Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services

Effectiveness of tailored talks between a cancer screening specialist and general practitioners to improve the uptake of colorectal cancer screening in Ancona (Italy) during the pandemic period

BACKGROUND

Colorectal cancer (CRC) screening uptake in many countries has been low and further impacted by the COVID-19 pandemic. General Practitioners (GPs) are key facilitators, however research on their impact on organised CRC screening is still limited.

OBJECTIVES

To evaluate the effectiveness of tailored talks with GPs to increase population uptake of the long-established CRC screening programme in Ancona province, Italy.

METHODS

In this prospective cohort study, one-to-one tailored talks were organised in January 2020 between the GPs of one county of the province (with GPs from other counties as controls) and the screening programme physician-in-chief to discuss the deployment and effectiveness of organised screening. Data was extracted from the National Healthcare System datasets and linear regression was used to assess the potential predictors of CRC screening uptake.

RESULTS

The mean CRC screening uptake remained stable from 39.9% in 2018-19 to 40.8% in 2020-21 in the 22 GPs of the intervention county, whereas it statistically significantly decreased from 38.7% to 34.7% in the 232 control GPs. In multivariate analyses, belonging to the intervention county was associated with an improved uptake compared to the control counties (+5.1%; 95% Confidence Intervals - CI: 2.0%; 8.1%).

CONCLUSION

Persons cared for by GPs who received a tailored talk with a cancer screening specialist avoided a drop in CRC screening adherence, which characterised all other Italian screening programmes during the COVID-19 emergency. If future randomised trials confirm the impact of tailored talks, they may be incorporated into existing strategies to improve population CRC screening uptake.

Assessment of barriers to cancer screening and interventions implemented to overcome these barriers in 27 Latin American and Caribbean countries

There is a gap in the understanding of the barriers to cancer screening participation and complying with downstream management in the Community of Latin American and Caribbean states (CELAC). Our study aimed to assess barriers across the cancer screening pathway from the health system perspective, and interventions in place to improve screening in CELAC. A standardized tool was used to collect information on the barriers across the screening pathway through engagement with the health authorities of 27 member states of CELAC. Barriers were organized in a framework adapted from the Tanahashi conceptual model and consisted of the following dimensions: availability of services, access (covering accessibility and affordability), acceptability, user-provider interaction, and effectiveness of services (which includes governance, protocols and guidelines, information system, and quality assurance). The tool also collected information of interventions in place, categorized in user-directed interventions to increase demand, user-directed interventions to increase access, provider-directed interventions, and policy and system-level interventions. All countries prioritized barriers related to the information systems, such as the population register not being accurate or complete (N = 19; 70.4%). All countries implemented some kind of intervention to improve cancer screening, group education being the most reported (N = 23; 85.2%). Training on screening delivery was the most referred provider-directed intervention (N = 19; 70.4%). The study has identified several barriers to the implementation of cancer screening in the region and interventions in place to overcome some of the barriers. Further analysis is required to evaluate the effectiveness of these interventions in achieving their objectives.

Barriers and facilitators of implementing a multicomponent intervention to improve faecal immunochemical test (FIT) colorectal cancer screening in primary care clinics, Alberta

BACKGROUND AND OBJECTIVE

Colorectal cancer (CRC) screening is effective at reducing the incidence and mortality of CRC. To address suboptimal CRC screening rates, a faecal immunochemical test (FIT) multicomponent intervention was piloted in four urban multidisciplinary primary care clinics in Alberta from September 2021 to April 2022. The interventions included in-clinic distribution of FIT kits, along with FIT-related patient education and follow-up. This study explored barriers and facilitators to implementing the intervention in four primary clinics using the Consolidated Framework for Implementation Research (CFIR).

METHODS

In-depth qualitative semistructured key informant interviews, guided by the CFIR, were conducted with 14 participants to understand barriers and facilitators of the FIT intervention implementation. Key informants were physicians, quality improvement facilitators and clinical staff. Interviews were analysed following an inductive-deductive approach. Implementation barriers and facilitators were organised and interpreted using the CFIR to facilitate the identification of strategies to mitigate barriers and leverage facilitators for implementation at the clinic level.

RESULTS

Key implementation facilitators reported by participants were patient perceived needs being met; the clinics' readiness to implement FIT, including staff's motivation, skills, knowledge, and resources to implement; intervention characteristics-evidence-based, adaptable and compatible with existing workflows; regular staff communications; and use of the electronic medical record (EMR) system. Key barriers to implementation were patient's limited awareness of FIT screening for CRC and discomfort with stool sample collection; the impacts of COVID-19 (patients missed appointment, staff coordination and communication were limited due to remote work); and limited clinic capacity (knowledge and skills using EMR system, staff turnover and shortage).

CONCLUSION

Findings from the study facilitate the refinement and adaption of future FIT intervention implementation. Future research will explore implementation barriers and facilitators in rural settings and from patients' perspectives to enhance the spread and scale of the intervention.

Implementation and Evaluation of a Large Community-Based Colorectal Cancer Screening Program

CONTEXT

Colorectal cancer (CRC) screening can significantly reduce incidence and mortality; however, screening rates are suboptimal. The lowest rates are among those with no usual source of care and the uninsured.

OBJECTIVE

We describe the implementation and evaluation of a community-based CRC screening program from 2012 to 2015 designed to increase screening within a predominantly Hispanic US-Mexico border population.

METHODS

The multicomponent, evidence-based program provided in-person, bilingual, culturally tailored health education facilitated by community health workers, no-cost primarily stool-based testing and diagnostic colonoscopy, and navigation. We recruited uninsured individuals due for CRC screening from clinics and community sites. An extensive qualitative and quantitative program process and outcome evaluation was conducted.

RESULTS

In total, 20 118 individuals were approached, 8361 were eligible for screening; 74.8% completed screening and 74.6% completed diagnostic testing; 14 cancers were diagnosed. The mean age of participants was 56.8 years, and the majority were Hispanic, female, and of low socioeconomic status. The process evaluation gathered information that enabled effective program implementation and demonstrated effective staff training, compliance with processes, and high patient satisfaction.

CONCLUSIONS

This program used a population-based approach focusing on uninsured individuals and proved successful at achieving high fecal immunochemical test kit return rates and colonoscopy completion rates. Key factors related to its success included tailoring the intervention to our priority population, strong partnerships with community-based sites and clinics, expertise in clinical CRC screening, and an active community advisory board. This program can serve as a model for similar populations along the border to increase CRC screening rates among the underserved.

Adaptation and qualitative evaluation of the BETTER intervention for chronic disease prevention and screening by public health nurses in low income neighbourhoods: views of community residents

BACKGROUND

The BETTER intervention is an effective comprehensive evidence-based program for chronic disease prevention and screening (CDPS) delivered by trained prevention practitioners (PPs), a new role in primary care. An adapted program, BETTER HEALTH, delivered by public health nurses as PPs for community residents in low income neighbourhoods, was recently shown to be effective in improving CDPS actions. To obtain a nuanced understanding about the CDPS needs of community residents and how the BETTER HEALTH intervention was perceived by residents, we studied how the intervention was adapted to a public health setting then conducted a post-visit qualitative evaluation by community residents through focus groups and interviews.

METHODS

We first used the ADAPT-ITT model to adapt BETTER for a public health setting in Ontario, Canada. For the post-PP visit qualitative evaluation, we asked community residents who had received a PP visit, about steps they had taken to improve their physical and mental health and the BETTER HEALTH intervention. For both phases, we conducted focus groups and interviews; transcripts were analyzed using the constant comparative method.

RESULTS

Thirty-eight community residents participated in either adaptation (n = 14, 64% female; average age 54 y) or evaluation (n = 24, 83% female; average age 60 y) phases. In both adaptation and evaluation, residents described significant challenges including poverty, social isolation, and daily stress, making chronic disease prevention a lower priority. Adaptation results indicated that residents valued learning about CDPS and would attend a confidential visit with a public health nurse who was viewed as trustworthy. Despite challenges, many recipients of BETTER HEALTH perceived they had achieved at least one personal CDPS goal post PP visit. Residents described key relational aspects of the visit including feeling valued, listened to and being understood by the PP. The PPs also provided practical suggestions to overcome barriers to meeting prevention goals.

CONCLUSIONS

Residents living in low income neighbourhoods faced daily stress that reduced their capacity to make preventive lifestyle changes. Key adapted features of BETTER HEALTH such as public health nurses as PPs were highly supported by residents. The intervention was perceived valuable for the community by providing access to disease prevention.

TRIAL REGISTRATION

#NCT03052959, 10/02/2017.

Willingness of healthcare providers to perform population-based cancer screening: a cross-sectional study in primary healthcare institutions in Tianjin, China

OBJECTIVE

To evaluate the willingness of healthcare providers to perform population-based screening in primary healthcare institutions in China.

METHODS

Healthcare providers of 262 primary healthcare institutions in Tianjin were invited to fill out a questionnaire consisting of demographic characteristics, workload, and knowledge of, attitude towards and willingness to perform breast, cervical and colorectal cancer screening. Willingness to screen was the primary outcome. Multilevel logistic regression models were conducted to analyse the determinants of healthcare providers' willingness to screen. ORs and 95% CIs were estimated.

RESULTS

A total of 554 healthcare providers from 244 institutions answered the questionnaire. 67.2%, 72.1% and 74.3% were willing to perform breast, cervical and colorectal cancer screening, respectively. A negative attitude towards screening was associated with a low willingness for cervical (OR=0.27; 95% CI 0.08, 0.94) and colorectal (OR=0.08; 95% CI 0.02, 0.30) cancer screening, while this was not statistically significant for breast cancer screening (OR=0.30; 95% CI 0.08, 1.12). For breast, cervical and colorectal cancer screening, 70.1%, 63.8% and 59.0% of healthcare providers reported a shortage of staff dedicated to screening. A perceived reasonable manpower allocation was a determinant of increased willingness to perform breast (OR=2.86; 95% CI 1.03, 7.88) and colorectal (OR=2.70; 95% CI 1.22, 5.99) cancer screening. However, this was not significant for cervical cancer screening (OR=1.76; 95% CI 0.74, 4.18).

CONCLUSIONS

In China, healthcare providers with a positive attitude towards screening have a stronger willingness to contribute to cancer screening, and therefore healthcare providers' attitude, recognition of the importance of screening and acceptable workload should be optimised to improve the uptake of cancer screening.

Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement

Colorectal cancer (CRC) screening reduces morbidity and mortality, but screening rates in the USA remain suboptimal. The Colorectal Cancer Control Program (CRCCP) was established in 2009 to increase screening among groups disproportionately affected. The CRCCP utilizes implementation science to support health system change as a strategy to reduce disparities in CRC screening by directing resources to primary care clinics to implement evidence-based interventions (EBIs) proven to increase CRC screening. As COVID-19 continues to impede in-person healthcare visits and compel the unpredictable redirection of clinic priorities, understanding clinics' adoption and implementation of EBIs into routine care is crucial. Mailed fecal testing is an evidence-based screening approach that offers an alternative to in-person screening tests and represents a promising approach to reduce CRC screening disparities. However, little is known about how mailed fecal testing is implemented in real-world settings. In this retrospective, cross-sectional analysis, we assessed practices around mailed fecal testing implementation in 185 clinics across 62 US health systems. We sought to (1) determine whether clinics that do and do not implement mailed fecal testing differ with respect to characteristics (e.g., type, location, and proportion of uninsured patients) and (2) identify implementation practices among clinics that offer mailed fecal testing. Our findings revealed that over half (58%) of clinics implemented mailed fecal testing. These clinics were more likely to have a CRC screening policy than clinics that did not implement mailed fecal testing (p = 0.007) and to serve a larger patient population (p = 0.004), but less likely to have a large proportion of uninsured patients (p = 0.01). Clinics that implemented mailed fecal testing offered it in combination with EBIs, including patient reminders (92%), provider reminders (94%), and other activities to reduce structural barriers (95%). However, fewer clinics reported having the leadership support (58%) or funding stability (29%) to sustain mailed fecal testing. Mailed fecal testing was widely implemented alongside other EBIs in primary care clinics participating in the CRCCP, but multiple opportunities for enhancing its implementation exist. These include increasing the proportion of community health centers/federally qualified health centers offering mailed screening; increasing the proportion that provide pre-paid return mail supplies with the screening kit; increasing the proportion of clinics monitoring both screening kit distribution and return; ensuring patients with abnormal tests can obtain colonoscopy; and increasing sustainability planning and support.

Worldwide association of the gender inequality with the incidence and mortality of cervical, ovarian, endometrial, and breast cancers

Background

There is a huge disparity in cancer incidence and mortality around the globe. A considerable share of this disparity can be explained by human development. Particularly in many less developed countries, women have been hindered in their human development. In this ecological study, we hypothesize that, notwithstanding acceptable overall development in countries, gender inequalities might affect the incidence and mortality of women's malignancies, and there is a distinct association between them.

Method

The data on the incidence and mortality of gynecologic and female breast cancers were retrieved from the GLOBOCAN database, and the data on the Human Development Index (HDI), Gender Development Index (GDI), and Gender Inequality Index (GII) were obtained from the United Nations Human Development Report. The Poisson regression modeling was then used to fit four models for each cancer.

Result

GII and GDI are both significantly associated with incidences of women's cancers, except for the insignificant association between GDI and the incidence of ovarian cancer. However, the association between GDI and the mortality of women's cancer is not strong. At the same time, there are significant direct relationships between GII and the mortality of breast, cervical, and endometrial cancer.

Conclusion

The incidence and mortality of women's cancers are ecologically associated with the country-level gender inequality captured with GDI and GII.

Interventions to Improve Surveillance for Hepatocellular Carcinoma in High-Risk Patients: A Scoping Review

PURPOSE

Hepatocellular carcinoma (HCC) is most often a sequela of chronic liver disease or chronic hepatitis B infection. Among high-risk patients, surveillance for HCC every 6 months is recommended by international guidelines. However, rates of HCC surveillance are suboptimal (11-64%). Barriers at the patient, provider, and healthcare delivery system levels have been identified.

METHODS

We performed a systemic scoping review to identify and characterize interventions to improve HCC surveillance that has previously been evaluated. Searches using key terms in PubMed and Embase were performed to identify studies examining interventions designed to improve the surveillance rate for HCC in patients with cirrhosis or chronic liver disease that were published in English between January 1990 and September 2021.

RESULTS

Included studies (14) had the following study designs: (1) randomized clinical trials (3, 21.4%), (2) quasi-experimental (2, 14.3%), (3) prospective cohort (6, 42.8%), and (4) retrospective cohort (3, 21.4%). Interventions included mailed outreach invitations, nursing outreach, patient education with or without printed materials, provider education, patient navigation, chronic disease management programs, nursing-led protocols for image ordering, automated reminders to physicians and nurses, web-based clinical management tools, HCC surveillance databases, provider compliance reports, radiology-led surveillance programs, subsidized HCC surveillance, and the use of oral medications. It was found that HCC surveillance rates increased after intervention implementation in all studies.

CONCLUSION

Despite improvements in HCC surveillance rates with intervention, compliance remained suboptimal. Further analysis of which interventions yield the greatest increases in HCC surveillance, design of multi-pronged strategies, and improved implementation are needed.

Cancer care and treatment during homelessness

People experiencing homelessness have not yet benefited from the substantial progress made in managing cancers, including advances in chemotherapy and radiotherapy, surgical interventions, multidisciplinary team approaches, and integrated cancer care models. People experiencing homelessness are at higher risks of developing cancers and their mortality due to cancer is twice that of the general population. Potential interventions to improve access to cancer treatment include alliances and active engagement with community organisations and shelters, cancer case management and peer-to-peer support, mHealth and navigation strategies, tailored hospital discharge to adult group homes, well equipped subacute rehabilitation centres, and specialised shelters and respite housing to assure appropriate follow-up care. Other interventions include improving preventive care, expanding data, targeted policy efforts, and broader housing advocacy. In this Personal View, I discuss challenges and opportunities in cancer treatment, with a review of the current evidence on potential interventions, and highlight strategies to improve access to cancer care for homeless populations.

Delays in Colorectal Cancer Screening for Latino Patients: The Role of Immigrant Healthcare in Stemming the Rising Global Incidence of Colorectal Cancer

The significant global burden of colorectal cancer accentuates disparities in access to preventive healthcare in most low- and middle-income countries (LMICs) as well as large sections of underserved populations within high-income countries. The barriers to colorectal cancer screening in economically transitioning Latin America are multiple. At the same time, immigration from these countries to the USA continues to increase. This case highlights the delays in diagnosis experienced by a recent immigrant from a country with no established colorectal cancer screening program, to an immigrant population in the USA with similar poor screening coverage. We discuss common challenges faced by Latinos in their home countries and the USA, as well as strategies that could be implemented to improve screening coverage in US immigrant populations.

Effective strategies for Fecal Immunochemical Tests (FIT) programs to improve colorectal cancer screening uptake among populations with limited access to the healthcare system: a rapid review

BACKGROUND

Colorectal cancer (CRC) is one of the leading causes of cancer death globally. CRC screening can reduce the incidence and mortality of CRC. However, socially disadvantaged groups may disproportionately benefit less from screening programs due to their limited access to healthcare. This poor access to healthcare services is further aggravated by intersecting, cumulative social factors associated with their sociocultural background and living conditions. This rapid review systematically reviewed and synthesized evidence on the effectiveness of Fecal Immunochemical Test (FIT) programs in increasing CRC screening in populations who do not have a regular healthcare provider or who have limited healthcare system access.

METHODS

We used three databases: Ovid MEDLINE, Embase, and EBSCOhost CINAHL. We searched for systematic reviews, meta-analysis, and quantitative and mixed-methods studies focusing on effectiveness of FIT programs (request or receipt of FIT kit, completion rates of FIT screening, and participation rates in follow-up colonoscopy after FIT positive results). For evidence synthesis, deductive and inductive thematic analysis was conducted. The findings were also classified using the Cochrane Methods Equity PROGRESS-PLUS framework. The quality of the included studies was assessed.

RESULTS

Findings from the 25 included primary studies were organized into three intervention design-focused themes. Delivery of culturally-tailored programs (e.g., use of language and interpretive services) were effective in increasing CRC screening. Regarding the method of delivery for FIT, specific strategies combined with mail-out programs (e.g., motivational screening letter) or in-person delivery (e.g., demonstration of FIT specimen collection procedure) enhanced the success of FIT programs. The follow-up reminder theme (e.g., spaced out and live reminders) were generally effective. Additionally, we found evidence of the social determinants of health affecting FIT uptake (e.g., place of residence, race/ethnicity/culture/language, gender and/or sex).

CONCLUSIONS

Findings from this rapid review suggest multicomponent interventions combined with tailored strategies addressing the diverse, unique needs and priorities of the population with no regular healthcare provider or limited access to the healthcare system may be more effective in increasing FIT screening. Decision-makers and practitioners should consider equity and social factors when developing resources and coordinating efforts in the delivery and implementation of FIT screening strategies.

Variation in State-Level Mammography Use, 2012 and 2020

OBJECTIVES

Mammography is a screening tool for early detection of breast cancer. Uptake in screening use in states can be influenced by Medicaid coverage and eligibility policies, public health outreach efforts, and the Centers for Disease Control and Prevention-funded National Breast and Cervical Cancer Early Detection Program. We described state-specific mammography use in 2020 and changes as compared with 2012.

METHODS

We estimated the proportion of women aged ≥40 years who reported receiving a mammogram in the past 2 years, by age group, state, and demographic and socioeconomic characteristics, using 2020 Behavioral Risk Factor Surveillance System data. We also compared 2020 state estimates with 2012 estimates.

RESULTS

The proportion of women aged 50-74 years who received a mammogram in the past 2 years was 78.1% (95% CI, 77.4%-78.8%) in 2020. Across measures of socioeconomic status, mammography use was generally lower among women who did not have health insurance (52.0%; 95% CI, 48.3%-55.6%) than among those who did (79.9%; 95% CI, 79.3%-80.6%) and among those who had a usual source of care (49.4%; 95% CI, 46.1%-52.7%) than among those who did not (81.0%; 95% CI, 80.4%-81.7%). Among women aged 50-74 years, mammography use varied across states, from a low of 65.2% (95% CI, 61.4%-69.0%) in Wyoming to a high of 86.1% (95% CI, 83.8%-88.3%) in Massachusetts. Four states had significant increases in mammography use from 2012 to 2020, and 8 states had significant declines.

CONCLUSION

Mammography use varied widely among states. Use of evidence-based interventions tailored to the needs of local populations and communities may help close gaps in the use of mammography.

Barriers and facilitators of colorectal cancer screening among East African men in Minnesota: a qualitative investigation

Objective: This study aimed to explore barriers and facilitators to colorectal cancer (CRC) screening among East African men in Minnesota.Design: Six focus groups were conducted in Minneapolis and St. Paul, MN, USA. Participants were asked to describe individual and structural barriers to CRC screening, and discuss strategies that would address individual and structural barriers to screening. Audio-recorded conversations were transcribed verbatim and translated to English. The transcriptions were analyzed using a thematic analysis. Major themes that emerged on individual barriers were lack of knowledge, fear, and privacy.Results: Themes that emerged on structural barriers were distrust in the medical system, lack of health care coverage, and access to the health care system. Education, client reminders, mass media, increased clarity in communication with the provider and translator, and increased access to health care were frequently mentioned strategies to increase CRC screening in the East African community. Participants expressed favorable views toward the concept of patient navigation.Conclusion: Our findings indicate the need to develop culturally appropriate, multi-faced, intervention programs that are aimed at eliminating personal, cultural, and structural barriers.

Receipt, uptake, and satisfaction with tailored DVD and patient navigation interventions to promote cancer screening among rural women

Process evaluation is essential to understanding and interpreting the results of randomized trials testing the effects of behavioral interventions. A process evaluation was conducted as part of a comparative effectiveness trial testing a mailed, tailored interactive digital video disc (DVD) with and without telephone-based patient navigation (PN) to promote breast, cervical and colorectal cancer screening among rural women who were not up-to-date (UTD) for at least one screening test. Data on receipt, uptake, and satisfaction with the interventions were collected via telephone interviews from 542 participants who received the tailored interactive DVD (n = 266) or the DVD plus telephone-based PN (n = 276). All participants reported receiving the DVD and 93.0% viewed it. The most viewed sections of the DVD were about colorectal, followed by breast, then cervical cancer screening. Most participants agreed the DVD was easy to understand, helpful, provided trustworthy information, and gave information needed to make a decision about screening. Most women in the DVD+PN group, 98.2% (n = 268), reported talking with the navigator. The most frequently discussed cancer screenings were colorectal (86.8%) and breast (71.3%); 57.5% discussed cervical cancer screening. The average combined length of PN encounters was 22.2 minutes with 21.7 additional minutes spent on coordinating activities. Barriers were similar across screening tests with the common ones related to the provider/health care system, lack of knowledge, forgetfulness/too much bother, and personal issues. This evaluation provided information about the implementation and delivery of behavioral interventions as well as challenges encountered that may impact trial results.

A qualitative analysis of patients' experiences with an emergency department diagnosis of gastrointestinal cancer

OBJECTIVES

Optimally, cancer is diagnosed through periodic screening or detection of early symptoms in primary care settings. However, an estimated 23%-52% of gastrointestinal (GI) cancers are diagnosed in the emergency department (ED). Cancer diagnosed in the ED has been associated with worse clinical and patient-reported outcomes even after adjustment for cancer stage. We sought to explore patients' accounts of patient and health care system factors related to their diagnosis in the ED and their lived experience of receiving a diagnosis in this setting.

METHODS

Patients with an ED visit during or within 30 days of their GI cancer diagnosis at an urban academic hospital serving a largely disadvantaged population were recruited. Interviews were coded in NVivo 12 and analyzed using a thematic analysis approach.

RESULTS

Patient-reported factors associated with their experiences included denial and avoidance of symptoms, mistrust of the health system, and lack of cancer screening knowledge. Health care system factors included misdiagnosis and delayed access to specialty care or tests. Experiences receiving a cancer diagnosis in the ED were overwhelmingly negative.

CONCLUSIONS

This study highlights the unmet needs in identifying and diagnosing patients who ultimately present to the ED for evaluation and eventual diagnosis of cancer. Our results shed light on several modifiable factors, including the need for increased public awareness of the asymptomatic nature of cancer and the importance of cancer screening. Additionally, health care systems modifications beyond the ED are needed to improve access to timely care when symptoms arise.

Disparities in cervical cancer screening among Arabic-speaking women refugees

OBJECTIVES

Cervical cancer remains one of the most common cancers among females and one of the top causes of cancer-related deaths worldwide. Minority women are disproportionately more vulnerable. This study addressed disparities in cervical cancer screening among Arabic-speaking women refugees.

DESIGN

We conducted a cross-sectional study using qualitative and quantitative research methods at a Federally Qualified Health Center (FQHC) in Cleveland, Ohio, in the United States of America (USA). A structured phone-based survey was developed and administered in Arabic. The study was conducted from 2018 to 2019 and involved 20 participants.

RESULTS

Inequity in cervical cancer screening exists among Arab women refugees (41% being up to date with their screening) compared to their English- and Spanish-speaking counterparts (51%). These women perceived that the top three barriers to cervical cancer screening were fear of cancer, language, and lack of knowledge. The top three perceived facilitators were the doctor's recommendation, reminders from the provider's office, and awareness of cervical cancer screening.

CONCLUSION

Our work brings unique insights into improving preventive care services for Arabic-speaking women. These findings add unique insight focused on improving preventive care in this group and can inform interventions to increase cancer screening amongst Arabic-speaking women.

Cervical Cancer Prevention in Rural Areas

Objective

Globally, cervical cancer (CC) incidence is higher in rural areas than in urban areas that could be explained by the influence of many factors, including inequity in accessibility of the CC prevention measures. This review aimed to identify and analyze factors associated with a lack of cervical cancer screening and HPV vaccination programs in people living in rural areas and to outline strategies to mitigate these factors.

Methods

The literature search encompassed two focal domains: cervical cancer screening and HPV vaccination among populations residing in rural areas, covering publications between January 1, 2004 to December 31, 2021 in the PubMed, Google Scholar, Scopus, and Cyberleninka databases, available in both English and Russian languages.

Result

A literature review identified 22 sources on cervical cancer screening and HPV vaccination in rural and remote areas. These sources revealed similar obstacles to screening and vaccination in both high and low-income countries, such as low awareness and knowledge about CC, screening, and HPV vaccination among rural residents; limited accessibility due to remoteness and dearth of medical facilities and practitioners, associated with a decrease in recommendations from them, and financial constraints, necessitating out-of-pocket expenses. The reviewed sources analyzed strategies to mitigate the outlined challenges. Possible solutions include the introduction of tailored screening and vaccination campaigns designed for residents of rural and remote locations. New screening and vaccination sites have been proposed to overcome geographic barriers. Integrating HPV testing-based CC screening is suggested to counter the lack of healthcare personnel. HPV vaccination is essential for primary cervical cancer prevention, especially in rural and remote areas, as it requires less medical infrastructure.

Conclusion

Certain measures can be proposed to improve the uptake of CC screening and HPV vaccination programs among rural residents, which are needed to address the higher prevalence of CC in rural areas. Further investigation into cervical cancer prevention in rural and remote contexts is necessary to ascertain the optimal strategies that promote health equity.

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial

Importance

Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results.

Objective

To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results.

Design, Setting, and Participants

Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021.

Intervention

Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment.

Main Outcomes and Measures

The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk.

Results

Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result.

Conclusions and Relevance

A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT03979495.

Lack of Awareness of Human Papillomavirus Testing Among U.S. Women

INTRODUCTION

National surveys provide important information for public health planning. Lack of preventive screenings awareness may result in unreliable survey estimates. This study examines women's awareness of receiving human papillomavirus testing using three national surveys.

METHODS

In 2022, self-reported data analyses on human papillomavirus testing status among women without hysterectomy were conducted from the 2020 Behavioral Risk Factor Surveillance System (BRFSS) (n=80,648, aged 30-64 years), the 2019 National Health Interview Survey (NHIS) (n=7,062, aged 30-65 years), and the 2017-2019 National Survey of Family Growth (n=2,973, aged 30-49 years). Associations between human papillomavirus awareness status (yes, no, don't know) and demographic characteristics were examined with generalized multinomial logistic model to generate adjusted prevalence ratios. Adjusted risk differences were assessed with the t-test for the Don't know answer.

RESULTS

A total of 21.8% or >12 million in the study population of women in the BRFSS, 19.5%, (>10.5 million women) in the NHIS, and 9.4% in the National Survey of Family Growth responded don't know to human papillomavirus testing awareness status question. Women aged 40-64 years in BRFSS and 50-65 years in NHIS were more likely to answer don't know than those aged 30-34 (p<0.05 and p<0.01, respectively). Non-Hispanic White women were more likely to answer don't know than non-Hispanic Native Hawaiian/Pacific Islander, non-Hispanic Black, non-Hispanic Asian, and Hispanic women in BRFSS and non-Hispanic Black women in NHIS (adjusted prevalence ratio range=0.60-0.78; p<0.001 and adjusted prevalence ratio=0.72; p<0.001, respectively).

CONCLUSIONS

One in five women was unaware of her human papillomavirus testing status, and awareness was lower among older and non-Hispanic White women. The awareness gap may affect the reliability of estimated human papillomavirus testing population uptake using survey data.

Implementation strategies in the Exploration and Preparation phases of a colorectal cancer screening intervention in community health centers

BACKGROUND

Adoption of colorectal cancer (CRC) screening has lagged in community health center (CHC) populations in the USA. To address this implementation gap, we developed a multilevel intervention to improve screening in CHCs in our region. We used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide this effort. Here, we describe the use of implementation strategies outlined in the Expert Recommendations for Implementing Change (ERIC) compilation in both the Exploration and Preparation phases of this project. During these two EPIS phases, we aimed to answer three primary questions: (1) What factors in the inner and outer contexts may support or hinder colorectal cancer screening in North Carolina CHCs?; (2) What evidence-based practices (EBPs) best fit the needs of North Carolina CHCs?; and (3) How can we best integrate the selected EBPs into North Carolina CHC systems?

METHODS

During the Exploration phase, we conducted local needs assessments, built a coalition, and conducted local consensus discussions. In the Preparation phase, we formed workgroups corresponding to the intervention's core functional components. Workgroups used cyclical small tests of change and process mapping to identify implementation barriers and facilitators and to adapt intervention components to fit inner and outer contexts.

RESULTS

Exploration activities yielded a coalition of stakeholders, including two rural CHCs, who identified barriers and facilitators and reached consensus on two EBPs: mailed FIT and navigation to colonoscopy. Stakeholders further agreed that the delivery of those two EBPs should be centralized to an outreach center. During Preparation, workgroups developed and refined protocols for the following centrally-delivered intervention components: a registry to identify and track eligible patients, a centralized system for mailing at-home stool tests, and a process to navigate patients to colonoscopy after an abnormal stool test.

CONCLUSIONS

This description may be useful both to implementation scientists, who can draw lessons from applied implementation studies such as this to refine their implementation strategy typologies and frameworks, as well as to implementation practitioners seeking exemplars for operationalizing strategies in early phases of implementation in healthcare.

Implementing a mailed stool sample screening program in clinics providing care for an underserved Hispanic population

Colorectal cancer (CRC) is a leading cause of cancer-related deaths in Hispanics in the US. Despite this, Hispanics are being screened for CRC at a much lower rate than their non-Hispanic white counterparts. Implementing mailed fecal immunochemical tests (FITs) is a cost-effective intervention for increasing CRC screening rates in vulnerable populations, such as Hispanic populations in border metroplexes. We aimed to describe the effect of introductory calls coupled with mailed in-home FIT kits on CRC screening completion in two federally qualified health centers (FQHCs) in a US-Mexico border county. This was a prospective, pragmatic, two-arm intervention study with participants allocated to receive a FIT kit with a reminder call (usual care) or usual care preceded by an introductory call. The primary outcome was the percentage of patients who returned the FIT kits. Participants who returned to the FIT were primarily unemployed (54.4%), had less than a high school education (60.2%), lived in the US for at least 20 years (74.4%), and had poor self-reported health (54.4%). In addition, we observed a statistically significant increase in the absolute rate (4.5%, P = 0.003) of FITs returned when a mailed FIT kit was preceded by an introductory call compared with no initial call. This study demonstrated that adding an introductory phone call significantly improved the screening completion rate in a mailed-out CRC screening intervention in the US-Mexico border population.

Rural barriers and facilitators of lung cancer screening program implementation in the veterans health administration: a qualitative study

Introduction

To assess healthcare professionals' perceptions of rural barriers and facilitators of lung cancer screening program implementation in a Veterans Health Administration (VHA) setting through a series of one-on-one interviews with healthcare team members.

Methods

Based on measures developed using Reach Effectiveness Adoption Implementation Maintenance (RE-AIM), we conducted a cross-sectional qualitative study consisting of one-on-one semi-structured telephone interviews with VHA healthcare team members at 10 Veterans Affairs medical centers (VAMCs) between December 2020 and September 2021. An iterative inductive and deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual model to depict rural barriers and facilitators of lung cancer screening program implementation.

Results

A total of 30 interviews were completed among staff, providers, and lung cancer screening program directors and a conceptual model of rural barriers and facilitators of lung cancer screening program implementation was developed. Major themes were categorized within institutional and patient environments. Within the institutional environment, participants identified systems-level (patient communication, resource availability, workload), provider-level (attitudes and beliefs, knowledge, skills and capabilities), and external (regional and national networks, incentives) barriers to and facilitators of lung cancer screening program implementation. Within the patient environment, participants revealed patient-level (modifiable vulnerabilities) barriers and facilitators as well as ecological modifiers (community) that influence screening behavior.

Discussion

Understanding rural barriers to and facilitators of lung cancer screening program implementation as perceived by healthcare team members points to opportunities and approaches for improving lung cancer screening reach, implementation and effectiveness in VHA rural settings.

Cost-effectiveness of Human Papillomavirus Self-collection Intervention on Cervical Cancer Screening Uptake among Underscreened U.S. Persons with a Cervix

BACKGROUND

We evaluate the cost-effectiveness of human papillomavirus (HPV) self-collection (followed by scheduling assistance for those who were HPV+ or inconclusive) compared with scheduling assistance only and usual care among underscreened persons with a cervix (PWAC).

METHODS

A decision tree analysis was used to estimate the incremental cost-effectiveness ratios (ICER), or the cost per additional PWAC screened, from the Medicaid/state and clinic perspectives. A hypothetical cohort represented 90,807 low-income, underscreened individuals. Costs and health outcomes were derived from the MyBodyMyTest-3 randomized trial except the usual care health outcomes were derived from literature. We performed probabilistic sensitivity analyses (PSA) to evaluate model uncertainty.

RESULTS

Screening uptake was highest in the self-collection alternative (n = 65,721), followed by the scheduling assistance alternative (n = 34,003) and usual care (n = 18,161). The self-collection alternative costs less and was more effective than the scheduling assistance alternative from the Medicaid/state perspective. Comparing the self-collection alternative with usual care, the ICERs were $284 per additional PWAC screened from the Medicaid/state perspective and $298 per additional PWAC screened from the clinic perspective. PSAs demonstrated that the self-collection alternative was cost-effective compared with usual care at a willingness-to-pay threshold of $300 per additional PWAC screened in 66% of simulations from the Medicaid/state perspective and 58% of simulations from the clinic perspective.

CONCLUSIONS

Compared with usual care and scheduling assistance, mailing HPV self-collection kits to underscreened individuals appears to be cost-effective in increasing screening uptake.

IMPACT

This is the first analysis to demonstrate the cost-effectiveness of mailed self-collection in the United States.

Screening Mammography Utilization in the United States

Breast cancer is the second leading cause of cancer mortality in adult women in the United States. Screening mammography reduces breast cancer mortality between 22% and 48%; however, screening mammography remains underutilized. Screening mammography utilization data are available from insurance claims, electronic medical records, and patient self-report via surveys, and each data source has unique benefits and challenges. Numerous barriers exist that adversely affect the use of screening mammography in the United States. This article will review screening mammography utilization in the United States, explore factors that impact utilization, and briefly discuss strategies to improve utilization.

Effect of HPV self-collection kits on cervical cancer screening uptake among under-screened women from low-income US backgrounds (MBMT-3): a phase 3, open-label, randomised controlled trial

BACKGROUND

Most cervical cancer in the USA occurs in under-screened women. The My Body, My Test-3 (MBMT-3) trial sought to assess the efficacy of mailed human papillomavirus (HPV) self-collection kits with appointment-scheduling assistance to increase uptake of cervical cancer screening among under-screened women from low-income backgrounds compared with scheduling assistance alone.

METHODS

MBMT-3 is a phase 3, open-label, two-arm, randomised controlled trial. Participants were recruited from 22 counties in North Carolina state, USA, and we partnered with 21 clinics across these counties. Participants were eligible for inclusion if they were aged 25-64 years, had an intact cervix, were uninsured or enrolled in Medicaid or Medicare, had an income of 250% or less of the US Federal Poverty Level, were living within the catchment area of a trial-associated clinic, and were overdue for screening (ie, Papanicolaou test ≥4 years ago or high-risk HPV test ≥6 years ago). Participants were randomly assigned (2:1) to receive a mailed HPV self-collection kit and assistance for scheduling a free screening appointment (intervention group) or to receive scheduling assistance alone (control group). Randomisation was conducted by county using permuted blocks of nine patients and assignment to group was not masked. Participants in the intervention group were mailed HPV self-collection kits to collect a cervical-vaginal sample and return it by mail for testing. Samples were tested with the Aptima HPV assay (Hologic, San Diego, CA, USA), and participants were informed of high-risk HPV results by telephone call. Trial staff made up to three telephone call attempts to provide scheduling assistance for in-clinic screening for all participants. The primary outcome was cervical cancer screening uptake (ie, attending an in-clinic screening appointment or testing negative for high-risk HPV with a returned self-collected sample) within 6 months of enrolment in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02651883, and has been completed.

FINDINGS

Recruitment occurred between April 11, 2016, and Dec 16, 2019. 4256 women contacted the trial to participate, of whom 899 (21%) were eligible for inclusion and 697 (78%) returned consent forms. Of those who consented, 461 (66%) women were randomly assigned to the intervention group and 236 (34%) women were randomly assigned to the control group. We excluded 32 ineligible women post-randomisation, leaving 665 for primary analysis. Screening uptake was higher in the intervention group (317 [72%] of 438) than control group (85 [37%] of 227; risk ratio 1·93, 95% CI 1·62-2·31). Among intervention participants, 341 (78%) of 438 returned a self-collection kit. Three participants reported hurt or injury when using the self-collection kit; no participants withdrew due to adverse effects.

INTERPRETATION

Among under-screened women from low-income backgrounds, mailed HPV self-collection kits with scheduling assistance led to greater uptake of cervical cancer screening than scheduling assistance alone. At-home HPV self-collection testing has the potential to increase screening uptake among under-screened women.

FUNDING

National Cancer Institute.

Breast, cervical, and colorectal cancer screening test use in the US territories of Guam, Puerto Rico, and the US Virgin Islands

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends breast, cervical, and colorectal cancer screening among eligible adults, but information on screening use in the US territories is limited.

METHODS

To estimate the proportion of adults up-to-date with breast, cervical, and colorectal cancer screening based on USPSTF recommendations, we analyzed Behavioral Risk Factor Surveillance System data from 2016, 2018, and 2020 for the 50 US states and DC (US) and US territories of Guam and Puerto Rico and from 2016 for the US Virgin Islands. Age-standardized weighted proportions for up-to-date cancer screening were examined overall and by select characteristics for each jurisdiction.

RESULTS

Overall, 67.2% (95% CI: 60.6-73.3) of women aged 50-74 years in the US Virgin Islands, 74.8% (70.9-78.3) in Guam, 83.4% (81.7-84.9) in Puerto Rico, and 78.3% (77.9-78.6) in the US were up-to-date with breast cancer screening. For cervical cancer screening, 71.1% (67.6-74.3) of women aged 21-65 years in Guam, 81.3% (74.6-86.5) in the US Virgin Islands, 83.0% (81.7-84.3) in Puerto Rico, and 84.5% (84.3-84.8) in the US were up-to-date. For colorectal cancer screening, 45.2% (40.0-50.5) of adults aged 50-75 years in the US Virgin Islands, 47.3% (43.6-51.0) in Guam, 61.2% (59.5-62.8) in Puerto Rico, and 69.0% (68.7-69.3) in the US were up-to-date. Adults without health care coverage reported low test use for all three cancers in all jurisdictions. In most jurisdictions, test use was lower among adults with less than a high school degree and an annual household income of < $25,000.

CONCLUSION

Cancer screening test use varied between the US territories, highlighting the importance of understanding and addressing territory-specific barriers. Test use was lower among groups without health care coverage and with lower income and education levels, suggesting the need for targeted evidence-based interventions.

Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors

PURPOSE

Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors.

METHODS

During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity.

RESULTS

The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed.

CONCLUSION

In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.

Colorectal cancer screening completion by patients due or overdue for screening after reminders: a retrospective study

BACKGROUND

Patient and clinician reminders were implemented as part of an adherence improvement project at University of Florida (UF) Internal Medicine Clinics. We sought to assess colorectal cancer (CRC) screening completion rates among patients not up-to-date with screening following distribution of reminders and to identify characteristics correlated with screening outcomes.

METHODS

Retrospective chart review was performed for patients not up-to-date with CRC screening for whom at least one reminder (patient and/or clinician) was issued in June 2018. The primary endpoint, the completion of a CRC screening test, is characterized as the ratio of completed screening tests to the number of patients not up-to-date with screening. All analyses were performed using R 4.0 software.

RESULTS

Of the 926 patients included, 403 (44%; 95% CI, 0.40-0.47) completed a CRC screening test within 24 months following a reminder. Family history of CRC (relative risk (RR) 1.33; P = 0.007), flu immunization within two years of the reminder (RR 1.23; P = 0.019), and receiving a patient reminder either alone (RR 1.62; P < 0.001) or in combination with a clinician reminder (RR 1.55; P = 0.006) were positively associated with CRC screening completion. Reporting being divorced, separated, or widowed was negatively associated with screening completion (RR 0.70; P = 0.004).

CONCLUSION

Reminders, in particular patient reminders, seem to be an effective method to enhance screening among patients not up-to-date with CRC screening. This study suggests that reminder efforts should be focused at the level of the patients and provides insight on target populations for practical interventions to further increase CRC screening adherence.

Primary care provider interventions for addressing cancer screening participation with marginalised patients: a scoping review protocol

INTRODUCTION

Cancer screening is an integral component of primary care, and providers can play a key role in facilitating screening. While much work has focused on patient interventions, there has been less attention on primary care provider (PCP) interventions. In addition, marginalised patients experience disparities in cancer screening which are likely to worsen if not addressed. The objective of this scoping review is to report on the range, extent and nature of PCP interventions that maximise cancer screening participation among marginalised patients. Our review will target cancers where there is strong evidence to support screening, including lung, cervical, breast and colorectal cancers.

METHODS AND ANALYSIS

This is a scoping review conducted in accordance with the framework by Levac et al. Comprehensive searches will be conducted by a health sciences librarian using Ovid MEDLINE, Ovid Embase, Scopus, CINAHL Complete and the Cochrane Central Register of Controlled Trials. We will include peer-reviewed English language literature published from 1 January 2000 to 31 March 2022 that describes PCP interventions to maximise cancer screening participation for breast, cervical, lung and colorectal cancers. Two independent reviewers will screen all articles and identify eligible studies for inclusion in two stages: title and abstract, then full text. A third reviewer will resolve any discrepancies. Charted data will be synthesised through a narrative synthesis using a piloted data extraction form informed by the Template for Intervention Description and Replication checklist.

ETHICS AND DISSEMINATION

Since this is a synthesis of digitally published literature, no ethics approval is needed for this work. We will target appropriate primary care or cancer screening journals and conference presentations to publish and disseminate the results of this scoping review. The results will also be used to inform an ongoing research study developing PCP interventions for addressing cancer screening with marginalised patients.

Using User-Centered Design to Facilitate Adherence to Annual Lung Cancer Screening: Protocol for a Mixed Methods Study for Intervention Development

BACKGROUND

Lung cancer is the leading cause of cancer-related death in the United States, with the majority of lung cancer occurrence diagnosed after the disease has already metastasized. Lung cancer screening (LCS) with low-dose computed tomography can diagnose early-stage disease, especially when eligible individuals participate in screening on a yearly basis. Unfortunately, annual adherence has emerged as a challenge for academic and community screening programs, endangering the individual and population health benefits of LCS. Reminder messages have effectively increased adherence rates in breast, colorectal, and cervical cancer screenings but have not been tested with LCS participants who experience unique barriers to screening associated with the stigma of smoking and social determinants of health.

OBJECTIVE

This research aims to use a theory-informed, multiphase, and mixed methods approach with LCS experts and participants to develop a set of clear and engaging reminder messages to support LCS annual adherence.

METHODS

In aim 1, survey data informed by the Cognitive-Social Health Information Processing model will be collected to assess how LCS participants process health information aimed at health protective behavior to develop content for reminder messages and pinpoint options for message targeting and tailoring. Aim 2 focuses on identifying themes for message imagery through a modified photovoice activity that asks participants to identify 3 images that represent LCS and then participate in an interview about the selection, likes, and dislikes of each photo. A pool of candidate messages for multiple delivery platforms will be developed in aim 3, using results from aim 1 for message content and aim 2 for imagery selection. The refinement of message content and imagery combinations will be completed through iterative feedback from LCS experts and participants.

RESULTS

Data collection began in July 2022 and will be completed by May 2023. The final reminder message candidates are expected to be completed by June 2023.

CONCLUSIONS

This project proposes a novel approach to facilitate adherence to annual LCS through the development of reminder messages that embrace content and imagery representative of the target population directly in the design process. Developing effective strategies to increase LCS adherence is instrumental in achieving optimal LCS outcomes at individual and population health levels.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46657.

Comparative Effectiveness of 2 Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Among Women in the Rural US: A Randomized Clinical Trial

Importance

Women living in rural areas have lower rates of breast, cervical, and colorectal cancer screening compared with women living in urban settings.

Objective

To assess the comparative effectiveness of (1) a mailed, tailored digital video disc (DVD) intervention; (2) a DVD intervention plus telephonic patient navigation (DVD/PN); and (3) usual care with simultaneously increased adherence to any breast, cervical, and colorectal cancer screening that was not up to date at baseline and to assess cost-effectiveness.

Design, Setting, and Participants

This randomized clinical trial recruited and followed up women from rural Indiana and Ohio (community based) who were not up to date on any or all recommended cancer screenings. Participants were randomly assigned between November 28, 2016, and July 1, 2019, to 1 of 3 study groups (DVD, DVD/PN, or usual care). Statistical analyses were completed between August and December 2021 and between March and September 2022.

Intervention

The DVD interactively assessed and provided messages for health beliefs, including risk of developing the targeted cancers and barriers, benefits, and self-efficacy for obtaining the needed screenings. Patient navigators counseled women on barriers to obtaining screenings. The intervention simultaneously supported obtaining screening for all or any tests outside of guidelines at baseline.

Main Outcomes and Measures

Receipt of any or all needed cancer screenings from baseline through 12 months, including breast, cervical, and colorectal cancer, and cost-effectiveness of the intervention. Binary logistic regression was used to compare the randomized groups on being up to date for all and any screenings at 12 months.

Results

The sample included 963 women aged 50 to 74 years (mean [SD] age, 58.6 [6.3] years). The DVD group had nearly twice the odds of those in the usual care group of obtaining all needed screenings (odds ratio [OR], 1.84; 95% CI, 1.02-3.43; P = .048), and the odds were nearly 6 times greater for DVD/PN vs usual care (OR, 5.69; 95% CI, 3.24-10.5; P < .001). The DVD/PN intervention (but not DVD alone) was significantly more effective than usual care (OR, 4.01; 95% CI, 2.60-6.28; P < .001) for promoting at least 1 (ie, any) of the needed screenings at 12 months. Cost-effectiveness per woman who was up to date was $14 462 in the DVD group and $10 638 in the DVD/PN group.

Conclusions and Relevance

In this randomized clinical trial of rural women who were not up to date with at least 1 of the recommended cancer screenings (breast, cervical, or colorectal), an intervention designed to simultaneously increase adherence to any or all of the 3 cancer screening tests was more effective than usual care, available at relatively modest costs, and able to be remotely delivered, demonstrating great potential for implementing an evidence-based intervention in remote areas of the midwestern US.

Trial Registration

ClinicalTrials.gov Identifier: NCT02795104.

Comparison of Lung Cancer Screening Eligibility and Use between Commercial, Medicare, and Medicare Advantage Enrollees

OBJECTIVE

Lung cancer screening does not require patient cost-sharing for insured people in the U.S. Little is known about whether other factors associated with patient selection into different insurance plans affect screening rates. We examined screening rates for enrollees in commercial, Medicare Fee-for-Service (FFS), and Medicare Advantage plans.

METHODS

County-level smoking rates from the 2017 County Health Rankings were used to estimate the number of enrollees eligible for lung cancer screening in two large retrospective claims databases covering: a 5% national sample of Medicare FFS enrollees; and 100% sample of enrollees associated with large commercial and Medicare Advantage carriers. Screening rates were estimated using observed claims, stratified by payer, before aggregation into national estimates by payer and demographics. Chi-square tests were used to examine differences in screening rates between payers.

RESULTS

There were 1,077,142 enrollees estimated to be eligible for screening. The overall estimated screening rate for enrollees by payer was 1.75% for commercial plans, 3.37% for Medicare FFS, and 4.56% for Medicare Advantage plans. Screening rates were estimated to be lowest among females (1.55%-4.02%), those aged 75-77 years (0.63%-2.87%), those residing in rural areas (1.88%-3.56%), and those in the West (1.16%-3.65%). Among Medicare FFS enrollees, screening rates by race/ethnicity were non-Hispanic White (3.71%), non-Hispanic Black (2.17%) and Other (1.68%).

CONCLUSIONS

Considerable variation exists in lung cancer screening between different payers and across patient characteristics. Efforts targeting historically vulnerable populations could present opportunities to increase screening.

Community Health Workers to Increase Cancer Screening: 3 Community Guide Systematic Reviews

INTRODUCTION

Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening.

METHODS

Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community.

RESULTS

The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.5‒23.5), cervical (median increase=12.8 percentage points, interquartile interval=6.4‒21.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.5‒17.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status.

DISCUSSION

Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake.

Breast cancer screening during the COVID-19 pandemic: moving from disparities to health equity

The COVID-19 pandemic created unprecedented disruptions to routine health care in the United States. Screening mammography, a cornerstone of breast cancer control and prevention, was completely halted in the spring of 2020, and screening programs have continued to face challenges with subsequent COVID-19 waves. Although screening mammography rates decreased for all women during the pandemic, a number of studies have now clearly documented that reductions in screening have been greater for some populations than others. Specifically, minoritized women have been screened at lower rates than White women across studies, although the specific patterns of disparity vary depending on the populations and communities studied. We posit that these disparities are likely due to a variety of structural and contextual factors, including the differential impact of COVID-19 on communities. We also outline key considerations for closing gaps in screening mammography. First, practices, health systems, and communities must measure screening mammography use to identify whether gaps exist and which populations are most affected. Second, we propose that strategies to close disparities in breast cancer screening must be multifaceted, targeting the health system or practice, but also structural factors at the policy level. Health disparities arise from a complex set of conditions, and multimodal solutions that address the complex, multifactorial conditions that lead to disparities may be more likely to succeed and are necessary for promoting health equity.

Factors Associated With False-Positive Recalls in Mammography Screening

BACKGROUND

We aimed to identify factors associated with false-positive recalls in mammography screening compared with women who were not recalled and those who received true-positive recalls.

METHODS

We included 29,129 women, aged 40 to 74 years, who participated in the Karolinska Mammography Project for Risk Prediction of Breast Cancer (KARMA) between 2011 and 2013 with follow-up until the end of 2017. Nonmammographic factors were collected from questionnaires, mammographic factors were generated from mammograms, and genotypes were determined using the OncoArray or an Illumina custom array. By the use of conditional and regular logistic regression models, we investigated the association between breast cancer risk factors and risk models and false-positive recalls.

RESULTS

Women with a history of benign breast disease, high breast density, masses, microcalcifications, high Tyrer-Cuzick 10-year risk scores, KARMA 2-year risk scores, and polygenic risk scores were more likely to have mammography recalls, including both false-positive and true-positive recalls. Further analyses restricted to women who were recalled found that women with a history of benign breast disease and dense breasts had a similar risk of having false-positive and true-positive recalls, whereas women with masses, microcalcifications, high Tyrer-Cuzick 10-year risk scores, KARMA 2-year risk scores, and polygenic risk scores were more likely to have true-positive recalls than false-positive recalls.

CONCLUSIONS

We found that risk factors associated with false-positive recalls were also likely, or even more likely, to be associated with true-positive recalls in mammography screening.

A Scoping Literature Review on Evidence-Based Strategies to Increase Cervical Cancer Screening

Previous reviews of strategies to increase cervical cancer screening are more than 10 years old, the U.S. continues to fall short of the Healthy People 2030 cervical cancer screening goal, and guidelines were revised in 2018, therefore an updated review of the existing literature is needed. We conducted a scoping review using electronic databases PubMed, Scopus, and Ovid Medline that included publication dates between 2012 and 2021 to answer the question, "Which strategies implemented in U.S. primary care settings have been most successful in increasing rates of cervical cancer screening since the 2012 US Preventative Services Task Force cervical cancer screening guidelines were published?" We mapped findings to pre-specified implementation strategy categories. After initially identifying 399 articles, we excluded 350 due to duplicates or not meeting review criteria, leaving 49 articles for full review. We excluded 37 of these during full-text review and identified 2 additional articles from the manual search of reference lists for a total of 14 studies for abstraction. Eleven articles reported on strategies resulting in increased cervical cancer screening, and 3 did not. Clinic workflow re-design strategies showed the greatest promise in improving cervical cancer screening rates, education strategies for patients had mixed results, and quality management strategies were not effective. These findings suggest clinical workflow re-structures and patient education strategies can increase cervical cancer screening in primary care settings. Results are particularly important in settings that care for underserved populations, as these settings may need additional implementation strategies to decrease cervical cancer screening disparities.

Developing a co-production strategy to facilitate the adoption and implementation of evidence-based colorectal cancer screening interventions for rural health systems: a pilot study

BACKGROUND

Evidence-based colorectal cancer screening (CRCS) interventions have not been broadly adopted in rural primary care settings. Co-production of implementation strategies through a bundled approach may be promising in closing this gap by helping rural healthcare practitioners select and implement the best fitting CRCS interventions to the local context. This paper describes the process and outcomes of co-development and delivery of the bundled implementation strategy to improve adoption and implementation of CRCS interventions with two rural clinics.

METHODS

We used a bundle of implementation strategies with a core focus on academic-clinical partnership development (strategy 1) and Plan-Do-Study-Act cycles (strategy 2) to identify clinical partner interests/preferences on delivery methods and content needed to facilitate intervention identification and implementation that improves CRCS. We also developed an implementation blueprint for each clinic (strategy 3) through an online blueprinting process based on adapted "Putting Public Health Evidence in Action" (PPHEA) training curriculum. Clinic physicians and staff (n = 7) were asked to evaluate the bundled approach based on overall reactions and perceptions of innovation characteristics using 5-point Likert scale. After completing the bundled approach, we collected implementation outcomes and limited intervention effectiveness of the CRCS evidence-based interventions (EBIs) developed through the process.

RESULTS

Our co-production strategy yielded a prototype online blueprinting process consisting of 8 distance-learning PPHEA modules that guide selection and implementation of EBIs tailored to CRCS. Modules were delivered to clinic participants with minor adaptations, using PDSA cycle to improve quality of module contents and formats. Overall, participants in both clinics reported positive reactions toward the bundled approach. Both clinics reported improvements in how they perceived the characteristics of the innovation (the bundled approach) to tailor selected CRCS EBIs. As a result of the bundled strategies, each clinic selected and adopted specific EBI(s) with the varying degrees of implementation and CRCS outcomes.

CONCLUSIONS

The bundle of implementation strategies used were feasible and acceptable in rural primary care practices to facilitate the use of EBIs to improve CRCS.

Understanding cancer genetic risk assessment motivations in a remote tailored risk communication and navigation intervention randomized controlled trial

Background

National guidelines recommend cancer genetic risk assessment (CGRA) (i.e. genetic counseling prior to genetic testing) for women at increased risk for hereditary breast and ovarian cancer (HBOC). Less than one-half of eligible women obtain CGRA, leaving thousands of women and their family members without access to potentially life-saving cancer prevention interventions.

Purpose

The Genetic Risk Assessment for Cancer Education and Empowerment Project (GRACE) addressed this translational gap, testing the efficacy of a tailored counseling and navigation (TCN) intervention vs. a targeted print brochure vs. usual care on CGRA intentions. Selected behavioral variables were theorized to mediate CGRA intentions.

Methods

Breast and ovarian cancer survivors meeting criteria for guideline-based CGRA were recruited from three state cancer registries (N = 654), completed a baseline survey, and were randomized. TCN and targeted print arms received the brochure; TCN also participated in a tailored, telephone-based decision coaching and navigation session grounded in the Extended Parallel Process Model and Ottawa Decision Support Framework. Participants completed a one-month assessment. Logistic regression was used to compare the rate of CGRA intentions. CGRA intentions and theorized mediator scores (continuous level variables) were calculated using mixed model analysis.

Results

CGRA intentions increased for TCN (53.2%) vs. targeted print (26.7%) (OR = 3.129; 95% CI: 2.028, 4.827, p < .0001) and TCN vs. usual care (23.1%) (OR = 3.778, CI: 2.422, 5.894, p < .0001). Perceived risk (p = 0.023) and self-efficacy (p = 0.035) mediated CGRA intentions in TCN.

Conclusions

Improvements in CGRA intentions and theorized mediators support the use of a tailored communication intervention among women at increased HBOC risk. (Clinicaltrials.gov: NCT03326713.)Trial registration: ClinicalTrials.gov identifier: NCT03326713.

Retrenchment of Wisconsin's Well Woman Program and changes in insurance coverage around the Affordable Care Act

Since before the Affordable Care Act (ACA), states have partnered with the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to support access to cancer screening and treatment for uninsured/underinsured women. The Wisconsin Well Woman Program (WWWP) was one such program, supporting low-income women across the state. With ACA introduction, Wisconsin substantially downsized/restructured the WWWP, expecting the reduction in services to be offset by the rise in ACA-provided insurance coverage. This study assesses whether retrenchment in the WWWP following the ACA indeed prompted a differential rise in insurance coverage among the program's target population. We use a difference-in-differences (DID) design to contrast changes in county-level, target-population insurance rates, over 2008-2018, in Wisconsin counties previously most served by the WWWP vs those least served, adjusting for systematic differences across counties, including pre-policy trends. Pre-ACA (2011-2013), most-served counties had lower insurance rates by 2.5 percentage points (pp) than least-served counties; WWWP services likely compensated for some of that gap. In 2014-2015, along with WWWP's steep contraction, insurance rates rose sharply across all counties. Our primary DID analysis and event study suggest that WWWP contraction might have differentially driven more insurance take-up in most-served counties, by 1.88 pp [95 % Confidence Interval: 0.23,3.54], thus narrowing the pre-ACA gap. Sensitivity analyses suggest much smaller gains. Notwithstanding such potential insurance gains following program contraction, continued support for care navigation and coordination remain necessary to truly meet the needs of the vulnerable women previously served by the WWWP and similar programs across states.

Patient perspectives on cervical cancer screening interventions among underscreened women

BACKGROUND

Cervical cancer is highly preventable with regular screening, yet over 4,000 women die from it annually in the United States. Over half of new cervical cancer cases in the U.S. are attributable to insufficient screening.

METHODS

Participants were 23 low-income, uninsured or Medicaid-insured women in North Carolina who were overdue for cervical cancer screening according to national guidelines. Semi-structured interviews examined perspectives on barriers to cervical cancer screening and on interventions to reduce these barriers. We also elicited feedback on three proposed evidence-based interventions: one-on-one education, coupons to reduce out-of-pocket costs, and self-collection of samples for detection of high-risk human papillomavirus (HPV) infection, the primary cause of cervical cancer.

RESULTS

Reported barriers included high cost, inconvenient clinic hours, lack of provider recommendation, poor transportation, difficulty finding a provider, fear of pain, and low perceived need. Participants suggested interventions including reducing cost, improving convenience through community-based screening or extended clinic hours, strengthening provider recommendations, and providing one-on-one counseling and education outreach. HPV self-collection was most frequently selected as the "most helpful" of 3 proposed interventions (n = 11), followed by reducing out-of-pocket costs (n = 7) and one-on-one education (n = 5).

CONCLUSION

Cost was the most reported barrier to cervical cancer screening, although women experience multiple simultaneous barriers. Novel interventions such as HPV self-collection promise to reduce some, but not all, barriers to primary screening. Interventions that work on reducing multiple barriers, including obstacles to receiving follow-up care, may be most effective to prevent cervical cancer among these high-risk women.

How effective are digital technology-based interventions at promoting colorectal cancer screening uptake in average-risk populations? A systematic review and meta-analysis of randomized controlled trials

Despite the global prevalence of colorectal cancer (CRC) and efforts in screening advocacy, screening uptake remains relatively low. Considering the greater accessibility and popularity of telemedicine in behaviour change interventions, this meta-analysis seeks to examine the usefulness of digital interventions in promoting CRC screening uptake as compared to existing non-digital strategies. A systematic search on five databases identified articles published before September 2022. Randomized controlled trials comparing the effectiveness of digital interventions to usual care were included and assessed using the Cochrane's Risk of Bias tool. Effectiveness of interventions was measured by CRC screening completion rates, and pooled effect sizes were computed for both digital intervention subtypes identified - decision-making aids and tailored educational interventions. 14 studies (17,075 participants) assessed to have low or some risk of bias were included in this meta-analysis. A random-effects model revealed that digital interventions were more likely to promote CRC screening uptake (OR = 1.31, 95% CI: 1.11-1.56), and using a decision-making aid was almost 1.5 times more likely to result in screening completion (i.e., completed a colorectal investigation using stool-based or direct visualization test) (OR = 1.42, 95% CI: 1.24-1.63). Meanwhile, the tailored educational intervention subtype failed to achieve statistical significance in promoting screening uptake, bearing in mind the significant heterogeneity across studies (I² = 88.6%). Digital decision-making aids significantly improved CRC screening uptake compared to tailored digital educational interventions and usual care. However, as all included studies were conducted in Western settings, its role in augmenting existing CRC screening promotion strategies especially among Asians should be further evaluated.

Identifying Priorities and Strategies for Improving Colorectal Cancer Screening in Tribal Clinics

BACKGROUND

Colorectal cancer (CRC) is the 3^rd most frequently diagnosed cancer and the 2^nd leading cause of cancer death in the United States (US), and incidence and mortality rates in Oklahoma are higher for many American Indian (AI) populations than other populations. The AI CRC Screening Consortium addresses major regional CRC screening disparities among AIs with shared objectives to increase CRC screening delivery and uptake in AIs aged 50 to 75 years at average risk for CRC and to assess the effectiveness of implementations of the interventions. This manuscript reports environmental scan findings related to current practices and multi-stakeholder experiences with CRC screening in two Oklahoma Indian health care systems.

METHOD

We conducted a mixed methods environmental scan across five clinical sites and with multiple stakeholders to determine the scope and scale of colorectal cancer screening in two separate AI health care delivery systems in Oklahoma. Data collection consisted of a mixture of individual interviews and group discussions at an urban site, and four clinical care sites within a tribal health system.

RESULTS

Sixty-two individuals completed interviews. Data from these interviews will inform the development of evidence-based intervention strategies to increase provider delivery, community access to, and community priority for CRC screening in diverse AI health care delivery systems. Conversations with patients, providers, and clinical leadership point to individual and system-level opportunities for improvement at each site, shaped in part by differences in the delivery of services, structure of the health care system, and capacity to implement new intervention strategies. The thematic areas most central to the process of evidenced-based intervention development included: current practices, needs and recommendations, and CRC site priorities.

CONCLUSION

Environmental scan data indicated clear opportunities for individual and system-level interventions to enhance CRC screening and was critical for understanding readiness for EBI implementation at each site.

Breast cancer knowledge and understanding treatment rationales among diverse breast cancer survivors

Purpose

The degree to which breast cancer survivors know about their tumors and understand treatment rationales is not well understood. We sought to identify information gaps within a diverse sample and explore whether knowledge about breast cancer and treatment may impact care.

Methods

We conducted a one-time, interviewer-administered survey of women who were diagnosed with breast cancer during 2013–2017 and received care at one of three centers in Boston, MA, and New York, NY. We examined knowledge of breast cancer and treatment rationales, information preferences, and treatment receipt.

Results

During 2018–2020, we interviewed 313 women (American Association for Public Opinion Research Cooperation Rates 58.4–76.5% across centers) who were 56.9% White, 23.6% Black, 14.1% Hispanic, and 5.4% other. Among the 296 included in analyses, we observed high variability in knowledge of breast cancer and treatment rationales, with a substantial number demonstrating limited knowledge despite feeling highly informed; > 25% actively avoided information. Black and Hispanic (vs. White) women consistently knew less about their cancers. Lack of understanding of treatment rationales for chemotherapy, radiation, and hormonal therapy was common but not consistently different by race and ethnicity. Understanding treatment rationale (but not cancer knowledge) was associated with treatment initiation, but small sample sizes limited in-depth examination.

Conclusions

Our study highlights the need for enhanced informational support for breast cancer survivors, who are challenged with complex information during the decision-making process and beyond. More research is needed to understand how to further educate and empower diverse populations of patients with breast cancer.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06752-8.

Association between Oxidative Stress Parameters and Hematological Indices in Breast Cancer Patients

Background

Breast cancer is one of the leading causes of death in women worldwide. This causes an increase in free radicals, resulting in oxidative stress. The aim of this study was to determine the effect of breast cancer on oxidative stress and its relationship with hematological indices.

Methods

This case-control study included 43 women with breast cancer and 37 age-matched healthy controls. Oxidative stress and its correlation with hematological profiles over seven months were evaluated. Finally, the data were compared between the two groups using the t-test and Pearson's test, and the results were analyzed using the SPSS 24 software.

Results

The results revealed that patients with breast cancer had significantly increased hemoglobin (HB), hematocrit (HCT), mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH) levels compared with healthy subjects (p < 0.05). In addition, oxidative stress parameters, such as superoxide dismutase (SOD), catalase (CAT), total oxidant status (TOS), and total antioxidant capacity (TAC), were significantly elevated. Glutathione peroxidase (GPX) and malondialdehyde (MDA) were significantly lower in patients with breast cancer than in the control group (p < 0.05). Statistical significance in hematological indices showed a positive or negative correlation with oxidative stress parameters.

Conclusion

Women with breast cancer showed a deranged complete blood count (CBC) pattern compared to healthy individuals.

Implementation fidelity in a multifaceted program to foster rational antibiotics use in primary care: an observational study

BACKGROUND

The ARena study (Sustainable Reduction of Antimicrobial Resistance in German Ambulatory Care) is a three-arm, cluster randomized trial to evaluate a multifaceted implementation program in a German primary care setting. In the context of a prospective process evaluation conducted alongside ARena, this study aimed to document and explore fidelity of the implementation program.

METHODS

This observational study is based on data generated in a three-wave survey of 312 participating physicians in the ARena program and attendance documentation. Measures concerned persistence of participation in the ARena program and adherence to intervention components (thematic quality circles, e-learning, basic expenditure reimbursements, additional bonus payments and a computerized decision support system). Participants' views on five domains of the implementation were also measured. Binary logistic and multiple linear regression analyses were used to explore which views on the implementation were associated with participants' adherence to quality circles and use of additional bonus compensation.

RESULTS

The analysis of fidelity showed overall high persistence of participation in the intervention components across the three intervention arms (90,1%; 97,9%; 92,9%). 96.4% of planned quality circles were delivered to study participants and, across waves, 30.4% to 93% of practices participated; 56.1% of physicians attended the maximum of four quality circles. 84% of the practices (n = 158) with a minimum of one index patient received a performance-based additional bonus payment at least once. In total, bonus compensation was triggered for 51.8% of affected patients. Participation rate for e-learning (a prerequisite for reimbursement of project-related expenditure) covered 90.8% of practices across all intervention arms, with the highest rate in arm II (96.5%). Uptake of expenditure reimbursement was heterogeneous across study arms, with a mean rate of 86.5% (89.1% in arm I, 96.4% in arm II and 74.1% in arm III). Participants' views regarding participant responsiveness (OR = 2.298) 95% CI [1.598, 3.305] and Context (OR = 2.146) 95% CI [1.135, 4.055] affected additional bonus payment. Participants' views on participant responsiveness (Beta = 0.718) 95% CI [0.479, 0.957], Context (Beta = 0.323) 95% CI [0.055, 0.590] and Culture of shared decision-making (Beta = -0.334) 95% CI [-0.614, -0.053] affected quality circle attendance.

CONCLUSION

This study showed an overall high fidelity to the implementation program. Participants' views on the implementation were associated with degree of intervention fidelity.

TRIAL REGISTRATION

ISRCTN, ISRCTN58150046.

Facilitators and Barriers to Implementation of Lung Cancer Screening: A Framework-Driven Systematic Review

BACKGROUND

The purpose of this study is to undertake a comprehensive systematic review to describe multilevel factors (barriers and facilitators) that may influence the implementation of low-dose chest computed tomography for lung cancer screening in the United States.

METHODS

Systematic literature searches were performed using 6 online databases and citation indexes for peer-reviewed studies, for articles published from 2013 to 2021. Studies were classified into 3 perspectives, based on the study's unit of analysis: system, health-care provider, and patient. Barriers and facilitators identified for each study included in our final review were then coded and categorized using the Consolidate Framework for Implementation Research domains.

RESULTS

At the system level, the 2 most common constructs were external policy and incentives and executing the implementation process. At the provider level, the most common constructs were evidence strength and quality of the intervention characteristics, patient needs and resources, implementation climate, and an individual's knowledge and beliefs about the intervention. At the patient level, the most common constructs were patient needs and resources, individual's knowledge and beliefs about the intervention, and engaging in the implementation process. These constructs can act as facilitators or barriers to lung cancer screening implementation.

CONCLUSIONS

Applying the Consolidate Framework for Implementation Research domains and constructs to understand and specify factors facilitating uptake of lung cancer screening as well as cataloging the lessons learned from previous efforts helps inform the development and implementation processes of lung cancer screening programs in the community setting.

REGISTRATION

PROSPERO, CRD42021247677.

Optimising Awareness and Knowledge of Breast Cancer Screening for Nurses Through Train-the-Trainer Workshops

Nurses play an important role in educating patients on breast cancer and have a positive influence in encouraging women to participate in breast screening. This current study aimed to use a train-the-trainer model to improve the level of knowledge of nurses on breast cancer and screening in Ras Al Khaimah, United Arab Emirates. The study also focused on the nurses' ability to train other nurses in assisting women to engage in breast screening. This interventional study used a mixed-method design. Seventeen female nurses (aged 28-60 years) were recruited from public and private health centers and participated in a breast cancer train-the-trainer workshop. They completed a survey before and after the workshop. The surveys included a series of open and closed questions to assess their knowledge of breast cancer symptoms, risk factors, diagnosis, and patient communication. The study found that nurse participants had good baseline knowledge of breast cancer topics, including breast self-examinations, clinical breast examinations, and mammography. Responses were deemed accurate if they answered open-ended questions without incorrect information and correct options were selected in the quantitative sections. However, training improved the detail and accuracy of the participant responses. Training also improved the confidence of nurse participants to teach other women and nurses how to perform breast self-examinations and provide breast cancer information. There were significant increases in nurse participants' knowledge of risk factors (p < 0.001, r = 0.6) and symptoms (p = 0.003, r = 0.5). The nurse participants perceived that health education was the best means of encouraging women to participate in breast screening.