The limited reach of population-based cancer control programs to racial and ethnic minority groups is a critical implementation issue that requires attention. Many studies have explored barriers to cancer screening from the perspective of women and some have examined the perspectives of primary care providers. However, the perspectives of representatives from stakeholder organizations are equally as important given that successful implementation of EBIs is associated with the inner context of organizations (e.g., readiness to adopt, leadership, culture), individuals within organizations (e.g., values, social networks perceived need for change), and the outer context such as sociopolitical factors (e.g., legislations, monitoring and review), funding (e.g., grants and continuity of funding), client advocacy (e.g., consumer organizations, lawsuits), and inter-organizational networks (e.g., professional organizations, leadership ties, communication) [35–40]. To date, the research on strategies to improve use of cancer screening shows that greater reach among racial and ethnic groups can be achieved when programs take into account the language and cultural characteristics of the target population, provide support to reduce logistical barriers (e.g., transportation, appointment making), and use multi-level strategies [4, 5, 34, 49]. However, whether these strategies are adopted will depend on organizational perspectives on the related barriers.
Little is known about the perspectives of representatives from health service (e.g., community health centers, primary care providers, hospitals, mammography facilities, public health) and community service organizations (e.g., health and fitness groups, settlement agencies, et al.) on barriers to use of mammography, Pap tests, and FOBTs among racial and ethnic minority groups. This study contributes new knowledge to implementation research in this area by examining which barriers are viewed by representatives from stakeholder organizations as most important and feasible to address to increase cancer screening among South Asians. We found considerable agreement among residents and representatives from organizations on the importance of the top barriers to cancer screening for South Asians. Notwithstanding the concurrence of these opinions, overall agreement in the ranking of clusters of barriers by residents and representatives from health service organizations was low. In particular, rankings were discordant for barriers associated with ‘cost’ and ‘limited knowledge among physicians,’ which suggest that important factors could be overlooked if only one stakeholder opinion is taken into account when planning health promotion programs. For example, if program developers prioritize implementation strategies to remove barriers to cancer screening based only on the perspective of South Asian residents then the need to address ‘limited knowledge among physicians’ might be overlooked, despite physician recommendation being among the strongest predictors of cancer screening [13, 50–54].
We found that residents’ perspectives on which barriers to cancer screening are most important to address and feasible to change are more closely aligned with representatives from community service organizations than health services organizations. This finding could be due to the similar ethnic characteristics of residents and employees of community service organizations. In addition, representatives from community service organizations gain a broader understanding of their clients’ perspectives through ongoing discussions about social and economic factors, even at the level of executive director because of the ‘hands-on’ nature of this role in small organizations. In contrast, communication between clients and representatives from health service organizations tends be limited to biomedical characteristics of clients, and client contact is limited to clinical and clinical support staff.
Furthermore, our results suggest opportunities for health service and community service organizations to work together to remove ethno-cultural barriers to cancer screening for South Asians. Representatives from both types of organizations ranked the ‘ethno-cultural discordance’ cluster among the top three important barriers for all three cancer screening tests. Yet only representatives from community service organizations ranked ethno-cultural discordance as feasible to address. We interpret this pattern of responses as being reflective of the expertise in community service organizations to address ethno-cultural barriers to cancer screening for South Asians and the lack of this expertise in health service organizations. Community service organizations are generally staffed by employees who are culturally representative of the clients they serve and have skills in interpretation and translation of medical information. In addition, foreign trained medical professionals often work in community service organizations because it is difficult for them to gain accreditation in the Canadian health system . This is among the reasons why health service organizations are generally understaffed in employees who are culturally representative of the populations they serve. Recently, Canada implemented strategies to improve the timely assessment and recognition of foreign trained medical personnel including bridge-to-licensure programs for licensed practical nurses, medical radiation technologists, and physicians . However, this gap in skills among employees of health organizations highlights opportunities for collaboration with community service organizations to remove ethno-cultural barriers to cancer screening for South Asians.
Findings from our study inform the field of implementation science by identifying ways in which stakeholders’ opinions about barriers to use of an EBI can differ. In addition, our analysis highlighted potential strategies by which these differences could be used to address barriers to cancer screening for South Asians. Because our study uses the KTA framework, our findings also contribute to the action cycle through which research is translated to action.
Through the participatory processes of concept mapping our community advisory group has grown from the initial three partners to 12 organizations. In phase two of this study we are engaging in multiple activities with the advisory group to utilize the concept mapping results. First, we discussed potential EBIs, based on the Guide to Community Preventive Services [4, 5, 57], to address the top three barriers to cancer screening that were identified by the community and barriers in the ‘limited knowledge among physicians’ cluster that were identified as important by health service organizations. From these discussions, we identified resources to support implementation of patient targeted, physician targeted, and health system targeted interventions. For example, a lay health advisor intervention is being developed with support from the Canadian Cancer Society. This intervention will include group education sessions for residents at local community service organizations and potentially South Asian screening clinics or blocked times for appointments with female physicians. Using logic models researchers and members of the advisory group developed a shared understanding of resources, activities, outputs, and outcomes for a multi-level intervention program (patient, provider, and health system level) to increase cancer screening among South Asians in Peel. To further inform the availability of and gaps in resources to support these interventions, we conducted a survey of all community service and health service organizations that provide services to promote cancer screening in Peel. When analyzed, the survey will inform us about the types of services organizations provide to promote cancer screening (e.g., outreach and education, navigation, clinic services), the inter-organizational relationships (e.g., communication, referral, collaboration) that support the delivery of the services, and the gaps in services that we need to fill through additional partnerships and resources. Following our accomplishment of a clearly defined intervention to improve rates of cancer screening among South Asians, we will seek funding for phase three in which we will examine the effect of change strategies on implementation of the multi-level cancer screening program.
Despite the strengths of this study, some limitations should be noted. We had limited participation from primary care physicians in the sorting and rating phase (n = 5) and no participation from residents in the interpretation phase. However, the impact of this limitation is minimal for two reasons. First, we were primarily interested in the organizational level perspective, not specifically primary care provider opinions, and physicians represented 26% (5/19) of the responses from representatives from health service organizations. Second, residents might not have felt comfortable speaking their opinions with a group of community leaders in the interpretation session. Fortunately, the multi-phase nature of our project will allow us to seek input on program development from South Asian residents at another point in the study. The generalizability of our findings to other provinces in Canada, to other countries, or healthcare settings may be limited because the perceptions of which barriers are most important and feasible to address will be influenced by local health policy, infrastructure, and practices. However, the methods used to conduct our study can be applied in other settings, and the general differences in opinion that we observed among stakeholders groups are likely representative of what we would find in other regions.
By using concept mapping, we identified barriers to cancer screening in the region of Peel that can be utilized in latter stages of the KTA process. Equally important was that concept mapping engaged a diverse range of stakeholders from the national level (e.g., Canadian Cancer Society), provincial level (Cancer Care Ontario), regional level (Peel Public Health, regional cancer center) and local level (e.g., hospitals, community health centers, community service organizations) that will make the implementation process relevant, feasible, and sustainable moving forward . Participatory research methods combined with an overarching KTA framework can facilitate the translation of research to action.