Supporting implementation science and health equity in cancer prevention and control through research networks.

The Cancer Prevention and Control Research Network (CPCRN) is a national network of academic, public health, and community organizational partners across multiple geographic sites who collaborate to reduce the cancer burden in diverse communities. Given key recommendations that suggest the need for cross-disciplinary collaboration in cancer prevention and control, we sought to explore the historical and contemporary evolution of health equity and disparities research as an area of focus within the CPCRN over time. We conducted 22 in-depth interviews with former and current leaders, co-investigators, and other members of the network. Several key themes emerged from data that were analyzed and interpreted using a constructivist, reflexive, thematic analysis approach. Nearly all participants reported a strong focus on studying health disparities since the inception of the CPCRN, which offered the network a distinct advantage in recent years for incorporating an intentional focus on health equity. Recent law enforcement injustices and the inequities observed during the COVID-19 pandemic have further invigorated network activities around health equity, such as development of a health equity-focused workgroup toolkit, among other cross-center activities. Several participants noted that, in terms of deep, meaningful, and impactful health equity-oriented research, there are still great strides for the network to make, while also acknowledging CPCRN as well-aligned with the national dialogue led by federal agency partners around health equity. Finally, several future directions were mentioned by the participants, including a focus on supporting a diverse workforce and engaging organizational partners and community members in equity-focused research. Findings from these interviews provide direction for the network in advancing the science in cancer prevention and control, with a strengthened focus on health equity.

The special sauce of the Cancer Prevention and Control Research Network: 20 years of lessons learned in developing the evidence base, building community capacity, and translating research into practice.

PURPOSE: The Cancer Prevention and Control Research Network (CPCRN) is a national network focused on accelerating the translation of cancer prevention and control research evidence into practice through collaborative, multicenter projects in partnership with diverse communities. From 2003 to 2022, the CPCRN included 613 members. METHODS: We: (1) characterize the extent and nature of collaborations through a bibliometric analysis of 20 years of Network publications; and (2) describe key features and functions of the CPCRN as related to organizational structure, productivity, impact, and focus on health equity, partnership development, and capacity building through analysis of 22 in-depth interviews and review of Network documentation. RESULTS: Searching Scopus for multicenter publications among the CPCRN members from their time of Network engagement yielded 1,074 collaborative publications involving two or more members. Both the overall number and content breadth of multicenter publications increased over time as the Network matured. Since 2004, members submitted 123 multicenter grant applications, of which 72 were funded (59%), totaling more than $77 million secured. Thematic analysis of interviews revealed that the CPCRN's success-in terms of publication and grant productivity, as well as the breadth and depth of partnerships, subject matter expertise, and content area foci-is attributable to: (1) its people-the inclusion of members representing diverse content-area interests, multidisciplinary perspectives, and geographic contexts; (2) dedicated centralized structures and processes to enable and evaluate collaboration; and (3) focused attention to strategically adapting to change. CONCLUSION: CPCRN's history highlights organizational, strategic, and practical lessons learned over two decades to optimize Network collaboration for enhanced collective impact in cancer prevention and control. These insights may be useful to others seeking to leverage collaborative networks to address public health problems.

Measuring and addressing health equity: an assessment of cancer center designation requirements.

PURPOSE: By requiring specific measures, cancer endorsements (e.g., accreditations, designations, certifications) promote high-quality cancer care. While 'quality' is the defining feature, less is known about how these endorsements consider equity. Given the inequities in access to high-quality cancer care, we assessed the extent to which equity structures, processes, and outcomes were required for cancer center endorsements. METHODS: We performed a content analysis of medical oncology, radiation oncology, surgical oncology, and research hospital endorsements from the American Society of Clinical Oncology (ASCO), American Society of Radiation Oncology (ASTRO), American College of Surgeons Commission on Cancer (CoC), and the National Cancer Institute (NCI), respectively. We analyzed requirements for equity-focused content and compared how each endorsing body included equity as a requirement along three axes: structures, processes, and outcomes. RESULTS: ASCO guidelines centered on processes assessing financial, health literacy, and psychosocial barriers to care. ASTRO guidelines related to language needs and processes to address financial barriers. CoC equity-related guidelines focused on processes addressing financial and psychosocial concerns of survivors, and hospital-identified barriers to care. NCI guidelines considered equity related to cancer disparities research, inclusion of diverse groups in outreach and clinical trials, and diversification of investigators. None of the guidelines explicitly required measures of equitable care delivery or outcomes beyond clinical trial enrollment. CONCLUSION: Overall, equity requirements were limited. Leveraging the influence and infrastructure of cancer quality endorsements could enhance progress toward achieving cancer care equity. We recommend that endorsing organizations 1) require cancer centers to implement processes for measuring and tracking health equity outcomes and 2) engage diverse community stakeholders to develop strategies for addressing discrimination.

Measuring capacity to use evidence-based interventions in community-based organizations: A comprehensive, scoping review.

Introduction: Community-based organizations (CBOs) are well-positioned to incorporate research evidence, local expertise, and contextual factors to address health inequities. However, insufficient capacity limits use of evidence-based interventions (EBIs) in these settings. Capacity-building implementation strategies are popular, but a lack of standard models and validated measures hinders progress in the field. To advance the literature, we conducted a comprehensive scoping review. Methods: With a reference librarian, we executed a comprehensive search strategy of PubMed/Medline, Web of Science Core Collection, and EBSCO Global Health. We included articles that addressed implementation science, capacity-building, and CBOs. Of 5527 articles, 99 met our inclusion criteria, and we extracted data using a double-coding process. Results: Of the 99 articles, 47% defined capacity explicitly, 31% defined it indirectly, and 21% did not define it. Common concepts in definitions were skills, knowledge/expertise, and resources. Of the 57 articles with quantitative analysis, 48 (82%) measured capacity, and 11 (23%) offered psychometric data for the capacity measures. Of the 99 studies, 40% focused exclusively on populations experiencing inequities and 22% included those populations to some extent. The bulk of the studies came from high-income countries. Conclusions: Implementation scientists should 1) be explicit about models and definitions of capacity and strategies for building capacity, 2) specify expected multi-level implementation outcomes, 3) develop and use validated measures for quantitative work, and 4) integrate equity considerations into the conceptualization and measurement of capacity-building efforts. With these refinements, we can ensure that the necessary supports reach CBO practitioners and critical partners for addressing health inequities.

Grounding implementation science in health equity for cancer prevention and control.

BACKGROUND: The past decade of research has seen theoretical and methodological advances in both implementation science and health equity research, opening a window of opportunity for facilitating and accelerating cross-disciplinary exchanges across these fields that have largely operated in siloes. In 2019 and 2020, the National Cancer Institute's Consortium for Cancer Implementation Science convened an action group focused on 'health equity and context' to identify opportunities to advance implementation science. In this paper, we present a narrative review and synthesis of the relevant literature at the intersection of health equity and implementation science, highlight identified opportunities (i.e., public goods) by the action group for advancing implementation science in cancer prevention and control, and integrate the two by providing key recommendations for future directions. DISCUSSION: In the review and synthesis of the literature, we highlight recent advances in implementation science, relevant to promoting health equity (e.g., theories/models/frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes). We acknowledge the contributions from the broader field of health equity research and discuss opportunities for integration and synergy with implementation science, which include (1) articulating an explicit focus on health equity for conducting and reviewing implementation science; (2) promoting an explicit focus on health equity in the theories, models, and frameworks guiding implementation science; and (3) identifying methods for understanding and documenting influences on the context of implementation that incorporate a focus on equity. To advance the science of implementation with a focus on health equity, we reflect on the essential groundwork needed to promote bi-directional learning between the fields of implementation science and health equity research and recommend (1) building capacity among researchers and research institutions for health equity-focused and community-engaged implementation science; (2) incorporating health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); and (3) continuing a focus on transdisciplinary opportunities in health equity research and implementation science. We believe that these recommendations can help advance implementation science by incorporating an explicit focus on health equity in the context of cancer prevention and control and beyond.

Decomposing socioeconomic disparities in the use of colonoscopy among the insured elderly population before and after the Affordable Care Act.

BACKGROUND: Out-of-pocket costs may significantly dampen patients' willingness to adopt preventive procedures. This is especially true for colonoscopies, which typically involved relatively high cost-sharing requirements prior to the Affordable Care Act (ACA) implementation in 2011. PURPOSE: We aim to examine the effects of income-related disparities in colonoscopy use in the years prior to and immediately after the implementation of the ACA. Further, we quantify the contributions of different factors in explaining the disparities in the use of colonoscopies among elderly population with health insurance coverage. METHODS: Five cycles (2008, 2010, 2012, 2014, and 2016) of Behavioral Risk Factor Surveillance System data were utilized. To examine income-related disparities in the use of CRC, individuals aged 65-75 were included, and the concentration index (CI) was calculated before and after the implementation of ACA. To identify and quantify the contribution of different factors, a decomposition analysis of CI was conducted. RESULTS: CIs decreased from 0.1935 in pre-ACA years to 0.1813 in the post-ACA years among the elderly, indicating that the disparities in the use of colonoscopy was relatively low and the disparities index declined after the implementation of ACA. Decomposition analyses showed that whereas decreases in disparities derived largely from income and educational level, higher level of income and educational attainment were major contributors to the observed disparities in colonoscopy use. CONCLUSIONS: Our findings indicate that the ACA's removal of financial barriers may have contributed toward the reduction in disparities of colonoscopy use. More direct interventions, e.g., improved knowledge, better access and lower indirect cost will be helpful in improving screening among low-income and low-educational attainment households.

Effects of the Affordable Care Act on the Receipt of Colonoscopies among the Insured Elderly.

BACKGROUND: The Affordable Care Act (ACA) waived deductibles and eliminated coinsurance for colonoscopies for Medicare beneficiaries beginning in January 1, 2011. This study investigated the effect of the ACA's directive to remove the financial barriers on the receipt of colonoscopies among the elderly insured, who are predominantly covered by Medicare. METHODS: Data from the 2008-2016 Behavioral Risk Factor Surveillance System (BRFSS) were used to examine the receipt of colonoscopies in two years prior to the implementation of the ACA (2008 and 2010) and three years after the change (2012, 2014, and 2016). Multivariate logistic regressions were estimated to examine the change in colonoscopy use before and after the introduction of the ACA, adjusting for patient characteristics and availability of health care providers in the geographic region. RESULTS: Of 349,899 eligible elderly insured in the age group 65 to 75 years, 236,275 (67.2%) had received a colonoscopy in the previous ten years. The receipt of colonoscopies increased from 63.5% in pre-ACA years to 69.2% in the post-ACA years (p < 0.001). Compared with the pre-ACA period, the odds ratio of colonoscopy uptake in post-ACA years was 1.15 (95% CI = 1.08-1.22). CONCLUSIONS: A statistically significant increase in colonoscopy use was observed in the post-ACA years. However, achieving the target coverage rate of 80% will require additional interventions to encourage higher levels of screenings.

A Bivariate Mapping Tutorial for Cancer Control Resource Allocation Decisions and Interventions.

Bivariate choropleth mapping is a straightforward but underused method for displaying geographic health information to use in public health decision making. Previous studies have recommended this approach for state comprehensive cancer control planning and similar efforts. In this method, 2 area-level variables of interest are mapped simultaneously, often as overlapping quantiles or by using other classification methods. Variables to be mapped may include area-level (eg, county level) measures of disease burden, health care use, access to health care services, and sociodemographic characteristics. We demonstrate how geographic information systems software, specifically ArcGIS, can be used to develop bivariate choropleth maps to inform resource allocation and public health interventions. We used 2 types of county-level public health data: South Carolina's Behavioral Risk Factor Surveillance System estimates of ever having received cervical cancer screening, and a measure of availability of cervical cancer screening providers that are part of South Carolina's Breast and Cervical Cancer Early Detection Program. Identification of counties with low screening rates and low access to care may help inform where additional resources should be allocated to improve access and subsequently improve screening rates. Similarly, identifying counties with low screening rates and high access to care may help inform where educational and behavioral interventions should be targeted to improve screening in areas of high access.

Policy opportunities to increase HPV vaccination in rural communities.

Rural communities experience health disparities, including elevated incidence and mortality of human papillomavirus (HPV)-associated cancers and correspondingly low HPV vaccination rates. There are numerous policy strategies that are available at multiple levels - patient, provider, clinic, community, state, and national - to address geographic, clinical, and communication barriers to HPV vaccination across rural America. Examples include policy development, implementation, and evaluation of healthcare provider and clinic-based assessment and education initiatives; school entry requirements; school, pharmacy, and community-based vaccination programs; evidence-based, community-driven communication efforts; and increased interventional research in rural communities. Strategically implemented policy measures will contribute to reduction in the incidence and mortality from HPV-related cancers through increased access to HPV vaccination in our rural communities.

Mentoring, Training, and Scholarly Productivity Experiences of Cancer-Related Health Disparities Research Trainees: Do Outcomes Differ for Underrepresented Scientists?

The study aims to explore variation in scholarly productivity outcomes by underrepresented status among a diverse sample of researchers in a community-engaged training program. We identified 141 trainees from a web-based survey of researchers in the National Cancer Institute-funded, Community Networks Program Centers (CNPCs) (2011-2016). We conducted a series of multiple logistic regression models to estimate the effect of National Institutes of Health (NIH)-defined underrepresented status on four, self-reported, scholarly productivity outcomes in the previous 5 years: number of publications (first-authored and total) and funded grants (NIH and any agency). Sixty-five percent (n = 92) indicated NIH underrepresented status. In final adjusted models, non-NIH underrepresented (vs. underrepresented) trainees reported an increased odds of having more than the median number of total publications (> 9) (OR = 3.14, 95% CI 1.21-8.65) and any grant funding (OR = 5.10, 95% CI 1.77-14.65). Reporting ≥ 1 mentors (vs. none) was also positively associated (p < 0.05) with these outcomes. The CNPC underrepresented trainees had similar success in first-authored publications and NIH funding as non-underrepresented trainees, but not total publications and grants. Examining trainees' mentoring experiences over time in relation to scholarly productivity outcomes is needed.

African American Women's Perceived Influences on and Strategies to Reduce Sedentary Behavior.

We conducted three focus groups to examine African American women's perceptions of factors influencing and proposed strategies for reducing sedentary behavior (SB). QSR NVivo 9 facilitated coding and organization of themes. Although participants ( n = 32, 53.6 ± 6.0 years, 75% obese) were unfamiliar with the term SB prior to focus groups, they described spending large amounts of time in SB at work and home. Participants viewed leisure-time SB as necessary and important but were amenable to decreasing SB at work. Participants also identified personal, social, and environmental factors contributing to SB as well as novel strategies for reducing SB. Results suggest that messages aimed at reducing SB in African American women should be positively framed, viewed within a socioecologic framework, and target nonleisure time SB. SB was viewed as a form of stress reduction; thus, future research might want to emphasize alternative stress management techniques that simultaneously reduce SB.

Barriers, facilitators, and potential strategies for increasing HPV vaccination: A statewide assessment to inform action.

OBJECTIVE: The objective was to investigate how state level strategies in South Carolina could maximize HPV vaccine uptake. DESIGN: An environmental scan identified barriers, facilitators, and strategies for improving HPV vaccination in South Carolina. Interviews were conducted with state leaders from relevant organizations such as public health agencies, medical associations, K-12 schools, universities, insurers, and cancer advocacy organizations. A thematic content analysis design was used. Digital interview files were transcribed, a data dictionary was created and data were coded using the data dictionary. RESULTS: Thirty four interviews were conducted with state leaders. Barriers to HPV vaccination included lack of HPV awareness, lack of provider recommendation, HPV vaccine concerns, lack of access and practice-level barriers. Facilitators included momentum for improving HPV vaccination, school-entry Tdap requirement, pharmacy-based HPV vaccination, state immunization registry, HEDIS measures and HPV vaccine funding. Strategies for improving HPV vaccination fell into three categories: 1) addressing lack of awareness about the importance of HPV vaccination among the public and providers; 2) advocating for policy changes around HPV vaccine coverage, vaccine education, and pharmacy-based vaccination; and 3) coordination of efforts. DISCUSSION: A statewide environmental scan generated a blueprint for action to be used to improve HPV vaccination in the state.

Using photovoice as a tool for community engagement to assess the environment and explore environmental health disparities.

Photovoice was used as a participatory research method to document perceived local environmental hazards, pollution sources, and potential impact on health among community members to address environmental health disparities. A convenience sample of 16 adults in Orangeburg, South Carolina participated in Photovoice. Photos depicted positive and negative implications of the environment across seven themes: recreation and leisure; food access; hazards and pollution; health, human, and social services; economic issues; beautification; and accommodation and accessibility. Positive and negative photos demonstrated a high level of interest among community members in considering how the environment influences health and health disparities.

Social and Structural Determinants of Cervical Health among Women Engaged in HIV Care.

Cervical cancer prevention/control efforts among women living with HIV/AIDS (WLH) are socially and structurally challenging. Healthcare access and perceived HIV stigma and discrimination are factors that may challenge risk reduction efforts. This study examined socio-structural determinants of cervical cancer screening among women engaged in HIV care. One hundred forty-five WLH seeking health/social services from AIDS Service Organizations in the southeastern US completed a questionnaire assessing factors related to cervical cancer prevention/control. Ninety percent were African American, mean age 46.15 ± 10.65 years. Eighty-one percent had a Pap test <1 year ago. Low healthcare access was positively associated with having a Pap test <1 year ago, (Odds ratio [OR] 3.80; 95 % Confidence interval [CI] 1.34-10.78). About 36 % reported ≥2 Pap tests during the first year after HIV diagnosis. Lower educational attainment was positively associated with having ≥2 Pap tests, OR 3.22; CI 1.08-9.62. Thirty-five percent reported more frequent Pap tests after diagnosis. Lower income was moderately associated with more frequent Pap tests post-diagnosis, OR 2.47; CI .98-6.23. Findings highlight the successes of HIV initiatives targeting socio-economically disadvantaged women and provide evidence that health policy aimed at providing and expanding healthcare access for vulnerable WLH has beneficial health implications.

Race and Prevalence of Large Bowel Polyps Among the Low-Income and Uninsured in South Carolina.

BACKGROUND: Compared to whites, blacks have higher colorectal cancer incidence and mortality rates and are at greater risk for early-onset disease. The reasons for this racial disparity are poorly understood, but one contributing factor could be differences in access to high-quality screening and medical care. AIMS: The present study was carried out to assess whether a racial difference in prevalence of large bowel polyps persists within a poor and uninsured population (n = 233, 124 blacks, 91 whites, 18 other) undergoing screening colonoscopy. METHODS: Eligible patients were uninsured, asymptomatic, had no personal history of colorectal neoplasia, and were between the ages 45-64 years (blacks) or 50-64 years (whites, other). We examined the prevalence of any adenoma (conventional, serrated) and then difference in adenoma/polyp type by race and age categories. RESULTS: Prevalence for ≥1 adenoma was 37 % (95 % CI 31-43 %) for all races combined and 36 % in blacks <50 years, 38 % in blacks ≥50 years, and 35 % in whites. When stratified by race, blacks had a higher prevalence of large conventional proximal neoplasia (8 %) compared to whites (2 %) (p value = 0.06) but a lower prevalence of any serrated-like (blacks 18 %, whites 32 %; p value = 0.02) and sessile serrated adenomas/polyps (blacks 2 %, whites 8 % Chi-square p value; p = 0.05). CONCLUSIONS: Within this uninsured population, the overall prevalence of adenomas was high and nearly equal by race, but the racial differences observed between serrated and conventional polyp types emphasize the importance of taking polyp type into account in future research on this topic.

Medicaid Coverage Expansion and Implications for Cancer Disparities.

OBJECTIVES: We estimated the impact on cancer disparities in US states that have chosen or not chosen to expand Medicaid since passage of the Patient Protection and Affordable Care Act. METHODS: Data came from the 2013 Uniform Data System for colorectal and cervical cancer screening rates among patients of federally qualified health centers (FQHCs); the 2012 Behavioral Risk Factor Surveillance System for colorectal, cervical, and breast cancer screening rates; and the US Cancer Statistics (2007-2011) for colorectal, cervical, and breast cancer mortality-to-incidence ratios (MIRs). Dyads of Medicaid expansion decisions with cancer screening rates and MIRs were mapped using ArcMap. RESULTS: States that had not expanded Medicaid as of September 2014 had lower cancer screening rates, especially among FQHC patients. Overall, cancer MIRs were not significantly different by Medicaid expansion status. However, Southeastern states without Medicaid expansion tended to have higher cancer MIRs and lower screening rates. CONCLUSIONS: Disparities in cancer screening that already disfavor states with high cancer rates may widen in states that have not chosen to expand Medicaid unless significant efforts are mounted to ensure their residents obtain preventive health care.

Dissemination of an Electronic Manual to Build Capacity for Implementing Farmers' Markets with Community Health Centers.

Community-university partnerships can lend themselves to the development of tools that encourage and promote future community health development. The electronic manual, "Building Farmacies," describes an approach for developing capacity and sustaining a community health center-based farmers' market that emerged through a community-university partnership. Manual development was guided by the Knowledge to Action Framework and experiences developing a multivendor, produce-only farmers' market at a community health center in rural South Carolina. The manual was created to illustrate an innovative solution for community health development. The manual was disseminated electronically through 25 listservs and interested individuals voluntarily completed a Web-based survey to access the free manual. During the 6-month dissemination period, 271 individuals downloaded the manual. Findings highlighted the value of translating community-based participatory research into user-friendly manuals to guide future intervention development and dissemination approaches, and demonstrate the need to include capacity building opportunities to support translation and adoption of interventions.

The National Cancer Institute's Community Networks Program Initiative to Reduce Cancer Health Disparities: Outcomes and Lessons Learned.

BACKGROUND: We describe reach, partnerships, products, benefits, and lessons learned of the 25 Community Network Programs (CNPs) that applied community-based participatory research (CBPR) to reduce cancer health disparities. METHODS: Quantitative and qualitative data were abstracted from CNP final reports. Qualitative data were grouped by theme. RESULTS: Together, the 25 CNPs worked with more than 2,000 academic, clinical, community, government, faith-based, and other partners. They completed 211 needs assessments, leveraged funds for 328 research and service projects, trained 719 new investigators, educated almost 55,000 community members, and published 991 articles. Qualitative data illustrated how use of CBPR improved research methods and participation; improved knowledge, interventions, and outcomes; and built community capacity. Lessons learned related to the need for time to nurture partnerships and the need to attend to community demand for sustained improvements in cancer services. IMPLICATIONS: Findings demonstrate the value of government-supported, community-academic, CBPR partnerships in cancer prevention and control research.

Mentoring and Training of Cancer-Related Health Disparities Researchers Committed to Community-Based Participatory Research.

BACKGROUND AND OBJECTIVE: The National Cancer Institute's (NCI) Community Networks Program Centers (CNPCs) provide community-based participatory research (CBPR)-oriented mentoring and training to prepare early-stage/midcareer investigators and student trainees (trainees) in disparities reduction. This paper describes the academic, mentoring, training, and work-life balance experiences of CNPC-affiliated trainees. METHODS: We used a collaborative and iterative process to develop a 57-item, web-based questionnaire completed by trainees from the 23 CNPCs between August 2012 and February 2013. Their CNPC mentors completed a 47-item questionnaire. Descriptive statistics were calculated. RESULTS: The final analytic sample included 189 of 269 individuals (70%) identified as active participants in CNPC research or training/mentoring. Mentors (n=45) were mostly non-Hispanic White (77.8%) and 48.9% were male. Mentors published a median of 6 (interquartile range [IQR], 3-12) first-authored and 15 (IQR, 6-25) senior authored manuscripts, and secured 15 (IQR, 11-29) grants from the National Institutes of Health (NIH) and other sources in the previous 5 years. Most trainees (n=144) were female (79.2%), 43.7% were underrepresented racial/ethnic minorities, and 36.8% were first-generation college graduates. Over the previous 5 years, trainees reported a median of 4 (IQR, 1-6) publications as first author and 4 (IQR, 2-8) as co-author; 27.1% reported having one or more NIH R01s. Trainees reported satisfaction with their CNPC mentor (79.1%) and confidence in demonstrating most CBPR competencies. CONCLUSION: The CNPC training program consists of a scientifically productive pool of mentors and trainees. Trainees reported rates of scholarly productivity comparable to other national training programs and provided insights into relationships with mentors, academic pressures, and professional-personal life balance.