Nonbiological Causes Research Articles

Social Autopsy a Tool for Maternal and Perinatal Death Surveillance and Response (MPDSR) Reporting in Pakistan

Social autopsy is a relatively new technique to report non-biological causes of death along with biological causes, which accounts for 12/15 maternal deaths in Pakistan, through direct interaction with the community. Pakistan had a highest neonatal mortality in the entire world. A significant number of unreported cases contributed to the high prevalence of neonatal and maternal mortality. Pakistan is one of the top 10 nations that contribute to 60% of maternal and perinatal deaths worldwide which demands social autopsy adoption in Pakistan. Information acquired by social autopsy will therefore be useful in developing any efforts to stop or treat causes linked with death. Social autopsy is a way of health promotion as it encourages individual and communal behavioral change and contributes in achieving United Nations Sustainable Development Goal (SDG) 3.1 by reducing maternal and perinatal death mortality by 2030 and 2035 respectively. In discussion with the family of a woman and community, health workers examine the social reasons of death and pinpoint reforms that are required. In Bangladesh, Brazil, Tanzania, India and Nigeria, maternal and perinatal deaths have been lowered due to adoption of social autopsy. Pakistan has embraced verbal autopsy, but it is an ineffective technique which just deals with the medical cause of death. Maternal and perinatal deaths are not just because of medical causes, it is also the result of interactions between several social, cultural and economic factors. Government of Pakistan is just spending 0.8% of its GDP on health. Standard of primary maternity care is generally unsatisfactory. Only 25% basic health units have qualified staff. Government of Pakistan should create a provincial MPDSR committee, strengthen the health care network and pilot social autopsy in Pakistan to meet SGD goal 3.

Different patterns of excess all-cause mortality by age and sex in Hungary during the 2nd and 3rd waves of the COVID-19 pandemic.

It is well accepted that COVID-19-related mortality shows a strong age dependency. However, temporal changes in the age distribution of excess relative mortality between waves of the pandemic are less frequently investigated. We aimed to assess excess absolute mortality and the age-distribution of all-cause mortality during the second and third waves of the COVID-19 pandemic in Hungary compared to the same periods of non-pandemic years. Rate ratios for excess all-cause mortality with 95% confidence intervals and the number of excess deaths for the second (week 41 of 2020 through week 4 of 2021) and third waves (weeks 7–21 of 2021) of the COVID pandemic for the whole of Hungary compared to the same periods of the pre-pandemic years were estimated for 10-year age strata using Poisson regression. Altogether, 9771 (95% CI: 9554–9988) excess deaths were recorded during the second wave of the pandemic, while it was lower, 8143 (95% CI: 7953–8333) during the third wave. During the second wave, relative mortality peaked for ages 65–74 and 75–84 (RR 1.37, 95%CI 1.33–1.41, RR 1.38, 95%CI 1.34–1.42). Conversely, during the third wave, relative mortality peaked for ages 35–44 (RR 1.43, 95%CI 1.33–1.55), while those ≥65 had substantially lower relative risks compared to the second wave. The reduced relative mortality among the elderly during the third wave is likely a consequence of the rapidly increasing vaccination coverage of the elderly coinciding with the third wave. The hugely increased relative mortality of those 35–44 could point to non-biological causes, such as less stringent adherence to non-pharmaceutical measures in this population.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11357-022-00622-3.

Managing Gout in Women: Current Perspectives.

Gout is a common inflammatory arthritis that tends to affect significantly more men than women. However, female gout patients are more likely to have comorbidities such as hypertension, diabetes mellitus, and renal dysfunction. Furthermore, they experience a greater disease burden due to gout than males. While nonbiological causes may possibly contribute to this sex discrepancy in burden, this raises questions regarding whether current gout pharmacotherapies are as efficacious in females as they are in males. In this review, we examine how the clinical profile of female gout patients differs from male patients; we then survey the literature for data on outcomes for female gout patients treated with urate-lowering therapies for chronic management of gout as well as commonly used agents for acute flares. We also discuss considerations for managing gout in women during pregnancy and lactation.

Sociocultural determinants and patterns of healthcare utilization for epilepsy care in Uganda

ObjectiveEpilepsy is a global public health concern, with the majority of cases occurring in lower- and middle-income countries where the treatment gap remains formidable. In this study, we simultaneously explore how beliefs about epilepsy causation, perceived barriers to care, seizure disorder characteristics, and demographics influence the initial choice of healthcare for epilepsy and its impact on attaining biomedical care (BMC). MethodsThis study utilized the baseline sample (n = 626) from a prospective cohort study of people with epilepsy (PWE) attending three public hospitals in Uganda (Mulago National Referral Hospital, Butabika National Referral Mental Hospital, and Mbarara Regional Referral Hospital) for epilepsy care. Patient and household demographics, clinical seizure disorder characteristics, and sociocultural questionnaires were administered. Logistic regression and principal component analyses (PCA) were conducted to examine associations with the choice of primary seizure treatment. ResultsThe sample was 49% female, and 24% lived in rural settings. A biomedical health facility was the first point of care for 355 (56.7%) participants, while 229 (36.6%) first sought care from a traditional healer and 42 (6.7%) from a pastoral healer. Preliminary inspection of candidate predictors using relaxed criteria for significance (p < 0.20) identified several factors potentially associated with a greater odds of seeking BMC first. Demographic predictors included older caredriver (decision-maker for the participant) age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: [0.99, 1.02], p-value: 0.09), greater caredriver education level (OR = 1.21, 95% CI: [1.07, 1.37], p-value = 0.003), and lower ratio of sick to healthy family members (OR = 0.77 [0.56, 1.05], P = 0.097). For clinical predictors, none of the proposed predictors associated significantly with seeking BMC first. Self-report causation predictors associated with a greater odds of seeking BMC first included higher belief in biological causes of epilepsy (OR = 1.31 [0.92, 1.88], P = 0.133) and lower belief in socio-spiritual causes of epilepsy (OR = 0.68 [0.56, 0.84], P < 0.001). In the multivariate model, only higher caredriver education (OR = 1.19 [1.04, 1.36], P = 0.009) and lower belief in socio-spiritual causes of epilepsy (OR = 0.69 [0.56, 0.86], P < 0.01) remained as predictors of seeking BMC first. Additionally, PCA revealed a pattern which included high income with low beliefs in nonbiological causes of epilepsy as being associated with seeking BMC first (OR = 1.32 [1.12, 1.55], p = 0.001). Despite reaching some form of care faster, individuals seeking care from traditional or pastoral healers experienced a significant delay to eventual BMC (P < 0.001), with an average delay of more than two years (traditional healer: 2.53 years [1.98, 3.24]; pastoral care: 2.18 [1.21, 3.91]). ConclusionsCoupled with low economic and educational status, belief in spiritual causation of epilepsy is a dominant determinant of opting for traditional or pastoral healing over BMC, regardless of concurrent belief in biological etiologies. There is a prolonged delay to eventual BMC for PWE who begin their treatment seeking with nonallopathic providers, and although nonallopathic healers provide PWE with benefits not provided by BMC, this notable delay likely prevents earlier administration of evidence-based care with known efficacy. Based on these findings, initiatives to increase public awareness of neurobiological causes of epilepsy and effectiveness of biomedical drug treatments may be effective in preventing delays to care, as would programs designed to facilitate cooperation and referral among traditional, faith-based, and biomedical providers.This article is part of the Special Issue “The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda”

A Modeling Approach for Investigating Opto-Mechanical Relationships in the Human Eye Lens.

The human visual system alters its focus by a shape change of the eye lens. The extent to which the lens can adjust ocular refractive power is dependent to a significant extent on its material properties. Yet, this fundamental link between the optics and mechanics of the lens has been relatively under-investigated. This study aims to investigate this opto-mechanical link within the eye lens to gain insight into the processes of shape alteration and their respective decline with age. Finite Element models based on biological lenses were developed for five ages: 16, 35, 40, 57, and 62 years by correlating in vivo measurements of the longitudinal modulus using Brillouin scattering with in vitro X-ray interferometric measurements of refractive index and taking into account various directions of zonular force. A model with radial cortical Young's moduli provides the same amount of refractive power with less change in thickness than a model with uniform cortical Young's modulus with a uniform stress distribution and no discontinuities along the cortico-nuclear boundary. The direction of zonular angles can significantly influence curvature change regardless of the modulus distribution. The present paper proposes a modelling approach for the human lens, coupling optical and mechanical properties, which shows the effect of parameter choice on model response. This advanced modelling approach, considering the important interplay between optical and mechanical properties, has potential for use in design of accommodating implant lenses and for investigating non-biological causes of pathological processes in the lens (e.g., cataract).

Tissue preservation can affect geometric morphometric analyses: a case study using fish body shape

Abstract In geometric morphometrics, the extent of variation attributable to non-biological causes (i.e. measurement error) is sometimes overlooked. The effects of this variation on downstream statistical analyses are also largely unknown. In particular, it is unclear whether specimen preservation induces substantial variation in shape and whether such variation affects downstream statistical inference. Using a combination of empirical fish body shape data and realistic simulations, we show that preservation introduces substantial artefactual variation and significant non-random error (i.e. bias). Most changes in shape occur when fresh fish are frozen and thawed, whereas a smaller change in shape is observed when frozen and thawed fish are fixed in formalin and transferred to ethanol. Surprisingly, we also show that, in our case, preservation produces only minor effects on three downstream analyses of shape variation: classification using canonical variate analysis, permutation tests of differences in means and computations of differences in mean shape between groups. Even mixing of differently preserved specimens has a relatively small effect on downstream analyses. However, we suggest that mixing fish with different preservation should still be avoided and discuss the conditions in which this practice might be justified.

Modeling Human Mortality from All Diseases in the Five Most Populated Countries of the European Union.

Age affects mortality from diseases differently than it affects mortality from external causes, such as accidents. Exclusion of the latter leads to the "all-diseases" category. The age trajectories of mortality from all diseases are studied in the five most populated countries of the EU, and the shape of these 156 age trajectories is investigated in detail. The arithmetic mean of ages where mortality reaches a minimal value is 8.47years with a 95% confidence interval of [8.08, 8.85]years. Two simple deterministic models fit the age trajectories on the two sides of the mortality minimum. The inverse relationship is valid in all cases prior to this mortality minimum and death rates exactly decreased to three thousandths of its original size during the first 3000days. After the mortality minimum, the standard Gompertz model fits the data in 63 cases, and the Gompertz model extended by a small quadratic element fits the remaining 93 cases. This analysis indicates that the exponential increase begins before the age of 15years and that it is overshadowed by non-biological causes. Therefore, the existence of a mechanism switching that would explain the exponential increase in mortality after the age of 35years is unlikely.

Onset of mortality increase with age and age trajectories of mortality from all diseases in the four Nordic countries.

BackgroundThe answer to the question “At what age does aging begin?” is tightly related to the question “Where is the onset of mortality increase with age?” Age affects mortality rates from all diseases differently than it affects mortality rates from nonbiological causes. Mortality increase with age in adult populations has been modeled by many authors, and little attention has been given to mortality decrease with age after birth.Materials and methodsNonbiological causes are excluded, and the category “all diseases” is studied. It is analyzed in Denmark, Finland, Norway, and Sweden during the period 1994–2011, and all possible models are screened. Age trajectories of mortality are analyzed separately: before the age category where mortality reaches its minimal value and after the age category.ResultsResulting age trajectories from all diseases showed a strong minimum, which was hidden in total mortality. The inverse proportion between mortality and age fitted in 54 of 58 cases before mortality minimum. The Gompertz model with two parameters fitted as mortality increased with age in 17 of 58 cases after mortality minimum, and the Gompertz model with a small positive quadratic term fitted data in the remaining 41 cases. The mean age where mortality reached minimal value was 8 (95% confidence interval 7.05–8.95) years. The figures depict an age where the human population has a minimal risk of death from biological causes.ConclusionInverse proportion and the Gompertz model fitted data on both sides of the mortality minimum, and three parameters determined the shape of the age–mortality trajectory. Life expectancy should be determined by the two standard Gompertz parameters and also by the single parameter in the model c/x. All-disease mortality represents an alternative tool to study the impact of age. All results are based on published data.

An Integrated Approach for RNA-seq Data Normalization.

BACKGROUNDDNA copy number alteration is common in many cancers. Studies have shown that insertion or deletion of DNA sequences can directly alter gene expression, and significant correlation exists between DNA copy number and gene expression. Data normalization is a critical step in the analysis of gene expression generated by RNA-seq technology. Successful normalization reduces/removes unwanted nonbiological variations in the data, while keeping meaningful information intact. However, as far as we know, no attempt has been made to adjust for the variation due to DNA copy number changes in RNA-seq data normalization.RESULTSIn this article, we propose an integrated approach for RNA-seq data normalization. Comparisons show that the proposed normalization can improve power for downstream differentially expressed gene detection and generate more biologically meaningful results in gene profiling. In addition, our findings show that due to the effects of copy number changes, some housekeeping genes are not always suitable internal controls for studying gene expression.CONCLUSIONSUsing information from DNA copy number, integrated approach is successful in reducing noises due to both biological and nonbiological causes in RNA-seq data, thus increasing the accuracy of gene profiling.

Crop losses due to diseases and their implications for global food production losses and food security

The status of global food security, i.e., the balance between the growing food demand of the world population and global agricultural output, combined with discrepancies between supply and demand at the regional, national, and local scales (Smil 2000; UN Department of Economic and Social Affairs 2011; Ingram 2011), is alarming. This imbalance is not new (Dyson 1999) but has dramatically worsened during the recent decades, culminating recently in the 2008 food crisis. It is important to note that in mid-2011, food prices were back to their heights of the middle of the 2008 crisis (FAO 2011). Plant protection in general and the protection of crops against plant diseases in particular, have an obvious role to play in meeting the growing demand for food quality and quantity (Strange and Scott 2005). Roughly, direct yield losses caused by pathogens, animals, and weeds, are altogether responsible for losses ranging between 20 and 40 % of global agricultural productivity (Teng and Krupa 1980; Teng 1987; Oerke et al. 1994; Oerke 2006). Crop losses due to pests and pathogens are direct, as well as indirect; they have a number of facets, some with short-, and others with long-term consequences (Zadoks 1967). The phrase “losses between 20 and 40 %” therefore inadequately reflects the true costs of crop losses to consumers, public health, societies, environments, economic fabrics and farmers. The components of food security include food availability (production, import, reserves), physical and economic access to food, and food utilisation (e.g., nutritive value, safety), as has been recently reviewed by Ingram (2011). Although crop losses caused by plant disease directly affect the first of these components, they also affect others (e.g., the food utilisation component) directly or indirectly through the fabrics of trade, policies and societies (Zadoks 2008). Most of the agricultural research conducted in the 20th century focused on increasing crop productivity as the world population and its food needs grew (Evans 1998; Smil 2000; Nellemann et al. 2009). Plant protection then primarily focused on protecting crops from yield losses due to biological and non-biological causes. The problem remains as challenging today as in the 20th century, with additional complexity generated by the reduced room for manoeuvre available environmentally, economically, and socially (FAO 2011; Brown 2011). This results from shrinking natural resources that are available to agriculture: these include water, agricultural land, arable soil, biodiversity, the availability of non-renewable energy, human labour, fertilizers (Smil 2000), and the deployment of some key inputs, such as high quality seeds and planting material (Evans 1998). In addition to yield losses caused by diseases, these new elements of complexity also include post harvest quality losses and the possible accumulation of toxins during and after the S. Savary (*) : J.-N. Aubertot INRA, UMR1248 AGIR, 24 Chemin de Borde Rouge, Auzeville, CS52627, 31326 Castanet-Tolosan Cedex, France e-mail: Serge.Savary@toulouse.inra.fr

Combining Biomedical Accounts of Mental Disorders With Treatability Information to Reduce Mental Illness Stigma

Biomedical accounts of mental disorders are increasingly prevalent but can yield pessimism about prognosis and fail to reduce stigma. The authors tested whether information emphasizing the treatability of mental disorders could reduce stigma by contradicting the prognostic pessimism associated with biological attributions. A total of 249 participants recruited online read vignettes about two individuals--one with schizophrenia and one with borderline personality disorder. The vignettes attributed the disorders to biological or nonbiological causes and did or did not include information about treatment. Participants' attitudes toward the individual were assessed with social distance scales. Participants who received information about treatment had more positive attitudes toward the individual described in the vignette if the disorder was attributed to a biological cause, but treatment information had no such effect if the disorder was attributed to a nonbiological cause. Combining biomedical accounts of psychopathology with information about treatment appears to be an effective destigmatization approach.

Short-term natural δ&amp;lt;sup&amp;gt;13&amp;lt;/sup&amp;gt;C and δ&amp;lt;sup&amp;gt;18&amp;lt;/sup&amp;gt;O variations in pools and fluxes in a beech forest: the transfer of isotopic signal from recent photosynthates to soil respired CO&amp;lt;sub&amp;gt;2&amp;lt;/sub&amp;gt;

Abstract. The fate of photosynthetic products within the plant-soil continuum determines how long the reduced carbon resides within the ecosystem and when it returns back to the atmosphere in the form of respiratory CO2. We have tested the possibility of measuring natural variation in δ13C and δ18O to disentangle the potential times needed to transfer carbohydrates produced by photosynthesis down to trunk, roots and, in general, to belowground up to its further release in the form of soil respiration into the atmosphere in a beech (Fagus sylvatica) forest. We have measured the variation in stable carbon and oxygen isotope compositions in plant material and in soil respired CO2 every three hours for three consecutive days. Possible steps and different signs of post-photosynthetic fractionation during carbon translocation were also identified. A 12 h-periodicity was observed for variation in δ13C in soluble sugars in the top crown leaves and it can be explained by starch day/night dynamics in synthesis and breakdown and by stomatal limitations under elevated vapour pressure deficits. Photosynthetic products were transported down the trunk and mixed with older carbon pools, therefore causing the dampening of the δ13C signal variation. The strongest periodicity of 24 h was found in δ13C in soil respiration indicating changes in root contribution to the total CO2 efflux. Other non-biological causes like diffusion fractionation and advection induced by gas withdrawn from the measurement chamber complicate data interpretation on this step of C transfer path. Nevertheless, it was possible to identify the speed of carbohydrates' translocation from the point of assimilation to the trunk breast height because leaf-imprinted enrichment of δ18O in soluble sugars was less modified along the downward transport and was well related to environmental parameters potentially linked to stomatal conductance. The speed of carbohydrates translocation from the site of assimilation to the trunk at breast height was estimated to be in the range of 0.3–0.4 m h−1.

“Mama just won’t accept this”: Adult Perspectives on Engaging Depressed African American Teens in Clinical Research and Treatment

This manuscript focuses on qualitative data collected for AAKOMA Project, a 2-phase treatment engagement intervention trial for depressed African American adolescents and families. Data are presented from our phase I study of adult perspectives on African American adolescent depression, depression treatment, and research engagement. The research team conducted four focus groups (N=24) and generated major themes from the data including ideas regarding the manifestations of depression in African American youth and psychosocial barriers to participation in depression research and treatment. Findings indicate that success in recruiting and retaining African American youth in depression research and treatment may include using innovative means to overcome the culturally embedded attributions of depression to non-biological causes, beliefs about the cultural insensitivity of treatments and challenges in the logistics of obtaining care. Adults report that encouraging youth and familial involvement in treatments and research should include targeted, community-partnered activities involving diverse staff in leadership roles and including community members as equal partners.

Changing Perceptions of Depression: Ten-Year Trends From the General Social Survey

Changing Perceptions of Depression: Ten-Year Trends From the General Social Survey

Public Conceptions of Serious Mental Illness and Substance Abuse, Their Causes and Treatments: Findings from the 1996 General Social Survey

We examined the degree to which lay beliefs about the causes of disorders may predict beliefs about what constitutes appropriate treatment. We analyzed randomized vignette data from the MacArthur Mental Health Module of the 1996 General Social Survey (n=1010). Beliefs in biological causes (i.e., chemical imbalance, genes) were significantly associated with the endorsement of professional, biologically focused treatments (e.g., prescription medication, psychiatrists, and mental hospital admissions). Belief that the way a person was raised was the cause of a condition was the only nonbiologically based causal belief associated with any treatment recommendations (talking to a clergy member). Lay beliefs about the biological versus nonbiological causes of mental and substance abuse disorders are related to beliefs regarding appropriate treatment. We suggest areas for further research with regard to better understanding this relationship in an effort to construct effective messages promoting treatment for mental health and substance abuse disorders.

Public Conceptions of Serious Mental Illness and Substance Abuse, Their Causes and Treatments: Findings from the 1996 General Social Survey

We examined the degree to which lay beliefs about the causes of disorders may predict beliefs about what constitutes appropriate treatment. We analyzed randomized vignette data from the MacArthur Mental Health Module of the 1996 General Social Survey (n=1010). Beliefs in biological causes (i.e., chemical imbalance, genes) were significantly associated with the endorsement of professional, biologically focused treatments (e.g., prescription medication, psychiatrists, and mental hospital admissions). Belief that the way a person was raised was the cause of a condition was the only nonbiologically based causal belief associated with any treatment recommendations (talking to a clergy member). Lay beliefs about the biological versus nonbiological causes of mental and substance abuse disorders are related to beliefs regarding appropriate treatment. We suggest areas for further research with regard to better understanding this relationship in an effort to construct effective messages promoting treatment for mental health and substance abuse disorders.

Why Am I Depressed?

We investigated whether patients' beliefs about the causes of their depression concurred with their diagnostic subtype. Depressed patients (N = 196) attending a tertiary referral clinic completed a questionnaire regarding putative biological and nonbiological causes of their depression. Subtyping diagnoses of melancholic or nonmelancholic depression were made. Patients with nonmelancholic depression were more likely to attribute nonbiological factors as the cause of their depression than those with melancholic depression, whereas patients with melancholic depression were no more likely to attribute biological factors as the cause of their depression. Patients can distinguish differing causes of depression. The implications of the findings for the current classificatory systems of depression are discussed.

Tick-borne encephalitis in the Baltic States: Identifying risk factors in space and time

This paper presents preliminary results in our investigations of the biological (abiotic and biotic) and non-biological causes of the spatial heterogeneity and temporal change of tick-borne encephalitis (TBE), both within and between Estonia, Latvia, and Lithuania. Spatial analysis revealed that the land cover and precise seasonal patterns of climatic indices (temperature and normalized difference vegetation index) can explain 55% of the observed spatial variation in TBE incidence over the period 1993–98 across all the Baltic States. Temporal analysis of climatic variables indicates a very specific change in spring temperature conditions from 1993 onwards that could enhance the transmission of TBE virus. Further time series analysis of climate, together with analysis of biotic factors, socio-economic conditions, and human behaviour is being undertaken to explain the epidemiological patterns more fully.

Flesh quality - the role of nutrition

Product quality includes a variety of aspects (Fig. 1), with both biological and nonbiological causes and parameters. Fish nutrition has an important impact on several parameters directly influencing the quality of the fish, such as colour and appearance, smell and taste, texture, nutritional quality, shelf life, and level of contaminants. Further, consumers (market) are becoming more concerned about how the fish are produced, which type of feed ingredients are used and other issues. Authorities in different countries have an increased focus on food safety and traceability of the production from egg to plate (for fish farming). The need for improved knowledge of fish nutrition is therefore of great importance. The present paper presents an overview of the role of fish nutrition on flesh quality. Figure 1. Schematic overview of parameters important for flesh quality. Download figure to PowerPoint

Institutional and Attitudinal Factors Involved in Higher Mortality of Israeli Women after Coronary Bypass Surgery: Another Case of Gender Bias

Despite their lower cardiovascular risks, women have higher case-fatality ratios after myocardial infarction (MI) and cardiac surgery. Along with women’s older age and co-morbidity, this reflects gender bias in the timely diagnosis and treatment of heart disease in many western countries. Drawing on the theoretical framework offered by McKinlay (1996), current study examined attitudes and practices contributing to late diagnosis and substandard treatment of cardiac symptoms in women. Personal interviews were conducted with 30 women and 25 men sampled via the data set of the national survey of coronary bypass operations in Israel in 1994. In this survey, women’s post-operative mortality has been found to be double that of men, also after adjustment for age and socio-economic factors. Interviews with the survivors helped elucidate some non-biological causes for female mortality disadvantage. Women’s accounts confirmed that primary practitioners often denied cardiac nature of symptoms presented by women and delayed their referral for in-depth testing and intensive treatment, while no such delays occurred with men presenting with similar complaints. Gender bias was stronger during the initial diagnostic process and gradually abated after women were labeled as ‘cardiac cases’ and referred for intensive treatment. At all stages of their ‘cardiac career,’ women received less support from their family members than did men. However, women’s own beliefs about their low cardiac risks and the primacy of family roles over health concerns may have also contributed to later diagnosis and poorer prognosis in women.