Nadine Wathen

What implementation interventions increase cancer screening rates? a systematic review

BackgroundAppropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. As part of a larger agenda to create an implementation guideline, we conducted a systematic review to evaluate interventions designed to increase the rate of breast, cervical, and colorectal cancer (CRC) screening. The interventions considered were: client reminders, client incentives, mass media, small media, group education, one-on-one education, reduction in structural barriers, reduction in out-of-pocket costs, provider assessment and feedback interventions, and provider incentives. Our primary outcome, screening completion, was calculated as the overall median post-intervention absolute percentage point (PP) change in completed screening tests.MethodsOur first step was to conduct an iterative scoping review in the research area. This yielded three relevant high-quality systematic reviews. Serving as our evidentiary foundation, we conducted a formal update. Randomized controlled trials and cluster randomized controlled trials, published between 2004 and 2010, were searched in MEDLINE, EMBASE and PSYCHinfo.ResultsThe update yielded 66 studies new eligible studies with 74 comparisons. The new studies ranged considerably in quality. Client reminders, small media, and provider audit and feedback appear to be effective interventions to increase the uptake of screening for three cancers. One-on-one education and reduction of structural barriers also appears effective, but their roles with CRC and cervical screening, respectively, are less established. More study is required to assess client incentives, mass media, group education, reduction of out-of-pocket costs, and provider incentive interventions.ConclusionThe new evidence generally aligns with the evidence and conclusions from the original systematic reviews. This review served as the evidentiary foundation for an implementation guideline. Poor reporting, lack of precision and consistency in defining operational elements, and insufficient consideration of context and differences among populations are areas for additional research.

Effective interventions to facilitate the uptake of breast, cervical and colorectal cancer screening: an implementation guideline

BackgroundAppropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. Several high-quality systematic reviews and practice guidelines exist to inform the most effective screening options. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. We developed an implementation guideline to answer the question: What interventions have been shown to increase the uptake of cancer screening by individuals, specifically for breast, cervical, and colorectal cancers?MethodsA guideline panel was established as part of Cancer Care Ontarios Program in Evidence-based Care, and a systematic review of the published literature was conducted. It yielded three foundational systematic reviews and an existing guidance document. We conducted updates of these reviews and searched the literature published between 2004 and 2010. A draft guideline was written that went through two rounds of review. Revisions were made resulting in a final set of guideline recommendations.ResultsSixty-six new studies reflecting 74 comparisons met eligibility criteria. They were generally of poor to moderate quality. Using these and the foundational documents, the panel developed a draft guideline. The draft report was well received in the two rounds of review with mean quality scores above four (on a five-point scale) for each of the items. For most of the interventions considered, there was insufficient evidence to support or refute their effectiveness. However, client reminders, reduction of structural barriers, and provision of provider assessment and feedback were recommended interventions to increase screening for at least two of three cancer sites studied. The final guidelines also provide advice on how the recommendations can be used and future areas for research.ConclusionUsing established guideline development methodologies and the AGREE II as our methodological frameworks, we developed an implementation guideline to advise on interventions to increase the rate of breast, cervical and colorectal cancer screening. While advancements have been made in these areas of implementation science, more investigations are warranted.

Strategies to promote uptake and use of intimate partner violence and child maltreatment knowledge: An integrative review

BackgroundIntimate partner violence (IPV) and child maltreatment (CM) are major social and public health problems. Knowledge translation (KT) of best available research evidence has been suggested as a strategy to improve the care of those exposed to violence, however research on how best to promote the uptake and use of IPV and CM evidence for policy and practice is limited. Our research asked: 1) What is the extent of IPV/CM-specific KT research? 2) What KT strategies effectively translate IPV/CM knowledge? and 3) What are the barriers and facilitators relevant to translating IPV/CM-specific knowledge?MethodsWe conducted an integrative review to summarize and synthesize the available evidence regarding IPV/CM-specific KT research. We employed multiple search methods, including database searches of Embase, CINAHL, ERIC, PsycInfo, Sociological Abstracts, and Medline (through April, 2013). Eligibility and quality assessments for each article were conducted by at least two team members. Included articles were analyzed quantitatively using descriptive statistics and qualitatively using descriptive content analysis.ResultsOf 1230 identified articles, 62 were included in the review, including 5 review articles. KT strategies were generally successful at improving various knowledge/attitude and behavioural/behavioural intention outcomes, but the heterogeneity among KT strategies, recipients, study designs and measured outcomes made it difficult to draw specific conclusions. Four key themes were identified: existing measurement tools and promising/effective KT strategies are underused, KT efforts are rarely linked to health-related outcomes for those exposed to violence, there is a lack of evidence regarding the long-term effectiveness of KT interventions, and authors’ inferences about barriers, facilitators, and effective/ineffective KT strategies are often not supported by data. The emotional and sometimes contested nature of the knowledge appears to be an important barrier unique to IPV/CM KT.ConclusionsTo direct future KT in this area, we present a guiding framework that highlights the need for implementers to use/adapt promising KT strategies that carefully consider contextual factors, including the fact that content in IPV/CM may be more difficult to engage with than other health topics. The framework also provides guidance regarding use of measurement tools and designs to more effectively evaluate and report on KT efforts.

Identifying and removing duplicate records from systematic review searches.

OBJECTIVE The purpose of this study was to compare effectiveness of different options for de-duplicating records retrieved from systematic review searches. METHODS Using the records from a published systematic review, five de-duplication options were compared. The time taken to de-duplicate in each option and the number of false positives (were deleted but should not have been) and false negatives (should have been deleted but were not) were recorded. RESULTS The time for each option varied. The number of positive and false duplicates returned from each option also varied greatly. CONCLUSION The authors recommend different de-duplication options based on the skill level of the searcher and the purpose of de-duplication efforts.

The Go-Betweens: Health, Technology and Info(r)mediation

Welcome or not, most people in Western countries are unable to get through a day without receiving a dose of health information. It is available from, passed through or pushed at health help seekers by health care professionals, alternative health care practitioners, pharmaceutical companies, employers, co-workers, friends, family members, vendors of health products and through government-sponsored health promotion campaigns. It is delivered through a variety of media, including self-help books, magazines, leaflets, television and radio advertising and programming and, increasingly, the internet. If the volume of health information present in the public domain in previous decades could be described as a mountain, the current situation might better be described as an avalanche. Recipes or directives about practices for healthy living, as well as information about medical conditions and treatments, prescription drugs and alternative health products and therapies, are everywhere. Against this dense backdrop of advice is the increasingly prevalent notion in public health policy that people, whether as patients, care providers, citizens or, increasingly, consumers, have an obligation to keep themselves informed about health matters.

Searching for health: the topography of the first page

Members of the lay public are turning increasingly to the internet to answer health-related questions. Some authors suggest that the widespread availability of online health information has dislodged medical knowledge from its traditional institutional base and enabled a growing role for alternative or previously unrecognized health perspectives and ‘lay health expertise’. Others have argued, however, that the organization of information retrieved from influential search engines, particularly Google, has merely intensified mainstream perspectives because of the growing consolidation of the internet with traditional, commercial media sources. In this paper we describe an analysis of ‘first page’ results retrieved through Google searches about several common health concerns, each of which has been the subject of controversy as a result of uncertain aetiology, diagnoses, outcomes and/or contested approaches to treatment. Our findings suggest that the online search tactics used by most lay health information seekers produce sources of information that, for the most part, reflect mainstream biomedical discourses, often linked to commercial interests, rather than a plurality of voices that offer a variety of perspectives and resources. We discuss the implications for health-interested internet searchers who fail to look beyond the ‘first page’.

‘Working to be Healthy: Empowering Consumers or Citizens’

Our purpose in putting this book together has been to explore how, in the context of emerging socio-technical arrangements in the health care sector, policies and practices that emphasise personal responsibility for health are influencing the lives of ordinary citizens, as well as those who work in the health professions. How are new expectations about citizens’ ‘health roles’ being negotiated in everyday life and affecting what Bury (2001) calls the ‘moral narratives’ of health and illness? Contributors to this collection discuss how members of the public have come to be positioned as health ‘consumers’ and what this means for the distribution of health-related work. They provide various examples of the marketisation of health care and the technologies that are used to mediate or enable the everyday ‘healthwork’ of citizens. They examine the shifting meaning of health ‘expertise’ and describe the ways in which people comply with, alter or resist the health ‘jobs’ they are assigned or take on new, unassigned healthwork roles. In this chapter, we bring together these themes and consider their implications for health policy and practice.

A Critical Discourse Analysis of Provincial Policies Impacting Shelter Service Delivery to Women Exposed to Violence

Shelters for abused women function within a broad context that includes intersecting social structures, policies, and resources, which may constrain and limit the options available to abused women and tacitly reinforce the cycle of abuse. This feminist, qualitative study combined in-depth interviews and focus groups conducted with 37 staff and four executive directors from four shelters in Ontario, Canada, along with a critical discourse analysis of salient policy texts. Together, the interviews and critical discourse analysis formed an integrated analysis of the dialectic between policy as written and enacted. The study findings illuminate the complexity of the system and its impact on women, shelters, and the community and highlight how specific types of social policies and various social system subsystems and structures, and system configuration, shape the day to day reality of shelter service delivery and impact outcomes for abused women and their children. Collectively, these findings offer direction regarding where these policies could be improved and provide a basis for shelters, policy makers, advocates, and the community to strengthen current services and policies, potentially enhancing outcomes for women.

Self-reported oral health among a community sample of people experiencing social and health inequities: cross-sectional findings from a study to enhance equity in primary healthcare settings

Objective To describe the self-reported oral health issues among a community sample of primary care clients experiencing socioeconomic disadvantages. Methods As part of a larger mixed-methods, multiple case study evaluating an equity-oriented primary healthcare intervention, we examined the oral health of a sample of 567 people receiving care at four clinics that serve marginalised populations in two Canadian provinces. Data collected included self-rated oral health and experiences accessing and receiving healthcare, standard self-report measures of health and quality of life, and sociodemographic information. Results The prevalence of self-rated poor oral health was high, with almost half (46.3%) of the participants reporting poor or fair oral health. Significant relationships were observed between poor oral health and vulnerabilities related to mental health, trauma and housing instability. Our findings suggest that the oral health of some Canadian populations may be dramatically worse than what is reported in existing population health surveys. Conclusions Our findings reinforce the importance of addressing oral health as part of health equity strategies. The health and oral health issues experienced by this client cohort highlight the need for interdisciplinary, team-based care that can address the intersections among peoples health status, oral health and social issues.

Assessing Performance in Shelters for Abused Women: Can “Caring Citizenship” Be Measured in “Value for Money” Accountability Regimes?

Results are reported from a study of shelters for abused women in Ontario, Canada, suggesting that what clients, managers, and frontline workers value most in shelter services is based on a care perspective in which ongoing relational support is seen as essential to effective service delivery. Presently, government-required metrics used to assess shelter services not only reflect a narrow, justice perspective where “fairness” is defined as equal access to publicly supported services, but reveal a New Public Management emphasis on efficiency in which the focus is more on the “what” than the “how” of practice. Findings are discussed in terms of their implications for the design of accountability systems for evaluating government-contracted social services.