Challenges, Strengths and Opportunities Related to Implementing Comprehensive Evidence-Based Guidelines on Breast Cancer Survivorship Care by Primary Care Physicians and Nurse Practitioners in Southeastern Ontario

Background Many breast cancer survivors continue to have a broad range of physical and psychosocial problems after breast cancer treatment. As cancer centres move forward with earlier discharge of stable breast cancer survivors to primary care follow-up it is important that comprehensive evidence-based breast cancer survivorship care is implemented to effectively address these needs. Research suggests primary care providers are willing to provide breast cancer survivorship care but many lack the knowledge and confidence to provide evidence-based care. Purpose The overall purpose of this thesis was to determine the challenges, strengths and opportunities related to implementing comprehensive evidence-based breast cancer survivorship guidelines by primary care physicians and nurse practitioners in southeastern Ontario. Methods This mixed-methods research was conducted in three phases: (1) synthesis and appraisal of clinical practice guidelines relevant to provision of breast cancer survivorship care within the primary care practice setting; (2) a brief quantitative survey of primary care providers to determine actual practices related to provision of evidence-based breast cancer survivorship care; and (3) individual interviews with primary care providers about the challenges, strengths and opportunities related to provision of comprehensive evidence-based breast cancer survivorship care. Results and Conclusions In the first phase, a comprehensive clinical practice framework was created to guide provision of breast cancer survivorship care and consisted of a one-page checklist outlining breast cancer survivorship issues relevant to primary care, a three-page summary of key recommendations, and a one-page list of guideline sources. The second phase identified several knowledge and practice gaps, and it was determined that guideline implementation rates were higher for recommendations related to prevention and surveillance aspects of survivorship care and lowest related to screening for and management of long-term effects. The third phase identified three major challenges to providing breast cancer survivorship care: inconsistent educational preparation, provider anxieties, and primary care burden; and three major strengths or opportunities to facilitate implementation of survivorship care guidelines: tools and technology, empowering survivors, and optimizing nursing roles. A better understanding of these challenges, strengths and opportunities will inform development of targeted knowledge translation interventions to provide support and education to primary care providers.

Teaching Empowerment Through Sport: An Analysis of Fast and Female

This project is about Fast and Female, a community-based girls’ sport organization, that focuses on empowering girls through sport. In this thesis I produce a discourse analysis from interviews with six expert sportswomen and a textual analysis of the organization’s online content – including its social media pages. I ground my analysis in poststructural theory as explained by Chris Weedon (1997) and in literature that helps contextualize and better define empowerment (Collins, 2000; Cruikshank, 1999; Hains, 2012; Sharma, 2008; Simon, 1994) and neoliberalism (Silk & Andrews, 2012). My analysis in this project suggests that Fast and Female develops a community through online and in-person interaction. This community is focused on girls’ sport and empowerment, but, as the organization is situated in a neoliberal context, organizers must take extra consideration in order for the organization to develop a girls’ sport culture that is truly representative of the desires and needs of the participants rather than implicit neoliberal values. It is important to note that Fast and Female does not identify as a feminist organization. Through this thesis I argue that Fast and Female teaches girls that sport is empowering – but, while the organization draws on “empowerment,” a term often used by feminists, it promotes a notion of empowerment that teaches female athletes how to exist within current mainstream and sporting cultures, rather than encouraging them to be empowered female citizens who learn to question and challenge social inequity. I conclude my thesis with suggestions for Fast and Female to encourage empowerment in spite of the current neoliberal situation. I also offer a goal-setting workbook that I developed to encourage girls to set goals while thinking about their communities rather than just themselves.