Using Evidence-Based Interventions to Improve Cancer Screening in the National Breast and Cervical Cancer Early Detection Program

Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020

Racial and ethnic disparities in women's health have existed for decades, despite efforts to strengthen women's reproductive health access and utilization. Recent guidance by the American College of Obstetricians and Gynecologists (ACOG) underscores the often unacknowledged and unmeasured role of racial bias and systemic racial injustice in reproductive health disparities and highlights a renewed commitment to eliminating them. Reaching health equity requires an understanding of current racial-ethnic gaps in reproductive health and a concerted effort to develop and implement strategies to close gaps. We summarized national data for several reproductive health measures, such as contraceptive use, Pap tests, mammograms, maternal mortality, and unintended pregnancies, by race-ethnicity to inform health-equity strategies. Studies were retrieved by systematically searching the PubMed (2010-2020) electronic database to identify most recently published national estimates by race-ethnicity (non-Hispanic Black or African American, Hispanic or Latinx, and non-Hispanic White women). Disparities were found in each reproductive health category. We describe relevant components of the Affordable Care Act (ACA) and the Preventing Maternal Deaths Act, which can help to further strengthen reproductive health care, close gaps in services and outcomes, and decrease racial-ethnic reproductive health disparities. Owing to continued diminishment of certain components of the ACA, to optimally reach reproductive health equity, comprehensive health insurance coverage is vital. Strengthening policy-level strategies, along with ACOG's heightened commitment to eliminating racial disparities in women's health by confronting bias and racism, can strengthen actions toward reproductive health equity.

Cervical Cancer Screening in Inflammatory Bowel Disease: Who Should Be Screening?

Background

Immunosuppressed women with inflammatory bowel disease (IBD) are at elevated risk of cervical cancer yet have lower screening rates. The objective of this study was to assess the familiarity with cervical cancer screening recommendations, and the perceived responsibility for implementing screening among three physician groups involved in the clinical care of women with IBD: primary care physicians (PCP), gastroenterologists (GI) and gynecologists (GYN).

Methods

We anonymously surveyed a sample of 117 PCP, 52 GYN and 35 GI physicians affiliated with Saint Louis University, Saint Louis, MO, USA, from April 2018 to January 2019. The physicians completed a questionnaire adressing essential aspects of cervical cancer screening such as screening age, screening frequency, human papillomavirus (HPV) vaccination, comfort level in performing Papanicolaou (Pap) smears, perception of physician responsibility in terms of which physicians should perform Pap smears.

Results

A total of 2.6% of PCPs, 37% of GIs and 29% of GYNs reported familiarity with cervical cancer screening recommendations. In addition, PCP and GI had no definite opinions regarding which physicians should be in charge of cervical cancer screening and performing Pap smears. However, 94% of GYNs felt that they should be in charge of cervical cancer screening and performing Pap smears.

Conclusions

An apparent lack of familiarity exists among all three physician groups regarding cervical cancer screening recommendations in immunosuppressed patients with IBD. Similarly, there is no consensus regarding which specialty should be responsible for cervical cancer screening in this patient population.

Patterns of Cross-Sector Collaboration in Local Health Departments: A Cluster Analysis

Local health departments (LHDs) are positioned to act as the community health strategist for their catchment area, which requires cross-sector collaboration. However, little research exists to understand how much and what types of cross-sector collaboration occur and its impact on LHD practice. Data from 490 LHDs who participated in the 2016 National Profile of Local Health Departments survey were analyzed to identify patterns of cross-sector collaboration among LHDs. In the survey, LHDs reported the presence of collaborative activities for each of 22 categories of organizations. Factor analysis was used to identify patterns in the types of organizations with which LHDs collaborate. Then, cluster analysis was conducted to identify patterns in the types of cross-sector collaboration, and cross-sectional analyses examined which LHD characteristics were associated with cluster assignment. LHDs collaborated most with traditional health care-oriented organizations, but less often with organizations focused on upstream determinants of health such as housing. Three distinct clusters represented collaboration patterns in LHDs: coordinators, networkers, and low-collaborators. LHDs who were low-collaborators were more likely to serve smaller populations, be unaccredited, have a smaller workforce, have a White top executive, and have a top executive without a graduate degree. These findings imply that public health practitioners should prioritize building bridges to a variety of organizations and engage in collaboration beyond information sharing. Furthermore, LHDs should prioritize accreditation and workforce development activities for supporting cross-sector collaboration. With these investments, the public health system can better address the social and structural determinants of health and promote health equity.

Perspectives on program mis-implementation among U.S. local public health departments

BACKGROUND

Public health resources are limited and best used for effective programs. This study explores associations of mis-implementation in public health (ending effective programs or continuing ineffective programs) with organizational supports for evidence-based decision making among U.S. local health departments.

METHODS

The national U.S. sample for this cross-sectional study was stratified by local health department jurisdiction population size. One person was invited from each randomly selected local health department: the leader in chronic disease, or the director. Of 600 selected, 579 had valid email addresses; 376 completed the survey (64.9% response). Survey items assessed frequency of and reasons for mis-implementation. Participants indicated agreement with statements on organizational supports for evidence-based decision making (7-point Likert).

RESULTS

Thirty percent (30.0%) reported programs often or always ended that should have continued (inappropriate termination); organizational supports for evidence-based decision making were not associated with the frequency of programs ending. The main reason given for inappropriate termination was grant funding ended (86.0%). Fewer (16.4%) reported programs often or always continued that should have ended (inappropriate continuation). Higher perceived organizational supports for evidence-based decision making were associated with less frequent inappropriate continuation (odds ratio = 0.86, 95% confidence interval 0.79, 0.94). All organizational support factors were negatively associated with inappropriate continuation. Top reasons were sustained funding (55.6%) and support from policymakers (34.0%).

CONCLUSIONS

Organizational supports for evidence-based decision making may help local health departments avoid continuing programs that should end. Creative mechanisms of support are needed to avoid inappropriate termination. Understanding what influences mis-implementation can help identify supports for de-implementation of ineffective programs so resources can go towards evidence-based programs.

Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs

Few data are available on patient navigators (PNs) across diverse roles and organizational settings that could inform optimization of patient navigation models for cancer prevention. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the Colorectal Cancer and Control Program (CRCCP) are two federally-funded screening programs that support clinical- and community-based PNs who serve low-income and un- or underinsured populations across the United States. An online survey assessing PN characteristics, delivered activities, and patient barriers to screening was completed by 437 of 1002 identified PNs (44%). Responding PNs were racially and ethnically diverse, had varied professional backgrounds and practice-settings, worked with diverse populations, and were located within rural and urban/suburban locations across the U.S. More PNs reported working to promote screening for breast/cervical cancers (BCC, 94%) compared to colorectal cancer (CRC, 39%). BCC and CRC PNs reported similar frequencies of individual- (e.g., knowledge, motivation, fear) and community-level patient barriers (e.g., beliefs about healthcare and screening). Despite reporting significant patient structural barriers (e.g., transportation, work and clinic hours), most BCC and CRC PNs delivered individual-level navigation activities (e.g., education, appointment reminders). PN training to identify and champion timely and patient-centered adjustments to organizational policies, practices, and norms of the NBCCEDP, CRCCP, and partner organizations may be beneficial. More research is needed to determine whether multilevel interventions that support this approach could reduce structural barriers and increase screening and diagnostic follow-up among the marginalized communities served by these two important cancer-screening programs.

Comparison of cervical cancer screening among women with and without hysterectomies: a nationwide population-based study in Korea

BACKGROUND

Cervical cancer screening is not recommended for women who underwent hysterectomy with no history of cervical intraepithelial neoplasia (CIN) of grade 2 or higher. We aimed to determine the cervical cancer screening rate in Korean women who underwent hysterectomies and compare it to that in women with intact uteri.

METHODS

We used data from the 2014-2016 Korean National Cancer Screening Survey; 6807 women aged 30-74 years were included in the study. Participants were asked about their experiences with cervical cancer screening, hysterectomy status, and other variables associated with cancer screening.

RESULTS

The screening rates among women who have undergone a hysterectomy vs. those who have not during the past 2 years were 61.8% (95% confidence interval [CI], 58.8-64.9) and 64.7% (95% CI, 64.1-65.3), respectively. Among younger women (30-44 years) and women with a family history of cancer, those with hysterectomies showed a higher cervical cancer screening rate than those without (77.8% vs. 57.1% and 75.0% vs. 67.1%, respectively).

CONCLUSIONS

Despite available evidence and clinical recommendations, a considerable number of Korean women who no longer have a cervix continue to undergo unnecessary cervical cancer screening. It is necessary to identify the exact underlying causes for this phenomenon, and systematic efforts are required to prevent unnecessary screening for women who have undergone a hysterectomy.

Addressing Potential Health Disparities in the Adoption of Advanced Breast Imaging Technologies

With the advent of new screening technologies, including digital breast tomosynthesis, screening ultrasound, and breast magnetic resonance imaging, there is growing concern that existing disparities among traditionally underserved populations will worsen. These newer screening modalities purport improved cancer detection over mammography alone but are not offered at all screening facilities and often require a larger co-pay or out-of-pocket expense. Thus, the potential for worsening disparities with regard to access and appropriate utilization of supplemental screening technologies exists. Currently, there is a dearth of literature on the topic of health disparities related to access and the use of supplemental breast cancer screening and their impact on outcomes. Identifying and addressing explanatory factors for persistent and potentially worsening disparities remain a central focus of efforts to improve equity in breast cancer care. Therefore, this paper provides an overview of factors that may contribute to present and future disparities in breast cancer screening and outcomes, and explores specific relevant topics requiring greater research efforts as more personalized, multimodality breast cancer screening approaches are adopted into clinical practice.

Toward optimal implementation of cancer prevention and control programs in public health: a study protocol on mis-implementation

BACKGROUND

Much of the cancer burden in the USA is preventable, through application of existing knowledge. State-level funders and public health practitioners are in ideal positions to affect programs and policies related to cancer control. Mis-implementation refers to ending effective programs and policies prematurely or continuing ineffective ones. Greater attention to mis-implementation should lead to use of effective interventions and more efficient expenditure of resources, which in the long term, will lead to more positive cancer outcomes.

METHODS

This is a three-phase study that takes a comprehensive approach, leading to the elucidation of tactics for addressing mis-implementation. Phase 1: We assess the extent to which mis-implementation is occurring among state cancer control programs in public health. This initial phase will involve a survey of 800 practitioners representing all states. The programs represented will span the full continuum of cancer control, from primary prevention to survivorship. Phase 2: Using data from phase 1 to identify organizations in which mis-implementation is particularly high or low, the team will conduct eight comparative case studies to get a richer understanding of mis-implementation and to understand contextual differences. These case studies will highlight lessons learned about mis-implementation and identify hypothesized drivers. Phase 3: Agent-based modeling will be used to identify dynamic interactions between individual capacity, organizational capacity, use of evidence, funding, and external factors driving mis-implementation. The team will then translate and disseminate findings from phases 1 to 3 to practitioners and practice-related stakeholders to support the reduction of mis-implementation.

DISCUSSION

This study is innovative and significant because it will (1) be the first to refine and further develop reliable and valid measures of mis-implementation of public health programs; (2) bring together a strong, transdisciplinary team with significant expertise in practice-based research; (3) use agent-based modeling to address cancer control implementation; and (4) use a participatory, evidence-based, stakeholder-driven approach that will identify key leverage points for addressing mis-implementation among state public health programs. This research is expected to provide replicable computational simulation models that can identify leverage points and public health system dynamics to reduce mis-implementation in cancer control and may be of interest to other health areas.