Surviving the Storm: The Impact of COVID-19 on Cervical Cancer Screening in Low- and Middle-Income Countries.

According to the Center for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program, the cervical cancer screening rate dropped by 84% soon after the declaration of the COVID-19 pandemic. The challenges facing cervical cancer screening were largely attributed to the required in-person nature of the screening process and the measures implemented to control the spread of the virus. While the impact of the COVID-19 pandemic on cancer screening is well-documented in high-income countries, less is known about the low- and middle-income countries that bear 90% of the global burden of cervical cancer deaths. In this paper, we aim to offer a comprehensive view of the impact of COVID-19 on cervical cancer screening in LMICs. Using our study, "Prevention of Cervical Cancer in India through Self-Sampling" (PCCIS), as a case example, we present the challenges COVID-19 has exerted on patients, healthcare practitioners, and health systems, as well as potential opportunities to mitigate these challenges.

Cancer Screening Disparities Before and After the COVID-19 Pandemic.

Importance: Breast, cervical, and colorectal cancer-screening disparities existed prior to the COVID-19 pandemic, and it is unclear whether those have changed since the pandemic. Objective: To assess whether changes in screening from before the pandemic to after the pandemic varied for immigrants and for people with limited income. Design, Setting, and Participants: This population-based, cross-sectional study, using data from March 31, 2019, and March 31, 2022, included adults in Ontario, Canada, the country's most populous province, with more than 14 million people, almost 30% of whom are immigrants. At both dates, the screening-eligible population for each cancer type was assessed. Exposures: Neighborhood income quintile, immigrant status, and primary care model type. Main Outcomes and Measures: For each cancer screening type, the main outcome was whether the screening-eligible population was up to date on screening (a binary outcome) on March 31, 2019, and March 31, 2022. Up to date on screening was defined as having had a mammogram in the previous 2 years, a Papanicolaou test in the previous 3 years, and a fecal test in the previous 2 years or a flexible sigmoidoscopy or colonoscopy in the previous 10 years. Results: The overall cohort on March 31, 2019, included 1 666 943 women (100%) eligible for breast screening (mean [SD] age, 59.9 [5.1] years), 3 918 225 women (100%) eligible for cervical screening (mean [SD] age, 45.5 [13.2] years), and 3 886 345 people eligible for colorectal screening (51.4% female; mean [SD] age, 61.8 [6.4] years). The proportion of people up to date on screening in Ontario decreased for breast, cervical, and colorectal cancers, with the largest decrease for breast screening (from 61.1% before the pandemic to 51.7% [difference, -9.4 percentage points]) and the smallest decrease for colorectal screening (from 65.9% to 62.0% [difference, -3.9 percentage points]). Preexisting disparities in screening for people living in low-income neighborhoods and for immigrants widened for breast screening and colorectal screening. For breast screening, compared with income quintile 5 (highest), the ß estimate for income quintile 1 (lowest) was -1.16 (95% CI, -1.56 to -0.77); for immigrant vs nonimmigrant, the ß estimate was -1.51 (95% CI, -1.84 to -1.18). For colorectal screening, compared with income quintile 5, the ß estimate for quntile 1 was -1.29 (95% CI, 16 -1.53 to -1.06); for immigrant vs nonimmigrant, the ß estimate was -1.41 (95% CI, -1.61 to -1.21). The lowest screening rates both before and after the COVID-19 pandemic were for people who had no identifiable family physician (eg, moving from 11.3% in 2019 to 9.6% in 2022 up to date for breast cancer). In addition, patients of interprofessional, team-based primary care models had significantly smaller reductions in ß estimates for breast (2.14 [95% CI, 1.79 to 2.49]), cervical (1.72 [95% CI, 1.46 to 1.98]), and colorectal (2.15 [95% CI, 1.95 to 2.36]) postpandemic screening and higher uptake of screening in general compared with patients of other primary care models. Conclusions and Relevance: In this cross-sectional study in Ontario that included 2 time points, widening disparities before compared with after the COVID-19 pandemic were found for breast cancer and colorectal cancer screening based on income and immigrant status, but smaller declines in disparities were found among patients of interprofessional, team-based primary care models than among their counterparts. Policy makers should investigate the value of prioritizing and investing in improving access to team-based primary care for people who are immigrants and/or with limited income.

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.

Effectiveness of family-centred sexual health education and HPV self-sampling in promoting cervical cancer screening among hard-to-reach indian women in rural and tribal areas: a community-based pilot study.

BACKGROUND: While cervical cancer deaths have declined steeply in high-income countries due to the widespread use of the Papanicolaou test (Pap test), the same trend has not emerged in low or middle-income countries (LMICs). Access to screening in LMICs like India is limited due to barriers such as limited healthcare infrastructures, lack of sexual health education, and stigma demarcating sexually transmitted infections (STIs). HPV self-sampling (HPV-SS), a woman-centered and at-home method for screening, can be utilized as a unique screening tool to overcome some of these barriers. Our study examined the effectiveness of HPV-SS, supported by family-centred arts-based sexual health literacy on the uptake of cervical cancer screening among hard-to-reach women in rural and remote areas in India. METHODS: Our community-based mixed methods pilot study recruited 240 participants (120 women and 120 male partners or family members) through female Accredited Social Health Activists (ASHA) across 3 Indian villages of Shirgoan, Khodala, and Jamsar in Palghar district. Inclusion criteria included women ages 30-69 who were under or never screened (UNS) and their male partners/family members aged 18 or over. Knowledge and attitudes about cervical cancer and screening and their perceived stigma surrounding STI were assessed using validated scales prior to and after attending a 2-hour arts-based sexual health education (SHE). In addition, participants' uptake of cervical cancer screening was assessed after attendance in SHE. FINDINGS: Results revealed significant improvement in knowledge and attitudes about cervical cancer and screening, and a reduction in the STI stigma after participation in SHE sessions (overall mean difference in Knowledge: z = 6.1 ± 2.4, P < 0.001; attitudes about Pap-test and VIA: z = 2.2 ± 8.4, P < 0.001 and z = 2.9 ± 8.2, P < 0.001; STI stigma: z = 2.8 ± 12.4, P < 0.001). 118 out of 120 female participants chose to be screened and 115 opted for HPV-SS. CONCLUSIONS: The implementation of HPV-SS coupled with family-centered arts-based and culturally appropriate SHE is highly promising in promoting cervical cancer screening among hard-to-reach women. Evidence from our study can be used to advance public health policies and inform the scale-up of similar initiatives in other villages and states across rural India and other LMICs.

The Mediating Effect of Stress between Extracurricular Activities and Suicidal Ideation in Chinese College Students.

OBJECTIVE: The objective of this study was to explore the relationship between extracurricular activities, stress, and suicidal ideation and to examine the mediating effect of stress between extracurricular activities and suicidal ideation in Chinese college students. METHOD: A total of 6446 college students were surveyed with a web-based online data collection system using the self-made demographic questionnaire, Suicidal Behaviors Questionnaire-Revised (SBQ-R), and the 21-Item Depression Anxiety Stress Scales (DASS-21). SPSS 24.0 was used for descriptive statistics and correlation analysis, and the bootstrap method in the process procedure for SPSS Version 3.4.1 was used to construct the mediating effect model. RESULTS: Gender, school grades, living area, and family income status were influencing factors for suicidal ideation, stress, and extracurricular activities. Extracurricular activities were negatively correlated with stress (r = -0.083, p < 0.001) and suicidal ideation (r = -0.039, p < 0.01). Extracurricular activities had no direct predictive effect on college students' suicidal ideation (c = -0.198, CI: -0.418, 0.023), while stress had a mediating effect between extracurricular activities and suicidal ideation; the indirect mediating effect was 0.159. CONCLUSIONS: Extracurricular activities indirectly predict college students' suicidal ideation through stress. A variety of extracurricular activities can decrease the stress and suicidal ideation of college students and benefit their mental health.

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.

A Family-Centered Sexual Health Intervention to Promote Cervical Cancer Screening Uptake Among Low-Income Rural Women in India: Protocol for a Community-Based Mixed Methods Pilot Study.

BACKGROUND: Human papillomavirus (HPV) is the primary cause of cervical cancer, which is preventable through screening and early treatment. The Papanicolaou (Pap) test and visual inspection with acetic acid (VIA), which are traditionally performed in clinical settings, have been used effectively to screen for cervical cancer and precancerous changes and reduce cervical cancer mortality in high-income countries for many decades. However, these screening methods are not easily accessible to women living in low- and middle-income countries, especially women living in rural areas. OBJECTIVE: The project will use HPV self-sampling, which will be supported by a sexual health literacy intervention, to increase rural women's participation in cervical cancer screening. The objectives are to determine the effectiveness of this program in (1) increasing sexual health literacy, (2) reducing the gendered stigma of HPV and cervical cancer, and (3) promoting cervical cancer screening by using HPV self-sampling. METHODS: The pilot study will use a community-based, family-centered, mixed methods design. We will recruit 120 women aged 30 to 69 years who are underscreened or were never screened for cervical cancer, along with 120 supportive male relatives or friends from 3 low-income rural/tribal villages in Maharashtra, India. Participants will attend gender-specific sexual health education sessions, followed by a movie matinee. Data will be collected through an interviewer-administered questionnaire before and after sexual health education sessions. The questionnaire will include items on social demographics, medical histories, attitudes, sexual health stigma, cervical cancer knowledge, and screening practices. Women will self-select whether to use HPV self-sampling. Those who do not may undergo a Pap test or VIA. Participants' views regarding barriers and facilitators and their suggestions for improving access and uptake will also be elicited. This protocol was approved by the research ethics boards of Toronto Metropolitan University (formerly known as Ryerson University; reference number: REB 2020-104) and Tata Memorial Center (reference number: OIEC/3786/2021 /00003). RESULTS: The Preventing Cervical Cancer in India Through Self-Sampling study was funded in January 2020 for 15 months. Due to the COVID-19 pandemic, the project was extended by 1 year. The study outcome measures will include changes in knowledge and attitudes about cervical cancer screening, the proportion of participants who self-select into each cohort, the proportion of positive test results in each cohort, and the proportion of participants with confirmed cervical cancer. Women's experiences regarding barriers and facilitators of screening uptake will be captured. CONCLUSIONS: Our multifaceted work could lead to reduced cervical cancer mortality and morbidity and increased community capacity in sexual health promotion and cervical cancer prevention. The insights and lessons learned from our project can be used to inform the adaptation and scale-up of HPV self-sampling among women across India and in other countries; promote collective commitment to family-centered wellness; and support women to make healthful, personalized cervical screening decisions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/35093.

COVID-19 Mental Health Stressors of Health Care Providers in the Pandemic Acceptance and Commitment to Empowerment Response (PACER) Intervention: Qualitative Study.

BACKGROUND: Since the pandemic, more Canadians have reported poorer mental health. A vital group experiencing a high level of stressors consists of health care providers (HCPs) caring for COVID-19 patients, carrying out public health responses, or working with vulnerable populations. The mental health of HCPs is negatively affected by the pandemic, not only at work but also at home and in the community. Intersecting stressors at multiple levels contribute to HCPs' experiences of fatigue, insomnia, anxiety, depression, and posttraumatic stress symptoms. OBJECTIVE: The aim of this qualitative study was to explore the pandemic stressors experienced by HCPs at work, at home, and in the community before participating in the Pandemic Acceptance and Commitment to Empowerment Response (PACER) online intervention. METHODS: Informed by a social ecological approach, we used a qualitative reflective approach to engage 74 HCPs in diverse roles. Data were collected during the first 2 waves of the COVID-19 pandemic (June 2020 to February 2021) in Canada. RESULTS: Informed by a social ecological framework, 5 overarching themes were identified in our thematic analysis: (1) personal level stressors that highlight HCPs' identities and responsibilities beyond the workplace; (2) interpersonal level stressors from disrupted social relationships; (3) organizational stressors that contributed to unsettled workplaces and moral distress; (4) community and societal stressors attributed to vicarious trauma and emotional labor; and (5) the multilevel and cumulative impacts of COVID-19 stressors on HCPs' health. CONCLUSIONS: COVID-19 is not merely a communicable disease but also a social and political phenomenon that intensifies the effects of social inequities. Current understanding of pandemic stressors affecting HCPs is largely partial in nature. Although workplace stressors of HCPs are real and intense, they need to be explored and understood in the context of stressors that exist in other domains of HCPs' lives such as family and community to ensure these experiences are not being silenced by the "hero" discourses or overshadowed by professional demands.

Effects of Acceptance and Commitment Therapy (ACT) on Mental Health and Resiliency of Migrant Live-in Caregivers in Canada: Pilot Randomized Wait List Controlled Trial.

BACKGROUND: Temporary migrant live-in caregivers constitute a vulnerable stream of temporary foreign workers in Canada. This is because the majority are racialized women from the Global South, the gendered nature of caregiving work has historically been undervalued, and their working and living spheres are intertwined which makes application of labor laws and surveillance almost impossible. Their invisible position in the fabric of Canadian society along with their precarious employment and immigration status place their mental health at jeopardy. There is a paucity of research about psychological support for this population. OBJECTIVE: Our pilot study Women Empowerment-Caregiver Acceptance and Resilience E-Learning (WE2CARE) aimed to assess the efficacy of a 6-week online delivery of a psychological intervention based on acceptance and commitment therapy (ACT) in reducing psychological distress and promoting resiliency among live-in care givers in the Greater Toronto Area. METHODS: A pilot randomized wait list controlled design was used. Participants were recruited by two community peer champions working with community health organizations serving migrant live-in caregivers. A total of 36 participants were recruited and randomly assigned to the intervention and wait list control groups; 7 dropped out of the study due to competing life priorities. Standardized self-reported surveys were administered online pre-, post-, and 6-week postintervention to assess mental distress (DASS-21), psychological flexibility (AAQ-2), mindfulness (CAMS-R), and Multi-System Model of Resilience (MSMR-I). Independent and dependent t tests were used to compare study outcomes at pre, post, and 6-week follow-up across and within both arms of the study. Linear mixed effects models were created for each outcome of interest from baseline to postintervention among intervention and control participants. Self-reported impact of the WE2CARE intervention was examined using independent t tests across the study arms. RESULTS: Average age of participants was 38 years. Many were born in the Philippines (23/29, 79%). The data on the impact of the psychological intervention showed a lower level of depression, anxiety, and stress among the intervention group compared with the control. However, the differences were not significant due to small sample size and COVID-19 crisis (6.94 vs 9.50, P=.54; 6.94 vs 10.83, P=.20; 7.76 vs 10.33, P=.44, respectively). There was a significant improvement in mindful qualities and external resilience, particularly in life satisfaction and accessible support among the intervention group (37.18 vs 32.92, t22=2.35, P=.03; 20.29 vs 16.5, t21=2.98, P=.007; 8.47 vs 6.75, t14=2.41, P=.03; 7.59 vs 5.33, t16=.008, respectively). CONCLUSIONS: WE2CARE is among the first studies exploring the efficacy of online delivery of ACT in addressing mental health challenges among live-in caregivers. While there are increased web-based ACT interventions, few use group videoconferencing to promote peer connection and mutual support. WE2CARE showed promising results in reducing psychological distress and promoting mindfulness and resiliency. The intervention highly motivated participants to engage collectively in building social support networks. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/preprints.31211.

Pandemic Acceptance and Commitment to Empowerment Response (PACER) Training: Protocol for the Development and Rapid-Response Deployment.

BACKGROUND: During a global pandemic, it is critical to rapidly deploy a psychological intervention to support the mental health and resilience of highly affected individuals and communities. OBJECTIVE: This is the rationale behind the development and implementation of the Pandemic Acceptance and Commitment to Empowerment Response (PACER) Training, an online, blended, skills building intervention to increase the resilience and well-being of participants while promoting their individual and collective empowerment and capacity building. METHODS: Based on acceptance and commitment therapy (ACT) and social justice-based group empowerment psychoeducation (GEP), we developed the Acceptance and Commitment to Empowerment (ACE) model to enhance psychological resilience and collective empowerment. The PACER program consists of 6 online, interactive, self-guided modules complemented by 6 weekly, 90-minute, videoconference, facilitator-led, group sessions. RESULTS: As of August 2021, a total of 325 participants had enrolled in the PACER program. Participants include frontline health care providers and Chinese-Canadian community members. CONCLUSIONS: The PACER program is an innovative intervention program with the potential for increasing resilience and empowerment while reducing mental distress during the pandemic. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33495.

Implementation of an Internet-Based Acceptance and Commitment Therapy for Promoting Mental Health Among Migrant Live-in Caregivers in Canada: Protocol.

BACKGROUND: Psychological distress, isolation, feelings of powerlessness, and limited social support are realities faced by temporary migrant live-in caregivers in Canada. Furthermore, they experience multiple barriers in accessing mental health services due to their long work hours, limited knowledge of health resources, precarious employment, and immigration status. OBJECTIVE: The Women Empowerment - Caregiver Acceptance & Resilience E-Learning (WE2CARE) project is a pilot intervention research project that aims to promote the mental well-being and resiliency of migrant live-in caregivers. The objectives include exploring the effectiveness of this program in achieving the following: (1) reducing psychological distress (depression, anxiety, and stress); (2) promoting committed actions of self-care; and (3) building mutual support social networks. Further, participants' satisfaction with the intervention and their perceived barriers to and facilitators of practicing the self-care strategies embedded in WE2CARE will be examined. METHODS: A total of 36 live-in caregivers residing in the Greater Toronto Area will be recruited and randomly assigned to either the intervention or waitlist control group. The intervention group will receive a 6-week web-based psychosocial intervention that will be based on Acceptance and Commitment Therapy (ACT). Standardized self-reported surveys will be administered online preintervention, postintervention, and at 6 weeks postintervention to assess mental distress (Depression, Anxiety and Stress Scale), psychological flexibility (Acceptance and Action Questionnaire), mindfulness (Cognitive and Affective Mindfulness Scale - Revised), and resilience (Multi-System Model of Resilience Inventory). In addition, two focus groups will be held with a subset of participants to explore their feedback on the utility of the WE2CARE program. RESULTS: WE2CARE was funded in January 2019 for a year. The protocol was approved by the research ethics boards of Ryerson University (REB 2019-036) and the University of Toronto (RIS37623) in February and May 2019, respectively. Data collection started upon ethics approval and was completed by May 2020. A total of 29 caregivers completed the study and 20 participated in the focus groups. Data analyses are in progress and results will be published in 2021. CONCLUSIONS: WE2CARE could be a promising approach to reducing stress, promoting resilience, and providing a virtual space for peer emotional support and collaborative learning among socially isolated and marginalized women. The results of this pilot study will inform the adaptation of an ACT-based psychological intervention for online delivery and determine its utility in promoting mental health among disadvantaged and vulnerable populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31211.

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.

Lung Cancer Inequalities in Stage of Diagnosis in Ontario, Canada.

Lung cancer is the most common cancer and cause of cancer death in Canada, with approximately 50% of cases diagnosed at stage IV. Sociodemographic inequalities in lung cancer diagnosis have been documented, but it is not known if inequalities exist with respect to immigration status. We used multiple linked health-administrative databases to create a cohort of Ontarians 40-105 years of age who were diagnosed with an incident lung cancer between 1 April 2012 and 31 March 2017. We used modified Poisson regression with robust standard errors to examine the risk of diagnosis at late vs. early stage among immigrants compared to long-term residents. The fully adjusted model included age, sex, neighborhood-area income quintile, number of Aggregated Diagnosis Group (ADG) comorbidities, cancer type, number of prior primary care visits, and continuity of care. Approximately 62% of 38,788 people with an incident lung cancer from 2012 to 2017 were diagnosed at a late stage. Immigrants to the province were no more likely to have a late-stage diagnosis than long-term residents (63.5% vs. 62.0%, relative risk (RR): 1.01 (95% confidence interval (CI): 0.99-1.04), adjusted relative risk (ARR): 1.02 (95% CI: 0.99-1.05)). However, in fully adjusted models, people with more comorbidities were less likely to have a late-stage diagnosis (adjusted relative risk (ARR): 0.82 (95% CI: 0.80-0.84) for those with 10+ vs. 0-5 ADGs). Compared to adenocarcinoma, small cell carcinoma was more likely to be diagnosed at a late stage (ARR: 1.29; 95% CI: 1.27-1.31), and squamous cell (ARR: 0.89; 95% CI: 0.87-0.91) and other lung cancers (ARR: 0.93; 95% CI: 0.91-0.94) were more likely to be diagnosed at an early stage. Men were also slightly more likely to have late-stage diagnosis in the fully adjusted model (ARR: 1.08; 95% CI: 1.05-1.08). Lung cancer in Ontario is a high-fatality cancer that is frequently diagnosed at a late stage. Having fewer comorbidities and being diagnosed with small cell carcinoma was associated with a late-stage diagnosis. The former group may have less health system contact, and the latter group has the lung cancer type most closely associated with smoking. As lung cancer screening programs start to be implemented across Canada, targeted outreach to men and to smokers, increasing awareness about screening, and connecting every Canadian with primary care should be system priorities.

Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening.

BACKGROUND: Individuals living with low income are more likely to smoke, have a higher risk of lung cancer, and are less likely to participate in preventative healthcare (i.e., low-dose computed tomography (LDCT) for lung cancer screening), leading to equity concerns. To inform the delivery of an organized pilot lung cancer screening program in Ontario, we sought to contextualize the lived experiences of poverty and the choice to participate in lung cancer screening. METHODS: At three Toronto academic primary-care clinics, high-risk screen-eligible patients who chose or declined LDCT screening were consented; sociodemographic data was collected. Qualitative interviews were conducted. Theoretical thematic analysis was used to organize, describe and interpret the data using the morphogenetic approach as a guiding theoretical lens. RESULTS: Eight participants chose to undergo screening; ten did not. From interviews, we identified three themes: Pathways of disadvantage (social trajectories of events that influence lung-cancer risk and health-seeking behaviour), lung-cancer risk and early detection (upstream factors that shape smoking behaviour and lung-cancer screening choices), and safe spaces of care (care that is free of bias, conflict, criticism, or potentially threatening actions, ideas or conversations). We illuminate how 'choice' is contextual to the availability of material resources such as income and housing, and how 'choice' is influenced by having access to spaces of care that are free of judgement and personal bias. CONCLUSION: Underserved populations will require multiprong interventions that work at the individual, system and structural level to reduce inequities in lung-cancer risk and access to healthcare services such as cancer screening.

Promoting the Mental Health of University Students in China: Protocol for Contextual Assessment to Inform Intervention Design and Adaptation.

BACKGROUND: Chinese students are extremely vulnerable to developing mental illness. The stigma associated with mental illness presents a barrier to seeking help for their mental health. OBJECTIVE: The Linking Hearts-Linking Youth and 'Xin' (hearts) project is an implementation science project that seeks to reduce mental illness stigma and promote the mental health of university students in Jinan, China. The Linking Hearts project consists of 3 components. In this paper, we outline the protocol for the first component, that is, the contextual assessment and analysis of the mental health needs of university students as the first step to inform the adaptation of an evidence-based intervention to be implemented in Jinan, China. METHODS: Six local universities will participate in the Linking Hearts project. A total of 100 students from each university (n=600) will engage in the contextual assessment through self-report surveys on depression, anxiety, stress, mental health knowledge, and mental health stigma. Quantitative data will be analyzed using several descriptive and inferential analyses via SPSS. A small number of participants (144 students and 144 service providers) will also be engaged in focus groups to assess the socio-environmental contexts of university students' health and availability of mental health resources. Qualitative data will be transcribed verbatim and NVivo will be used for data management. Social network analysis will also be performed using EgoNet. RESULTS: Linking Hearts was funded in January 2018 for 5 years. The protocol of Linking Hearts and its 3 components was approved by the research ethics boards of all participating institutions in China in November 2018. Canadian institutions that gave approval were Ryerson University (REB2018-455) in January 2019, University of Alberta (Pro00089364), York University (e2019-162) in May 2019, and University of Toronto (RIS37724) in August 2019. Data collection took place upon ethics approval and was completed in January 2020. A total of 600 students were surveyed. An additional 147 students and 138 service providers took part in focus groups. Data analysis is ongoing. Results will be published in 2021. CONCLUSIONS: Findings from this contextual assessment and analysis will generate new knowledge on university students' mental health status, mental health knowledge, and resources available for them. These findings will be used to adapt and refine the Acceptance and Commitment to Empowerment-Linking Youth N' Xin intervention model. The results of this contextual assessment will be used to inform the adaptation and refinement of the mental health intervention to promote the mental health of Chinese university students in Jinan. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/25009.

Association between Mental Health Knowledge Level and Depressive Symptoms among Chinese College Students.

This study aimed to explore the association between mental health knowledge level and the prevalence of depressive symptoms among Chinese college students. A cross-sectional study was conducted in six universities in Jinan, Shandong Province, China, and a total of 600 college students were recruited to self-complete a series of questionnaires. The Mental Health Knowledge Questionnaire (MHKQ) was used to investigate the level of mental health knowledge. Depressive symptoms were investigated with the depression subscale of the Depression Anxiety Stress Scale (DASS-21). The prevalence rate of depressive symptoms among college students was 31.2%. Compared with MHKQ scoring in the 1st quartile, college students with MHKQ scoring in the 3rd quartile and in the 4th quartile reported lower levels of depressive symptoms after adjusting for potential confounding factors. Since mental health knowledge level was related to depressive symptoms among college students, increased efforts to promote the level of mental health knowledge in Chinese college students are critical.

Correlates of non-adherence to breast, cervical, and colorectal cancer screening among screen-eligible women: a population-based cohort study in Ontario, Canada.

PURPOSE: Breast, cervical, and colorectal cancers are cancers that can be detected early through screening. Despite organized cancer screening programs in Ontario, Canada participation remains low among marginalized populations. Although extensive research has been done about factors contributing to under-screening by cancer site, the predictors of under/never screened conjointly for all three types of cancer remain unknown. METHODS: Using provincial-level linked administrative data sets, we examined Ontario women who were screen-eligible for all three types of cancer over a 36-month period (i.e., April 2014-March 2017) and determined how many were up to date on 0, 1, 2, and all three types of screenings. Multivariate logistic regression was utilized to examine individual and structural predictors of screening with the group overdue for all screening being the reference group. RESULTS: Of the 1,204,551 screen-eligible women, 15% were overdue for all. Living in the lowest income neighborhoods (AOR 0.46 [95% CI 0.45-0.47]), being recent immigrants (AOR 0.54 [95% CI 0.53-0.55]), having no primary care provider (AOR 0.17 [95% CI 0.16-0.17]), and having no contact with health care services (AOR 0.09 [95% CI 0.09-0.09]) significantly increased the likelihood of being overdue for all versus no screening type. CONCLUSIONS: Considering that more than 15% of screen-eligible women in Ontario were overdue for all types of cancer screening, it is imperative to address structural barriers such as lack of a primary care provider. Innovative interventions like "one-stop shopping" where screening for different cancers can be offered at the same time could promote screening uptake.

Perspectives of family physicians towards access to lung cancer screening for individuals living with low income - a qualitative study.

BACKGROUND: Individuals living with low income are less likely to participate in lung cancer screening (LCS) with low-dose computed tomography. Family physicians (FPs) are typically responsible for referring eligible patients to LCS; therefore, we sought to understand their perspectives on access to lung cancer screening for individuals living with low income in order to improve equity in access to LCS. METHODS: A theory-informed thematic analysis was conducted using data collected from 11 semi-structured interviews with FPs recruited from three primary care sites in downtown Toronto. Data was coded using the Systems Model of Clinical Preventative Care as a framework and interpretation was guided by the synergies of oppression analytical lens. RESULTS: Four overarching themes describe FP perspectives on access to LCS for individuals living with low income: the degree of social disadvantage that influences lung cancer risk and opportunities to access care; the clinical encounter, where there is often a mismatch between the complex health needs of low income individuals and structure of health care appointments; the need for equity-oriented health care, illustrated by the neglect of structural origins of health risk and the benefits of a trauma-informed approach; and finally, the multiprong strategies that will be needed in order to improve equity in health outcomes. CONCLUSION: An equity-oriented and interdisciplinary team based approach to care will be needed in order to improve access to LCS, and attention must be given to the upstream determinants of lung cancer in order to reduce lung cancer risk.

Transnational contexts and local embeddedness of HIV/STI vulnerabilities among Thai and Filipino agricultural temporary foreign workers in Canada.

Each year Canada approves about 70,000 agricultural temporary foreign worker positions. However, few studies have examined temporary foreign workers' sexual health. In this mixed-methods study, we used surveys and focus groups to explore the knowledge of HIV and sexually transmitted infections (STI), sexual behaviours and the perspectives of sexual health of 100 Thai and Filipino temporary foreign workers in southwestern Ontario, Canada. The findings revealed that transnational migration had opened up social space that workers were not familiar with. Social isolation, stress and prolonged separation from spouses and partners resulted in the formation of new intimate relationships. Close to two-thirds of the 100 participants were sexually active in the twelve months prior to the study and over three-quarters did not use condoms. Many participants had misconceptions about HIV risks and safer sex practices. Few temporary workers accessed sexual health services due to language barriers, time constraints, stigma and lack of transport. As a result, many obtained medical advice and medicine through their families back home and relied on self-treatment in dealing with symptoms of genital infections. Effective sexual health promotion for temporary foreign workers must consider the complex interactive sociocultural and political processes that involve institutional practices in the local and transnational contexts.