Validation of an instrument for assessing the medicolegal death investigation system: A public health approach

Background. This study validated the content of an instrument designed to assess the performance of the medicolegal death investigation system. The instrument was modified from Version 2.0 of the Local Public Health System Performance Assessment Instrument (CDC) and is based on the 10 Essential Public Health Services. ^ Aims. The aims were to employ a cognitive testing process to interview a randomized sample of medicolegal death investigation office leaders, qualitatively describe the results, and revise the instrument accordingly. ^ Methods. A cognitive testing process was used to validate the survey instrument's content in terms of the how well participants could respond to and interpret the questions. Twelve randomly selected medicolegal death investigation chiefs (or equivalent) that represented the seven types of medicolegal death investigation systems and six different state mandates were interviewed by telephone. The respondents also were representative of the educational diversity within medicolegal death investigation leadership. Based on respondent comments, themes were identified that permitted improvement of the instrument toward collecting valid and reliable information when ultimately used in a field survey format. ^ Results. Responses were coded and classified, which permitted the identification of themes related to Comprehension/Interpretation, Retrieval, Estimate/Judgment, and Response. The majority of respondent comments related to Comprehension/Interpretation of the questions. Respondents identified 67 questions and 6 section explanations that merited rephrasing, adding, or deleting examples or words. In addition, five questions were added based on respondent comments. ^ Conclusion. The content of the instrument was validated by cognitive testing method design. The respondents agreed that the instrument would be a useful and relevant tool for assessing system performance. ^

Barriers to adolescent and young men's access of reproductive health care

Purpose. The purpose of this study was to identify the health needs and barriers that young men face in accessing health care and family planning services and to identify what health centers can do to attract young men to the clinic. A focus group format was used to elicit ideas from participants. ^ Methods. Forty-eight young men participated in nine focus groups. The young men were asked about the health issues they have, the barriers they face in accessing reproductive health care, and what clinics can do to attract young men to the clinic. Thematic analysis principles were used to identify the main themes that emerged in the focus groups. ^ Results. Sexually transmitted infections (STIs), mental health problems, and drug use were the major health issues that were mentioned in the majority of the focus groups. The main barriers discussed in the focus groups were attitudinal factors such as young men thinking it is unmanly to seek help, emotional factors such as young men not seeking help because of their ego or pride, and institutional factors such as the location of the clinic. The main suggestions for improvements in the health clinic included decreasing waiting times, emphasizing the fact that the clinics are free for males, having more female nurses, and encouraging clinic staff to treat the young men with respect. Young men suggested advertising and promoting the clinic in schools, in the community, and through the media. Focus group participants also provided their input about the design and format of the clinic flyer. ^ Conclusions. Many studies focus on the reproductive health care needs of adolescent and young females. This study has helped to show that young men also have health care needs and face barriers to accessing reproductive health care services.^

Demographic and social factors which influence periodontal disease using the National Health and Nutritional Examination Survey (NHANES)

Periodontal diseases include the various forms of gingivitis and periodontitis. Scientific literature submits 80% of the population suffers from some form of periodontal disease. The comparison of studies measuring periodontal disease is difficult because researchers use various parameters and indexes to define disease severity. The purposes of this paper were to examine the associations of gingival bleeding and 3 or more millimeters periodontal attachment loss, and age, sex, income, race/ethnicity, current tobacco use, dental visits, health insurance, stroke, heart attack, and diabetes using the periodontal examination population from the National Health and Nutritional Examination Survey (NHANES) 1999-2004. ^ When all risk factors were analyzed in the model as a whole sex, race/ethnicity, poverty, and education were statistically significant for bleeding on probing. When all risk factors were analyzed in the model as a whole sex, age, and education were statistically significant for loss of attachment. ^

A path analysis of an after-school health and exercise program for elementary school children in El Paso, Texas

As schools are pressured to perform on academics and standardized examinations, schools are reluctant to dedicate increased time to physical activity. After-school exercise and health programs may provide an opportunity to engage in more physical activity without taking time away from coursework during the day. The current study is a secondary data analysis of data from a randomized trial of a 10-week after-school program (six schools, n = 903) that implemented an exercise component based on the CATCH physical activity component and health modules based on the culturally-tailored Bienestar health education program. Outcome variables included BMI and aerobic capacity, health knowledge and healthy food intentions as assessed through path analysis techniques. Both the baseline model (χ2 (df = 8) = 16.90, p = .031; RMSEA = .035 (90% CI of .010–.058), NNFI = 0.983 and the CFI = 0.995) and the model incorporating intervention participation proved to be a good fit to the data (χ2 (df = 10) = 11.59, p = .314. RMSEA = .013 (90% CI of .010–.039); NNFI = 0.996 and CFI = 0.999). Experimental group participation was not predictive of changes in health knowledge, intentions to eat healthy foods or changes in Body Mass Index, but it was associated with increased aerobic capacity, β = .067, p < .05. School characteristics including SES and Language proficiency proved to be significantly associated with changes in knowledge and physical indicators. Further effects of school level variables on intervention outcomes are recommended so that tailored interventions can be developed aimed at the specific characteristics of each participating school. ^

The assessment of standardized training programs in public health preparedness

The Texas Bioterrorism Continuing Education Consortium (BCE) provided National Disaster Life Support (NDLS) training courses throughout the state of Texas in 2005, to help improve knowledge and skills pertaining to bioterrorism and other public health emergencies. The NDLS training courses include curriculum in Basic Disaster Life Support (BDLS) and Core Disaster Life Support (CDLS). A course evaluation which included items assessing ability and willingness of training participants, role of responders, and other variables was mailed to all NDLS participants who provided contact information. An analysis was conducted to determine whether the survey respondents participated in the Hurricanes Katrina and/or Rita relief efforts, as well as to evaluate the impact of the NDLS training courses on the participant's ability and willingness to respond during a disaster. The study population (n = 2150) consisted mostly of nurses (50%) (n=1074). A chi-square test of analysis indicated the following results. Among the survey respondents who took the CDLS course, there was no statically significant difference by occupation pertaining to ability or willingness to respond (x2 [df = 5] = 4.02, p= 0.546); (x2 [df = 5] = 2.45, p = .783). However, there was a statistically significant difference among those respondents who took the BDLS course with respect to ability, and a slightly significant difference with respect to willingness (x2 [df = 5] = 13.35, p = .020 and (x2 = [df = 5] = 10.299, p = .067). These findings are similar to previous studies assessing willingness to respond to a disaster.^ A second analysis was conducted with these survey data to evaluate the implications for disaster response training for the NDLS courses. Results indicated that the majority of disaster responders served in the role for which they were professionally trained (Physicians=68%; Nurses = 50.4%). Nurses, EMT, and Fire professionals served in multiple roles. These results suggest the importance of developing training programs that will prepare professionals to serve in multiple roles. The development of standardized evaluation methods would fill an important gap in assessing impact of national training programs. ^

Evaluating the U.S. Global Health Policy Initiative

In understanding that the efforts made in improving global health affects the health of U.S. citizens, a policy analysis of President Barak Obama's Global Health Initiative was conducted. Using materials gathered from experts in the field of health and their findings and recommendations, paired with the current policies of other G8 countries that pledged to support the efforts of improving global health, the analysis was conducted using four specifically defined criteria. The set criteria determine the appropriateness, responsiveness, effectiveness and equity of Obama's GHI in comparison to other G8 country health policies and overall global health priorities. G8 countries without a specific global health policy, or with a policy that was not in English were excluded from this study and Switzerland, headquarters of the World Health Organization, was added due to its membership in the OECD, and the fact that it has a specific foreign health policy. In evaluating the U.S. Global Health Initiative it is clear that in terms of implementing foreign policy specific to health, the United States is on the forefront alongside the United Kingdom and Switzerland. Other G8 Countries have pledged monies and in order to Millennium Development Health Goals by 2015. The U.S. Global Health Policy does not address issues necessary to meet Millennium Development Goals in Health. Instead the Global Health Initiative is focused narrowly on Fighting and rolling back the HIV/Aids Epidemic based on President Bush's PEPFAR policy. Policy recommendations for a more effective and efficient Global Health Initiative include building upon the PEPFAR policy foundation in order to strengthen health systems worldwide, allowing individuals and communities to combat unnecessary death and disease through research, education, and other preventative methods.^

Texas Health & Safety Code, Section 165.002 - Right to Breastfeed in Texas

The language used in Section 165.002 of the Texas Health and Safety Code renders breastfeeding women vulnerable and susceptible to harassment, discrimination, and persecution via the Texas Penal Code, Sec. 30.05 (Criminal Trespassing), Sec. 21.08 (Indecent Exposure), and Sec. 21.22 (Indecency with a Child). ^ The overall goal of this paper is to develop a solution to this problem via a proposed law or legislative action that offers protection and support for breastfeeding women who choose to nurse in public. Data to inform these recommendations were collected through a literature review and structured interviews with several breastfeeding stakeholders. A literature review of state and federal breastfeeding legislation was conducted to compare and contrast differences between existing legislation in the United States. Interviews were conducted with breastfeeding legislation stakeholders, which included state legislators who have been active in breastfeeding legislation, breastfeeding mothers, and representatives from the Central Texas Healthy Mothers Healthy Babies Coalition (Centex HMHB Coalition), Texas Breastfeeding Coalition (TXBF coalition), La Leche League International, and the Texas Business Association. Data from the literature and legislation reviews and interviews were transcribed and examined for common themes using qualitative data techniques. ^ Overall, most of the stakeholders came to a general consensus on three points, (1) breastfeeding women are supported by stakeholders within the community, (2) other legislation or penal codes should not override the right to breastfeed, and (3) the current breastfeeding legislation needs to be improved to adequately support breastfeeding women. The interviews with breastfeeding legislation stakeholders yielded two major recommendations for the improvement of Section 165.002 of the Texas Health and Safety Code: advocacy efforts to change the wording of the legislation and education to inform people about the legislation. ^ The right to breastfeed is an important public health issue in that it provides a host of health benefits for mothers and children, and is more economical and environmentally superior to alternative feeding methods. While breastfeeding in public is not illegal nor ever has been, adequate legislation is important to affirm this right for women so that they can confidently feed their children without embarrassment or harassment.^

Policy implications of public health workforce development for disaster preparedness in the United States

Public health efforts were initiated in the United States with legislative actions for enhancing food safety and ensuring pure drinking water. Some additional policy initiatives during the early 20th century helped organize and coordinate relief efforts for victims of natural disasters. By 1950's the federal government expanded its role for providing better health and safety to the communities, and its disaster relief activities became more structured. A rise in terrorism related incidents during the late 1990's prompted new proactive policy directions. The traditional policy and program efforts for rescue, recovery, and relief measures changed focus to include disaster preparedness and countermeasures against terrorism.^ The study took a holistic approach by analyzing all major disaster related policies and programs, in regard to their structure, process, and outcome. Study determined that United States has a strong disaster preparedness agenda and appropriate programs are in place with adequate policy support, and the country is prepared to meet all possible security challenges that may arise in the future. The man-made disaster of September 11th gave a major thrust to improve security and enhance preparedness of the country. These new efforts required large additional funding from the federal government. Most existing preparedness programs at the local and national levels are run with federal funds which is insufficient in some cases. This discrepancy arises from the fact that federal funding for disaster preparedness programs at present are not allocated by the level of risks to individual states or according to the risks that can be assigned to critical infrastructures across the country. However, the increased role of the federal government in public health affairs of the states is unusual, and opposed to the spirit of our constitution where sovereignty is equally divided between the federal government and the states. There is also shortage of manpower in public health to engage in disaster preparedness activities, despite some remarkable progress following the September 11th disaster.^ Study found that there was a significant improvement in knowledge and limited number of studies showed improvement of skills, increase in confidence and improvement in message-mapping. Among healthcare and allied healthcare professionals, short-term training on disaster preparedness increased knowledge and improved personal protective equipment use with some limited improvement in confidence and skills. However, due to the heterogeneity of these studies, the results and interpretation of this systematic review may be interpreted with caution.^

Health disparities between the United States mainland and Puerto Rico, Guam, and the United States Virgin Islands (United States territories)

Health disparities have been documented for the United States mainland. No literature was found comparing the mainland population to that of Puerto Rico, Guam, and the United States Virgin Islands (United States territories). Using Healthy Lifestyle Characteristics of non-smoking, maintaining a healthy weight, consuming fruits/vegetables daily, and exercising regularly, the health of the mainland was compared to United States territories. The research questions were: (1) Among the characteristics, what are similarities/differences between citizens of the mainland United States and territories?, (2) Among the characteristics, what are similarities/differences in how the territories compare to each other?, (3) Does the mainland and the territories meet Healthy People 2010 goals for these characteristics?, (4) Are perceptions of health concordant or discordant with the characteristics for mainlanders and Puerto Ricans? ^ Using 2007 data from Behavioral Risk Factor Surveillance System (BRFSS), frequency distributions were compared for the Healthy Lifestyle Characteristics for the mainland territories. Research found smoking rates on Guam were statistically greater than the mainland, Puerto Rico or the Virgin Islands. Healthy body mass index levels and physical activity rates were better on Guam compared to other locations. Puerto Rico had significantly more overweight and obese persons, lower fruit/vegetable consumption rates, and lower physical activity rates than the mainland, Guam and the Virgin Islands. Research found mainlanders reported statistically greater participation in regular physical activity than did Puerto Ricans and Virgin Islanders; there were significant differences in fruit/vegetable consumption rates compared to both. The research found no locations met all four of Healthy People 2010 goals. Compared to mainlanders, research showed Puerto Ricans perceive their health significantly worse.^ A better understanding is needed for how United States citizens (mainlanders and territory residents) view participation in healthy behaviors and how health is affected by participating or not in healthy behaviors. For the year examined, Healthy People 2010 goals were not achieved. This study demonstrates Puerto Ricans’ health, using the four characteristics, is significantly worse than residents in the other locations. Public health programs targeting Puerto Ricans are warranted. Finally, this study highlights the need for continued research on the relationships among the mainland and territories.^

Parental acculturation and adolescent HPV uptake among Hispanics: Results from the California Health Interview Survey

Background. The Centers for Disease Control and Prevention (CDC), the American Cancer Society (ACS), and the American College of Obstetricians and Gynecologists (ACOG) all recommend the HPV vaccine for girls 11-12. The vaccine has the potential to reduce cervical cancer disparities if it is used by populations that do not participate in screening. Evidence suggests that incidence and mortality are higher among Hispanic women compared to non-Hispanic white women because they do not participate in screening. Past literature has found that acculturation has a mixed effect on cervical cancer screening and immunization. Little is known about whether parental acculturation is associated with adolescent HPV vaccine uptake among Hispanics and the mechanisms through which acculturation may affect vaccine uptake.^ Aims. To examine the association between parental acculturation and adolescent HPV uptake among Hispanics in California and test the structural hypothesis of acculturation by determining if socioeconomic status (SES) and health care access mediate the association between acculturation and HPV vaccine uptake.^ Methods. Cross-sectional data from the 2007 California Health Interview Survey (CHIS) were used for bivariate and multivariate logistic regression analyses. The sample used for analysis included 1,090 Hispanic parents, with a daughter age 11-17, who answered questions about the HPV vaccine. Outcome variable of interest was HPV vaccine uptake (≥1dose). Independent variables of interest were language spoken at home (a proxy variable for acculturation), household income (percent of federal poverty level), education level, and health care access (combined measure of health insurance coverage and usual source of care).^ Results. Parents who spoke only English or English and Spanish in the home were more likely to get the HPV vaccine for their daughter than parents who only spoke Spanish (Odds Ratio [OR]: 0.55, 95% Confidence Interval [CI]: 0.31-0.98). When SES and health care access variables were added to the logistic regression model, the association between language acculturation and HPV vaccine uptake became non-significant (OR: 0.68, 95% CI: 0.35-1.29). Both income and health care access were associated with uptake. Parents with lower income or who did not have insurance and a usual source of care were less likely to have a vaccinated daughter.^ Discussion. Socioeconomic status and health care access have a more proximal effect on HPV vaccine uptake than parental language acculturation among Hispanics in California.^ Conclusion. This study found support for the structural hypothesis of acculturation and suggest that interventions focus on informing low SES parents who lack access to health care about programs that provide free HPV vaccines.^

Sexual initiation of U.S. Latino and Colombian high school students: Toward a new theory of adolescent sexuality and implications for sexual health prevention and promotion

The general research question for this dissertation was: do the data on adolescent sexual experiences and sexual initiation support the explicit or implicit adolescent sexuality theories informing the sexual health interventions currently designed for youth? To respond to this inquiry, three different studies were conducted. The first study included a conceptual and historical analysis of the notion of adolescence introduced by Stanley Hall, the development of an alternative model based on a positive view of adolescent sexuality, and the rationale for introducing to adolescent sexual health prevention programs the new definitions of sexual health and the social determinants of health approach. The second one was a quantitative study aimed at surveying not only adolescents' risky sexual behaviors but also sexual experiences associated with desire/pleasure which have been systematically neglected when investigating the sexual and reproductive health of the youth. This study was conducted with a representative sample of the adolescents attending public high schools in the State of Caldas in the Republic of Colombia. The third study was a qualitative analysis of 22 interviews conducted with male and female U.S. Latino adolescents on the reasons for having had or having not had vaginal sex. The more relevant results were: most current adolescent sexual health prevention programs are still framed in a negative approach to adolescent sexuality developed a century ago by Stanley Hall and Sigmund Freud which do not accept the adolescent sexual experience and propose its sublimation. In contrast, the Colombian study indicates that, although there are gender differences, adolescence is for males and females a normal period of sexual initiation not limited to coital activity, in which sexual desire/pleasure is strongly associated with sexual behavior. By the same token, the study about the reasons for having had or not had initiated heterosexual intercourse indicated that curiosity, sexual desire/pleasure, and love are basic motivations for deciding to have vaginal sexual intercourse for the first time and that during adolescence, young women and men reach the cognitive development necessary for taking conscious decisions about their sexual acts. The findings underline the importance of asking pertinent questions about desire/pleasure when studying adolescent sexuality and adopting an evidence-based approach to sexual health interventions.^

Concordance between medical records and personal interview in ascertaining breast cancer and diabetes status: Analysis of the south Texas women's health project

Accurate ascertainment of risk factors and disease status is vital in public health research for proper classification of research subjects. The two most common ways of obtaining this data is by self-report and review of medical records (MRs). South Texas Women’s Health Project was a case-control study looking at interrelationships between hormones, diet, and body size and breast cancer among Hispanic women 30-79 years of age. History of breast cancer, diabetes mellitus (DM) and use of DM medications was ascertained from a personal interview. At the time of interview, the subject identified her major health care providers and signed the medical records release form, which was sent to the designated providers. The MRs were reviewed to confirm information obtained from the interview.^ Aim of this study was to determine the sensitivity and specificity between MRs and personal interview in diagnosis of breast cancer, DM and DM treatment. We also wanted to assess how successful our low-cost approach was in obtaining pertinent MRs and what factors influenced the quality of MR or interview data. Study sample was 721 women with both self-report and MR data available by June 2007. Overall response rate for MR requests was 74.5%. MRs were 80.9% sensitive and 100% specific in confirming breast cancer status. Prevalence of DM was 22.7% from the interviews and 16% from MRs. MRs did not provide definite information about DM status of 53.6% subjects. Sensitivity and specificity of MRs for DM status was 88.9% and 90.4% respectively. Disagreement on DM status from the two sources was seen in 15.9% subjects. This discordance was more common among older subjects, those who were married and were predominantly Spanish speaking. Income and level of education did not have a statistically significantly association with this disagreement.^ Both self-report and MRs underestimate the prevalence of DM. Relying solely on MRs leads to greater misclassification than relying on self-report data. MRs have good to excellent specificity and thus serve as a good tool to confirm information obtained from self-report. Self-report and MRs should be used in a complementary manner for accurate assessment of DM and breast cancer status.^

Identifying characteristics of mentally ill homeless individuals who are successfully linked to health and social services post-incarceration via the jail inreach project

Healthcare for the Homeless—Houston (HHH) received a research grant from The Medallion Foundation, Inc. in March 2006 to pilot The Jail Inreach Project, an intensive “inreach” initiative to assess the impact of providing continuity of mental and primary health care services for homeless individuals who suffer from mental illness and/or substance abuse being released from jail. This pilot project was initiated by HHH, in collaboration with the Harris County Sheriff’s Office and the Mental Health Mental Retardation Authority of Harris County (MHMRA). Those who are flagged as “frequent flyers” and who are diagnosed with a mental illness are referred to the Jail Inreach Project. In order to maximize the effectiveness of the discharge plan, case managers offer the option of meeting the client at the time of release and bring them to the HHH clinic located four blocks from the jail. Participation in both the program and the option for direct release to the care of a case manager are voluntary.^ The purpose of this study is to determine the outcomes of the Jail Inreach Project and addresses the following objectives: (1) to evaluate the characteristics of inmates that chose to be released from jail to the direct care of an HHH case manager versus those who opt for self release and (2) to determine the number and percent of inmates that are linked to services and relationship with type of release (direct versus indirect), (3) to determine if there is a relationship between outcomes and characteristics and (4) to determine what outcomes are a function of release, controlling for characteristics. Statistical analysis, including frequencies, cross tabulations, chi-square and logistical regression, found that those who opt for self release are six times less likely to be successfully linked to services and that gender is the most significant predictor of choosing self release. Men are far more likely to opt for self release than women engaged in this program. These findings help inform policy and program design and development that addresses the difference in service utilization and successful linkage to services post-incarceration. Successful linkage to services, thus continuity of and access to care, further impact the effects of the revolving door phenomenon of mentally ill homeless individuals cycling between the streets, jails and hospital emergency centers.^

Report on the practice based culminating experience as teaching assistant for "Pathology and Public Health" class taught at University of Texas School of Public Health, Houston

Objectives. The objectives of this report were to describe current best standards in online education, class competencies, class objectives, class activities and to compare the class competencies, objectives and activities undertaken with the current best practices in online teaching and to provide a list of recommendations based on the most efficacious practices. ^ Methods. Utilizing the key words- online teaching, national standards, quality, online courses, I: (1) conducted a search on Google to find the best standard for quality online courses; the search yielded National Standards for Quality Online Teaching as the gold standard in online course quality; (2) specified class objectives and competencies as well as major activities undertaken as a part of the class. Utilizing the Southern Regional Education Board evaluation checklist for online courses, I: (1) performed an analysis comparing the class activities, objectives, and competencies with the current best standards; (2) utilized the information obtained from the analysis and class experiences to develop recommendations for the most efficacious online teaching practices. ^ Results. The class met the criteria set by the Southern Regional Education Board for evaluating online classes completely in 75%, partially in 16% and did not meet the criteria in 9% cases. The majority of the parameters in which the class did not meet the standards (4 of 5) were due to technological reasons beyond the scope of the class instructor, teaching assistant and instructional design. ^ Discussion. Successful online teaching requires awareness of technology, good communication, methods, collaboration, reflection and flexibility. Creation of an online community, engaging online learners and utilizing different learning styles and assessment methods promote learning. My report proposes that online teaching should actively engage the students and teachers with multiple interactive strategies as evidenced from current best standards of online education and my “hands-on” work experience. ^ Conclusion. The report and the ideas presented are intended to create a foundation for efficacious practice on the online teaching platform. By following many of the efficacious online practices described in the report and adding from their own experiences, online instructors and teaching assistants can contribute to effective online learning. ^

Cancer perceptions: Implications from the 2007 Health Information National Trends Survey

Background. Research has demonstrated associations between sociodemographic characteristics and illness perceptions; however, the impact of cancer exposure through personal or family diagnoses is not well-studied. The purposes of this study were to examine the prevalence of different cancer beliefs and the disparity in cancer beliefs across groups of individuals with distinct cancer histories; and to identify whether, when adjusted for sociodemographic characteristics, cancer history predicts a set of cancer beliefs.^ Methods. Using Leventhal’s Common Sense Model and data from the 2007 Health Information National Trends Survey (N=7172), we constructed multivariable logistic regressions to evaluate the effect of different stimuli, including cancer experience, on cancer perceptions (e.g., risk, worry, causation, outcome).^ Results. Findings indicate significant associations between cancer history and cancer perceptions. Individuals with family and personal cancer histories were more likely than individuals without any cancer history to worry about getting cancer (OR=3.55, P<0.01), agree they will develop cancer in the future (OR=8.81, P<0.01), and disagree that cancer is most often caused by a person’s behavior or lifestyle (OR=1.24, P=0.03). Additionally, results support education’s role in forming cancer perceptions. Individuals with high levels of education were more likely to endorse cancer prevention (OR=1.68, P<0.01) and higher 5-year survival rates (OR=1.41, P<0.01). ^ Conclusions. Results indicate cancer history affects cancer perceptions throughout the cancer continuum. Additionally, cancer history may influence coping behaviors and outcomes related to cancer.^ Impact. Cancer education and survivorship programs should assess important variables (e.g., cancer history) to more effectively tailor services and monitor evolving needs throughout cancer care.^