Primary Care Initiative Research Articles

Equity in practice: Integrating cross cultural health brokers for culturally safe primary care for immigrants and refugees in British Columbia.

Umbrella Multicultural Health Co-op is a community health centre serving cultural communities of immigrants/refugees in British Columbia. It uses Cross Cultural Health Brokers (CCHBs), multicultural workers bridging patients and the healthcare system, to better meet the primary care needs of immigrant/refugee populations. Through the Team Primary Care initiative, Umbrella Co-op: (1) added new CCHBs alongside allied health practitioners; and (2) implemented team workshops and evaluation for quality improvement. The learning health system framework guided project activities. Comprehensive, culturally responsive primary care for immigrants and refugees benefits from a team-based approach that includes the integration of CCHBs. Team development activities improved team function. Co-developing evaluation with the interprofessional team enabled meaningful participation. Health system design for equity-oriented team-based primary care for immigrants and refugees should include resources for CCHBs and team development infrastructure.

From margins to mainstream: Incorporating internationally educated health professionals' skills into primary care.

This case study explores the collaborative integration of Internationally Educated Healthcare Professionals (IEHPs) into comprehensive primary care through partnerships between non-profit organizations and health systems actors. It addresses the critical need for such collaboration amidst challenges of limited access to primary care and underutilization of IEHPs' skills in the Canadian healthcare workforce. Through the examination of ACCES Employment's integration into the Team Primary Care initiative, this article demonstrates the importance of coordinated efforts in overcoming longstanding barriers faced by IEHPs. Data collection involved a review of program activities, program reports, policy documents, and interviews with key collaborators to highlight strategies, partnerships, and outcomes. Data were analyzed to identify recurring patterns in collaborative integration efforts. The initiative reveals promising outcomes in facilitating IEHPs' transition into various healthcare roles through increasing collaboration between non-profit workforce development organizations and health systems actors.

The role of primary healthcare amid the COVID-19 pandemic: Evidence from the Family Health Strategy in Brazil

This paper investigates the role of primary healthcare in mitigating the consequences of the COVID-19 pandemic, focusing on the Brazilian Family Health Strategy (ESF) as a case study. ESF is Brazil’s major primary care initiative, with prior evidence indicating its effectiveness in improving various health outcomes. The COVID-19 pandemic submitted the Brazilian healthcare system to a rigorous and unprecedented stress test, whose repercussions are still under study. Using comprehensive administrative microdata from 2016 to 2022 encompassing dimensions related to mortality, healthcare service, supply of family health teams, and vaccination coverage, our empirical strategy accounts for heterogeneous effects based on program intensity and pandemic evolution of the 5570 Brazilian municipalities. Our findings reveal that municipalities with high-intensity of ESF coverage (i.e. stronger primary care) experienced 347.93 (95% CI: 289.04, 406.81) fewer COVID-19 and cardiorespiratory deaths per million inhabitants throughout the pandemic period, compared to those in low-intensity ESF areas, despite sharing similar profiles of deaths from respiratory and cardiovascular causes. Among the channels contributing to this relative performance, high-intensity ESF municipalities were found to engage in more home-based primary care visits and health promotion activities while maintaining a similar supply of community health workers. Additionally, they achieved higher vaccination coverage, and these effects were more pronounced in areas with greater ESF presence, emphasising the importance of primary care coverage. In conclusion, our findings underscore the relevance of strong primary care in mitigating the consequences of the pandemic and addressing post-pandemic health challenges.

Advancing equity, diversity, inclusivity, and accessibility in primary care: The development of an integrated educational experience model.

This article presents the development of the Equity, Diversity, Inclusivity, and Accessibility (EDIA) Cross-Cutting Theme Project within the Team Primary Care (TPC) initiative, aimed at addressing systemic inequities through innovative educational strategies. Grounded in the social accountability of health professions framework, this project aims to equip primary care teams with the knowledge, skills, and attitudes necessary to promote health equity. The EDIA Integrated Educational Experience (IEE) model includes a self-assessment tool, digital learning space, and national mentorship network, providing a comprehensive approach for primary care teams to promote health equity. The IEE model utilizes a layered micro, meso, and macro approach to support cultural transformation within highly complex healthcare environments. Key lessons learned involve trust- and relationship-building processes to help dismantle historical silos and encourage open dialogue. Future efforts focus on implementation, ensuring adaptability, scalability, and sustainability, positioning the model as a catalyst for equitable primary care delivery.

Temporal evolution of newly diagnosed and late syphilis prevalence: a notification analysis over the past 10 years in the state of Tocantins and the northern region of Brazil

Syphilis, a sexually or vertically transmitted pathology during gestation, represents a significant threat to maternal and child health. The absence of early diagnosis during pregnancy can result in vertical transmission, leading to recent or late congenital syphilis, both associated with severe sequelae and potentially fatal outcomes for the newborn. This study aimed to analyze epidemiological data regarding cases of gestational syphilis in the State of Tocantins, comparing them with the Northern region of Brazil over the last decade. The results revealed that, despite awareness initiatives in primary care, cases of recent congenital syphilis remain prevalent, with the years 2017 and 2018 recording the highest notification rates. It is concluded that the increase in the prevalence of recently diagnosed syphilis signals the need for improvement in health policies in Tocantins and the Northern region. The importance of early screening during prenatal care is emphasized, highlighting that accurate diagnosis and effective treatment can exempt the pregnant woman and the baby from potential future sequelae.

“It’s so scary, and you’re so alone with it”: Clinicians’ perspectives on suicide risk management in integrated primary care

Primary care clinics serve many patients experiencing latent or evident suicide risk and may benefit from implementing suicide care improvements such as the Zero Suicide model. However, little is known about the readiness of clinics to implement such initiatives. We interviewed a range of clinicians (e.g., medical providers, behavioral health providers, nurses; n = 24) from six integrated primary care clinics to better understand strengths and limitations of the milieu, how suicide risk is currently detected and managed, and which implementation strategies could be employed to improve suicide prevention. We found clinics were extremely busy and resource-constrained but had a strong and longitudinal commitment to patients and families. Suicide risk was detected in a variety of ways and clinicians had limited resources to offer these patients. Clinicians sought to preserve patients’ autonomy and trust while also ensuring their safety. Preferred strategies included dissemination of protocols and tools, training, electronic health record changes, and improved staffing. Our findings suggest that suicide prevention initiatives in primary care should attend to the constraints of the care setting, adapting their approach to ensure they fit with workflow while also centering patient autonomy and rapport.

Structuralizing Culture: Multicultural Neoliberalism, Migration, and Mental Health in Santiago, Chile

The arrival of Afro-descendant migrants, mainly from Haiti and the Dominican Republic, has led to the emergence of new discourses on migration, multiculturalism, and mental health in health services in Chile since 2010. In this article, I explore how mental health institutions, experts, and practitioners have taken a cultural turn in working with migrant communities in this new multicultural scenario. Based on a multisited ethnography conducted over 14 months in a neighbourhood of northern Santiago, I focus on the Migrant Program—a primary health care initiative implemented since 2013. I argue that health practitioners have tended to redefine cultural approaches in structural terms focusing mainly on class aspects such poverty, social stratification, and socioeconomic inequalities. I affirm that this structural-based approach finds its historical roots in a political and ideological context that provided the conditions for the development of community psychiatry experiences during the 1960s and 1970s, as well as in multicultural and gender policies promoted by the state since the 1990s. This case reveals how health institutions and practitioners have recently engaged in debates on migration and intersectionality from a structural approach in Chile.

Implementation of Interprofessional Pharmaceutical Care Initiatives: Lessons Learned from Successful Bottom-Up Initiatives in Primary Care.

Although there is evidence that interprofessional, person-centred, integrated care is important for optimising pharmaceutical care of older people with polypharmacy, this way of working is often not implemented in practice. The aim of this study was to identify common characteristics of successful interprofessional initiatives and factors influencing their implementation, in order to close this know-do gap. A qualitative, explorative design with in-depth semi-structured interviews was used. Flemish primary healthcare professionals (HCPs) and patients aged over 75, involved in successful initiatives of interprofessional pharmaceutical care for older people with polypharmacy, were included. Inductive analysis was conducted to identify main topics. Fifteen HCPs and four patients, involved in nine interprofessional initiatives, were interviewed. In all initiatives the HCPs had interprofessional consultations about older people with polypharmacy. The interaction between the characteristics of the initiatives and the context had an important impact on the implementation. These context factors were positioned under the micro-, meso- and macro context. Implementation strategies, actions to enhance the initiatives' adoption, corresponded with three themes: communication and influence, coordination by different stakeholders, and (dis)incentives. The identification of these success factors might inspire HCPs, providers of interprofessional education and policymakers to facilitate interprofessional pharmaceutical care.

Application of implementation science for improving the utilization of an international clinical practice guidance on familial hypercholesterolemia

The International Atherosclerosis Society (IAS) published an evidence-informed guidance for familial hypercholesterolemia (FH) that provides both clinical and implementation recommendations. We reference examples of strategies from the literature to explore how these implementation recommendations can be tailored into implementation strategies at the local-level for stakeholders guided by a framework proposed by Sarkies and Jones. Four authors of the IAS guidance selected two published exemplar implementation recommendations for detection, management, and general implementation. Each recommendation was described as an implementation strategy using Proctor's guidance for specifying and reporting implementation strategies. It recommends reporting the actor (who), action (what), action-target (who is impacted), temporality (how often), and dose (how much) for each implementation strategy. Detection: A centralized cascade testing model, mobilized nurses (actor) to relative's homes, after the diagnosis of the proband (temporality), once (dose) to consent, obtain a blood sample and health information (action) on relatives (action-target). A primary care initiative to improve FH management included an educational session (action) with clinicians (action-target), computer-based reminder message and message to patients to have their cholesterol screened once (dose) at a visit or outreach (temporality) by researchers (actor). General: A partnership between a statewide public pathology provider, local public hospital network, primary health network, government health ministry, and an academic university (actors) was established to implement a primary-tertiary shared care model (action) to improve the detection of FH (action-target). We demonstrate that implementation recommendations can be specified and reported for different local contexts with examples on monitoring, evaluation, and sustainability in practice.

The Australian Health Care Homes trial: quality of care and patient outcomes. A propensity score-matched cohort study.

To assess the impact of the Health Care Homes (HCH) primary health care initiative on quality of care and patient outcomes. Quasi-experimental, matched cohort study; analysis of general practice data extracts and linked administrative data from ten Australian primary health networks, 1 October 2017 - 30 June 2021. People with chronic health conditions (practice data extracts: 9811; linked administrative data: 10 682) enrolled in the HCH 1 October 2017 - 30 June 2019; comparison groups of patients receiving usual care (1:1 propensity score-matched). Participants were involved in shared care planning, provided enhanced access to team care, and encouraged to seek chronic condition care at the HCH practice where they were enrolled. Participating practices received bundled payments based on clinical risk tier. Access to care, processes of care, diabetes-related outcomes, hospital service use, risk of death. During the first twelve months after enrolment, the mean numbers of general practitioner encounters (rate ratio, 1.14; 95% confidence interval [CI], 1.11-1.17) and Medicare Benefits Schedule claims for allied health services (rate ratio, 1.28; 95% CI, 1.24-1.33) were higher for the HCH than the usual care group. Annual influenza vaccinations (relative risk, 1.20; 95% CI, 1.17-1.22) and measurements of blood pressure (relative risk, 1.09; 95% CI, 1.08-1.11), blood lipids (relative risk, 1.19; 95% CI, 1.16-1.21), glycated haemoglobin (relative risk, 1.06; 95% CI, 1.03-1.08), and kidney function (relative risk, 1.13; 95% CI, 1.11-1.15) were more likely in the HCH than the usual care group during the twelve months after enrolment. Similar rate ratios and relative risks applied in the second year. The numbers of emergency department presentations (rate ratio, 1.09; 95% CI, 1.02-1.18) and emergency admissions (rate ratio, 1.13; 95% CI, 1.04-1.22) were higher for the HCH group during the first year; other differences in hospital use were not statistically significant. Differences in glycaemic and blood pressure control in people with diabetes in the second year were not statistically significant. By 30 June 2021, 689 people in the HCH group (6.5%) and 646 in the usual care group (6.1%) had died (hazard ratio, 1.07; 95% CI, 0.96-1.20). The HCH program was associated with greater access to care and improved processes of care for people with chronic diseases, but not changes in diabetes-related outcomes, most measures of hospital use, or risk of death.

2052 Polypharmacy reviews in outpatient clinics - beginning the structured medication review in bone health clinic

Abstract Introduction Inappropriate polypharmacy is recognised as a contributing factor towards adverse outcomes in frail patients. Current efforts at national level are centred around primary care initiatives in completing structured medication reviews (SMR) where shared decision making takes place with open discussion around risks and benefits of treatments. The aim of this review was to assess whether recommendations for discussion in SMR have been adopted for patients attending frailty bone health clinic led by Consultant Pharmacist, in hospital outpatient setting. Method Retrospective analysis of notes was undertaken in a sample of 30 patients reviewed in clinic in the period 01.09.22-28.02.23 who were on at least five medications, were still alive six months post review and where suggestions with regards to actions to discuss during a structured medication review were made. Results Average age of patients sampled was 79 years with average CFS of 5.75. Number of medicines documented at outpatient appointment was on average 10.6 which reduced to 9.95 at review six months after the appointment. Around a third of recommendations were adapted fully, with another third partially completed and a third not completed. Interventions included review of falls risk increasing drugs (FRIDs), reduction of anticholinergic load, identification of possible prescribing cascades, review of opioid medication in chronic pain context and review of medicines where benefit may no longer be derived due to frailty progression. In cases where review of medication with high anticholinergic load was advised, an average reduction of -3 was achieved at six-month review. Conclusion(s) Starting a structured medication review in outpatient clinic has the potential to reduce the risk of adverse events and improve outcomes for patients. Further work will be undertaken to ascertain reasons for not adopting the recommendations and continuous collaboration with primary care colleagues will continue to address problematic polypharmacy.

Implementation of interprofessional pharmaceutical care initiatives: lessons learned from successful bottom-up initiatives in primary care

Background: Although there is evidence that interprofessional, person-centred, integrated care is important for optimising pharmaceutical care of older persons with polypharmacy, this way of working is often not implemented in practice. Identification and description of successful initiatives between physicians, pharmacists and nurses, their context and implementation strategies are important to close this know-do gap.
 Objective: The aim of this study was to identify common characteristics of successful interprofessional initiatives and factors influencing the implementation of these initiatives.
 Methods: A qualitative, explorative design with in-depth semi-structured interviews was used. Flemish primary healthcare professionals and patients aged over 75, involved in successful initiatives for interprofessional pharmaceutical care of older persons with polypharmacy, were included. Inductive analysis was conducted to identify main topics.
 Results: Several interprofessional initiatives, successfully implemented in primary healthcare, were explored. Fifteen healthcare professionals and four patients involved in these initiatives were interviewed. In all initiatives the healthcare professionals had interprofessional consultations about older persons with polypharmacy. Five common characteristics could be identified in these initiatives: a) bottom-up design with voluntary participation of healthcare professionals, b) team made decisions, c) the presence of a project coordinator d) consultation with older persons and e) the availability of supporting documents. The interaction between the characteristics of the initiatives and the context had an important impact on the implementation. These context factors were positioned under a) the micro context – including personal characteristics of healthcare professionals and interprofessional relations, b) the meso context - including a culture of cooperation, scale and available time, and c) the macro context, including the political context and ICT possibilities. Implementation strategies, actions to enhance the adoption of the initiatives, were identified and corresponded with three themes: communication and influence, coordination of different stakeholders, and incentives or disincentives.
 Discussion: Raising the visibility of these success stories will inspire healthcare professionals, providers of interprofessional education and policymakers to facilitate interprofessional pharmaceutical care. Since patients seemed to have limited interest in collaboration strategies of their healthcare professionals, more in-depth research to explore patients’ expectations is suggested.

The relationship of cancer history and chronic disease status to colorectal cancer screening: A cross-sectional analysis of 2020-2021 Behavioral Risk Factor Surveillance System.

We examined whether having a history of cancer and chronic diseases was associated with guideline-concordant colorectal cancer (CRC) screening utilization. Self-reported data from the 2020 and 2021 Behavioral Risk Factor Surveillance System in Oregon and West Virginia were used. Guideline-concordant CRC screening was the outcome of interest. The exposure was having a personal history of cancer, chronic diseases, or both. Multivariable logistic regressions were applied to assess the abovementioned association. Among 10,373 respondents aged 45-75years, 75.5% of those with a history of cancer and chronic diseases had guideline-concordant CRC screening use versus 52.8% of those without any history (p-value < 0.05). In multivariable analysis, having a history of cancer (OR 1.74; 95% CI 1.11-2.71), chronic diseases (OR 1.35; 95% CI 1.14-1.59), and both cancer and chronic diseases (OR 2.14; 95% CI 1.62-2.82) were positively associated with screening uptake compared to respondents without any history. Regardless of disease history, older age was associated with greater CRC screening uptake (p-value < 0.05). Among respondents with chronic diseases only or without any condition, those with a health care provider had 1.7-fold and 2.7-fold increased odds of receiving CRC screening, respectively. However, current smokers were 28% and 34% less likely to be screened for CRC among those with chronic diseases only and without any conditions, respectively. Having a personal history of cancer and chronic diseases appears to be positively associated with guideline-concordant CRC screening use. Effective implementation of patient-centered communication through primary care initiatives may increase adherence to CRC screening recommendations.

Innovative shortcuts and initiatives in primary health care for rural/remote localities: a scoping review on how to overcome the COVID-19 pandemic.

The COVID-19 pandemic has emerged as one of the greatest challenges to societies, world health systems and science in the past century, making it imperative to restructure care networks. Therefore, it is essential to discuss the role and initiatives of primary health care (PHC) to deal with it. However, regarding the response to the pandemic, including the current global effort against COVID-19, the nuances of the rural/remote PHC context in the pandemic is barely visible. Rural and remote communities have differentiated health risks, such as socioeconomic disadvantages, difficulties in mobility and access to health services, in addition to linguistic and cultural barriers. This scoping review aimed to analyze the set of individual and collective initiatives and innovations developed to face the COVID-19 pandemic, within the PHC scope, in rural and remote areas. A scoping review methodology was applied to peer-reviewed articles. Eight databases were searched to identify scientific articles published in English, Spanish and Portuguese, initially from January 2020 to July 2021, complemented by a rapid review of articles published from January 2022 to April 2023. The main focus sought in the literature was the set of initiatives and innovations carried out within the PHC scope in rural and remote locations during the pandemic, as well as the comparison with pre-pandemic situations and between different countries. The bibliographic information of each search result was imported into Rayyan (Intelligent Systematic Review), followed by the screening and eligibility stages, performed independently by two reviewers, with a third reviewer being accessed in case of conflicts. This review included 54 studies, with publications mostly from Australia, Canada, the US and India. The main PHC initiatives were related to access; to the roles of community health workers and health surveillance; and to the importance of placing, retaining and valuing human resources in health. Cultural, equity and vulnerability issues occupy a major place among the initiatives. Regarding the innovations, telehealth and customized communication are highlighted. From an organizational point of view, rural and remote locations showed enormous flexibility to deal with the pandemic and to improve intersectoral activities at the local level. The description of rurality and remoteness is practically coincident with that of the specific populations, present in geographic areas of difficult sociospatial and cultural access. Rarely, there is an index to measure rurality, or its description deals with the need to overcome distances and obstacles. The findings highlight and summarize knowledge about initiatives and innovations developed to face the COVID-19 pandemic, within the PHC scope in rural and remote areas in the world. This review has identified collective, clinical, intersectoral and, mainly, organizational health initiatives. An articulation between different government levels would be paramount in evaluating the implementation of policies and protocols in rural and remote locations for future sanitary crises. Innovations and lessons learned are equally relevant in strengthening health services and systems. This issue calls for considerable further exploration by new reviews and empirical research that seek evidence to assess the sustainability and effectiveness of the implemented measures to face post-pandemic difficulties and other adversities.

Understanding Dalit equity: a critical analysis of primary health care policy discourse of Kerala in the context of ‘Aardram’ mission

BackgroundThe Government of Kerala in 2017 launched the Aardram Mission with the aim to revamp public health delivery in the State. A key strategy under the mission was its focus on comprehensive primary health care to achieve equitable health care delivery through the Family Health Centre (FHC) initiative. Given this, the current study aims to examine the primary health care policy discourse for their perspectives on caste-driven inequities.MethodsThe study undertook a Critical Discourse Analysis (CDA) of the primary health care policy discourse in Kerala. This included CDA of spoken words by senior health policy actors and policy texts on Aardram Mission and FHC.ResultsThough equity was a major aspirational goal of the Mission, related policy discourse around equity failed to acknowledge caste as a potential axis of health marginalisation in the State. The dismissal of caste manifested in three major ways within the policy discourse. One, the ‘invisibilisation’ of caste-driven inequities through strategies of (un)conscious exclusion of Dalit issues and ‘obliteration’ of caste differences through the construction of abstract and homogenous groups that invisibilise Dalits. Secondly, locating caste as a barrier to primary health care initiatives and health equity in the state, and finally through the maintenance of an ‘apoliticised’ social determinants discourse that fails to recognize the role of caste in shaping health disparities, specifically among Dalits in Kerala.ConclusionGiven Kerala’s renewed commitment to strengthening its public health provisioning, the acknowledgment of caste-driven inequities is invariable in its path toward health equity and social justice.

Impact of a Pharmacist-Led Telemedicine Visit in a Geriatric Primary Care Clinic

Purpose: Unintentional medication discrepancies (UMD) are common amongst geriatric patients. If not addressed, these UMD can lead to suboptimal care and increased health care spending. Ambulatory care pharmacists are trained to identify and resolve UMD, and help tailor medication regimens to assure optimized and safe patient-centered care. The purpose of this retrospective study was to highlight the role of a remote, ambulatory care pharmacist in a geriatric primary care setting. Methods: This was a multicenter, single cohort, retrospective chart review of patients enrolled in a geriatric primary care initiative. Patients met with an ambulatory care pharmacist for a 60-minute telemedicine appointment. The primary endpoint was the percent of patients seen by the ambulatory care pharmacist with at least 1 medication discrepancy identified. Results: A total of 275 visits were scheduled with the ambulatory care pharmacist during the 6-month study period. At least 1 unintentional medication discrepancy (UMD) was identified in 151 patients (66%). At least 1 edit was made to the patient’s medication list in 224 patients (97%). The ambulatory care pharmacist made recommendations to the provider in 210 patients (91%). The CPA was utilized in 75 patients (33%). Conclusion: This study highlights the utility of a remote, ambulatory care pharmacist in a geriatric primary care setting. Two-thirds of patients were noted to have at least 1 UMD, and more than 90% of patients were identified as having suboptimal regimens. This initiative shows the impact of a remote, ambulatory care pharmacist on patient care.

Risk Factors Associated With Polypharmacy and Potentially Inappropriate Medication Use in Ambulatory Care Among the Elderly in the United States: A Cross-Sectional Study.

Polypharmacy, defined as the concurrent use of multiple (commonly five or more) prescription drugs, is widely prevalent among the elderly. It is a preventable and significant contributor to morbidity and mortality among older people. It is linked to prescribing potentially inappropriate medications (PIMs), which have been shown to be associated with an increased risk of adverse drug interactions and reduced compliance, and in some cases result in prescribing cascades where more drugs are prescribed to manage adverse outcomes. This study aimed to examine risk factors associated with polypharmacy and PIMs among elderly patients in outpatient settings in the US. We conducted a cross-sectional analysis using the nationally representative National Ambulatory Medical Care Survey, between 2010 and 2016. We extracted data from all people aged 65 years or older and evaluated factors associated with polypharmacy and PIMs using multivariable logistic regression. Weights were applied to obtain national estimates. During the study period, there were a total of 81,295 ambulatory visits among adults 65 years and older. Being a woman (compared with a man) was more likely to be associated with greater prevalence of PIMs (OR: 1.31, 95% CI 1.23-1.40), and living in rural areas were more likely to be associated with both polypharmacy (OR: 1.15, 95% CI 1.07-1.23) and PIMs (OR: 1.19, 95% CI 1.09-1.29), compared with living in urban areas. Older age was positively associated with polypharmacy (OR: 1.08, 95% CI 1.06-1.10), but negatively associated with PIMs (OR: 0.97, 95% CI 0.95-0.99). Our study suggests age, being a woman, and living in rural areas are risk factors for both polypharmacy and PIMs usage. Aside from primary care providers' roles in managing polypharmacy, collaborative care with other specialty providers, such as clinical pharmacists, should also be considered as an approach to improving the quality of prescribing in geriatric patients. Future research should further explore reasons for polypharmacy and focus on deprescribing and quality improvement initiatives in primary care to lower polypharmacy among the elderly.

Factors That Affect Opioid Quality Improvement Initiatives in Primary Care: Insights from Ten Health Systems.

To improve patient safety and pain management, the Centers for Disease Control and Prevention (CDC) released the Guideline for Prescribing Opioids for Chronic Pain (CDC Guideline). Recognizing that issuing a guideline alone is insufficient for transforming practice, CDC supported an Opioid Quality Improvement (QI) Collaborative, consisting of 10 health care systems that represented more than 120 practices across the United States. The research team identified factors related to implementation success using domains described by the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) implementation science framework. Data from interviews, notes from check-in calls, and documents provided by systems were used. The researchers collected data throughout the project through interviews, meeting notes, and documents. The iPARIHS framework was used to identify factors that affected implementation related to the context, innovation (implementing recommendations from the CDC Guideline), recipient (clinicians), and facilitation (QI team). Contextual characteristics were at the clinic, health system, and broader external context, including staffing and leadership support, previous QI experience, and state laws. Characteristics of the innovation were its adaptability and challenges operationalizing the measures. Recipient characteristics included belief in the importance of the innovation but challenges engaging in the initiative. Finally, facilitation characteristics driving differential outcomes included staffing and available time of the QI team, the ability to make changes, and experience with QI. As health care systems continue to implement the CDC Guideline, these insights can advance successful implementation efforts by describing common implementation challenges and identifying strategies to prepare for and overcome them.

Abstract A121: Colorectal cancer screening utilization among breast, cervical, prostate, skin, and lung cancer survivors

Abstract Background: Advancement in cancer detection and treatment has improved survival rates leading to a growing population of cancer survivors, yet cancer survivors are at a 20% increased risk of developing a secondary cancer. Breast, cervical, prostate, and lung cancer survivors as well as malignant melanoma survivors have been reported an increased risk for developing colorectal cancer (CRC). Although receiving appropriate cancer screening for secondary cancers is recommended, evidence on CRC screening among different cancer survivors are lacking. Methods: We examined the relationship between sociodemographic characteristics, access to care, risk behavior factors, and chronic health conditions in cancer survivors, with up-to-date CRC screening utilization (colonoscopy, flexible sigmoidoscopy, fecal occult blood test) among breast, cervical, prostate, skin (including melanoma), and lung cancer survivors, using data from the 2020 Behavioral Risk Factor Surveillance System. Descriptive statistics were used to summarize the data and multivariable logistic regressions were applied to assess the association of these characteristics with up-to-date CRC screening use. Results: Among 9,780 cancer survivors included in the analysis, most were age 60-69 years, had first cancer at 41-59 years, were Non-Hispanic White, and had some college or college graduate education. Compared to CRC screening rates in breast, prostate, skin, and lung cancer survivors, cervical cancer survivors had a lower rate of screening at 65% (breast cancer: 82%, prostate cancer: 88%, skin cancer: 78%, and lung cancer: 80%). In multivariable analysis, breast, cervical, and skin cancer survivors aged ≥ 60 years were associated with higher odds of receiving CRC screening compared to adults aged 45-59 years (p-value &amp;lt;0.05). Respondents that had their last routine checkup two or more years prior, had lower odds of having CRC screening among cervical (OR=0.06; 95% CI, 0.02-0.22), prostate (OR=0.26; 95% CI, 0.14-0.49), and skin cancer (OR=0.50; 95% CI, 0.36-0.70) survivors. The presence of one or more chronic diseases were associated with higher odds of having up-to-date CRC screening among breast, prostate, and skin cancer survivors; however, lung cancer survivors with one or two chronic diseases exhibited lower odds of receiving CRC screening (OR=0.16; 95% CI, 0.04-0.61) compared to respondents without chronic disease. Conclusion: Findings from this study provide important evidence on factors that may be associated with up-to-date CRC screening use across different cancer survivors which include older age, routine checkup, and multiple chronic diseases. Moreover, variations of CRC screening utilization among cancer survivors may highlight missed opportunities for secondary cancer prevention. These findings will inform the importance of secondary cancer prevention in survivorship care plans for breast, cervical, prostate, skin, and lung cancer survivors and effective implementation of these plans through primary health care initiatives. Citation Format: Meng-Han Tsai, Justin X. Moore, Lorriane Odhiambo, Sydney E. Andrzejak, Martha S. Tingen. Colorectal cancer screening utilization among breast, cervical, prostate, skin, and lung cancer survivors [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A121.

Examining Psychosocial and Economic Barriers to Green Space Access for Racialised Individuals and Families: A Narrative Literature Review of the Evidence to Date.

Social prescribing (such as green social prescribing), aims to address health disparities cross-culturally to improve well-being. However, evidence highlights racial disparities in relation to access to quality green space (including local/national parks and recreational spaces). This review aimed to identify the psycho-socioeconomic barriers to green space access for racialised individuals/families and Black Indigenous People of Colour (BIPOC), to understand what cultural adaptations might be made to help support them to access green social prescribing within the UK. A narrative systematic review was conducted to identify barriers to green space access for racialised individuals/families and BIPOC. Searches of publication databases (APA PsycInfo, Cochrane Database of Systematic Reviews [CDSR], Cochrane Central Register of Controlled Trials [CENTRAL], Cumulated Index to Nursing and Allied Health Literature [CINAHL], and SCOPUS Preview) were undertaken from January to February 2022, to identify quantitative peer reviewed studies. Of the 4493 abstracts identified, ten studies met the inclusion criteria and were included for final review. The results suggest that interpersonal, practical (such as transportation costs, entrance fees and lodging costs) and environmental factors can act as barriers to green space access for racialised individuals/families. Most frequently reported barriers were perceptions of safety and costs associated with travel and accessing green spaces, particularly for families. Factors such as diversity-friendly schemes (e.g., multiple languages on signs and additional prayer spaces in parks), funding and strategies to improve safety should be considered in the design and commissioning of green space and green social prescribing initiatives in primary care. By mitigating these barriers green space can become more accessible and improve inclusivity for racialised individuals/families. Future research could explore the inter-racial differences between racialised populations and which mechanisms reduce barriers to access and in what contexts.