I have prepared an analytical report that can be used as a probable solution the dilemma of women diagnosed with cancer who are pregnant in Ontario. While researching this topic I have come to understand various benefits and positive impacts of having an intervention for this issue. I am sure the data that I have gathered and put together will help you comprehend why our organization, "Circle of Wings", is a needed clinical intervention for the future.
Cancer, an ever-growing disease within communities, is now targeting pregnant women. Cancer occurs in approximately one out of every 1,000 pregnancies. Due to the fact that this there is little research and information provided to the public of this dilemma, women are finding it more stressful and difficult to live with their situations. The need for a clinical intervention that specifies in this issue is growing.
Circle of Wings is dedicated to providing treatment, support and hope in various methods to women newly diagnosed with cancer who are pregnant. This intervention comprises of inter-professional members who work as a team to achieve the objectives and goals set by our executives. This clinic also consists of a volunteer support group which aims to provide support and hope to the women.
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We currently have an intervention program running in the heart of Toronto, Ontario. However, due to its immense accomplishment and needs by the communities (found from surveys and interviews), we have decided on creating two more interventions within this province. This clinical intervention is mandatory as it will provide guidance and hope to the women within our community.
ANALYTICAL REPORT FOR
WOMEN DIAGNOSED WITH CANCER
WHO ARE PREGNANT
March 9, 2010
Table of Contents
Cancer is an ever-growing disease in our society. Statistics show that an estimated 171,000 new cases of cancer and 75,300 deaths from cancer occurred in Canada in 2009 (Canadian Cancer Society. 2010). Unfortunately, some women had to and will face cancer while pregnant. Cancer occurs in approximately one out of every 1,000 pregnancies. The cancers that are most likely to occur during pregnancy are those that are most common in younger people, such as breast cancer, cervical cancer, malignant melanoma, Hodgkin lymphoma, and thyroid cancer (American Society of Clinical Oncology. 2009). Cancer during pregnancy is rare and little research is available to guide women and doctors. Anxiety and helplessness in women with cancer who are pregnant due to lack of research and support for this dilemma greatly increases. The solution to the lack of research and support to this crisis is none other than a clinical intervention called "Circle of Wings". The mission, 'Circle of Wings is targeted and dedicated to providing women diagnosed with cancer while pregnant with information, treatment, support, and hope', is greatly valued in this organization. As the name describes, this clinical intervention consists of an inter-professional (professionals and non-professionals) team designed to aid these women. This is a for-profit organization, which focuses on providing professional counseling and treatments like chemotherapy, magnetic resonance imaging test (MRI) and ultrasound. However, there are sectors within the intervention which consists of a support group created by the volunteers of this organization to provide free information and support for women diagnosed with cancer who are pregnant and simply want general guidance and hope.
1.1.1 STATEMENT OF NEED/OBJECTIVES
Certain criteria must be met before uncovering a clinical intervention. This new organization must serve more than one purpose and must be able to be applied to many different parts. In order for the intervention to be efficient and valuable, these guiding principles/objectives must be met:
Should be used to serve women in all socioeconomic, ethnic, and religious backgrounds nation-wide.
Should be used to provide accurate and complete services (treatments and counseling) and information to women trying to obtain options for dealing with cancer while pregnant.
Should not negatively affect the women's personal decisions.
Always on Time
Marked to Standard
The intended purpose of this project is to provide the Chief Executives of Health Canada an analytical overview of the advantages and resolutions of the pregnant with cancer crisis by constructing a nation-wide, community-based clinical intervention in Canada. As mentioned in the background information, constructing this intervention will in fact benefit women and their babies, who are our future generation. The following report mainly focuses on the staffing, projected costs, and schedule for completion.
1.2 RESEARCH AND DEVELOPMENT METHOD
1.2.1 PRELIMINARY RESEARCH
Most of the ideas, research and information which have provided the evidence supporting the need for Circle of Wings came from a series of interviews, statistics from journals, and surveys with hospital professionals, volunteers, and newly diagnosed cancer patients. According to a study done by Temple University for the issue of the Journal of Health Communication, newly diagnosed cancer patients (pregnant/not pregnant) who attend clinical interventions to gather information about their disease have a more positive outlook and are more active participants in their treatment (Harris. 2006). Currently, there is an internet based organization called Hope for Two dedicated to providing information and support to women diagnosed with cancer who are pregnant. According to a study done by this organization, the patients saw the Internet as a powerful tool that enhanced their decision-making ability (Hope for Two. 2010). Our intervention is not computer-based, but rather an in-person support intervention with many aspects such as treatment and counseling. However, we now have a vision and knowledge of an organization dedicated to this type of issue already in operation, to base and guide our own proposed plan. Some issues that were addressed and guided upon by Hope for Two included the different methods of providing support, the type of information to provide to aid the women, and how to communicate/get the message out in a comprehendible and universal way.
1.2.2 EARLY CONCEPT FOR REDESIGN OF THE CLINICAL INTERVENTION
The redesign was to plan and create a clinical intervention that is accessible to the citizens of Ontario. Three clinics in each province will be constructed to provide a wider range of accessibility. We have been allocated initial funds from the government to start up this clinical intervention. The Ministry of Health Canada has provided us with sufficient funds to construct a small clinic within each province. Different professionals (and non-professionals) from different areas commit their time to attend this clinic. Please see Section 2.0 for more details. Each of these professionals are also paid by the government privately. We have started off with only one intervention for each province an year before. Seeing the great amount of success and need, we have decided to sustain and advance our organization. As a result, the redesigning task was viewed as one large problem to be solved as a team. By working as a team, the key design flaws and problems were attacked methodically because all the team members were able to provide input into the redesign of the clinical intervention.
Interviews were conducted for the purpose of recruitment for core sectors which include mathematical analysis, cost analysis, and engineering design.
2.1.1 ADMINISTRATION, CEO
Alex Stapleton, age 50, MBA, grad of 1990, has been at the clinical intervention for one year. He is the CEO for Scarborough Grace Hospital and has committed his time to also administer this intervention. He has big ideas for where the new center can go, and is keen that the agency makes inroads into integrated care, taking down the walls and moving more and more into an integrated approach to care that incorporates an active marketing campaign with community outreach. He is a hands-on leader and works closely with his senior managers to get his ideas across and coach them on working more effectively with the multidisciplinary teams.
2.1.2 ASSOCIATE EXECUTIVE DIRECTOR, FINANCE, SUPPLIES AND SYSTEMS
Tom Rumble, age 43, MBA, grad of 1993. He is in charge for planning, controlling, and directing financial and administrative functions for the clinical intervention. His responsibilities include preparing the budget for the services being provided, for equipment that is used for treatment, and other supplies that deals with offering information and support; conducting financial analysis and preparing financial reports; developing and implementing an effective accounting system; maintaining the payroll system for the professionals; and maintaining accurate and current bylaw records.
2.1.3 SENIOR MEDICAL ADVISOR
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Dr. Clive Becker, age 59, MD from the Princess Margaret Hospital. He is the head of the medical team, and without his approval, medical services will not go forward. His team consists of three cancer specialists and one reproductive specialist. These cancer specialists include; Medical oncologist; Radiation oncologist; and Surgical oncologist. The medical oncologist oversees the general care and coordinates treatments with other specialists. He is also in charge of chemotherapy, hormone therapy, and immunotherapy. The radiation oncologist is in charge of treating cancer with radiation therapy, and reading X-rays, CT scans, and MRIs. The surgical oncologist has special training in treating cancer. She is in charge of diagnosing cancer with biopsies and removing tumours and other cancerous tissues. The reproductive specialist is a gynecologist. She is in charge of examining patients to determine medical problems within a female's genital, urinary, and rectal organs. She uses lab test results, diagnostic images and patient's statements as diagnostic aids. Dr. Becker is a renowned physician in Ontario for providing excellent diagnostics and services. Patients were always eager and content to meet him as he always satisfies his patients' needs. He is also known for being an excellent leader at the Princess Margaret Hospital as he advices and delegates his peer physicians on routine policies and treatment guidance.
2.1.4 SENIOR STAFF NURSE, ONCOLOGY
Kelly Peplau age 32, BScN. She has been working with Dr. Clive Becker for 10 years and enjoys working with seniors. Her responsibilities at the clinical intervention include assessing, planning, implementing and evaluating care for patients in the appropriate discipline under the direction of Dr. Becker. She is also in charge of delegating duties to the primary nurse and other nurses. She has chosen her own team of nurses, to aid her in delivering the appropriate service to the women. Her team consists of four nurses who are very dedicated to Kelly.
2.1.5 CASE MANAGER, COMMUNITY CARE ACCESS CENTRE
Jill Taylor, age 47, Education, BSc. She has been employed at a Community Care Access Centre (CCAC) since 1992. Ellen's primary responsibility as an intervention case manager is to assess patient needs, identify mutual goals, develop a service plan that addresses the needs of the patient and help patients navigate through the complexities of the health care system.Â She will aid the women coming in by navigating them to their most appropriate sectors such as treatment, or psychiatry ward, or general support, or even the whole service offer. Her job is to make these women feel at ease and guide them in their appropriate route. She also has a major role in bringing together and maintaining the inter-professionals as a team. She is dedicated to a team-based approach so the services provided will be effective and efficient.
2.1.6 DIRECTOR, PATIENT INFORMATION SERVICES & DECISION SUPPORT
Dan Moore, age 30, MHSc, CHIM. Dan is a relatively new member to Wings of Circle team. As part of the redevelopment project he has been hired to implement a new electronic patient information system. In these roles, his key responsibilities are to align the new health information system (HIS) with the new program management structure, as well as provide analytical administrative data to assist in decision making within the organization, particularly as it applies to more efficient and evidence-based practice.
Dr. Mike Reitman, age 43, MD from Oshawa General Hospital. His responsibility in this intervention is to provide professional counseling to these women with mild and severe cases of anxiety, behavioural disorder, or depression due to their dilemma. He is dedicated to having a comfortable and open communication with the patients in order to help them find solutions in overcoming their problems or worries.
2.1.8 VOLUNTEERS, SUPPORT GROUP
This support group was created by volunteers to aid women in feeling at ease and provides accurate information on their dilemma. Like previously stated, information is the first step in guidance to not only making the right decision. This group provides support and information in brochure forms, and communication based service in either one-on-one or group discussions. These volunteers consist majorly of women who were previously diagnosed with cancer when pregnant, and who have survived this disease. Their presence creates an inspirational atmosphere to the women seeking guidance and hope. There are a total of six volunteers in each support group.
3.0 IN DEPTH DESCRIPTION
Circle of wings is secondary prevention intervention where activities are aimed at early disease detection, thereby increasing opportunities for us to prevent progression of the disease (cancer) and the emergence of symptoms. The goals include preventing further physical deterioration and maximizing quality of life. Secondary interventions like ours provide health promotion and treatment.
Our organization is funded by the provincial government publicly and privately delivered. OHIP covers the treatments, so the patients receive a free coverage for quality care.
Circle of Wings is an organization dedicated to providing services, support and hope to women newly diagnosed with cancer who are pregnant. The specific services that will be provided will to treat the women include sectors from the medical oncology, radiation oncology, and surgical oncology. Medical oncology deals with general care and coordination of treatments. This also includes services like chemotherapy, hormone therapy and immunotherapy. Radiation oncology deals with providing radiation therapy, X-rays, CT scans, and MRIs. Surgical oncology deals with biopsies and removing tumours and cancerous tissues. Lastly, patients may also come to see a gynecologist in this intervention who determine problems with the female's genital, urinary and rectal organs. The specialists are not available every day, so appointments must be made 2 weeks in advance.
The support section of the intervention deals with professional counseling by our psychiatrist in the mild and severe cases of anxiety, behavioural disorder, or depression. The psychiatrist will have an open and semi-structured communication with the patients. The purpose of the semi-structured conversation allows the psychiatrist to freely ask questions regarding their communication to gain a better knowledge and perspective of the patients in order to connect and diagnose them properly. Family members are also welcome to this counseling period with the patients for moral support or to provide them with ideas and plans on how to take care of their loved ones. The psychiatrist will be in the clinical intervention everyday to provide support.
The hope section of the intervention deals with the volunteer support group. This group was formed by former women in this dilemma to provide hope for the new women and share their experiences and advices. There will be a support group meeting every Wednesdays. However, if the patients would like advice on another day, they have the opportunity to email these dedicated volunteers in our organization website. There will be group discussions, personal discussions, and information sessions. There will be an hour of group discussions where topics about treatment plans, diagnosis and prognosis will be discussed (or any topics brought up by the women). The second hour will consist of personal discussions between the volunteers and the patients, or patient-to-patient conversations. These times will be filled with laughter, tears, and joy, but at the end of the day, this support group will give these women the most important thing; hope.
To appropriately evaluate our intervention to see the effectiveness and usefulness, we ask our patients to fill out a survey after the completion of their services. We use the Likert scale (10-Strongly Agree, 1- Strongly Disagree) to receive the answers to our questions. The survey will consist of questions on if the treatment was done accordingly, if the staff and physicians were professional and helpful, if the support group has gave them courage and hope, if our patient flow was timely. Also there will be a space for suggestions to further improve the quality of our service. We would also have bi-weekly meetings with the staff of our intervention to gain perspectives of each of the inter-professional aspects. This not only encourages to work as a team, but to further advance our organization and achieve our goals.
4.0 EXAMINIATION OF COMPETITORS
In order to conduct further research, and in an effort to determine whether or not the clinical intervention is unique, we examined two other types of services dedicated to pregnant women with cancer currently being provided in this time: 'Hope for Two' Cancer Support Network, and the Motherisk program.
4.1 'HOPE FOR TWO' CANCER SUPPORT NETWORK
Hope for Two is a pregnant with cancer network dedicated to providing women diagnosed with cancer while pregnant with information, support, and hope (Hope for Two. 2010).
The main advantages of Hope for Two include that this organization is internet-based, so making information easily accessible to women any time of the day, anywhere, without having to make appointments. Also some women may be timid to come in for an in-person support group, and this organization provides valuable information and support in the comfort of the women's homes.
The main drawback of this organization is that because it is internet-based, some women may not get the full effect of comfort and hope from having a face-to-face conversation or discussions. Another disadvantage is that this website only offers support and information, the basic steps to just understand about the disease. It does not provide professional service like treatments, and counseling with psychiatrists and other professionals in order for survival and good health of the mother and the child.
4.2 MOTHERISK PROGRAM
Motherisk is a program at the Sick Children's Hospital in Toronto, in affiliation with the University of Toronto, which provides evidence-based information and guidance about the safety or risk to the developing fetus, of maternal exposure to disease, drugs, and chemicals (Motherisk. 2010)
The main advantages of Motherisk include that it provides rational treatment in pregnancy, the means to make well-informed choices, and a healthy start for their unborn children. They also offer toll-free helplines which assist nearly 200 women daily (Motherisk. 2010). They also offer advice and treatment to variety of diseases during pregnancy.
Their only disadvantage is that their toll-free helplines are not accessible anytime of the day. It is only from Monday to Friday 9am-5pm. If a patient is working and after she comes from work, she is depressed and needs guidance, she cannot call them for support.
5.0 TIME LINE
This project is very serious and requires a lot of planning in order to put in operation a clinical intervention in a populated city. The following chart outlines the projected schedule for main components of the intervention for the next ten years of construction.
Table 1: Construction Timeline for Circle of Wings: Ten Year Plan
Get approval by Health Canada for further funding
Get approval by Public Service Commission of Toronto- license to buy two other buildings for intervention within Toronto
Interviewing process of the professionals and formation of the support group
Marketing of the two new locations using marketing tools mentioned below
June 2010-process ongoing
First shipment of medical equipment and supplies should arrive
Opening of the two new interventions
Providing treatments, support and hope
January 2011-December 2011
Initialization of asking for more funding to open up more clinics in other provinces (if the three interventions in Ontario are successful)
-changing of plans, structures, and services might be necessary based on provinces and communities needs and demands
January 2012- December 2018
Market the organization in other countries through media (internet, television, and health magazines)
If marketing is a success, do a collaboration with other organizations, funders, and supporters to make this intervention world-wide service
January 2020-on going
*If problems occur due to any reason, we have considered additional costs in our budget summary, seen in Section 6.0.
6.0 COST ANALYSIS
6.1 COST ANALYSIS PROCEDURE AND COST/DESIGN RELATIONSHIP
Two main issues were considered in order to figure out an actual manufacturing cost for the intervention:
The relationship between features and specifications of the type of intervention (and the stage of the intervention) and the services provided. All research, prototype, and final plan of the intervention had to be completed before costs could be considered
Cost factors such as medical/non-medical equipment and supplies, real estate, and marketing could not be determined until a full analysis had been completed.
This situation therefore led to a cost/design contradiction that could only be determined through a method of iteration. The cost of the final clinical intervention was projected with a likelihood of fluctuations.
6.1.1 COST SUMMARY
Circle of Wings will originally be funded by the federal health care system. This organization is publicly funded and the services provided privately (Understanding Healthcare and Therapeutics. 2010). The women going in for specific treatments such as chemotherapy, and ultrasound are covered by Ontario Health Insurance Plan (OHIP). The initial cost to start up this intervention was funded by Status of Women Canada- Women's Community Fund (Status of Women Canada. 2009). The estimate cost to build the intervention is $16 million. Table 1 illustrates the allocated budget for all the costs.
Cost (CA dollars)
Real Estate- Purchase of a new building
Medical/Non Medical Equipment & Supplies
Legal & Accounting
Table 1: Component costs of manufacturing Circle of Wings
As detailed in Table 1, an additional $0.5 million has been set to the side for extra costs that may arise in the process of starting up this health intervention.
Marketing is very important step into getting the message out to distressed women wanting support and guidance. Without marketing, women within this community would not be aware of certain services provided that may benefit them, and without awareness prevention and treatment would not occur. So therefore marketing is a critical aspect of creating community-based health intervention and it gets the service out in the market, promotes it, influences behaviour, and also promotes healthy living within communities (ICOM. 2010). Furthermore, the marketing strategies must be portrayed in an honest and trustworthy manner so the target audience will connect to our service and would come to the intervention. The tools that will be used to market our organization include: Promotional video, company logo, website, e-mail marketing campaign, and publicity in local hospitals via doctor referrals and brochures.
6.1 PROMOTIONAL VIDEO
Promotional video is advanced through television in local channels. This video will be broadcasted in prime time during 7pm-10pm in the local channels (to save costs). Promotional video is utilized to show the audience the visual aspect of our intervention. By showing a video of what services we provide, how our services are delivered, the inter-professional team members involved in our intervention, and women who have and are getting treatment and counseling, the targeted audience will connect with our organization.
This promotional video will commence by showing a clip of patients getting treated or in a support group. Then it discusses about the treatments provided and introduction to the friendly and helpful team members. This video will also include testimonials of past and present patients. These testimonials will contain matters of how the patients were treated and how they felt about the treatment and how it affected their lives and their family members. It will also contain clips of past patients after they have survived from their dilemmas in a happy setting with their new, happy and healthy babies. Furthermore, testaments on how helpful and comforting the staff was would promote the integrity and commitment of our intervention.
6.2 COMPANY LOGO
Our company logo (Please See the Appendix) was created based on our target audience-women diagnosed with cancer who are pregnant. This logo will signify the importance of the women (our target) and that this intervention is solely for serving their needs.
As the name states "Circle of Wings" represents our team players within this intervention that come together like angels to provide support, treatment, and hope for the women and their babies. Inside the circle, an image of a mother and her baby are centered as they are our main focus.
Nearly all households have access to the internet (ICOM. 2010). The great thing about the internet is that it can reach anywhere around the world, at anytime. Basically, the website is the shop window and it is open 24/7 (ICOM. 2010). Although our service is targeted to promote treatment and counseling in a face-to-face manner, we will also have information that will aid the women in making appropriate decisions. The information provided in our website will include details on the type of services we provide, testimonials, our professional staff, and the volunteer support group. We will also provide information on cancer with pregnancy; diagnostics, treatment options, prognostics. This will provide the readers the basic knowledge on their disease. This website will also include an email to the support group, where women can access free support through the internet in the comfort of their homes.
6.4 PUBLICITY IN LOCAL HOSPITALS VIA DOCTORS AND HOSPITAL STAFF
Hospitals and physicians are well respected and trusted within the communities. Patients go to doctors for referrals and guidance on treatment plans and counseling. If doctors/nurses/administrators in local hospitals refer the women to our clinical intervention, there would be a greater opportunity to assist and treat them. Knowing this fact, we have teamed up with local hospitals to publicize our organization.
Our CEO, Alex Stapleton, has done an excelling job in ensuring the hospital managers/executives at his hospital, Scarborough Grace Hospital, pass the information about our organizations to their staff to pass to the patients. Dr. Clive Becker and our senior staff nurse Kelly Peplau have also made referrals to their cancer patients at Princess Margaret Hospital. In fact, Dr. Becker has referred twelve of his patients who were diagnosed with cancer (most of them breast cancer) while they are pregnant to our clinic last year. We are proud to announce that these twelve women have been treated and guided exceptionally by our staff and they are all now proud and happy mothers of beautiful babies. Five of these women have in fact came back as volunteers and joined the support group to guide new patients.
6.6 MOUTH MARKETING
One of the most important marketing strategies is mouth marketing. Mouth marketing or word-of-mouth marketing is a reference to the passing of information from person to person. This strategy works rather well due to the personal nature of communication between individuals, so therefore it has an added layer of credibility. According to research, the receiver of word-of-mouth referrals tends to believe that the communicator is speaking truthful and is unlikely to have a hidden motive, such as them not receiving an incentive for their referrals (ICOM. 2010). As technology advances, there are more sources through which word-of-mouth marketing can be put in effect. We have utilized many web-start ups like Facebook, YouTube, MySpace, and Twitter as mouth marketing tools. Furthermore, with the increasing use of the internet as a research and communication platform, word-of-mouth has become an even more efficient and effective resource for us.
Our volunteers in the support group and our past and present patients at Circle of Wings have done an excellent job in word-of-mouth marketing. Due to these referrals we have so many women coming in for help, and therefore the need to expand to three interventions within the city has been increased.
8.1 RECOMMENDATION AND BENEFITS
At this time we would recommend the Circle of Wings organization to construct its two other clinical interventions within Toronto, Ontario. This means that the final budget would be settled by December 2010 and the opening of the clinics could start in February 2011. Meantime, the next rational step would be to do further research on new medical technological advancements for treatment, methods of delivery and marketing to solve any last minute concerns of the planning of expansion. Furthermore, the new medical staff that is needed for the new interventions must be interviewed and a team goal/plan must be decided on.
Constructing a clinical intervention for women diagnosed with cancer while pregnant will serve as a great new service and is a long term solution to the health of women with this disease. Our short term goal is to expand this organization to nationwide, and our long term goal/future hope is to expand in to worldwide service. Also, we are planning on providing treatments and counseling for other diseases while pregnant, not just cancer. This is because new diseases are being discovered and encountered upon, and must be treated before it affects the future generations. We also believe that the constructing this local clinical intervention can cut down provincial costs. According to research, a shift from the current hospital-based system to a community-based system can be the cost-effective solution to our health care budget crisis in Canada, and save $10 million to $12 million a year while providing access to quality health care (Bartkowski. 1995). We believe this organization is definitely a valuable investment for such a vastly populated city. Circle of Wings has a brilliant future ahead of it and we believe it will soon become a worldwide intervention program.
Figure 1: "Circle of Wings" Company Logo
American Society of Clinical Oncology. 2009. Pregnancy and Cancer. Cancer.Net. Retrieved from http://www.cancer.net/patient/Coping/Emotional+and+Physical+Matters/Sexual+and+Reproductive+Health/Pregnancy+and+Cancer
Bartkowsi. 1995. Community-based clinics offer best solution to health care crisis. BNet Article. Retrieved from http://findarticles.com/p/articles/mi_qn4207/is_19950221/ai_n10186061/
Canadian Cancer Society. 2010. Canadian Cancer Statistics. Canada. Retrieved from http://www.cancer.ca/Canada-wide/About%20cancer/Cancer%20statistics/~/media/CCS/Canada%20wide/Files%20List/English%20files%20heading/pdf%20not%20in%20publications%20section/Stats%202009E%20Cdn%20Cancer.ashx
Harris. T. 2006. Internet Research Builds Cancer Patients' Confidence. Temple University. Retrieved from http://www.pregnantwithcancer.org/articles/Internet_Research_March_06.pdf
Hope for Two. 2010. The Pregnant with Cancer Network. Retrieved from http://www.pregnantwithcancer.org/
ICOM. 2010. Why Should Marketers Care? Retrieved from http://www.marketingmag.ca/
Motherisk. 2010. Halton Resources. Hospital for Sick Children. Retrieved from http://search.hipinfo.info/record/OAK4167?UseCICVw=52
Status of Women Canada. 2009. Status of Women Canada Funding. Canada. Retrieved from http://www.swc-cfc.gc.ca/index-eng.html
Understanding Healthcare and Therapeutics. 2010. Brenda Gamble. Lecture 2-Slide 34-36