Sara Javanparast

How equitable are colorectal cancer screening programs which include FOBTs? A review of qualitative and quantitative studies.

OBJECTIVE To review published literature on the equity of participation in colorectal cancer screening amongst different population subgroups, in addition to identifying factors identified as barriers and facilitators to equitable screening. Studies were included in the review if they included FOBT as at least one of the screening tests. METHOD Relevant published articles were identified through systematic electronic searches of selected databases and the examination of the bibliographies of retrieved articles. Studies of the association with colorectal cancer screening test participation, barriers to equitable participation in screening, and studies examining interventional actions to facilitate screening test participation were included. Data extraction and analysis was undertaken using an approach to the synthesis of qualitative and quantitative studies called Realist Review. RESULTS Sixty-three articles were identified that met the inclusion criteria. SES status, ethnicity, age and gender have been found as predictors of colorectal cancer screening test participation. This review also found that the potential for equitable cancer screening test participation may be hindered by access barriers which vary amongst population sub-groups. CONCLUSION This review provides evidence of horizontal inequity in colorectal cancer screening test participation, but limited understanding of the mechanism by which it is sustained, and few evidence-based solutions.

Barriers to and facilitators of colorectal cancer screening in different population subgroups in Adelaide, South Australia

Objectives: To identify barriers to and facilitators of colorectal cancer (CRC) screening participation among different cultural subgroups in South Australia, and to describe how these might be shared or be distinct across these groups.

Community health workers' perspectives on their contribution to rural health and well-being in Iran.

OBJECTIVES The activities of community health workers (CHWs) have been identified as key to improvements in the health of Irans rural population. We explored the perceptions of CHWs regarding their contribution to rural health in Iran. METHODS Three research assistants familiar with the Iranian primary health care network conducted face-to-face interviews with CHWs in 18 provinces in Iran. RESULTS Findings showed that Iranian CHWs have an in-depth understanding of health, including its social determinants, and are responsible for a wide range of activities. Respondents reported that trust-based relationships with rural communities, an altruistic motivation to serve rural people, and sound health knowledge and skills are the most important factors facilitating successful implementation of the CHW program in Iran. By contrast, high workload and the lack of a support system were mentioned as barriers to effective performance. CONCLUSIONS The CHW program in Iran is a compelling example of comprehensive primary health care, in that CHWs provide basic health care but also work with community members and other sectors to address the social determinants of health.

A policy review of the community health worker programme in Iran

Irans Community Health Worker (CHW) programme survived as an integral element of the health system during a period when many other nations’ CHW programmes collapsed and therefore warrants detailed analysis of the policies supporting the programme. We draw on a wide range of information about the Iranian programme and from this analysis draw important lessons on how to improve rural population health outcomes through Primary Health Care.

Equity of colorectal cancer screening: cross‐sectional analysis of National Bowel Cancer Screening Program data for South Australia

Objective: The National Bowel Cancer Screening Program (NBCSP) is a population‐based screening program based on a mailed screening invitation and immunochemical faecal occult blood test. Initial published evidence from the NBCSP concurs with international evidence on similar colorectal cancer screening programs about the unequal participation by different population sub‐groups. The aim of the paper is to present an analysis of the equity of the NBCSP for South Australia, using the concept of horizontal equity, in order to identify geographical areas and population groups which may benefit from targeted approaches to increase participation rates in colorectal cancer screening.

The experience of community health workers training in Iran: a qualitative study

BackgroundThe role of Community Health Workers (CHWs) in improving access to basic healthcare services, and mobilising community actions on health is broadly recognised. The Primary Health Care (PHC) approach, identified in the Alma Ata conference in 1978, stressed the role of CHWs in addressing community health needs. Training of CHWs is one of the key aspects that generally seeks to develop new knowledge and skills related to specific tasks and to increase CHWs’ capacity to communicate with and serve local people. This study aimed to analyse the CHW training process in Iran and how different components of training have impacted on CHW performance and satisfaction.MethodsData were collected from both primary and secondary sources. Training policies were reviewed using available policy documents, training materials and other relevant documents at national and provincial levels. Documentary analysis was supplemented by individual interviews with ninety-one Iranian CHWs from 18 provinces representing a broad range of age, work experience and educational levels, both male and female.ResultsRecognition of the CHW program and their training in the national health planning and financing facilitates the implementation and sustainability of the program. The existence of specialised training centres managed by district health network provides an appropriate training environment that delivers comprehensive training and increases CHWs’ knowledge, skills and motivation to serve local communities. Changes in training content over time reflect an increasing number of programs integrated into PHC, complicating the work expected of CHWs. In-service training courses need to address better local needs.ConclusionAlthough CHW programs vary by country and context, the CHW training program in Iran offers transferable lessons for countries intending to improve training as one of the key elements in their CHW program.

Equity of colorectal cancer screening: which groups have inequitable participation and what can we do about it?

The National Bowel Cancer Screening Program (NBCSP) offers population-based screening for colorectal cancer (CRC) across Australia. The aims of this paper were to highlight the inequities in CRC screening in South Australia (SA) and the system-related barriers and enablers to CRC screening from the perspective of participants identified as having inequitable participation. First, de-identified data for the SA population of the NBCSP were statistically analysed and then mapped. Second, 117 in-depth interviews were conducted with culturally and linguistically diverse (CALD) groups, Indigenous and Anglo-Saxon Australians. Participation rates in the NBCSP were geographically and statistically significantly different (P < 0.0001) on the basis of gender (higher for women), age (higher for older people) and socioeconomic status (higher for more affluent people). The main system-related barriers were the lack of awareness of CRC or CRC screening within these groups, the problems with language due to most of the information being in English and the lack of recommendation by a doctor. This study revealed that inequity exists in the NBCSP participation in SA, and we identified both barriers and facilitators to CRC screening that require action at the level of both policy and practice. There is a large role in primary health care of both recommending CRC screening and facilitating equitable participation.

Cultural respect strategies in Australian Aboriginal primary health care services: beyond education and training of practitioners.

Objective: There is little literature on health‐service‐level strategies for culturally respectful care to Aboriginal and Torres Strait Islander Australians. We conducted two case studies, which involved one Aboriginal community controlled health care service and one state government‐managed primary health care service, to examine cultural respect strategies, client experiences and barriers to cultural respect.

Comprehensive primary health care under neo-liberalism in Australia

This paper applies a critical analysis of the impact of neo-liberal driven management reform to examine changes in Australian primary health care (PHC) services over five years. The implementation of comprehensive approaches to primary health care (PHC) in seven services: five state-managed and two non-government organisations (NGOs) was tracked from 2009 to 2014. Two questions are addressed: 1) How did the ability of Australian PHC services to implement comprehensive PHC change over the period 2009-2014? 2) To what extent is the ability of the PHC services to implement comprehensive PHC shaped by neo-liberal health sector reform processes? The study reports on detailed tracking and observations of the changes and in-depth interviews with 63 health service managers and practitioners, and regional and central health executives. The documented changes were: in the state-managed services (although not the NGOs) less comprehensive service coverage and more focus on clinical services and integration with hospitals and much less development activity including community development, advocacy, intersectoral collaboration and attention to the social determinants. These changes were found to be associated with practices typical of neo-liberal health sector reform: considerable uncertainty, more directive managerial control, budget reductions and competitive tendering and an emphasis on outputs rather than health outcomes. We conclude that a focus on clinical service provision, while highly compatible with neo-liberal reforms, will not on its own produce the shifts in population disease patterns that would be required to reduce demand for health services and promote health. Comprehensive PHC is much better suited to that task.

Exploring health stakeholders' perceptions on moving towards comprehensive primary health care to address childhood malnutrition in Iran: a qualitative study

BackgroundDue to the multifaceted aspect of child malnutrition, a comprehensive approach, taking social factors into account, has been frequently recommended in health literature. The Alma-Ata declaration explicitly outlined comprehensive primary health care as an approach that addresses the social, economic and political causes of poor health and nutrition.Iran as a signatory country to the Alma Ata Declaration has established primary health care since 1979 with significant progress on many health indicators during the last three decades. However, the primary health care system is still challenged to reduce inequity in conditions such as child malnutrition which trace back to social factors. This study aimed to explore the perceptions of the Iranian health stakeholders with respect to the Iranian primary health care performance and actions to move towards a comprehensive approach in addressing childhood malnutrition. Health stakeholders are defined as those who affect or can be affected by health system, for example health policy-makers, health providers or health service recipients.MethodsStakeholder analysis approach was undertaken using a qualitative research method. Different levels of stakeholders, including health policy-makers, health providers and community members were interviewed as either individuals or focus groups. Qualitative content analysis was used to interpret and compare/contrast the viewpoints of the study participants.ResultsThe results demonstrated that fundamental differences exist in the perceptions of different health stakeholders in the understanding of comprehensive notion and action. Health policy-makers mainly believed in the need for a secure health management environment and the necessity for a whole of the government approach to enhance collaborative action. Community health workers, on the other hand, indicated that staff motivation, advocacy and involvement are the main challenges need to be addressed. Turning to community stakeholders, greater emphasis has been placed on community capabilities, informal link with other social sectors based on trust and local initiatives.ConclusionThis research provided a picture of the differences in the perceptions and values of different stakeholders with respect to primary health care concepts. The study suggests that a top-down approach, which still exists among health policy-makers, is a key obstacle that delays, and possibly worse, undermines the implementation of the comprehensive strategy codified by the Alma-Ata Declaration. A need to revitalise primary health care to use its full potential and to combine top-down and bottom-up approaches by narrowing the gap between perceptions of policy makers and those who provide and receive health-related services is crucial.