In our primary care organization, we have observed income gradients in cancer screening for our patients despite outreach. We hypothesized that outreach strategies could be improved upon to be more compelling for our patients living with low income.
To use co-design to adapt our current strategies and create new strategies to improve cancer screening uptake for patients living with low income.
An exploratory, qualitative study in two phases: interviews and focus groups.
For interviews, we recruited 25 patient participants who were or had been overdue for cancer screening and had been identified by their provider as potentially living with low income. For subsequent focus groups, we recruited 14 patient participants, 11 of whom had participated in Phase I interviews.
To analyse written transcripts, we took an iterative, inductive approach using content analysis and drawing on best practices in Grounded Theory methodology. Emergent themes were expanded and clarified to create a derived model of possible strategies to improve the experience of cancer screening and encourage screening uptake for patients living with low income.
Fear and competing priorities were two key barriers to cancer screening identified by patients. Patients believed that a warm and encouraging outreach approach would work best to increase cancer screening participation. Phone calls and group education were specifically suggested as potentially promising methods. However, these views were not universal; for example, women were more likely to be in favour of group education.
We used input from patients living with low income to co-design a new approach to cancer screening in our primary care organization, an approach that could be broadly applicable to other contexts and settings. We learned from our patients that a multi-modal strategy will likely be best to maximize screening uptake.
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Cancer Screening in Canada: An Overview of Screening Participation for Breast, Cervical and Colorectal Cancer. Toronto: Canadian Partnership Against Cancer; 2015.
Cervical Screening - CCO: Cancer Care Ontario; 2012 [Available from: https://www.cancercare.on.ca/pcs/screening/cervscreening/.
About the Ontario Breast Screening Program: Cancer Care Ontario; [February 9, 2016]. Available from: https://www.cancercare.on.ca/pcs/screening/breastscreening/OBSP/.
CancerCareOntario. Screening - CCO [Available from: https://www.cancercare.on.ca/pcs/screening/.
Colorectal Cancer Screening Participation: Cancer Quality Council of Ontario; [Available from: http://www.csqi.on.ca/by_patient_journey/screening/colorectal_screening_participation/.
Screening: Cancer Screening Quality Index; [Available from: http://www.csqi.on.ca/by_patient_journey/screening/.
Elit L, Krzyzanowska M, Saskin R, Barbera L, Razzaq A, Lofters A, et al. Sociodemographic factors associated with cervical cancer screening and follow-up of abnormal results. Can Fam Physician. 2012;58(1):e22-31.
Fernandes K, Sutradhar R, Borkhoff C, Baxter N, Lofters A, Rabeneck L, et al. Cross-sectional small area variation study of cancer, glucose, and cholesterol screening in Ontario: data to motivate community and primary care strategies to improve participation. CMAJ Open.
Lofters AK, Moineddin R, Hwang SW, Glazier RH. Predictors of low cervical cancer screening among immigrant women in Ontario, Canada. BMC Womens Health. 2011;11:20.
Lofters AK, Ng R, Lobb R. Primary care physician characteristics associated with cancer screening: a retrospective cohort study in Ontario, Canada. Cancer Med. 2014.
Shen SC, Lofters A, Tinmouth J, Paszat L, Rabeneck L, Glazier RH. Predictors of non-adherence to colorectal cancer screening among immigrants to Ontario, Canada: a population-based study. Prev Med. 2018;111:180-9.
Borkhoff CM, Saskin R, Rabeneck L, Baxter NN, Liu Y, Tinmouth J, et al. Disparities in receipt of screening tests for cancer, diabetes and high cholesterol in Ontario, Canada: a population-based study using area-based methods. Can J Public Health. 2013;104(4):e284-90.
Income and Health: Opportunities to achieve health equity in Ontario. Toronto: Health Quality Ontario; 2016.
Vahabi M, Lofters A, Kumar M, Glazier RH. Breast cancer screening disparities among urban immigrants: a population-based study in Ontario, Canada. BMC Public Health. 2015;15:679.
Lofters AK, Schuler A, Slater M, Baxter NN, Persaud N, Pinto AD, et al. Using self-reported data on the social determinants of health in primary care to identify cancer screening disparities: opportunities and challenges. BMC Fam Pract. 2017;18(1):31.
Feldman J, Davie S, Kiran T. Measuring and improving cervical, breast, and colorectal cancer screening rates in a multi-site urban practice in Toronto, Canada. BMJ Qual Improv Rep. 2017;6(1).
Low Income Cut-Offs: Statistics Canada; [Available from: http://www.statcan.gc.ca/pub/75f0002m/2012002/lico-sfr-eng.htm.
Kiran T, Davie S, Moineddin R, Lofters A. Mailed Letter Versus Phone Call to Increase Uptake of Cancer Screening: A Pragmatic, Randomized Trial. J Am Board Fam Med. 2018;31(6):857-68.
Bate P, Robert G. Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Qual Saf Health Care. 2006;15(5):307-10.
Trischler J, Pervan SJ, Kelly SJ, Scott DR. The value of codesign: The effect of customer involvement in service design teams. Journal of Service Research. 2017;21(1):75-100.
Israel BA, Schulz AJ, Parker EA, Becker AB, Health C-CPf. Community-based participatory research: policy recommendations for promoting a partnership approach in health research. Educ Health (Abingdon). 2001;14(2):182-97.
Sandelowski M. Whatever Happened to Qualitative Description? Research in Nursing & Health. 2000;23:334-40.
Strauss A, Corbin J. Basics of Qualitative Research - Techniques and Procedures for Developing Grounded Theory. London: Sage Publications; 1998.
Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Thousand Oaks: Sage Publications; 1998.
Bauer MW, Gaskell G. Qualitative researching with text, image and sound: A practical handbook. London: Sage Publications; 2000.
Kvale S. InterViews: An Introduction to Qualitative Research Interviewing. Thousand Oaks: Sage Publications; 1996.
Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3:77-101.
Novick G. Is there a bias against telephone interviews in qualitative research? Res Nurs Health. 2008;31(4):391-8.
Tessier S. From Field Notes, to Transcripts, to Tape Recordings: Evolution or Combination? International Journal of Qualitative Methods. 2012;11(4):446-60.
Morse JM. The significance of saturation. Qualitative Health Research. 1995;5:147-9.
Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136(9):641-51.
Baron RC, Rimer BK, Breslow RA, Coates RJ, Kerner J, Melillo S, et al. Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review. Am J Prev Med. 2008;35(1 Suppl):S34-55.
Dunn SF, Lofters AK, Ginsburg OM, Meaney CA, Ahmad F, Moravac MC, et al. Cervical and Breast Cancer Screening After CARES: A Community Program for Immigrant and Marginalized Women. Am J Prev Med. 2017;52(5):589-97.
Purkey E, Patel R, Phillips SP. Trauma-informed care: Better care for everyone. Can Fam Physician. 2018;64(3):170-2.
Hall N, Birt L, Rees CJ, Walter FM, Elliot S, Ritchie M, et al. Concerns, perceived need and competing priorities: a qualitative exploration of decision-making and non-participation in a population-based flexible sigmoidoscopy screening programme to prevent colorectal cancer. BMJ Open. 2016;6(11):e012304.
Kouyoumdjian FG, McConnon A, Herrington ERS, Fung K, Lofters A, Hwang SW. Cervical Cancer Screening Access for Women Who Experience Imprisonment in Ontario, Canada. JAMA Netw Open. 2018;1(8):e185637.
Hudson SV, Ferrante JM, Ohman-Strickland P, Hahn KA, Shaw EK, Hemler J, et al. Physician recommendation and patient adherence for colorectal cancer screening. J Am Board Fam Med. 2012;25(6):782-91.
We would like to thank Anne Crassweiler, Sam Davie, Jean Wilson and all other members of our community advisory committee for their guidance, input and support throughout this study. AL is supported by a Chair in Implementation Science at Women’s College Hospital.
This study was funded by an Academic Health Sciences Centre Alternate Funding Plan Innovation Fund from St. Michael’s Hospital. AL is supported by a Canadian Institutes for Health Research (CIHR) New Investigator Award. Both AL and TK are supported as Clinician Scientists by the Departments of Family & Community Medicine at St. Michael’s Hospital and the University of Toronto. TK is also supported by CIHR and Health Quality Ontario as an Embedded Clinician Scientist and as the Fidani Endowed Chair in Improvement and Innovation at the University of Toronto.
Ethics approval for the study was provided by the St. Michael’s Hospital Research Ethics Board.
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Lofters, A.K., Baker, N.A., Schuler, A. et al. A “Tea and Cookies” Approach: Co-designing Cancer Screening Interventions with Patients Living with Low Income. J GEN INTERN MED 35, 255–260 (2020). https://doi.org/10.1007/s11606-019-05400-0