A Pilot Study of a Comprehensive Financial Navigation Program in Patients With Cancer and Caregivers.

BACKGROUND: Few studies have engaged patients and caregivers in interventions to alleviate financial hardship. We collaborated with Consumer Education and Training Services (CENTS), Patient Advocate Foundation (PAF), and Family Reach (FR) to assess the feasibility of enrolling patient-caregiver dyads in a program that provides financial counseling, insurance navigation, and assistance with medical and cost of living expenses. METHODS: Patients with solid tumors aged ≥18 years and their primary caregiver received a financial education video, monthly contact with a CENTS counselor and PAF case manager for 6 months, and referral to FR for help with unpaid cost of living bills (eg, transportation or housing). Patient financial hardship and caregiver burden were measured using the Comprehensive Score for Financial Toxicity-Patient-Reported Outcomes (COST-PRO) and Caregiver Strain Index (CSI) measures, respectively, at baseline and follow-up. RESULTS: Thirty patients (median age, 59.5 years; 40% commercially insured) and 18 caregivers (67% spouses) consented (78% dyad participation rate). Many participants faced cancer-related financial hardships prior to enrollment, such as work change or loss (45% of patients; 39% of caregivers) and debt (64% of patients); 39% of caregivers reported high levels of financial burden at enrollment. Subjects received $11,000 in assistance (mean, $772 per household); 66% of subjects with income ≤$50,000 received cost-of-living assistance. COST-PRO and CSI scores did not change significantly. CONCLUSIONS: Patient-caregiver dyads were willing to participate in a financial navigation program that addresses various financial issues, particularly cost of living expenses in lower income participants. Future work should address financial concerns at diagnosis and determine whether doing so improves patient and caregiver outcomes.

Barriers and facilitators to HPV vaccination in primary care practices: a mixed methods study using the Consolidated Framework for Implementation Research.

BACKGROUND: In the United States, the effective, safe huma papilloma virus (HPV) vaccine is underused and opportunities to prevent cancer continue to be missed. National guidelines recommend completing the 2-3 dose HPV vaccine series by age 13, well before exposure to the sexually transmitted virus. Accurate characterization of the facilitators and barriers to full implementation of HPV vaccine recommendations in the primary care setting could inform effective implementation strategies. METHODS: We used the Consolidated Framework for Implementation Research (CFIR) to systematically investigate and characterize factors that influence HPV vaccine use in 10 primary care practices (16 providers) using a concurrent mixed methods design. The CFIR was used to guide collection and analysis of qualitative data collected through in-person semi-structured interviews with the primary care providers. We analyzed HPV vaccine use with data abstracted from medical charts. Constructs that most strongly influenced vaccine use were identified by integrating the qualitative and quantitative data. RESULTS: Of the 72 CFIR constructs assessed, seven strongly distinguished and seven weakly distinguished between providers with higher versus lower HPV vaccine coverage. The majority of strongly distinguishing constructs were facilitators and were related to characteristics of the providers (knowledge and beliefs; self-efficacy; readiness for change), their perception of the intervention (relative advantage of vaccinating younger vs. older adolescents), and their process to deliver the vaccine (executing). Additional weakly distinguishing constructs that were facilitators were from outer setting (peer pressure; financial incentives), inner setting (networks and communications and readiness for implementation) and process (planning; engaging, and reflecting and evaluating). Two strongly distinguishing constructs were barriers to use, one from the intervention (adaptability of the age of initiation) and the other from outer setting (patient needs and resources). CONCLUSIONS: Using CFIR to systematically examine the use of this vaccine in independent primary care practices enabled us to identify facilitators and barriers at the provider, interpersonal and practice level that need to be addressed in future efforts to increase vaccine use in such settings. Our findings suggest that implementation strategies that target the provider and help them to address multi-level barriers to HPV vaccine use merit further investigation.

Using organizational network analysis to plan cancer screening programs for vulnerable populations.

OBJECTIVES: We examined relationships among organizations in a cancer screening network to inform the development of interventions to improve cancer screening for South Asians living in the Peel region of Ontario. METHODS: From April to July 2012, we surveyed decision-makers, program managers, and program staff in 22 organizations in the South Asian cancer screening network in the Peel region. We used a network analytic approach to evaluate density (range = 0%-100%, number of ties among organizations in the network expressed as a percentage of all possible ties), centralization (range = 0-1, the extent of variability in centrality), and node characteristics for the communication, collaboration, and referral networks. RESULTS: Density was similar across communication (15%), collaboration (17%), and referral (19%) networks. Centralization was greater in the collaboration network (0.30) than the communication network (0.24), and degree centralization was greater in the inbound (0.42) than the outbound (0.37) referral network. Diverse organizations were central to the networks. CONCLUSIONS: Certain organizations were unexpectedly important to the South Asian cancer screening network. Program planning was informed by identifying opportunities to strengthen linkages between key organizations and to leverage existing ties.

Strategies to promote language inclusion at 17 CTSA hubs.

The prioritization of English language in clinical research is a barrier to translational science. We explored promising practices to advance the inclusion of people who speak languages other than English in research conducted within and supported by NIH Clinical Translational Science Award (CTSA) hubs. Key informant interviews were conducted with representatives (n = 24) from CTSA hubs (n = 17). Purposive sampling was used to identify CTSA hubs focused on language inclusion. Hubs electing to participate were interviewed via Zoom. Thematic analysis was performed to analyze interview transcripts. We report on strategies employed by hubs to advance linguistic inclusion and influence institutional change that were identified. Strategies ranged from translations, development of culturally relevant materials and consultations to policies and procedural changes and workforce initiatives. An existing framework was adapted to conceptualize hub strategies. Language justice is paramount to bringing more effective treatments to all people more quickly. Inclusion will require institutional transformation and CTSA hubs are well positioned to catalyze change.

Implementation science and its application to population health.

Implementation science studies the use of strategies to adapt and use evidence-based interventions in targeted settings (e.g., schools, workplaces, health care facilities, public health departments) to sustain improvements to population health. This nascent field of research is in the early stages of developing theories of implementation and evaluating the properties of measures. Stakeholder engagement, effectiveness studies, research synthesis, and mathematical modeling are some of the methods used by implementation scientists to identify strategies to embed evidence-based interventions in clinical and public health programs. However, for implementation science to reach its full potential to improve population health the existing paradigm for how scientists create evidence, prioritize publications, and synthesize research needs to shift toward greater stakeholder input and improved reporting on external validity. This shift will improve the relevance of the research that is produced and provide information that will help guide decision makers in their selection of research-tested interventions.

Using geographic methods to inform cancer screening interventions for South Asians in Ontario, Canada.

BACKGROUND: Literature suggests that South Asians in Ontario, Canada are under-screened for breast, cervical and colorectal cancer. Accordingly, we are involved in a community-engaged multi-phase study aimed at increasing cancer screening for this vulnerable group. In the work described in this manuscript, we aimed to use visual displays of spatial analyses to identify the most appropriate small geographic areas in which to pilot targeted cancer screening interventions for Ontario's South Asian community. METHODS: We used Geographic Information Systems (GIS), including Local Indicators of Spatial Association (LISA) using GeoDa software, and population-level administrative data to create multi-layered maps of: i) rates of appropriate cancer screening, ii) the percentage of residents of South Asian ethnicity, and iii) the locations of primary care practices and community health centres by census tract in the Peel Region of Ontario (population: 1.2 million). The maps were shared with partner health service and community service organizations at an intervention development workgroup meeting to examine face validity. RESULTS: The lowest rates of appropriate cancer screening for census tracts across the region were 51.1% for cervical cancer, 48.5% for breast cancer, and 42.5% for colorectal cancer. We found marked variation both in screening rates and in the proportion of South Asians residents by census tract but lower screening rates in the region were consistently associated with larger South Asian populations. The LISA analysis identified a high-risk area consisting of multiple neighbouring census tracts with relatively low screening rates for all three cancer types and with a relatively large South Asian population. Partner organizations recognized and validated the geographic location highlighted by the LISA analysis. Many primary care practices are located in this high-risk area, with one community health centre located very nearby. CONCLUSIONS: In this populous region of Ontario, South Asians are more likely to reside in areas with lower rates of appropriate breast, cervical and colorectal cancer screening. We have identified a high-risk area appropriate for both patient- and provider-focused interventions. Geographic Information Systems, in particular LISA analyses, can be invaluable when working with health service and community organizations to define areas with the greatest need for interventions to reduce health inequities.

Networking and knowledge exchange to promote the formation of transdisciplinary coalitions and levels of agreement among transdisciplinary peer reviewers.

CONTEXT: Funding for transdisciplinary chronic disease prevention research has increased over the past decade. However, few studies have evaluated whether networking and knowledge exchange activities promote the creation of transdisciplinary teams to successfully respond to requests for proposals (RFPs). Such evaluations are critical to understanding how to accelerate the integration of research with practice and policy to improve population health. OBJECTIVE: To examine (1) the extent of participation in pre-RFP activities among funded and nonfunded transdisciplinary coalitions that responded to a RFP for cancer and chronic disease prevention initiatives and (2) levels of agreement in proposal ratings among research, practice, and policy peer reviewers. DESIGN/SETTING: Descriptive report of a Canadian funding initiative to increase the integration of evidence with action. PARTICIPANTS: Four hundred forty-nine representatives in 41 research, practice, and policy coalitions who responded to a RFP and whose proposals were peer reviewed by a transdisciplinary adjudication panel. INTERVENTION: The funder hosted 6 national meetings and issued a letter of intent (LOI) to foster research, practice, and policy collaborations before issuing a RFP. RESULTS: All provinces and territories in Canada were represented by the coalitions. Funded coalitions were 2.5 times more likely than nonfunded coalitions to submit a LOI. A greater proportion of funded coalitions were exposed to the pre-RFP activities (100%) compared with coalitions that were not funded (68%). Overall research, practice, and policy peer reviewer agreement was low (intraclass correlation 0.12). CONCLUSIONS: There is widespread interest in transdisciplinary collaborations to improve cancer and chronic disease prevention. Engagement in networking and knowledge exchange activities, and feedback from LOIs prior to submission of a final application, may contribute to stronger proposals and subsequent funding success. Future evaluations should examine best practices for transdisciplinary peer review to facilitate funding of proposals that on balance have both scientific rigor and are relevant to the real world.

A discussion among deans on advancing community engaged research.

The benefits of community-engaged research (CEnR) have been documented in the literature. However, the adoption of community engaged (CE) and participatory approaches among health researchers remains limited. The Boston University (BU) Clinical Translational Science Institute's community engagement program initiated a discussion among five BU Deans to explore their approaches to support the practice of CEnR among faculty in their schools. The discussion was recorded and the transcript analyzed to identify and explore themes that emerged. Most strategies discussed by the Deans were not focused on changing institutional systems to advance CEnR. Instead, the analyses showed that institutional CE efforts highlighted by the Deans were focused on "responsibility centered on one person" or "research mentors." Approaches to developing a culture of CEnR that centers responsibility for promoting it on a few people in a university may place significant burden on leadership and researchers and is not an effective way to promote culture change. Systems change is needed to support CEnR, improve accountability, and realize successful partnerships between academic institutions and communities. The dialogue among Deans focused on the topic of CEnR provided an effective method to catalyze discussion and over time may help to strengthen a culture of CEnR research.

Community engagement and financial arrangements: Navigating institutional change.

Despite their documented benefits, the widespread adoption of community-engaged and participatory approaches among health researchers remains limited. Institutional practices and policies influence the uptake of community engagement and participatory approaches. We examine the role of financial arrangements between university researchers and community partners, by exploring efforts to bridge the gap between research administration and researchers at two research-intensive institutions. The type of financial arrangement a researcher has with a community partner plays an important role in setting the stage for the structure of the partnership as it relates to shared decision-making and ownership of the research. Continued efforts to clarify and streamline subcontracting processes are needed as is infrastructure to support community partners and researchers as they navigate financial arrangements if progress is to be made.

Integrating community engagement with implementation science to advance the measurement of translational science.

This special communication provides an approach for applying implementation science frameworks to a Clinical and Translational Science Institutes (CTSIs) community engagement (CE) program that measures the use of implementation strategies and outcomes that promote the uptake of CE in research. Using an iterative multi-disciplinary group process, we executed a four-phased approach to developing an evaluation plan: 1) creating an evaluation model adapted from Proctor's conceptual model of implementation research; 2) mapping implementation strategies to CTSI CE program interventions that support change in research practice; 3) identifying and operationalizing measures for each strategy; and 4) conducting an evaluation. Phase 2 employed 73 implementation strategies across 9 domains generated by the Expert Recommendations for Implementing Change project. The nine domains were used to classify each CE program implementation strategy. In Phase 3, the group used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to define measures for each individual strategy. Phase 4 demonstrates the application of this framework and measures Year 1 outcomes for the strategy providing interactive assistance, which we implemented using a centralized consultation model. This approach can support the CTSA program in operationalizing CE program measurement to demonstrate which activities and strategies may lead to benefits derived by the program, institution, and community.

Research, practice, and policy partnerships in pan-Canadian coalitions for cancer and chronic disease prevention.

OBJECTIVE: To describe the development stages of the Coalitions Linking Action and Science for Prevention (CLASP) initiative of the Canadian Partnership Against Cancer to support research, practice, and policy coalitions focused on cancer and chronic disease prevention in Canada. DESIGN: Coalitions Linking Action and Science for Prevention was implemented in 3 stages. This article describes Stage 1 that consisted of an online concept-mapping consultation process, 3 topic specific networking and consultation workshops, and 3 context-specific networking, coalition development, and planning meetings. These were all completed using a participatory engagement approach to encourage knowledge exchange across jurisdictions and sectors in Canada. SETTING: Toronto, Ontario; Calgary, Alberta; Montreal, Québec; and Ottawa, Ontario. PARTICIPANTS: More than 500 researchers, practitioners, and policy specialists were invited to take part in the first stage activities. MAIN OUTCOME MEASURES: (1) Participant-identified high-priority opportunities for strategic collaboration; (2) Cross-jurisdictional and cross-sector representation; and (3) Participant feedback on the CLASP processes and activities. RESULTS: Participants from Stage 1 activities were distributed across all provinces/territories; 3 jurisdictional levels; and research, practice, and policy sectors. Ninety priority opportunities for strategic collaboration were identified across all 3 workshops. Participants provided detailed feedback about transparency of the RFP (Request for Proposals) application process, support needed to level the playing field for potential applicants, and valuable suggestions for the adjudication process. CONCLUSIONS: Coalitions Linking Action and Science for Prevention engaged hundreds of research, practice, and policy experts across Canada focusing social-behavioral, clinical, and environmental and occupational opportunities for cancer and chronic disease prevention. Given the extent of expert and jurisdictional engagement, the substantial Partnership investment in a participatory engagement approach to RFP development and potential applicant response suggests that efforts to link cancer and chronic disease prevention efforts across jurisdictions and through research, practice, and policy collaboration may require this type of a priori investment in networking, communication, coordination, and collaboration.

"It has to be designed in a way that really challenges people's assumptions": preparing scholars to build equitable community research partnerships.

INTRODUCTION: Clinical and Translational Award (CTSA) programs are developing relevant training for researchers and community stakeholders participating in community-engaged research (CEnR). However, there is limited research exploring the ways community stakeholders and partners with key CEnR experiences can inform and shape training priorities for prospective CEnR scholars to build meaningful and equitable partnerships. METHODS: This study conducted and analyzed online individual semi-structured in-depth interviews with community stakeholders (n = 13) engaged in CEnR to identify training priorities for graduate students and emerging scholars. FINDINGS: Thematic analysis of 13 interview transcripts revealed four major training priorities for prospective scholars interested in engaging in CEnR: 1) researcher's positionality, 2) equitable power sharing, 3) funding, and 4) ethics. CONCLUSION: Building equitable research partnerships was a central theme woven across all four training priorities. Further research should focus on examining the development, implementation, and evaluation of CEnR training in partnership with community stakeholders and partners with relevant CEnR experience. Adopting a collaborative approach to incorporate both community stakeholders and researchers' priorities can align training competencies to better prepare scholars to engage in building research partnerships.

Rural Health Networks: How Network Analysis Can Inform Patient Care and Organizational Collaboration in a Rural Breast Cancer Screening Network.

PURPOSE: Rural health networks have the potential to improve health care quality and access. Despite this, the use of network analysis to study rural health networks is limited. The purpose of this study was to use network analysis to understand how a network of rural breast cancer care providers deliver services and to demonstrate the value of this methodology in this research area. METHODS: Leaders at 47 Federally Qualified Health Centers and Rural Health Clinics across 10 adjacent rural counties were asked where they refer patients for mammograms or breast biopsies. These clinics and the 22 referral providers that respondents named comprised the network. The network was analyzed graphically and statistically with exponential random graph modeling. FINDINGS: Most (96%, n = 45) of the clinics and referral sites (95%, n = 21) are connected to each other. Two clinics of the same type were 62% less likely to refer patients to the same providers as 2 clinics of different types (OR = 0.38, 95% CI = 0.29-0.50). Clinics in the same county have approximately 8 times higher odds of referring patients to the same providers compared to clinics in different counties (OR = 7.80, CI = 4.57-13.31). CONCLUSIONS: This study found that geographic location of resources is an important factor in rural health care providers' referral decisions and demonstrated the usefulness of network analysis for understanding rural health networks. These results can be used to guide delivery of patient care and strengthen the network by building resources that take location into account.

Theory-based development of an implementation intervention to increase HPV vaccination in pediatric primary care practices.

BACKGROUND: The national guideline for use of the vaccine targeting oncogenic strains of the human papillomavirus (HPV) is an evidence-based practice that is poorly implemented in primary care. Recommendations include completion of the vaccine series before the 13th birthday for girls and boys, giving the first dose at the 11- to 12-year-old check-up visit, concurrent with other recommended vaccines. Interventions to increase implementation of this guideline have had little impact, and opportunities to prevent cancer continue to be missed. METHODS: We used a theory-informed approach to develop a pragmatic intervention for use in primary care settings to increase implementation of the HPV vaccine guideline recommendation. Using a concurrent mixed methods design in 10 primary care practices, we applied the Consolidated Framework for Implementation Research (CFIR) to systematically investigate and characterize factors strongly influencing vaccine use. We then used the Behavior Change Wheel (BCW) and the Theoretical Domains Framework (TDF) to analyze provider behavior and identify behaviors to target for change and behavioral change strategies to include in the intervention. RESULTS: We identified facilitators and barriers to guideline use across the five CFIR domains: most distinguishing factors related to provider characteristics, their perception of the intervention, and their process to deliver the vaccine. Targeted behaviors were for the provider to recommend the HPV vaccine the same way and at the same time as the other adolescent vaccines, to answer parents' questions with confidence, and to implement a vaccine delivery system. To this end, the intervention targeted improving provider's capability (knowledge, communication skills) and motivation (action planning, belief about consequences, social influences) regarding implementing guideline recommendations, and increasing their opportunity to do so (vaccine delivery system). Behavior change strategies included providing information and communication skill training with graded tasks and modeling, feedback of coverage rates, goal setting, and social support. These strategies were combined in an implementation intervention to be delivered using practice facilitation, educational outreach visits, and cyclical small tests of change. CONCLUSIONS: Using CFIR, the BCW and the TDF facilitated the development of a pragmatic, multi-component implementation intervention to increase use of the HPV vaccine in the primary care setting.

Rural Cancer Screening and Faith Community Nursing in the Era of the Affordable Care Act.

Rural populations often face higher cancer rates and have lower cancer screening rates than urban populations. Screening disparities may be mediated by limited access to care, less knowledge of screening, and psychosocial factors. While the improved insurance rates and more comprehensive coverage under the Affordable Care Act may address some of these barriers, rural-urban disparities in cancer screening may not be fully attenuated. Faith-based interventions have been an effective approach to improving cancer screening among rural and underserved populations. Similarly, faith community nurses (FCNs) may be an effective agents for implementing evidence-based cancer screening strategies in rural communities. We provide a model for how FCNs standards of professional performance and practice can enable them to implement screening strategies. We also posit two recommendations of services that FCNs can provide to improve cancer screening in rural areas: educational messaging and patient navigation.

Screening patients with a family history of colorectal cancer.

OBJECTIVES: To compare screening practices and beliefs in patients with and without a clinically important family history. DESIGN: We mailed a brief questionnaire asking about family history and a second, longer survey asking about knowledge of and beliefs about colorectal cancer to all respondents with a family history and a random sample of respondents without a family history of colorectal cancer. We reviewed electronic medical records for screening examinations and recording of family history. PARTICIPANTS: One thousand eight hundred seventy of 6,807 randomly selected patients ages 35-55 years who had been continuously enrolled in a large multispecialty group practice for at least 5 years. MEASUREMENTS: Recognition of increased risk, screening practices, and beliefs-all according to strength of family history and patient's age. RESULTS: Nineteen percent of respondents reported a family history of colorectal cancer. In 11%, this history was strong enough to warrant screening before age 50 years. However, only 39% (95% CI 36, 42) of respondents under the age of 50 years said they had been asked about family history and only 45% of those with a strong family history of colorectal cancer had been screened appropriately. Forty-six percent of patients with a strong family history did not know that they should be screened at a younger age than average risk people. Medical records mentioned family history of colorectal cancer in 59% of patients reporting a family history. CONCLUSIONS: More efforts are needed to translate information about family history of colorectal cancer into the care of patients.

Impact of intervention dose on cancer-related health behaviors among working-class, multiethnic, community health center patients.

PURPOSE: To examine the relationship between intervention dose and health behavior change in Healthy Directions-Health Centers, an intervention designed to reduce cancer risk factors. DESIGN. Analysis of intervention condition participant data from a randomized controlled trial. SETTING: Community health centers in Massachusetts. SUBJECTS: Patients residing in low-income, working-class, multiethnic neighborhoods. INTERVENTION: Components were clinician endorsement, in-person counseling session and four telephone counseling sessions with a trained health advisor, and social-contextual tailored materials. MEASURES: Intervention dose was number of six possible intervention components completed by each participant. Changes in fruit and vegetable consumption, red meat consumption, physical activity, and multivitamin intake between baseline (n=1088) and 8-month follow-up (n=967; 89% of baseline sample) were determined. ANALYSIS: Bivariate and multivariate associations between intervention dose and change in health behaviors were examined. RESULTS: In multivariate analysis, the association between intervention dose and increase in multivitamin intake approached significance (p < .07). Seventy percent of participants completed all intervention activities. In bivariate analysis, completion of four telephone counseling calls was associated with decrease in red meat consumption (p < .05). CONCLUSION: These findings indicate that future studies should examine the number, content, and length of contacts needed for behavior change. The results also suggest that health centers are a channel for reaching diverse populations, as shown by the high level of intervention implementation.

Induction of physiological thermotolerance in MDCK monolayers: contribution of heat shock protein 70.

Enhanced survival of both individual cells and whole organisms following a heat stress is termed thermotolerance. In organisms, the maintenance of tissue function rather than the survival of individual cells ultimately determines outcome following thermal challenge. We used MDCK kidney epithelial cells to compare alterations in chaperone activity (as a measure of cellular tolerance) and epithelial barrier function (as a measure of physiological tolerance) after thermal challenge. Quercetin, an inhibitor of heat shock factor-dependent transcriptional activity, both potentiated the effects of heat on naive monolayers and blocked conditioning of monolayers following moderate heat shock, suggesting a central role of heat shock protein (HSP) family members in the maintenance of epithelial integrity. We used MDCK cells that constitutively overexpressed HSP70 to demonstrate 2 functionally distinct components of the response of monolayers to thermal stress. The maintenance of epithelial barrier function during exposure to elevated temperatures is regulated by a complex network of processes that involve the actions of HSP70 but that are independent of alterations in chaperone activity as reflected by changes in the thermal inactivation/refolding of luciferase. In contrast, the restoration of barrier function following a heat stress is directly modulated by HSP70 in a manner that can be fully accounted for by changes in chaperone activity. This study demonstrates an important, albeit complex, protective role for heat shock proteins in the modulation of MDCK epithelial barrier function following a thermal stress.

Using Knowledge Exchange to Build and Sustain Community Support to Reduce Cancer Screening Inequities.

BACKGROUND: "Knowledge exchange" (KE) refers to the interaction between knowledge users and researchers toward a goal of mutual learning and collaborative problem solving. METHODS: Using a case study approach, this article describes how researchers leading a multiphase community engagement project, the Peel Cancer Screening Study (PCSS), used KE to engage a community advisory group (CAG) of knowledge users to build community support for interventions to reduce cancer screening inequities for South Asians in Peel Region, Ontario, Canada. RESULTS: As a result of KE activities (concept mapping, a CAG launch meeting, regular CAG meetings, workgroup meetings, a community report), there is currently a resident-targeted, community-level program being implemented and a provider-targeted intervention that is funded, with both ethnospecific and health service organizations involved. The process of KE received positive evaluations from advisory group members. CONCLUSIONS: The experiences of the PCSS illustrate the benefits of KE for researchers and community members.

Primary care physician characteristics associated with cancer screening: a retrospective cohort study in Ontario, Canada.

Primary care physicians can serve as both facilitators and barriers to cancer screening, particularly for under-screened groups such as immigrant patients. The objective of this study was to inform physician-targeted interventions by identifying primary care physician characteristics associated with cancer screening for their eligible patients, for their eligible immigrant patients, and for foreign-trained physicians, for their eligible immigrant patients from the same world region. A population-based retrospective cohort study was performed, looking back 3 years from 31 December 2010. The study was performed in urban primary care practices in Ontario, Canada's largest province. A total of 6303 physicians serving 1,156,627 women eligible for breast cancer screening, 2,730,380 women eligible for cervical screening, and 2,260,569 patients eligible for colorectal screening participated. Appropriate breast screening was defined as at least one mammogram in the previous 2 years, appropriate cervical screening was defined as at least one Pap test in the previous 3 years, and appropriate colorectal screening as at least one fecal occult blood test in the previous 2 years or at least one colonoscopy or barium enema in the previous 10 years. Just fewer than 40% of physicians were female, and 26.1% were foreign trained. In multivariable analyses, physicians who attended medical schools in the Caribbean/Latin America, the Middle East/North Africa, South Asia, and Western Europe were less likely to screen their patients than Canadian graduates. South Asian-trained physicians were significantly less likely to screen South Asian women for cervical cancer than other foreign-trained physicians who were seeing region-congruent patients (adjusted odds ratio: 0.56 [95% confidence interval 0.32-0.98] versus physicians from the USA, Australia and New Zealand). South Asian patients were the most vulnerable to under-screening, and decreasing patient income quintile was consistently associated with lower likelihood of screening, although less so for immigrant patients. This study highlights certain physician characteristics that are associated with cancer screening for eligible patients, including immigrant patients, and that should be considered when designing physician-targeted interventions. We have also highlighted an ethnic community, South Asians, which requires particular attention, both among its patients and its primary care providers. Future research should further explore the reasons for these findings.