Using Public Health & Afrocentric Approaches for Increasing Cancer Screening in Primary Care O. Nnorom, MD L. Gebremikael, E.D. TAIBU N. Shi, PA

Disclosure of Commercial Support

CFPC Conflict of Interest

Presenter Disclosure Presenters: Onye Nnorom, Liben Gebremikael, Nan Shi Relationships with commercial interests: • Grants/Research Support: None • Speakers Bureau/Honoraria: None • Consulting Fees: None • Other: None

Context: Health disparities & Vulnerable communities Interventions based on broad population-based

(i.e. Geoffrey Rose) approaches … “may have led to unintended exacerbations of health disparities.”

TAIBU CHC is an example of an organization that uses a vulnerable communities approach to address health disparities.

“A focus on vulnerable populations is comple- mentary to a population approach and necessary for addressing social inequalities in health”

Frohlich KL1, Potvin L. Transcending the known in public health practice: the inequality paradox: the population approach and vulnerable populations. Am J Public Health. 2008 Feb;98(2):216-21.2007.

Overview Background – TAIBU Cancer screening Taskforce

phase 1 (2013) – internally-focused Methods (PDSA, Afrocentric values) Results (MSAA Indicators)

Phase 2 (2014+) – community-focused

Think Tank – promising practices

TAIBU VALUES WE BELIEVE:

• Equity is essential to the achievement of a healthy community • Quality service is integral to our community • Cultural competence is a key component in how the

organization functions • The community’s success lies in within its inherent strengths

and assets

WE RECOGNIZE: • The prevalence of Anti-black Racism and its impact on the way

the community accesses and receives services

WE ARE COMMITTED TO: • Cultivating an environment free of discrimination of any type

Clinical Programs PRIMARY HEALTHCARE:

o Hypertension Management Program in partnership with the Heart & Stroke Foundation

o Sexual Health Clinic in partnership with Toronto Public Health

o Diabetes Education Program

o Specialized Primary Care services for Adults with Sickle Cell Disease

o Chiropody o Social Work o Nutrition Support

Stand up for Health – innovative program targeted at youth to learn about the social determinants of health in a fun and experiential environment.

• Elders Program – UBUNTU

• L.E.A.R.N. afterschool program

• Physical activity programs

Health Promotion

TAIBU - Cancer Screening Cancer Screening rates (Dec 31, 2012):

• PAP offered: 53% • FOBT offered: 22% • Mammography offered: 21%

Cancer Prevention Taskforce

• Deva Nicholas, MD • Nan Shi, PA • Nancy Akor, RN • Patricia Wright, NP • Onye Nnorom, MD (Lead)

Engage staff using PDSA & Afrocentric model of care Plan, Do, Study, Act

Iterative process Continuous Quality Improvement Learn as we go!

Afrocentric values approach: Focus on the collective/community Need to identify those who got screened so we

can find those who didn’t, and save lives! Not about indicators, LHIN/MOHLTC, or bonuses

(FHTs, not CHCs!)

Assessment – data & literature Review data

Ask staff if TAIBU indicators valid Assess vulnerability (Black pop-cancer risk)

Quick Literature Review Identify barriers, solutions

Cancer Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S.,

2005

From: CDC, OHMD. Black or African American Populations. Slides. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm#Disparities

Original Source: CDC, OMHD, 2007 report. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm

Colon, Rectum & Anus Cancer Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S.,

2005

From: CDC, OHMD. Black or African American Populations. Slides. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm#Disparities

Original Source: CDC, OMHD, 2007 report. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm

Breast Cancer Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S.,

2005

From: CDC, OHMD. Black or African American Populations. Slides. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm#Disparities

Original Source: CDC, OMHD, 2007 report. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm

Prostate Cancer Age-Adjusted Death Rates per 100,000 Persons by Race & Hispanic Origin: U.S.,

2005

From: CDC, OHMD. Black or African American Populations. Slides. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm#Disparities

Original Source: CDC, OMHD, 2007 report. http://www.cdc.gov/omhd/Populations/BAA/BAA.htm

Situation: Health disparities & vulnerable communities Under-screened population/communities

(SES, education, culture, marginalization)

Potentially at increased risk (race/genetics)

Planning • Goal/Objectives: • Increase the Cancer Screening rates at TAIBU, and

beyond • Obtain accurate data, target under-screened clients • Reduce barriers to screening • Educate and empower the community

Evidence-Informed Activities (lit review & exp) Barriers: health education, beliefs, other health

conditions, gender of provider/tech, provider time constraints

Promising practices: culturally-relevant educational sessions, videos, facilitating transportation, provider reminders, audits

Doing – Provider Education Provider Guideline Review package Instructions on how to enter cancer screening

data into EMR (Purkinje/NOD)

TAIBU staff education session • Dr. Onye Nnorom: Overview • Dr. Sheila Mae Young, CCO Primary Care Lead

for CE-LHIN: Guidelines Review • Ms. Aggie Mazzucco: Barriers & Promising

practices to screening in immigrant populations

Doing – Audits Cancer Screening Audit

• Review of clients overdue for screening in EMR

• Corrected if tests in chart indicated they had colon, breast, cervical CA screening recently or did not qualify

TAIBU Cancer Screening Audit (2013) Total charts reviewed: 603

Patient need FOBT test: 244 Patient need Mammography: 135 Patient need Pap smear test: 224

Purkinje Where to find the information:

Reports Previous record CPX

TAIBU Cancer Screening Audit (2013) Data correction (tests that were done but

were not entered into EMR): Pap Smear done within 3 years: 24 FOBT done within 2 years: 64 Mammography done within 2 years: 48

Doing – Addressing client barriers Identification of nearest OBSP site (female

technicians) – 1333 Neilson= less travel

Call-back program (pilot) Provider audit of patients overdue for screening Front-desk: calls - Nancy (RN) & Nan (PA)

performed pap, ordered FOBT, mammogram Medical directives, training, checklists

Study – the Results – MSAA Indicators Test Offered Ending Dec

2012 Ending July 2013

Ending Dec 2013

FOBT (colon) 22% 39.9% 43% Pap (cervical)

53% 53.1% 48%

Mammogram (breast)

21% 46.8% 46%

We also obtained informal feedback about the call-back program

Act - Phase 2 – Optimization & Community engagement Improved Call-back program (longer duration,

NOT during Ramadan) Basic info for clients - Pamphlets, signs KTE (town halls, community education)

Repeat data correction (2013-2014) due to EMR

change Start tracking actual outcomes (% test completed,

diagnosed, treated, connected with culturally-appropriate support groups)

Considering: letters, staff reminders

[Future PH-relevant research] Population health assessment (TAIBU

clients at time of intake, DoH) for program planning

Flu vaccine – exploring reasons for declining vaccination

KTE – topic area: Black women - breast and cervical cancer risk & screening awareness

THANK YOU!!! TAIBU Community Health Centre Cancer Screening Taskforce CCO AOHC & ALPHA

Group Discussion: Promising Practices Examples/ways that PHUs/PH practitioners

can work with CHC’s to: Increase cancer screening in under-

screened/vulnerable communities Improve chronic disease prevention in

vulnerable communities (diabetes, CVD, etc.)

Positively impact social determinants of health in vulnerable communities