Toward equity-oriented cancer care: a Strategy for Patient-Oriented Research (SPOR) protocol to promote equitable access to lung cancer screening.

BACKGROUND: Screening for lung cancer with low dose CT can facilitate the detection of early-stage lung cancers that are amenable to treatment, reducing mortality related to lung cancer. Individuals are considered eligible for lung cancer screening if they meet specific high-risk criteria, such as age and smoking history. Population groups that are at highest risk of lung cancer, and therefore, the target of lung cancer screening interventions, are also the least likely to participate in lung cancer screening. This can lead to a widening of health inequities. Deliberate effort is needed to both reduce lung cancer risk (through upstream interventions that promote smoking cessation) as well as midstream interventions that promote equitable access to lung cancer screening. METHODS: This protocol paper describes an equity-informed patient-oriented research study. Our study aims to promote equitable access to lung cancer screening by partnering with patients to co-design an e-learning module for healthcare providers. The learning module will describe the social context of lung cancer risk and promote access to lung cancer screening by increasing equity at the point of care. We have applied the Generative Co-Design Framework for Healthcare Innovation and detail our study processes in three phases and six steps: Pre-design (establishing a study governance structure); Co-design (identifying research priorities, gathering and interpreting data, co-developing module content); and Post-design (pilot testing the module and developing an implementation plan). DISCUSSION: Patient engagement in research can promote the design and delivery of healthcare services that are accessible and acceptable to patients. This is particularly important for lung cancer screening as those at highest risk of developing lung cancer are also those who are least likely to participate in lung cancer screening. By detailing the steps of our participatory co-design journey, we are making visible the processes of our work so that they can be linked to future outcomes and related impact, and inform a wide range of patient co-led processes.

Lung cancer is the most commonly diagnosed cancer in Canada and is responsible for a quarter of all cancer-related deaths in the country. Screening for lung cancer using tools such as a CT scan can allow us to find lung cancers when they are still small and curable. People can receive a lung CT scan depending on how old they are and for how long they have smoked cigarettes. Certain groups of people, particularly those who have fewer resources such as time and money, and those who experience injustice because of who they are and how they look are less likely to participate in lung cancer screening. We can increase participation in lung cancer screening by educating healthcare providers on appropriate and timely ways to talk to patients about lung cancer screening. In this paper, we outline the steps of a patient-partnered study in which many different stakeholders such as patients, providers and policy-makers have come together with a goal to improve equity in access to lung cancer screening. We will do this by jointly creating an online learning module that will educate healthcare providers on how life experiences shape smoking behaviour and lung cancer risk. The module will also impart key skills on how to deliver care which is timely, appropriate and safe. Once the module is ready it will be freely available to all healthcare providers to support the fair and just delivery of lung cancer screening in the province of Ontario and elsewhere.

Nurse home visiting and prenatal substance use in a socioeconomically disadvantaged population in British Columbia: analysis of prenatal secondary outcomes in an ongoing randomized controlled trial.

BACKGROUND: Nurse-Family Partnership (NFP) involves public health nurses providing frequent home visits from early pregnancy until children reach age 2 years, focusing on first-time parents experiencing socioeconomic disadvantage. Our aim was to evaluate NFP's effectiveness in improving child and maternal health. METHODS: We conducted an analysis of prenatal secondary outcomes in an ongoing randomized controlled trial in British Columbia; the data used in this analysis were collected from January 2014 to May 2017. Participants were pregnant girls and women aged 14-24 years who were preparing to parent for the first time and experiencing socioeconomic disadvantage. They were randomly allocated 1:1 to the intervention (NFP plus existing services) or control group (existing services). Prespecified prenatal secondary outcome indicators were changes in use of nicotine cigarettes and alcohol use by 34-36-weeks' gestation. We also report on prespecified exploratory cannabis and street drug use measures. We used mixed-effect models for longitudinal and clustered data to estimate intervention effects. Analyses were by intention to treat. RESULTS: The median gestational age at baseline for the 739 participants (368 participants in the intervention group, 371 in the comparison group) was 20 weeks, 6 days. By 34-36 weeks' gestation, NFP significantly reduced cigarette counts (over the past 2 d) (difference in changes [DIC] of count -1.6, 95% confidence interval [CI] -6.4 to -1.3) in those who smoked. NFP also significantly reduced rates of prenatal cannabis use (DIC -6.4, 95% CI -17.0 to -1.7), but not rates of street drug or "any" substance use. While we observed decreased rates of cigarette and alcohol use in both groups (DIC of proportions -2.8, 95% CI -15.3 to 0.6; DIC -0.5, 95% CI -8.7 to 1.8, respectively), these changes were not statistically significant. INTERPRETATION: We found no evidence that NFP was effective in reducing rates of prenatal cigarette and alcohol use; however, it led to reduced prenatal cannabis use, and in smokers it led to modest reductions in cigarette use. NFP may therefore hold promise for reducing some types of prenatal substance use in disadvantaged populations. Trial registration: ClinicalTrials.gov, no. NCT01672060.

Toward equitably high-quality cancer survivorship care.

Although models of cancer survivorship care are rapidly evolving, there is increasing evidence of health disparities among cancer survivors. In the current context, Canada's survivorship care systems privilege some and not others to receive high-quality care and optimize their health outcomes. The aim of this study was to improve survivorship care systems by helping clinicians and decision makers to a better understanding of how various psychosocial/political factors, survivors' health experiences and health management strategies might shape the development of and access to high-quality survivorship care for Canadians with cancer. Using a nursing epistemological approach informed by critical and intersectional perspectives, we conducted a three-phased Interpretive Description study. We engaged in critical textual analysis of documentary sources, a secondary analysis of interview transcripts from an existing database, and qualitative interviews with 34 survivors and 12 system stakeholders. On the basis of these data, we identified individual, group, and system factors that contributed to gaps between survivors' expected and actual survivorship care experiences. By understanding what shapes survivorship care systems and resources, we help illuminate and unravel the complex nature of the issue, supporting clinicians and decision makers to find multi-layered approaches for equitably high-quality survivorship care.

Wisdom and influence of elders: possibilities for health promotion and decreasing tobacco exposure in First Nations communities.

OBJECTIVES: This community-based project examined the interpersonal and system influences on smoking practices and exposure to cigarette smoke that place young pregnant and parenting First Nations women and their children at risk. The aim was to work with the community using this information to develop meaningful strategies to support tobacco reduction and reduce exposure to second-hand smoke. METHOD: Ethnographic methods informed by decolonizing approaches were used to study smoking practices and exposure within the context of six First Nations rural reserve villages in the Gitxsan territory in North-Western British Columbia. Data were collected through individual interviews with key community members, individual and group interviews with women, men, youth and older people, including Elders, and participant observation. FINDINGS: Older people, including grandparents and Elders expressed great interest in being more involved in their communities, particularly with youth. Other community members, especially mothers, saw such older people as important in diminishing the tobacco exposure problem, with ideas for their involvement ranging from role modeling non-smoking or respectful smoking to teaching cultural traditions. CONCLUSION: Elders in First Nations communities represent a culturally-relevant resource for health that is currently underused. Communities might draw upon their wisdom and influence to decrease tobacco exposure and promote community health in other ways. This offers a concrete, practical strategy in response to widespread calls for supporting the culture of Aboriginal people as part of health promotion.

Women's health and use of crack cocaine in context: structural and 'everyday' violence.

BACKGROUND: There is increasing public health evidence that women who use crack cocaine and are street-involved experience significant health problems and are more isolated with regards to accessing harm reduction and other health-related services. Simultaneously, there is growing acknowledgement that structural and 'everyday' violence are significant factors influencing the health of women who use illegal drugs. Little research has examined how these social processes play out for women who use crack cocaine. METHODS: A critical ethnography informed by the theoretical constructs of structural and everyday violence and intersectionality was undertaken to explore women's use of crack cocaine within an inner-city neighbourhood in Western Canada. Data collection included baseline survey (n=126), participant observation and field notes, informal interviews (n=53), and in-depth interviews (n=13). RESULTS: Based on thematic and theoretical analysis two interrelated themes were identified that reflected the interrelationships between women's use of crack, poverty, discrimination, racism, gendered relations of power, and legal policies and practices: (a) the context of health care; and (b) the smoking context. CONCLUSIONS: Structural inequities and 'everyday' violence are perilously damaging for women who use crack. Interventions to reduce these inequities are urgently needed if we are to reduce the significant suffering of women who are street-involved and use crack cocaine.

Bingo halls and smoking: perspectives of First Nations women.

The purpose of this study was to examine bingo halls as a frequent site for exposure to secondhand cigarette smoke for First Nations women in rural communities. Thematic analysis of interviews with key informants, group discussions with young women, and observations in the study communities revealed that smoky bingo halls provided an important refuge from everyday experiences of stress and trauma, as well as increased women's risk for addiction, marginalization, and criticism. The findings illustrate how the bingo economy in isolated, rural First Nation communities influences tobacco use and second-hand smoke exposure, and how efforts to establish smoke-free bingos can be supported.

Chronic pain in women survivors of intimate partner violence.

UNLABELLED: In this descriptive study of chronic pain in a community sample of 292 women who had separated from their abusive partners on average 20 months previously, more than one-third experienced high disability pain as measured by Von Korff's Chronic Pain Grade. Beyond the usual pain locations associated with abuse, 43.2% reported swollen/painful joints. More interference in daily life was attributed to joint pain than to back, head, stomach, pelvic or bowel pain. Women with high disability pain were more likely to have experienced child abuse, adult sexual assault, more severe spousal abuse, lifetime abuse-related injuries, symptoms of depression and post-traumatic stress disorder, lifetime suicide attempts, difficulty sleeping, and unemployment. High disability pain also was associated with visits to a family doctor and psychiatrist and use of medication in more than prescribed dosages. Less than 25% of women with high disability pain were taking opioids, or prescription nonsteroidal anti-inflammatory medications. Interestingly, high disability pain was not related to smoking, use of street drugs, potential for alcohol dependence, age, income, or education. The findings add to knowledge of severity and patterns of chronic pain in abused women and support the need for further multivariate analysis of the relationships among abuse experiences, mental health, and chronic pain severity to better inform decisions regarding diagnosis and treatment. PERSPECTIVE: Understanding patterns of chronic pain in abuse survivors and their associations with abuse history, mental health symptoms, health service use, and medication is important for clinical assessment and intervention. Chronic pain persisted long after leaving abusive partners and extended beyond usual locations (back, headache, pelvic, gastrointestinal) to include swollen/painful joints.

Toward a safer moral climate.

The authors define moral climate in the context of health care as the implicit and explicit values that drive health-care delivery and shape the workplaces in which care is delivered. Over the past six years, their research has focused on describing the moral climates of nurses' workplaces and improving them. In this article, the authors argue that nurses in direct care delivery roles have the insights, expertise and interpersonal skills required to create a much safer moral climate for practice. To make this happen, nurses require opportunities for self-reflection and for true collaboration with their colleagues in management and administration and other health-care disciplines.