Qualitative Interviews to Add Patient Perspectives in Colorectal Cancer Screening: Improvements in a Learning Health System.

Health systems are interested in increasing colorectal cancer (CRC) screening rates as CRC is a leading cause of preventable cancer death. Learning health systems are ones that use data to continually improve care. Data can and should include qualitative local perspectives to improve patient and provider education and care. This study sought to understand local perspectives on CRC screening to inform future strategies to increase screening rates across our integrated health system. Health insurance plan members who were eligible for CRC screening were invited to participate in semi-structured phone interviews. Qualitative content analysis was conducted using an inductive approach. Forty member interviews were completed and analyzed. Identified barriers included ambivalence about screening options (e.g., "If it had the same performance, I'd rather do home fecal sample test. But I'm just too skeptical [so I do the colonoscopy]."), negative prior CRC screening experiences, and competing priorities. Identified facilitators included a positive general attitude towards health (e.g., "I'm a rule follower. There are certain things I'll bend rules. But certain medical things, you just got to do."), social support, a perceived risk of developing CRC, and positive prior CRC screening experiences. Study findings were used by the health system leaders to inform the selection of CRC screening outreach and education strategies to be tested in a future simulation model. For example, the identified barrier related to ambivalence about screening options led to a proposed revision of outreach materials that describe screening types more clearly.

Rural vs urban inequalities in stage at diagnosis for lung cancer.

OBJECTIVES: Early diagnosis of lung cancer increases the chance of survival. The aim of this study was to measure the relationship between geographic residence in Saskatchewan and stage of lung cancer at the time of diagnosis. MATERIALS AND METHODS: Retrospective cohort analysis of 2,972 patients with a primary diagnosis of either non-small cell cancer (NSCLC) or small cell lung cancer (SCLC) between 2007 and 2012 was performed. Incidence proportion of early and advanced stage cancer, and relative risk of being diagnosed with advanced-stage lung cancer relative to early-stage was calculated. RESULTS: Compared to urban Saskatchewan, rural Saskatchewan lung cancer patients had a higher relative risk of advanced stage NSCLC (relative risk [RR] = 1.11, 95% confidence interval [CI]: 1.01-1.22). Rural Saskatchewan was further subdivided into north and south. The relative risk of advanced stage NSCLC in rural north Saskatchewan compared to urban Saskatchewan was even greater (RR = 1.17, 95% CI: 1.03-1.31). Although not statistically significant, there was a trend for a higher incidence of advanced stage SCLC in rural and rural north vs urban Saskatchewan (RR = 1.16, 95% CI: 0.95-1.43 and RR = 1.22; 95% CI: 0.94-1.58, respectively). There was a higher incidence proportion of advanced stage NSCLC in rural areas relative to urban (31.6-34.4 vs 29.5 per 10,000 people). CONCLUSION: Patients living in rural Saskatchewan have higher incidence proportion of and were more likely to present with advanced stage NSCLC in comparison to urban Saskatchewan patients at time of diagnosis. This inequality was even greater in rural north Saskatchewan.

Tobacco messages encountered in real-time among low socio-economic position groups: a descriptive study.

BACKGROUND: Tobacco advertising disproportionately targets low socio-economic position (SEP) groups, causing higher rates of tobacco use in this population. Anti-tobacco public health education campaigns persuade against use. This study measured real-time exposure of pro- and anti-tobacco messages from low SEP groups in two American cities. METHODS: Individuals in low SEP groups (N = 95), aged 18-34 years old, who were smokers and non-smokers, from the Boston and Houston areas, took part in a mobile health study. They submitted images of tobacco-related messages they encountered via a mobile application for a 7-week period. Two coders analyzed the images for message characteristics. Intercoder reliability was established using Krippendorff's alpha and data were analyzed descriptively. RESULTS: Of the submitted images (N = 131), 83 were pro-tobacco and 53 were anti-tobacco. Of the pro-tobacco messages, the majority were cigarette ads (80.7%) seen outside (36.1%) or inside (30.1%) a convenience store or gas station and used conventional themes (e.g., price promotion; 53.2%). Of the anti-tobacco messages, 56.6% were sponsored by public health campaigns or were signage prohibiting smoking in a public area (39.6%). Most focused on the health harms of smoking (28.3%). CONCLUSION: Low SEP groups in this study encountered more pro-tobacco than anti-tobacco messages at places that were point-of-sale using price promotions to appeal to this group. Anti-tobacco messages at point-of-sale and/or advertising regulations may help combat tobacco use.

A dynamic modelling analysis of the impact of tobacco control programs on population-level nicotine dependence.

According to the 'hardening hypothesis', average nicotine dependence will increase as less dependent smokers quit relatively easily in response to effective public health interventions, so that sustained progress in reducing smoking prevalence will depend on shifting the emphasis of tobacco control programs towards intensive treatment of heavily dependent smokers (who comprise an increasing fraction of continuing smokers). We used a system dynamics model of smoking behaviour to explore the potential for hardening in a population of smokers exposed to effective tobacco control measures over an extended period. Policy-induced increases in the per capita cessation rate are shown to lead inevitably to a decline in the proportion of smokers who are heavily dependent, contrary to the hardening hypothesis. Changes in smoking behaviour in Australia over the period 2001‒2016 resulted in substantial decreases in current smoking prevalence (from 23.1% in 2001 to 14.6% in 2016) and the proportion of heavily dependent smokers in the smoking population (from 52.1% to 36.9%). Public health interventions that have proved particularly effective in reducing smoking prevalence (tobacco tax increases, smoke-free environment legislation, antismoking mass media campaigns) are expected to also contribute to a decline in population-level nicotine dependence.

Using System Dynamics tools to gain insight into intervention options related to the interaction between tobacco and tuberculosis.

Tobacco exposure is an important risk factor for tuberculosis (TB) when considering its effects on population-level disease outcomes. If we hope to gain control over TB globally, we must begin to think 'outside of the box' to identify an extended and multi-faceted intervention strategy that is grounded in an understanding of the particular ways in which key risk factors worsen TB. In light of the role of tobacco exposure as an important, identifiable, modifiable, and preventable risk factor for TB, efforts aiming at reducing tobacco use merit inclusion in such a comprehensive TB control program. The goal of this paper is to share the conceptual framework we have developed using System Dynamics methodology, which diagrams the likely effects of tobacco exposure on TB dynamics in a typical low-income country setting. Using this framework as a guide, we leverage an understanding of the likely mechanisms by which tobacco exposure affects TB risk to systematically explore TB control intervention options. We hope that this paper will help inspire new approaches to extend and enhance traditional TB control efforts. We also hope that the conceptual framework will spark further discussion and research on this important and potentially explosive combination of global public health crises.