Implementation of a Cervical Cancer Screening Intervention for Under- or Never-Screened Women in Ontario, Canada: Understanding the Acceptability of HPV Self-Sampling.

With appropriate screening, cervical cancer can be prevented. In Ontario, Canada, some groups of women have low screening rates. South Asian, Middle Eastern and North African women are particularly at risk of under-screening. Currently, cytology-based screening is used in Ontario, although the growing evidence and adoption of HPV testing for cervical screening has encouraged many jurisdictions around the world to move towards HPV testing, with the option of self-sampling. We conducted an intervention beginning in June 2018, where we recruited over 100 under- or never-screened (UNS) women who identify as South or West Asian, Middle Eastern or North African from the Greater Toronto Area, to understand the uptake and acceptability of HPV self-sampling as an alternative to a Pap test. Participants self-selected if they tried the kit or not and completed both quantitative and qualitative research activities. This paper focuses on the qualitative arm of the study, where follow-ups and five focus groups were conducted with those who tried the kit (three groups) and those who did not (two groups), as well as eight key informant interviews with community champions and others who were involved in our recruitment. We used the Consolidated Framework for Implementation Research (CFIR) to guide our data collection and analysis. Major themes around convenience, privacy and comfort came from the data as important drivers of the uptake of the intervention. The role of community champions and peers in engaging and educating UNS women, as well as having self-confidence to collect the sample, also came out as factors impacting uptake and plans for continued use. Overall, the intervention showed that HPV self-sampling is an acceptable alternative to a Pap test for some but not all UNS women in Ontario.

The potential benefits of "community champions" in the healthcare system.

In a study to understand acceptability and uptake of Human Papilloma Virus (HPV) self-sampling, we engaged community champions to lead recruitment and other study activities. This article describes qualitative findings relevant to the role of the community champion. We found that community champions were critical to promoting awareness about and encouraging cervical screening and HPV self-sampling. They were well-connected community members who had healthcare backgrounds, which created trust in their messages. They were highly effective at encouraging screening because of their education and cultural congruency, combined with the time for thorough and clear explanations. Women had an inherent level of comfort with the community champions that often did not exist with their physician. The community champions were seen as being able to address some of the barriers that exist within the healthcare system. We encourage health leaders to consider how this role can be sustainably and meaningfully incorporated into the healthcare system.

Reach and effectiveness of an HPV self-sampling intervention for cervical screening amongst under- or never-screened women in Toronto, Ontario Canada.

BACKGROUND: Cervical cancer is almost entirely preventable with appropriate and timely screening. In Ontario, Canada, South Asian, Middle Eastern and North African women have some of the lowest rates of screening and a suggested higher burden of cervical cancer. With increasing international evidence and adoption of HPV testing, many screening programs are making the move away from Pap tests and towards HPV testing with the option of HPV self-sampling seeming promising for under- or never-screened (UNS) women. Our study aimed to understand the uptake and acceptability of an HPV self-sampling intervention amongst these disproportionately UNS women in Peel region and surrounding areas in Ontario. METHODS: A community -based mixed methods approach guided by the RE-AIM framework was used to recruit approximately 100 UNS racialized immigrant women aged 30-69, during the period of June 2018 to December 2019. The main recruitment strategy included community champions (i.e. trusted female members of communities) to engage people in our selected areas in Peel Region. Participants completed a study questionnaire about their knowledge, attitudes and practices around cervical cancer screening, self-selected whether to use the HPV self-sampling device and completed follow-up questions either about their experience with self-sampling or going to get a Pap test. RESULTS: In total, 108 women participated in the study, with 69 opting to do self-sampling and 39 not. The majority of women followed through and used the device (n = 61) and found it 'user friendly.' The experience of some participants suggests that clearer instructions and/or more support once at home is needed. Survey and follow-up data suggest that privacy and comfort are common barriers for UNS women, and that self-sampling begins to address these concerns. Across both groups addressing misinformation and misconceptions is needed to convince some UNS women to be screened. Family, friends and peers also seemed to play a role in the decision-making process. CONCLUSIONS: HPV self-sampling is viewed as an acceptable alternative to a Pap test for cervical screening, by some but not all UNS women. This method begins to address some of the barriers that often prevent women from being screened and is already being offered in some jurisdictions as an alternative to clinical cervical cancer screening.

Snakes and ladders: A qualitative study understanding the active ingredients of social interaction around the use of audit and feedback.

Explore characteristics of the facilitator, group, and interaction that influence whether a group discussion about data leads to the identification of a clearly specified action plan. Peer-facilitated group discussions among primary care physicians were carried out and recorded. A follow-up focus group was conducted with peer facilitators to explore which aspects of the discussion promoted action planning. Qualitative data was analyzed using an inductive-deductive thematic analysis approach using the conceptual model developed by Cooke et al. Group discussions were coded case-specifically and then analyzed to identify which themes influenced action planning as it relates to performance improvement. Physicians were more likely to interact with practice-level data and explore actions for performance improvement when the group facilitator focused the discussion on action planning. Only one of the three sites (Site C) converged on an action plan following the peer-facilitated group discussion. At Site A, physicians shared skepticism of the data, were defensive about performance, and explained performance as a product of factors beyond their control. Site B identified several potential actions but had trouble focusing on a single indicator or deciding between physician- and group-level actions. None of the groups discussed variation in physician-level performance indicators, or how physician actions might contribute to the reported outcomes. Peer facilitators can support data interpretation and practice change; however their success depends on their personal beliefs about the data and their ability to identify and leverage change cues that arise in conversation. Further research is needed to understand how to create a psychologically safe environment that welcomes open discussion of physician variation.

Family doctors have access to a lot of data on their practice. However, doctors report difficulties in thinking of ways to use this data to improve their practice. Group discussions among doctors may be one way to support practice improvements. This study analyzed discussions among three groups of doctors to see which aspects of the discussions helped the doctors come up with new ways to improve their practices. The ability of the person leading the discussion to continually re-focus the conversation on the goal of making a change was key to whether the group made any progress. The first group was skeptical of the data and felt that its findings were beyond their control; the second group had trouble focusing on a single outcome; and the third group successfully identified an action. None of the groups discussed how their actions might contribute to the outcomes.

Understanding the Acceptability and Uptake of HPV Self-Sampling Amongst Women Under- or Never-Screened for Cervical Cancer in Toronto (Ontario, Canada): An Intervention Study Protocol.

Cervical cancer remains a global public health concern, even though scientific advancements have made the disease almost entirely preventable. With the link between human papillomavirus (HPV) and cervical cancer, and the subsequent improvement in screening technology, there is potential to improve access and coverage of cervical screening with the introduction of HPV self-sampling. In Ontario, Canada, a province with a cytology-based screening program (i.e., Pap test), women who identify as South Asian, West Asian, Middle Eastern and North African have some of the lowest rates of screening, and research suggests they have a higher burden of cervical cancer. In this study, we will use both quantitative and qualitative methods to understand the acceptability and uptake of a take-home HPV self-sampling kit. Working with community champions-people with pre-existing connections with local groups-we will recruit women from these groups who are under- or never-screened for cervical cancer. Women will self-select whether they are in the group that tries HPV self-sampling or in the group that does not. We will aim for 100 women in each group. All participants will provide feedback on the feasibility, acceptability and preferences for cervical screening through a survey and phone follow-up. Women who self-select the HPV self-sampling group, will be followed up to find out if they followed through with self-sampling and to understand their experience using the device. Women who do not want to try self-sampling will be followed up to see if they went on to get a Pap test. The qualitative phase of this study consists of five focus groups with participants and semi-structured interviews with key informants in the community.

Awareness and Use of Community Services among Primary Care Physicians.

Primary care physicians play an important role in care coordination, including initiating referrals to community resources. Yet, it is unclear how awareness and use of community resources vary between physicians practising with and without an extended healthcare team. We conducted a cross-sectional survey of primary care physicians practising in Toronto, Canada, to compare awareness and use of community services between physicians practising in team- and non-team-based practice models. Team-based models included Community Health Centres and Family Health Teams - settings in which the government provides funding for the practice to hire non-physician health professionals, such as social workers, pharmacists, nurse practitioners, registered nurses and others. The survey was mailed to physicians, and reminders were done by phone, fax and e-mail. We used logistic regression to compare awareness between physicians in team-based (N = 89) and non-team-based (N = 138) models after controlling for confounders. We found that fewer than half of the physicians were aware of five of eight centralized intake services (e.g., ConnexOntario, Telehomecare). For most services, team-based physicians had at least twice the odds of being aware of the service compared to non-team-based physicians. Our findings suggest that patients in team-based practices may be doubly advantaged, with access to non-physician health professionals within the practice as well as to physicians who are more aware of community resources.

Patient and caregiver experience in the transition from hospital to home - brainstorming results from group concept mapping: a patient-oriented study.

BACKGROUND: Improving the quality of care for patients who return home after a hospital stay is an international priority; however, few jurisdictions have engaged broadly with patients and caregivers to understand what most affects their experience transitioning home. We performed Ontario-wide group concept mapping, beginning with a brainstorming phase, to understand patient and caregiver priorities in the transition. METHODS: We used group concept mapping to engage patients and caregivers who had lived experience transitioning from hospital to home in Ontario in the previous 3 years. We report on the first phase, brainstorming, conducted over 10 weeks beginning Jan. 11, 2018 via an online survey or facilitated group discussion. Participants responded to a single focal prompt: "When leaving the hospital for home, some thing(s) that affected the experience were: ____." The study team identified recurrent concepts and overarching themes. Patients and caregivers informed the study design, recruitment and data interpretation. RESULTS: In all, 665 people (263 patients [39.5%], 352 caregivers [52.9%] and 50 people who were both patient and caregiver [7.5%]) participated in brainstorming online, and 71 people participated in 1 of 8 group discussions. Participants identified 6 key areas affecting their experience of transition from hospital to home: home and community care, the discharge process, medical follow-up after discharge, medications, patient and caregiver education, and the kindness and caring of the health care team in hospital. Most notable were challenges with the timeliness, sufficiency, reliability and consistency of publicly funded home care services. INTERPRETATION: Patients and caregivers from across Ontario noted a range of issues affecting their experience transitioning from hospital to home, particularly the quality and sufficiency of publicly funded home care. Our findings will be used to inform a provincial quality standard on the transition from hospital to home.

Patient and caregiver priorities in the transition from hospital to home: results from province-wide group concept mapping.

BACKGROUND: Patients and caregivers often face significant challenges when they are discharged home from hospital. We sought to understand what influenced patient and caregiver experience in the transition from hospital to home and which of these aspects they prioritised for health system improvement. METHODS: We conducted group concept mapping over 11 months with patients-and their caregivers-who were admitted to a hospital overnight in the last 3 years in Ontario, Canada and discharged home. Home included supportive housing, shelters and long-term care. Participants responded to a single focal prompt about what affected their experience during the transition. We summarised responses in unique statements. We then recruited participants to rate each statement on a five-point scale on whether addressing this gap should be a priority for the health system. The provincial quality agency recruited participants in partnership with patient, community and healthcare organisations. Participation was online, in-person or virtual. RESULTS: 736 participants provided 2704 responses to the focal prompt. Unique concepts were summarised in 52 statements that were then rated by 271 participants. Participants rated the following three statements most highly as a gap that should be a priority for the health system to address (in rank order): 'Not enough publicly funded home care services to meet the need', 'Home care support is not in place when arriving home from hospital' and 'Having to advocate to get enough home care'. The top priority was consistent across multiple subgroups. CONCLUSIONS: In a country with universal health insurance, patients and caregivers from diverse backgrounds consistently prioritised insufficient public coverage for home care services as a gap the health system should address to improve the transition from hospital to home.

Patient perspectives on routinely being asked about their race and ethnicity: Qualitative study in primary care.

OBJECTIVE: To understand patients' perspectives on responding to a question about their race and ethnicity in a primary care setting. DESIGN: Qualitative study using semistructured individual interviews conducted between May and July 2016. SETTING: An academic family health team in Toronto, Ont, where collection of sociodemographic data has been routine since 2013. PARTICIPANTS: Twenty-seven patients from 5 of the 6 clinic sites of the family health team, ranging in age, sex, educational background, and immigration status. METHODS: Semistructured interviews were conducted with patients who completed a sociodemographic questionnaire after registration for their medical appointment. Patients were asked whether responding to the question was difficult or uncomfortable, how they interpreted the term race and ethnicity, and what response options they considered. Interviews were audiorecorded, transcribed, and coded iteratively. MAIN FINDINGS: Patients did not report discomfort with responding to a question about race and ethnicity in their family doctor's office. Although many patients considered the question straightforward, some patients reported different interpretations of the question. For example, some thought the question about race and ethnicity related to parental origin or ancestry, whereas others considered the question to be about personal place of birth or upbringing. Many patients appreciated being able to select from a variety of specific response options, but this also posed a difficulty for patients who could not easily find an option that reflected their identity. Patients with mixed heritage experienced the most challenges selecting a response. CONCLUSION: Patients attending a primary care clinic were not uncomfortable responding to a question about race and ethnicity. However, patients had different interpretations of what was being asked. Future research should explore perspectives of patients in other primary care settings and test different methods for collecting data about their race and ethnicity.

Shrinking the language accessibility gap: a mixed methods evaluation of telephone interpretation services in a large, diverse urban health care system.

INTRODUCTION: Language interpretation services for patients who are not proficient in a country's official language(s) are essential for improving health equity across diverse populations, and achieving clinical safety and quality for both patients and providers. Nevertheless, overall use of these services remains low, regardless of how they are delivered. In Toronto, Ontario, one of the most ethnically diverse urban centres, the regional local health integration network which oversees the highest concentration of health care organizations servicing 1.2 million residents, partnered with key stakeholders to make Over-the-Phone (OPI) interpretation services broadly and economically available in 170 different languages to its diverse network of health care organizations. This evaluation aimed to assess patients' and providers' experiences with OPI in these varied settings and the impact (if any) on alternative interpretation services and on health service delivery access and quality. METHODS: This study used a two-phased sequential exploratory mixed-methods approach to evaluate the initiative. Phase I was comprised of semi-structured interviews with representatives from the program stakeholders; these findings were applied to identify appropriate survey questions and response categories, and provided context and depth of understanding to Phase II results. Phase II included web-based and self-administered surveys for both providers and patients engaging with OPI. RESULTS: Both providers and patients identified a broad range of positive impacts OPI had on health care service delivery quality and access, and high levels of satisfaction with OPI, in a variety of health care settings. Providers also revealed a marked decrease in the use of ad-hoc, nonprofessional strategies for interpretation after the implementation of OPI, and noted it had either no impact on their workload or had decreased it overall. CONCLUSIONS: OPI is clearly not the sole answer to the complex array of health care needs and access gaps that exist for persons without proficiency in their country's official language. Nevertheless, this evaluation provides compelling evidence that OPI is a valuable component, and that it may contribute to a broader range of positive impacts, and within a broader range of health care settings, than previously explored.

Prevalence of gambling problems among the clients of a toronto homeless shelter.

Few studies have examined the prevalence of problem and pathological gambling among clients of homeless service agencies. The objective of this study was to estimate the prevalence of problem gambling among these clients. We collected primary data on gambling using the NORC diagnostic screen for disorders. Using a modified time-location recruitment approach 264 clients of a community homeless service agency were screened for lifetime gambling problems. Descriptive statistics were produced using SPSSX. The prevalence of lifetime problem gambling was 10 % and that of pathological gambling was 25 % in this sample. The prevalence of lifetime problem and pathological gambling was alarmingly high relative to the general population lifetime prevalence. Better insight into interventions for gambling that might reduce risk of homelessness will help service agencies gauge the needs of their clients and to implement change to service delivery and screening practices.

Representations of disability in the Canadian news media: a decade of change?

PURPOSE: To assess stability and change in representations of disability and persons with disability in the Canadian news media between 1998 and 2008. METHOD: The study replicated research conducted in 1998 that assessed the representation of disability in the Canadian news media. Following the earlier study, three newspapers were selected (Globe and Mail, Toronto Star and Toronto Sun) and all articles from a three-month period in 1998 and 2008 were assessed for disability content. In total, 362 articles were found in the two time periods. These were coded for structure and content using a schema developed in the earlier research. RESULTS: Between 1998 and 2008, there was a significant increase in the proportion of stories using "person first" language, and a significant increase in the proportion of "progressively" themed articles (e.g. dealing with barriers to participation, or disability awareness and inclusion). At the same time, there were significant differences between newspapers, with the Toronto Sun (a tabloid) maintaining a strong focus on "traditional" themes (e.g. special education, charitable provision). CONCLUSIONS: The differences in news media representations between 1998 and 2008 suggest a positive change in the way people with disabilities are represented, with greater attention to the complexity of their identity and their multiple social roles. IMPLICATIONS FOR REHABILITATION: The participation of persons with disabilities in society continues to be limited by negative attitudes. Media reporting has a significant influence on public attitudes toward disability. In a content analysis of three Canadian newspapers, this study found several significant changes in the language and content of disability-related articles. Together, these changes provide some evidence of more favorable media representations of disability. Further research in rehabilitation is needed to understand how such changes may both reflect and facilitate ongoing efforts to enhance people with disabilties' participation in social life.