Multisectoral Collaborations to Increase the Use of Recommended Cancer Screening and Other Clinical Preventive Services by Older Adults

Multisectoral interventions and health system performance: a systematic review

Objective

To conduct a systematic review on the effects of multisectoral interventions for health on health system performance.

Methods

We conducted a systematic review according to the preferred reporting items for systematic review and meta-analysis protocols. We searched for peer-reviewed journal articles in PubMed®, Scopus, Web of Science, Cumulated Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews on 31 August 2023 (updating on 28 February 2024). We removed duplicates, screened titles and abstracts, and then conducted a full-text eligibility and quality assessment.

Findings

We identified an initial 1118 non-duplicate publications, 62 of which met our inclusion and exclusion criteria. The largest proportions of reviewed studies focused on multisectoral interventions directly related to specific health outcomes (66.1%; 41 studies) and/or social determinants of health (48.4%; 30 studies), but without explicit reference to overall health system performance. Most reviewed publications did not address process indicators (83.9%; 52/62) or discuss sustainability for multisectoral interventions in health (72.6%; 45/62). However, we observed that the greatest proportion (66.1%; 41/62) considered health system goals: health equity (68.3%; 28/41) and health outcomes (63.4%; 26/41). Although the greatest proportion (64.5%; 40/62) proposed mechanisms explaining how multisectoral interventions for health could lead to the intended outcomes, none used realistic evaluations to assess these.

Conclusion

Our review has established that multisectoral interventions influence health system performance through immediate improvements in service delivery efficiency, readiness, acceptability and affordability. The interconnectedness of these effects demonstrates their role in addressing the complexities of modern health care.

Use of and barriers to adopting standardized social risk screening tools in federally qualified health centers during the first year of the COVID-19 pandemic

OBJECTIVE

To describe the national rate of social risk factor screening adoption among federally qualified health centers (FQHCs), examine organizational factors associated with social risk screening adoption, and identify barriers to utilizing a standardized screening tool in 2020.

DATA SOURCE

2020 Uniform Data System, a 100% sample of all US FQHCs (N = 1375).

STUDY DESIGN

We used multivariable linear probability models to assess the association between social risk screening adoption and key FQHC characteristics. We used descriptive statistics to describe variations in screening tool types and barriers to utilizing standardized tools. We thematically categorized open-ended responses about tools and barriers.

DATA COLLECTION

None.

PRINCIPAL FINDINGS

In 2020, 68.9% of FQHCs screened patients for any social risk factors. Characteristics associated with a greater likelihood of screening adoption included having high proportions of patients best served in a language other than English (18.8 percentage point [PP] increase, 95% CI: 6.0, 31.6) and being larger in size (10.3 PP increase, 95% CI: 0.7, 20.0). Having higher proportions of uninsured patients (14.2 PP decrease, 95% CI: -25.5, -0.3) and participating in Medicaid-managed care contracts (7.3 PP decrease, 95% CI: -14.2, -0.3) were associated with lower screening likelihood. Among screening FQHCs, the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) was the most common tool (47.1%). Among non-screening FQHCs, common barriers to using a standardized tool included lack of staff training to discuss social issues (25.2%), inability to include screening in patient intake (21.7%), and lack of funding for addressing social needs (19.2%).

CONCLUSIONS

Though most FQHCs screened for social risk factors in 2020, various barriers have prevented nearly 1 in 3 FQHCs from adopting a screening tool. Policies that provide FQHCs with resources to support training and workflow changes may increase screening uptake and facilitate engagement with other sectors.

Public Health Messaging and Strategies to Promote "SWIFT" Lung Cancer Detection: a Qualitative Study Among High-Risk Individuals

Lung cancer (LC) is the most common cancer and the leading cause of cancer mortality globally. A positive association between LC incidence and socioeconomic deprivation exists. High-risk individuals are less likely to be aware of LC and to correctly appraise LC symptoms and seek medical help accordingly. This qualitative study explored strategies to promote early detection of LC among at-risk individuals living in high-incidence areas in Ireland. Five semi-structured focus groups were conducted with 46 individuals. Data were collected face-to-face in community centres and organisations in high-incidence areas in two Irish counties and analysed using inductive qualitative content analysis. Participants believed that there was insufficient information regarding LC and recommended promoting LC awareness at a young rather than old age. They favoured public health messages that are Simple, clear, and honest; Worded positively; Incorporating a shock element; Featuring a celebrity, healthcare professional, or survivor; and Targeted (SWIFT). Most participants reported becoming immune to messages on cigarette packaging and recommended using a combination of broadcast and print media within national government-run campaigns to promote LC awareness and early detection. Study findings suggest that promoting LC awareness, help-seeking, early presentation, and diagnosis can be achieved by developing and testing targeted interventions. Promoting LC awareness requires a multi-sectoral policy network, or a whole systems approach. Such approaches ought to consider the multifactorial drivers of LC risk behaviours; involve coordinated, collective actions across various stakeholders; operate across multiple agencies; and take a life course perspective.

Measuring capacity to use evidence-based interventions in community-based organizations: A comprehensive, scoping review

Introduction:

Community-based organizations (CBOs) are well-positioned to incorporate research evidence, local expertise, and contextual factors to address health inequities. However, insufficient capacity limits use of evidence-based interventions (EBIs) in these settings. Capacity-building implementation strategies are popular, but a lack of standard models and validated measures hinders progress in the field. To advance the literature, we conducted a comprehensive scoping review.

Methods:

With a reference librarian, we executed a comprehensive search strategy of PubMed/Medline, Web of Science Core Collection, and EBSCO Global Health. We included articles that addressed implementation science, capacity-building, and CBOs. Of 5527 articles, 99 met our inclusion criteria, and we extracted data using a double-coding process

Results:

Of the 99 articles, 47% defined capacity explicitly, 31% defined it indirectly, and 21% did not define it. Common concepts in definitions were skills, knowledge/expertise, and resources. Of the 57 articles with quantitative analysis, 48 (82%) measured capacity, and 11 (23%) offered psychometric data for the capacity measures. Of the 99 studies, 40% focused exclusively on populations experiencing inequities and 22% included those populations to some extent. The bulk of the studies came from high-income countries.

Conclusions:

Implementation scientists should 1) be explicit about models and definitions of capacity and strategies for building capacity, 2) specify expected multi-level implementation outcomes, 3) develop and use validated measures for quantitative work, and 4) integrate equity considerations into the conceptualization and measurement of capacity-building efforts. With these refinements, we can ensure that the necessary supports reach CBO practitioners and critical partners for addressing health inequities.

Validation of rule-based algorithms to determine colorectal, breast, and cervical cancer screening status using electronic health record data from an urban healthcare system in New York City

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Cancer screening adherence can be estimated using electronic health record data.

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Screening algorithms had high sensitivity and specificity compared to manual review.

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Validation of screening algorithms can be performed using de-identified data.

Although cancer screening has greatly reduced colorectal cancer, breast cancer, and cervical cancer morbidity and mortality over the last few decades, adherence to cancer screening guidelines remains inconsistent, particularly among certain demographic groups. This study aims to validate a rule-based algorithm to determine adherence to cancer screening. A novel screening algorithm was applied to electronic health record (EHR) from an urban healthcare system in New York City to automatically determine adherence to national cancer screening guidelines for patients deemed eligible for screening. First, a subset of patients was randomly selected from the EHR and their data were exported in a de-identified manner for manual review of screening adherence by two teams of human reviewers. Interrater reliability for manual review was calculated using Cohen’s Kappa and found to be high in all instances. The sensitivity and specificity of the algorithm was calculated by comparing the algorithm to the final manual dataset. When assessing cancer screening adherence, the algorithm performed with a high sensitivity (79%, 70%, 80%) and specificity (92%, 99%, 97%) for colorectal cancer, breast cancer, and cervical cancer screenings, respectively. This study validates an algorithm that can effectively determine patient adherence to colorectal cancer, breast cancer, and cervical cancer screening guidelines. This design improves upon previous methods of algorithm validation by using computerized extraction of essential components of patients’ EHRs and by using de-identified data for manual review. Use of the described algorithm could allow for more precise and efficient allocation of public health resources to improve cancer screening rates.

Inequitable access to surveillance colonoscopy among Medicare beneficiaries with surgically resected colorectal cancer

BACKGROUND

After colorectal cancer (CRC) surgery, surveillance with colonoscopy is an important step for the early detection of local recurrence. Unfortunately, surveillance colonoscopy is underused, especially among racial/ethnic minorities. This study assesses the association between patient and neighborhood factors and receipt of surveillance colonoscopy.

METHODS

This retrospective, population-based cohort study used Surveillance, Epidemiology, and End Results-Medicare linked data (2009-2014). Beneficiaries with surgically resected stage II or III CRC between the ages of 66 and 85 years were identified, and multivariable logistic regression was used to assess the effect of factors on receipt of colonoscopy.

RESULTS

Overall, 57.5% of the patients received initial surveillance colonoscopy. After adjustments for all factors, Blacks and Hispanics had lower odds of receiving colonoscopy than non-Hispanic Whites (NHWs; 29.6% for Blacks; P = .002; 12.9% for Hispanics; P > .05). NHWs with Medicaid coverage had 35% lower odds of surveillance colonoscopy than NHWs without Medicaid coverage. Minority patients with Medicaid were more likely to receive colonoscopy than their racial/ethnic counterparts without Medicaid coverage (P > .05). Hispanics residing in neighborhoods with incomes of ≥$90,000 had significantly lower odds of surveillance colonoscopy than Hispanics residing in neighborhoods with incomes of $0 to $30,000.

CONCLUSIONS

Receipt of initial surveillance colonoscopy remains low, and there are acute disparities between Black and NHW patients. The association between factors that assess a patient's ability to access colonoscopy and actual receipt of colonoscopy suggests inequitable access to surveillance colonoscopy within and across racial/ethnic groups.

Cancer Risk Among Older Adults: Time for Cancer Prevention to Go Silver

Over two-thirds of all new cancers are diagnosed among adults aged ≥60 years. As the number of adults living to older ages continues to increase, so too will the number of new cancer cases. Can we do more as a society to reduce cancer risk and preserve health as adults enter their 60s, 70s, and beyond? Cancer development is a multi-step process involving a combination of factors. Each cancer risk factor represents a component of cancer causation, and opportunities to prevent cancer may exist at any time up to the final component, even years after the first. The characteristics of the community in which one lives often shape cancer risk-related behaviors and exposures over time, making communities an ideal setting for efforts to reduce cancer risk at a population level. A comprehensive approach to cancer prevention at older ages would lower exposures to known causes of cancer, promote healthy social and physical environments, expand the appropriate use of clinical preventive services, and engage older adults in these efforts. The collection of articles in this supplement provide innovative insights for exciting new directions in research and practice to expand cancer prevention efforts for older adults. This brief commentary sets the stage for the papers that follow.

Highlights From an Expert Meeting on Opportunities for Cancer Prevention Among Older Adults

This paper provides highlights from an expert meeting to explore opportunities to reduce cancer risk and promote health at older ages. Factors that increase cancer risk among older adults include exposure to carcinogens from multiple sources, chronic conditions such as obesity and diabetes, and unhealthy behaviors. Emerging research points to chronic social stressors - social isolation, loneliness, and financial hardship - as being linked to accelerated biological aging and increased cancer risk later in life. Older adults may disproportionately encounter these stressors as well as barriers to preventive health care services, accurate health information, and environments that promote health. Researchers can use existing cohort studies of older adults to deepen our understanding of the relative benefit of modifying specific behaviors and circumstances. The evidence points to the value of comprehensive, transdisciplinary approaches to promote health and reduce cancer risk across the entire lifespan, extending through older adulthood. Clinical encounters with older adults provide opportunities for psychosocial and behavioral screening and counseling. In the presence of multiple morbidities, preventive health services may offer greater health benefits than cancer-screening tests. Strategies that involve families and caregivers, promote positive attitudes about aging, and engage many different community sectors have the potential to prevent or delay the development of cancer at older ages.