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The unequal social and economic burden of the COVID-19 pandemic is evident in racialized and low-income communities across Canada. Importantly, social inequities have not been adequately addressed and current public policies are not reflective of the needs of diverse populations. Public participation in decision-making is crucial and there is, therefore, a pressing need to increase diversity of representation in patient partnerships in order to prevent the further exclusion of socially marginalized groups from research and policy making. Deliberate effort and affirmative action are needed to meaningfully engage and nurture diverse patient partnerships by broadening the scope of the patient community to include excluded or underrepresented individuals or groups. This will help us co-develop ways to enhance access and equity in healthcare and prevent the systematic reproduction of structural inequalities that have already been heightened by the COVID-19 pandemic.

Equity-Mobilizing Partnerships in Community (EMPaCT) is a novel approach to patient engagement that centres diverse lived experiences and promotes equity-oriented and inclusive partnerships. As an independent community table, EMPaCT is made up primarily of patients/diverse members of community. Researchers and other decision makers come to this table with their projects to learn how to make their project more inclusive and equitable. In this paper, we detail how we used participatory co-design to define, build and grow EMPaCT as an innovative and scalable patient partnership model that promotes bottom-up action for health equity.

RATIONALE: Appropriate management of low-dose computed tomography (LDCT) screening detected lung nodules will have significant implications for health care resource utilization and minimizing harm ...

Screening for lung cancer with low dose CT can facilitate the detection of early-stage lung cancers that are amenable to treatment, reducing mortality related to lung cancer. Individuals are considered eligible for lung cancer screening if they meet specific high-risk criteria, such as age and smoking history. Population groups that are at highest risk of lung cancer, and therefore, the target of lung cancer screening interventions, are also the least likely to participate in lung cancer screening. This can lead to a widening of health inequities. Deliberate effort is needed to both reduce lung cancer risk (through upstream interventions that promote smoking cessation) as well as midstream interventions that promote equitable access to lung cancer screening.This protocol paper describes an equity-informed patient-oriented research study. Our study aims to promote equitable access to lung cancer screening by partnering with patients to co-design an e-learning module for healthcare providers. The learning module will describe the social context of lung cancer risk and promote access to lung cancer screening by increasing equity at the point of care. We have applied the Generative Co-Design Framework for Healthcare Innovation and detail our study processes in three phases and six steps: Pre-design (establishing a study governance structure); Co-design (identifying research priorities, gathering and interpreting data, co-developing module content); and Post-design (pilot testing the module and developing an implementation plan).Patient engagement in research can promote the design and delivery of healthcare services that are accessible and acceptable to patients. This is particularly important for lung cancer screening as those at highest risk of developing lung cancer are also those who are least likely to participate in lung cancer screening. By detailing the steps of our participatory co-design journey, we are making visible the processes of our work so that they can be linked to future outcomes and related impact, and inform a wide range of patient co-led processes.Lung cancer is the most commonly diagnosed cancer in Canada and is responsible for a quarter of all cancer-related deaths in the country. Screening for lung cancer using tools such as a CT scan can allow us to find lung cancers when they are still small and curable. People can receive a lung CT scan depending on how old they are and for how long they have smoked cigarettes. Certain groups of people, particularly those who have fewer resources such as time and money, and those who experience injustice because of who they are and how they look are less likely to participate in lung cancer screening. We can increase participation in lung cancer screening by educating healthcare providers on appropriate and timely ways to talk to patients about lung cancer screening. In this paper, we outline the steps of a patient-partnered study in which many different stakeholders such as patients, providers and policy-makers have come together with a goal to improve equity in access to lung cancer screening. We will do this by jointly creating an online learning module that will educate healthcare providers on how life experiences shape smoking behaviour and lung cancer risk. The module will also impart key skills on how to deliver care which is timely, appropriate and safe. Once the module is ready it will be freely available to all healthcare providers to support the fair and just delivery of lung cancer screening in the province of Ontario and elsewhere.

BackgroundIndividuals living with low income are less likely to participate in lung cancer screening (LCS) with low-dose computed tomography. Family physicians (FPs) are typically responsible for referring eligible patients to LCS; therefore, we sought to understand their perspectives on access to lung cancer screening for individuals living with low income in order to improve equity in access to LCS.MethodsA theory-informed thematic analysis was conducted using data collected from 11 semi-structured interviews with FPs recruited from three primary care sites in downtown Toronto. Data was coded using the Systems Model of Clinical Preventative Care as a framework and interpretation was guided by the synergies of oppression analytical lens.ResultsFour overarching themes describe FP perspectives on access to LCS for individuals living with low income: the degree of social disadvantage that influences lung cancer risk and opportunities to access care; the clinical encounter, where there is often a mismatch between the complex health needs of low income individuals and structure of health care appointments; the need for equity-oriented health care, illustrated by the neglect of structural origins of health risk and the benefits of a trauma-informed approach; and finally, the multiprong strategies that will be needed in order to improve equity in health outcomes.ConclusionAn equity-oriented and interdisciplinary team based approach to care will be needed in order to improve access to LCS, and attention must be given to the upstream determinants of lung cancer in order to reduce lung cancer risk.

Background Individuals living with low income are more likely to smoke, have a higher risk of lung cancer, and are less likely to participate in preventative healthcare (i.e., low-dose computed tomography (LDCT) for lung cancer screening), leading to equity concerns. To inform the delivery of an organized pilot lung cancer screening program in Ontario, we sought to contextualize the lived experiences of poverty and the choice to participate in lung cancer screening. Methods At three Toronto academic primary-care clinics, high-risk screen-eligible patients who chose or declined LDCT screening were consented; sociodemographic data was collected. Qualitative interviews were conducted. Theoretical thematic analysis was used to organize, describe and interpret the data using the morphogenetic approach as a guiding theoretical lens. Results Eight participants chose to undergo screening; ten did not. From interviews, we identified three themes: Pathways of disadvantage (social trajectories of events that influence lung-cancer risk and health-seeking behaviour), lung-cancer risk and early detection (upstream factors that shape smoking behaviour and lung-cancer screening choices), and safe spaces of care (care that is free of bias, conflict, criticism, or potentially threatening actions, ideas or conversations). We illuminate how ‘choice’ is contextual to the availability of material resources such as income and housing, and how ‘choice’ is influenced by having access to spaces of care that are free of judgement and personal bias. Conclusion Underserved populations will require multiprong interventions that work at the individual, system and structural level to reduce inequities in lung-cancer risk and access to healthcare services such as cancer screening.

Background: The human papillomavirus (HPV) is a common sexually transmitted infection and a primary cause of cervical cancer. The Government of Canada has set a target of reaching 90% HPV vaccine coverage among adolescents by 2025. Here, we examine HPV vaccine uptake in school-based immunization programs across Canada and explore how achieving the 90% target could affect the future incidence of cervical cancer, mortality, and health system expenditures in a cohort of Canadian women. Methods: Data for HPV vaccine uptake in the most recent reported school year available in each jurisdiction were provided in 2017 by jurisdictional school-based immunization programs and were used to estimate a national weighted average of 67%. The OncoSim microsimulation model (version 2.5) was used to compare 3 different levels of HPV vaccine uptake (0%, 67%, 90%) on health and economic outcomes for a hypothetical cohort of all 5- to 10-year-old girls in Canada in 2015. Results: Vaccine uptake for girls in school-based programs varied from 55.0% to 92.0% in the jurisdictions reviewed. The OncoSim model projects that increasing uptake to 90% from 67% would result in a 23% reduction in cervical cancer incidence rates (to 3.1 cases from 4.0 cases per 100,000, averaged across the lifetime of the cohort) and a 23% decline in the average annual mortality rate (to 1.0 deaths from 1.3 deaths per 100,000). Finally, the model projects that the health system will incur a cost of $9 million (1% increase) during the lifetime of the cohort if uptake is increased to 90% from 67%. Costs are discounted (1.5%) and expressed in 2016 Canadian dollars. Costs reflect the payer perspective. Conclusions: Our model shows that increasing HPV vaccine uptake to 90% from current levels for girls in school-based immunization programs could result in substantial reductions in the future incidence and mortality rates for cervical cancer in Canada.