID: PMC4071226  PMID: 24907918
diabetes mellitus; type 2; health coaching; telehealth
4.  Who are the under- and never- screened for cancer in Ontario: a qualitative investigation 
BMC Public Health  2014;14:495.
Observed breast, cervical and colon cancer screening rates are below provincial targets for the province of Ontario, Canada. The populations who are under- or never-screened for these cancers have not been described at the Ontario provincial level. Our objective was to use qualitative methods of inquiry to explore who are the never- or under-screened populations of Ontario.
Qualitative data were collected from two rounds of focus group discussions conducted in four communities selected using maps of screening rates by dissemination area. The communities selected were archetypical of the Ontario context: urban, suburban, small city and rural. The first phase of focus groups was with health service providers. The second phase of focus groups was with community members from the under- and never- screened population. Guided by a grounded theory methodology, data were collected and analyzed simultaneously to enable the core and related concepts about the under- and never-screened to emerge.
The core concept that emerged from the data is that the under- and never-screened populations of Ontario are characterized by diversity. Group level characteristics of the under- and never- screened included: 1) the uninsured (e.g., Old Order Mennonites and illegal immigrants); 2) sexual abuse survivors; 3) people in crisis; 4) immigrants; 5) men; and 6) individuals accessing traditional, alternative and complementary medicine for health and wellness. Under- and never-screened could have one or multiple group characteristics.
The under- and never-screened in Ontario comprise a diversity of groups. Heterogeneity within and intersectionality among under- and never-screened groups adds complexity to cancer screening participation and program planning.
PMCID: PMC4229738  PMID: 24885998
Cancer screening; Qualitative methods; Sexual abuse; Mennonites; Ethics
5.  The acute effects of exercise on cortical excitation and psychosocial outcomes in men treated for prostate cancer: a randomized controlled trial 
Purpose: Regular exercise improves psychological well-being in men treated for prostate cancer (PCa). For this population and among cancer survivors in general, the effect of a single bout of exercise on self-report or objective measures of psychological well-being has not been examined. We examined the acute effect of a single bout of exercise on the cortical silent period (CSP) and on self-reported mood in men that have received treatment for PCa.
Methods: Thirty-six PCa survivors were randomly assigned to 60 min of low to moderate intensity exercise or to a control condition. Outcomes were assessed immediately before and after either the exercise or the control condition.
Results: No significant between-group differences were observed in CSP or mood were observed following the exercise session or control conditions. Participants with higher scores of trait anxiety had significantly shorter CSP at baseline, as well as those receiving androgen deprivation therapy. Age and baseline CSP had a low-moderate, but significant negative correlation. Changes in CSP following the exercise condition were strongly negatively correlated with changes in self-reported vigor.
Conclusion: While we did not observe any acute effect of exercise on the CSP in this population, the associations between CSP and trait anxiety, age, and vigor are novel findings requiring further examination.
Implications for Cancer Survivors: Exercise did not acutely affect our participants in measures of psychological well-being. Additional mechanisms to explain the chronic psychosocial benefits of exercise previously observed in men with PCa require further exploration. Identifier: NCT01715064 (
PMCID: PMC4244640  PMID: 25505413
cortical silent period; anxiety; depression; physical activity; prostate cancer; randomized controlled trial
6.  ColonCancerCheck Primary Care Invitation Pilot project 
Canadian Family Physician  2013;59(12):e541-e549.
To describe the perceptions of those who received invitations to the ColonCancerCheck Primary Care Invitation Pilot (the Pilot) about the mailed invitation, colorectal cancer (CRC) screening in general, and their specific screening experiences.
Qualitative study with 6 focus group sessions, each 1.5 hours in length.
Hamilton, Ont; Ottawa, Ont; and Thunder Bay, Ont.
Screening-eligible adults, aged 50 years and older, who received a Pilot invitation for CRC screening.
The focus groups were conducted by a trained moderator and were audiorecorded and transcribed verbatim. The transcripts were analyzed using grounded-theory techniques facilitated by the use of electronic software.
Main findings
Key themes related to the invitation letter, the role of the family physician, direct mailing of the fecal occult blood testing (FOBT) kit, and alternate CRC screening promotion strategies were identified. Specifically, participants suggested the letter content should use stronger, more powerful language to capture the reader’s attention. The importance of the family physician was endorsed, although participants favoured clarification of the physician and program roles in the actual mailed invitation. Participants expressed support for directly mailing FOBT kits to individuals, particularly those with successful previous test completion, and for communication of both negative and positive screening results.
This study yielded a number of important findings including strategies to optimize letter content, support for directly mailed FOBT kits, and strategies to report results that might be highly relevant to other health programs where population-based CRC screening is being considered.
PMCID: PMC3860944  PMID: 24336559
7.  Exercise effects on adipokines and the IGF axis in men with prostate cancer treated with androgen deprivation: A randomized study 
Canadian Urological Association Journal  2013;7(11-12):E692-E698.
Androgen deprivation therapy (ADT) has significant deleterious effects on body composition that may be accompanied by unfavourable changes in adipokine levels. While exercise has been shown to improve a number of side effects associated with ADT for prostate cancer, no studies have assessed the effect of exercise on adiponectin and leptin levels, which have been shown to alter the mitogenic environment.
Twenty-six men with prostate cancer treated with ADT were randomized to home-based aerobic exercise training or resistance exercise training for 24 weeks. Adiponectin, leptin, insulin-like growth factor 1 (IGF-1), insulin-like growth factor binding protein 3 (IGFBP-3) were analyzed by ELISA (enzyme-linked immunosorbent assay), in addition to physical activity volume, peak aerobic capacity, and anthropometric measurements, at baseline, 3 months and 6 months.
Resistance exercise significantly reduced IGF-1 after 3 months (p = 0.019); however, this change was not maintained at 6 months. At 6 months, IGFBP-3 was significantly increased compared to baseline for the resistance training group (p = 0.044). In an exploratory analysis of all exercisers, favourable changes in body composition and aerobic fitness were correlated with favourable levels of leptin, and favourable leptin:adiponectin and IGF-1:IGFBP-3 ratios at 3 and 6 months.
Home-based exercise is correlated with positive changes in adipokine levels and the IGF-axis that may be related to healthy changes in physical fitness and body composition. While the improvements of adipokine markers appear to be more apparent with resistance training compared to aerobic exercise, these findings must be considered cautiously and require replication from larger randomized controlled trials to clarify the role of exercise on adipokines and IGF-axis proteins for men with prostate cancer.
PMCID: PMC3840521  PMID: 24282459
8.  Accuracy of Self-Reported Screening Mammography Use: Examining Recall among Female Relatives from the Ontario Site of the Breast Cancer Family Registry 
ISRN Oncology  2013;2013:810573.
Evidence of the accuracy of self-reported mammography use among women with familial breast cancer risk is limited. This study examined the accuracy of self-reported screening mammography dates in a cohort of 1,114 female relatives of breast cancer cases, aged 26 to 73 from the Ontario site of the Breast Cancer Family Registry. Self-reported dates were compared to dates abstracted from imaging reports. Associations between inaccurate recall and subject characteristics were assessed using multinomial regression. Almost all women (95.2% at baseline, 98.5% at year 1, 99.8% at year 2) accurately reported their mammogram use within the previous 12 months. Women at low familial risk (OR = 1.77, 95% CI: 1.00–3.13), who reported 1 or fewer annual visits to a health professional (OR = 1.97, 95% CI: 1.15, 3.39), exhibited a lower perceived breast cancer risk (OR = 1.90, 95% CI: 1.15, 3.15), and reported a mammogram date more than 12 months previous (OR = 5.22, 95% CI: 3.10, 8.80), were significantly more likely to inaccurately recall their mammogram date. Women with varying levels of familial risk are accurate reporters of their mammogram use. These results present the first evidence of self-reported mammography recall accuracy among women with varying levels of familial risk.
PMCID: PMC3747415  PMID: 23984098
9.  Gender differences in attitudes impeding colorectal cancer screening 
BMC Public Health  2013;13:500.
Colorectal cancer screening (CRCS) is the only type of cancer screening where both genders reduce risks by similar proportions with identical procedures. It is an important context for examining gender differences in disease-prevention, as CRCS significantly reduces mortality via early detection and prevention. In efforts to increase screening adherence, there is increasing acknowledgment that obstructive attitudes prevent CRCS uptake. Precise identification of the gender differences in obstructive attitudes is necessary to improve uptake promotion. This study randomly sampled unscreened, screening - eligible individuals in Ontario, employing semi-structured interviews to elicit key differences in attitudinal obstructions towards colorectal cancer screening with the aim of deriving informative differences useful in planning promotions of screening uptake.
N = 81 participants (49 females, 32 males), 50 years and above, with no prior CRCS, were contacted via random-digit telephone dialing, and consented via phone-mail contact. Altogether, N = 4,459 calls were made to yield N = 85 participants (1.9% response rate) of which N = 4 participants did not complete interviews. All subjects were eligible for free-of-charge CRCS in Ontario, and each was classified, via standard interview by CRCS screening decision-stage. Telephone-based, semi-structured interviews (SSIs) were employed to investigate gender differences in CRCS attitudes, using questions focused on 5 attitudinal domains: 1) Screening experience at the time of interview; 2) Barriers to adherence; 3) Predictors of Adherence; 4) Pain-anxiety experiences related to CRCS; 5) Gender-specific experiences re: CRCS, addressing all three modalities accessible through Ontario’s program: a) fecal occult blood testing; b) flexible sigmoidoscopy; c) colonoscopy.
Interview transcript analyses indicated divergent themes related to CRCS for each gender: 1) bodily intrusion, 2) perforation anxiety, and 3) embarrassment for females and; 1) avoidant procrastination with underlying fatalism, 2) unnecessary health care and 3) uncomfortable vulnerability for males. Respondents adopted similar attitudes towards fecal occult blood testing, flexible sigmoidoscopy and colonoscopy, and were comparable in decision stage across tests. Gender differences were neither closely tied to screening stage nor modality. Women had more consistent physician relationships, were more screening-knowledgeable and better able to articulate views on screening. Men reported less consistent physician relationships, were less knowledgeable and kept decision-making processes vague and emotionally distanced (i.e. at ‘arm’s length’).
Marked differences were observed in obstructive CRCS attitudes per gender. Females articulated reservations about CRCS-associated distress and males suppressed negative views while ambiguously procrastinating about the task of completing screening. Future interventions could seek to reduce CRCS-related stress (females) and address the need to overcome procrastination (males).
PMCID: PMC3672022  PMID: 23706029
10.  A pilot study of an exercise & cognitive behavioral therapy intervention for epithelial ovarian cancer patients 
Ovarian cancer has the highest mortality rate of all gynaecologic cancers. Faced with poor prognoses, stressful treatment effects and a high likelihood of recurrence, survivors must confront significant physical and psychological morbidities that negatively impact health-related quality of life. Frequently reported side effects include cancer-related fatigue, peripheral neuropathy, and psychological distress. Exercise and cognitive behavioral therapy interventions have counteracted such adverse effects in other cancer populations.
To investigate the feasibility and benefits of a 24-week home-based exercise intervention, coordinated with 12 weeks of cognitive behavioral therapy (two sessions per month), developed for two types of patients diagnosed with epithelial ovarian cancer: 1) those undergoing primary treatment with adjuvant chemotherapy after primary surgery; 2) those on surveillance after completing treatment within the last 2 years.
Participants were recruited from the Gynaecologic Oncology Clinic. Eligible participants completed baseline assessments and were provided with home-based exercise equipment. Cognitive behavioral therapy was provided every other week for patients via telephone. Assessments were completed at baseline (T1), 3 months (T2) and 6 months (T3).
19 of the 46 eligible patients approached were enrolled, with 7 patients in the treatment group and 12 in the surveillance group. There was a significant within group increase in peak VO2 from baseline to 6 months: F(2,16) = 5.531, p = 0.015, partial η2 = 0.409.
The combined 6-month exercise-cognitive behavioral therapy intervention was associated with significant increases in aerobic fitness in epithelial ovarian cancer patients assessed. These improvements were similar regardless of whether the patient was receiving chemotherapy or under surveillance.
PMCID: PMC3623735  PMID: 23557323
Ovarian cancer; Exercise; Cognitive behavioral therapy; Chemotherapy; Health-related quality of life; Epithelial ovarian cancer
11.  Canadian national surveys on pandemic influenza preparations: pre-pandemic and peri-pandemic findings 
BMC Public Health  2013;13:271.
Prior to the 2009 H1N1 Influenza pandemic, public health authorities in Canada and elsewhere prepared for the future outbreak, partly guided by an ethical framework developed within the Canadian Program of Research on Ethics in a Pandemic (CanPREP). We developed a telephone-based survey based on that framework, which was delivered across Canada in late 2008. In June, 2009, the WHO declared pandemic Phase 6 status and from the subsequent October (2009) until May 2010, the CanPREP team fielded a second (revised) survey, collecting another 1,000 opinions from Canadians during a period of pre-pandemic anticipation and peri-pandemic experience.
Surveys were administered by telephone with random sampling achieved via random digit dialing. Eligible participants were adults, 18 years or older, with per province stratification approximating provincial percentages of national population. Descriptive results were tabulated and logistic regression analyses used to assess whether demographic factors were significantly associated with outcomes, and to identify divergences (between the pre-pandemic and intra-pandemic surveys).
N = 1,029 interviews were completed from 1,986 households, yielding a gross response rate of 52% (AAPOR Standard Definition 3). Over 90% of subjects indicated the most important goal of pandemic influenza preparations was saving lives, with 41% indicating that saving lives solely in Canada was the highest priority and 50% indicating saving lives globally was the highest priority. About 90% of respondents supported the obligation of health care workers to report to work and face influenza pandemic risks excepting those with serious health conditions which that increased risks. Strong majorities favoured stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%). Over 70% agreed Canada should provide international assistance to poorer countries for pandemic preparation, even if resources for Canadians were reduced.
Results suggest Canadians trust public health officials to make difficult decisions, providing emphasis is maintained on reciprocity and respect for individual rights. Canadians also support international obligations to help poorer countries and associated efforts to save lives outside the country, even if intra-national efforts are reduced.
PMCID: PMC3627899  PMID: 23530550
Pandemic influenza; Canada; Survey research; Public health ethics; Bioethics; H1N1
12.  Adherence to breast and ovarian cancer screening recommendations for female relatives from the Ontario Site of the Breast Cancer Family Registry 
This study compares adherence to breast and ovarian cancer screening recommendations among a population cohort of women at familial risk to breast and/or ovarian cancer.
This cross-sectional study included 1039 first-degree female relatives without breast cancer identified from the Ontario site of the Breast Cancer Family Registry. We compared breast and ovarian cancer screening behaviours, using a telephone-administered questionnaire, among three groups of women defined by their familial risk (high; moderate; low) to breast and/or ovarian cancer. Associations between screening behaviours and familial risk were assessed using multinomial regression models adjusted by familial clustering.
Women 40 to 49 years of age at moderate or high familial risk were significantly more likely to have had a screening mammogram within the past 12 months (OR: 2.80; 95% CI: 1.40-5.58), and women less than 50 years of age were more likely to have a clinical breast examination (OR: 1.84; 95% CI: 1.02-3.31) compared to women at low familial risk. Compared to women at low or moderate familial risk, women at high familial risk were significantly more likely to have ever had a genetic test for the BRCA 1/2 genes (OR: 2.67; 95% CI: 1.76-4.05).
Although the overall level of adherence among higher risk women is sub-optimal in the community, women at a higher familial risk are adhering more often to cancer screening recommendations than women at a lower familial risk.
PMCID: PMC3179806  PMID: 21691207
breast cancer; ovarian cancer; cancer screening; family history
13.  Predictors of Patient Self-Ratings of Quality of Life in Alzheimer’s Disease: Cross-Sectional Results from the Canadian Alzheimer’s Disease Quality of Life (CADQOL) Study 
To assess whether the core symptoms of Alzheimer’s disease (AD) consistently predict patient self-rated quality of life (QOL) as assessed by a variety of QOL measures in a large national sample of AD patients.
Fifteen dementia and geriatric clinics across Canada.
Community-living patients with AD (n = 370) with Mini-Mental State Examination (MMSE) scores > 10.
Patients rated their QOL using two utility indexes, the EQ-5D, the Quality of Well-Being Scale, a global QOL visual analogue scale, and the disease-specific QOL-AD instrument. Cognition was assessed with the AD Assessment Scale-Cognitive subscale and MMSE, function with the Disability Assessment for Dementia, and behavioral and psychological symptoms with the Neuropsychiatric Inventory (NPI) and the Geriatric Depression Scale (GDS). One-way analysis of variance and fully adjusted multiple linear regression were used to assess the relationship between core dementia symptoms and QOL ratings.
The QOL measures had only small to moderate correlations with each other. For all QOL measures, patient ratings were significantly lower among patients with more depressive symptoms. In multivariable analyses, the GDS score was the only significant independent predictor of patient self-ratings for all four QOL measures.
Self-rated symptoms of depression were a consistent independent predictor of patient-rated QOL across diverse QOL measures, while performance-based measures of cognition and informant-based functional status were not. These findings confirm the importance of identifying and treating depression in patients with AD and endorse the use of measures of self-rated depressive symptoms and QOL as outcomes in AD clinical trials.
PMCID: PMC3267777  PMID: 21946804 CAMSID: cams2069
Alzheimer’s disease; dementia; quality of life; utility; depression
14.  Predictors of Family Caregiver Ratings of Patient Quality of Life in Alzheimer’s Disease: Cross-Sectional Results from the Canadian Alzheimer’s Disease Quality of Life (CADQOL) Study 
To assess whether the core symptoms of Alzheimer’s disease (AD) and caregiver factors consistently predict family caregiver ratings of patient quality of life (QOL) as assessed by a variety of QOL measures in a large national sample.
Fifteen dementia and geriatric clinics across Canada.
Family caregivers (n = 412) of community-living patients with AD of all severities.
Caregiver ratings of patient QOL using three utility indexes, the EQ-5D, Quality of Well-Being Scale and Health Utilities Index, a global QOL visual analogue scale, a disease-specific measure, the QOL-AD, and a generic health status measure, the Short Form-36. Patient cognition was assessed with the AD Assessment Scale-Cognitive Subscale and Mini-Mental State Examination, function with the Disability Assessment for Dementia, and behavioral and psychological symptoms with the Neuropsychiatric Inventory and the Geriatric Depression Scale. Caregiver burden was assessed with the Zarit Burden Interview and caregiver depression with the Center for Epidemiologic Studies-Depression scale. One-way analysis of variance and fully adjusted multiple linear regression were used to assess the relationship between patient dementia symptom and caregiver variables with QOL ratings.
In multivariable analyses, caregiver ratings of patient function and depressive symptoms were the only consistent independent predictors of caregiver-rated QOL across the QOL measures.
Caregiver ratings of patient function and depression were consistent independent predictors of caregiver-rated QOL using a spectrum of QOL measures, while measures of patient cognition and caregiver burden and depression were not. These findings support the continued use of caregiver ratings as an important source of information about patient QOL and endorse the inclusion in AD clinical trials of caregiver-rated measures of patient function, depression and QOL.
PMCID: PMC3267778  PMID: 21946805 CAMSID: cams2070
Alzheimer’s disease; dementia; quality of life; utility; family caregiver; depression; function
15.  ColonCancerCheck Primary Care Invitation Pilot project 
Canadian Family Physician  2012;58(10):e570-e577.
To determine family physician perspectives regarding the acceptability and effectiveness of 2 interventions—a targeted, mailed invitation for screening to patients, and family physician audit-feedback reports—and on the colorectal cancer (CRC) screening program generally. This information will be used to guide program strategies for increasing screening uptake.
Qualitative study.
Family physicians (n = 65).
Seven 1-hour focus groups were conducted with family physicians using teleconferencing and Web-based technologies. Responses were elicited regarding family physicians’ perspectives on the mailing of invitations to patients, the content and design of the audit-feedback reports, the effect of participation in the pilot project on daily practice, and overall CRC screening program function.
Main findings
Key themes included strong support for both interventions and for the CRC screening program generally. Moderate support was found for direct mailing of fecal occult blood testing (FOBT) kits. Participants identified potential pitfalls if interventions were implemented outside of patient enrolment model practices. Participants expressed relatively strong support for colonoscopy as a CRC screening test but relatively weak support for FOBT.
Although the proposed interventions to increase the uptake of CRC screening were highly endorsed, concerns about their applicability to non–patient enrolment model practices and the current lack of physician support for FOBT will need to be addressed to optimize intervention and program effectiveness. Our study is highly relevant to other public health programs planning organized CRC screening programs.
PMCID: PMC3470535  PMID: 23064936
16.  Beliefs about optimal age and screening frequency predict breast screening adherence in a prospective study of female relatives from the Ontario Site of the Breast Cancer Family Registry 
BMC Public Health  2012;12:518.
Although few studies have linked cognitive variables with adherence to mammography screening in women with family histories of breast and/or ovarian cancer, research studies suggest cognitive phenomena can be powerful adherence predictors.
This prospective study included 858 women aged 30 to 71 years from the Ontario site of the Breast Cancer Family Registry with at least one first-degree relative diagnosed with breast and/or ovarian cancer. Data on beliefs about breast cancer screening and use of mammography were obtained from annual telephone interviews spanning three consecutive years. Self-reported mammogram dates were confirmed with medical imaging reports. Associations between beliefs about breast cancer screening and adherence with annual mammography were estimated using polytomous logistic regression models corrected for familial correlation. Models compared adherers (N = 329) with late-screeners (N = 382) and never-screeners (N = 147).
Women who believed mammography screening should occur annually were more likely to adhere to annual screening recommendations than women who believed it should happen less often (OR: 5.02; 95% CI: 2.97-8.49 for adherers versus late-screeners; OR: 6.82; 95% CI: 3.29-14.16 for adherers versus never-screeners). Women who believed mammography screening should start at or before age 50 (rather than after) (OR: 9.72; 95% CI: 3.26-29.02) were significantly more likely to adhere when compared with never-screeners.
Study results suggest that women with a family history of breast cancer should be strongly communicated recommendations about initial age of screening and screening intervals as related beliefs significantly predict adequate adherence.
PMCID: PMC3432622  PMID: 22788119
Breast cancer; Breast screening; Family history; Beliefs; Adherence
17.  Influence of perceived breast cancer risk on screening behaviors of female relatives from the Ontario Site of the Breast Cancer Family Registry 
Few studies have examined the influence of perceived risk on breast screening behaviors among women with an increased familial breast cancer risk.
This study included 1019 women aged 20 to 71 years from the Ontario site of the Breast Cancer Family Registry who had at least one first-degree relative diagnosed with breast and/or ovarian cancer. Information was obtained from a self-administered questionnaire completed at the time of recruitment and a follow-up telephone questionnaire. The associations between breast screening behaviors and perceived risk of developing breast cancer, measured on both a numerical and Likert-type verbal scale, were estimated using logistic regression analyses.
Women who rated their risk of developing breast cancer as greater than 50% compared to less than 50% were significantly more likely to have a screening mammogram within the last 12 months (OR: 1.91, 95% CI: 1.15 – 3.16). Women were significantly more likely to have a screening mammogram (OR: 1.82, 95% CI: 1.17 – 2.81) in the past 12 months if they rated their risk as above or much above average compared to same as average or below.
These findings may inform educational messages for improving risk communication of women at elevated familial breast cancer risk.
PMCID: PMC3104111  PMID: 21467941
Breast cancer; breast screening; family history; perceived risk
18.  Worry Is Good for Breast Cancer Screening: A Study of Female Relatives from the Ontario Site of the Breast Cancer Family Registry 
Journal of Cancer Epidemiology  2012;2012:545062.
Background. Few prospective studies have examined associations between breast cancer worry and screening behaviours in women with elevated breast cancer risks based on family history. Methods. This study included 901 high familial risk women, aged 23–71 years, from the Ontario site of the Breast Cancer Family Registry. Self-reported breast screening behaviours at year-one followup were compared between women at low (N = 305), medium (N = 433), and high (N = 163) levels of baseline breast cancer worry using logistic regression. Nonlinear relationships were assessed using likelihood ratio tests. Results. A significant non-linear inverted “U” relationship was observed between breast cancer worry and mammography screening (P = 0.034) for all women, where women at either low or high worry levels were less likely than those at medium to have a screening mammogram. A similar significant non-linear inverted “U” relationship was also found among all women and women at low familial risk for worry and screening clinical breast examinations (CBEs). Conclusions. Medium levels of cancer worries predicted higher rates of screening mammography and CBE among high-risk women.
PMCID: PMC3391896  PMID: 22792104
19.  Reactions to a targeted intervention to increase fecal occult blood testing among average-risk adults waiting for screening colonoscopy 
Increasing demand combined with limited capacity has resulted in long wait times for average-risk adults referred for screening colonoscopy for colorectal cancer. Management of patients on these growing wait lists is an emerging clinical issue.
To inform the content and design of a mailed targeted invitation for patients to undergo annual fecal occult blood testing (FOBT) while awaiting colonoscopy.
Focus groups (FGs) with average-risk patients on a wait list for screening colonoscopy at a high-throughput academic outpatient colonoscopy facility were conducted. During each FG session, feedback regarding a range of materials under consideration for the planned intervention was elicited using a semistructured facilitator guide. The FG sessions were recorded and transcribed verbatim, and analyzed using the constant comparative method to identify key themes.
Findings from the three FGs (n=28) suggested that average-risk patients on a wait list for screening colonoscopy would be receptive to a targeted intervention recommending they undergo FOBT while waiting. Participants indicated that the invitation to undergo FOBT was an important acknowledgement that they were on an actively managed list, and that a mechanism to ensure that they were correctly triaged while waiting was in place. Several specific suggestions to improve the design of the targeted intervention were obtained.
Results of the present study provide useful information for developing effective strategies to manage average-risk individuals facing long wait times for screening colonoscopy.
PMCID: PMC3115003  PMID: 21647457
Cancer screening; Colorectal cancer; Fecal occult blood tests; Focus groups
20.  A workshop report on HIV mHealth synergy and strategy meeting to review emerging evidence-based mHealth interventions and develop a framework for scale-up of these interventions 
mHealth is a term used to refer to mobile technologies such as personal digital assistants and mobile phones for healthcare. mHealth initiatives to support care and treatment of patients are emerging globally and this workshop brought together researchers, policy makers, information, communication and technology programmers, academics and civil society representatives for one and a half days synergy meeting in Kenya to review regional evidence based mHealth research for HIV care and treatment, review mHealth technologies for adherence and retention interventions in anti-retroviral therapy (ART) programs and develop a framework for scale up of evidence based mHealth interventions. The workshop was held in May 2011 in Nairobi, Kenya and was funded by the Canadian Global Health Research Initiatives (GHRI) and the US Centre for Disease Control and Prevention (CDC). At the end of the workshop participants came up with a framework to guide mHealth initiatives in the region and a plan to work together in scaling up evidence based mHealth interventions. The participants acknowledged the importance of the meeting in setting the pace for strengthening and coordinating mHealth initiatives and unanimously agreed to hold a follow up meeting after three months.
PMCID: PMC3240930  PMID: 22187619
mHealth; mobile phones; anti-retroviral therapy; adherence; retention
21.  A qualitative evaluation of strategies to increase colorectal cancer screening uptake 
Canadian Family Physician  2011;57(1):e7-e15.
To obtain data that could be used to optimize the content and design of the targeted, mailed invitations that Ontario’s provincewide colorectal cancer (CRC) screening program plans to use to increase screening uptake; to identify other strategies to increase CRC screening uptake; and to describe the effects of this qualitative work on a subsequent quantitative pilot study.
Qualitative study using semistructured focus groups.
Four different Ontario communities.
Six focus groups comprising a total of 62 participants.
Six focus groups were conducted in 4 different Ontario communities. For 3 of the communities, participants were recruited from the general population by a private marketing firm, using random-digit dialing, and received a small honorarium for participating. In Sault Ste Marie, participants were convenience samples recruited from a large primary care practice and were not offered compensation. Responses were elicited regarding various strategies for promoting CRC screening. Findings represent all responses observed as well as recommendations to program planners based on focus groups observations.
Main findings
Key themes identified included the importance of receiving a CRC screening invitation from one’s family physician; a desire for personalized, brief communications; and a preference for succinct information in mailed materials. Strong support was indicated for direct mailing of the CRC screening kit (fecal occult blood test). Our findings substantially influenced the final design and content of the envelope and letter to be mailed in the subsequent quantitative pilot study.
We report strong support from our focus groups for a succinct, personalized invitation for CRC screening from one’s own family physician. We have also shown that qualitative evaluation can be used to provide decision makers with pertinent and timely knowledge. Our study is highly relevant to other public health programs, particularly other Canadian jurisdictions planning organized CRC screening programs.
PMCID: PMC3024174  PMID: 21322288
22.  Physical activity and quality of life after radical prostatectomy 
There are significant post-surgical reductions in health-related quality of life (HRQOL) in prostate cancer (PCa) patients undergoing radical prostatectomy (RP). Physical activity (PA) interventions have improved treatment outcomes for PCa patients undergoing radiation and hormone therapy, but PA effects have not previously been examined in the RP setting. This study examined the relationship between preoperative PA levels and postoperative HRQOL outcomes in PCa patients treated with RP.
Sixty patients were interviewed regarding lifetime PA and completed preoperative (2 weeks prior to surgery) and postoperative (4 weeks after surgery) HRQOL questionnaires. Aerobic fitness testing was conducted on a subsample of 22 patients.
Higher levels of total past-year PA and occupational PA significantly correlated with lesser HRQOL declines from presurgery to 4 weeks post-surgery (Beta = −0.364, p = 0.037 and Beta = −0.243, p = 0.089, respectively) in models adjusted for age, postoperative questionnaire completion date, Gleason score and education. Past-year occupational PA was highly positively correlated with past-year total PA (r = 0.785, p < 0.001). Lifetime total PA was correlated with estimated VO2 max (r = 0.486, p = 0.026) in the 22 patients who were aerobically tested. Lifetime and past-year PA volumes were not correlated with waist circumference or body mass index.
Declines in HRQOL after RP may be reduced in patients with higher preoperative levels of self-reported PA. These findings require further study with larger samples to confirm results. If confirmed, findings suggest exercise preoperatively may improve HRQOL outcomes after RP.
PMCID: PMC2874592  PMID: 20514281
23.  Canadian survey on pandemic flu preparations 
BMC Public Health  2010;10:125.
The management of pandemic influenza creates public health challenges.
An ethical framework, 'Stand on Guard for Thee: ethical considerations in pandemic influenza preparedness' that served as a template for the World Health Organization's global consultation on pandemic planning, was transformed into a survey administered to a random sample of 500 Canadians to obtain opinions on key ethical issues in pandemic preparedness planning.
All framework authors and additional investigators created items that were pilot-tested with volunteers of both sexes and all socioeconomic strata. Surveys were telephone administered with random sampling achieved via random digit dialing (RDD). Eligible participants were adults, 18 years or older, with per province stratification equaling provincial percent of national population. Descriptive results were tabulated and logistic regression analyses were used to assess whether demographic factors were significantly associated with outcomes.
5464 calls identified 559 eligible participants of whom 88.5% completed surveys. Over 90% of subjects agreed the most important goal of pandemic influenza preparations was saving lives, with 41% endorsing saving lives solely in Canada and 50% endorsing saving lives globally as the highest priority. Older age (OR = 8.51, p < 0.05) and current employment (OR = 9.48, p < 0.05) were associated with an endorsement of saving lives globally as highest priority. About 90% of respondents supported the obligation of health care workers to report to work and face influenza pandemic risks excepting those with a serious health condition that increased risks. Over 84% supported the government's provision of disability insurance and death benefits for health care workers facing elevated risk. Strong majorities favored stocking adequate protective antiviral dosages for all Canadians (92%) and, if effective, influenza vaccinations (95%). Over 70% agreed Canada should provide international assistance to poorer countries for pandemic preparation, even if resources for Canadians were reduced. While 92% of this group, believed provision should be 7 to 10% of all resources generated, 43% believed the provision should be greater than 10%.
Results suggest trust in public health officials to make difficult decisions, providing emphasis on reciprocity and respect for individual rights.
PMCID: PMC2842233  PMID: 20219140
24.  The HAART cell phone adherence trial (WelTel Kenya1): a randomized controlled trial protocol 
Trials  2009;10:87.
The objectives are to compare the effectiveness of cell phone-supported SMS messaging to standard care on adherence, quality of life, retention, and mortality in a population receiving antiretroviral therapy (ART) in Nairobi, Kenya.
Methods and Design
A multi-site randomized controlled open-label trial. A central randomization centre provided opaque envelopes to allocate treatments. Patients initiating ART at three comprehensive care clinics in Kenya will be randomized to receive either a structured weekly SMS ('short message system' or text message) slogan (the intervention) or current standard of care support mechanisms alone (the control). Our hypothesis is that using a structured mobile phone protocol to keep in touch with patients will improve adherence to ART and other patient outcomes. Participants are evaluated at baseline, and then at six and twelve months after initiating ART. The care providers keep a weekly study log of all phone based communications with study participants.
Primary outcomes are self-reported adherence to ART and suppression of HIV viral load at twelve months scheduled follow-up. Secondary outcomes are improvements in health, quality of life, social and economic factors, and retention on ART. Primary analysis is by 'intention-to-treat'. Sensitivity analysis will be used to assess per-protocol effects. Analysis of covariates will be undertaken to determine factors that contribute or deter from expected and determined outcomes.
This study protocol tests whether a novel structured mobile phone intervention can positively contribute to ART management in a resource-limited setting.
Trial Registration
Trial Registration Number: NCT00830622
PMCID: PMC2760542  PMID: 19772596
25.  Fecal occult blood testing 
Canadian Family Physician  2009;55(2):176-177.e4.
To determine factors that influence awareness of, and readiness to undergo, fecal occult blood testing (FOBT) for colorectal cancer (CRC) screening.
Validated survey designed to ascertain respondents’ stages of decision making regarding CRC screening using FOBT.
A total of 1013 people 50 years old and older drawn from all regions of the province using a random-digit dialing telephone protocol.
Awareness of FOBT and readiness to undergo it for screening for CRC.
Response rate was 69%. Results indicated that 54% of women and 45% of men had “heard of” FOBT, and 26% of women and 17% of men had heard of it but were still “not considering” FOBT screening. Only 17% of all respondents had “decided to have” FOBT screening. Demographic factors associated with having heard of FOBT were female sex, completion of college or higher education, and being married or living as married. Demographic factors associated with active consideration of FOBT among those who reported awareness of it were male sex and being married or living as married.
Many people seemed uninformed about FOBT and not ready to undertake this type of screening. Results of this survey could help guide strategies and develop programs to make eligible people aware of CRC screening using FOBT and to motivate them to undergo testing.
PMCID: PMC2642507  PMID: 19221081

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