Background: Mortality from colorectal cancer (CRC) in the Northwest Territories (NWT), a northern region of Canada, is nearly double the national rate. While mortality could be reduced with greater adherence to CRC screening, this requires colonoscopy access which is limited, and difficult to predict in a complex remote health system. Simulation modeling has been used to plan CRC screening but the impact on decision-making and utility in complex remote health system is unclear. Aim: This thesis aims to estimate the colonoscopy requirements and outcomes of CRC screening in the NWT using simulation modeling in a way that will inform feasible patient-centered strategies to enhance screening. Methods: We conducted a systematic review of the validity and utility of simulation modeling in CRC screening delivery (Chapter 1, 2). Next, a retrospective cohort study of CRC screening participation and outcomes between 2014-2019 was conducted (Chapter 3). We used this data and the findings of the systematic review to inform our participatory simulation modeling approach (Chapter 4). With end-users of the simulation model (clinicians, administrators, and patients), we revised an existing simulation model, OncoSim-CRC, to estimate the resource requirements and outcomes of various strategies to deliver a CRC screening program in the NWT. Each scenario model was run for 500 million cases and model validity was assessed. To enhance ongoing collaboration, we shared the concepts of a Communities of Practice (CoP) framework with stakeholders and assisted in generating consensus on priorities for a CoP to address (Chapter 5). Results: The systematic review showed that simulation models have been used to generate evidence critical to informing decision making for a broad range of decisions related to CRC screening delivery. However, the impact of these models on decision making, end-user engagement, and model validity were rarely described. In the retrospective cohort study, we observed that fecal immunohistochemical test(FIT)-based CRC screening did not appear to prevent CRC or provide earlier detection, but did result in more frequent positive pathology results than anticipated for average risk screening. Factors associated with this include long wait times for colonoscopy, over 1 in 3 FIT positive individuals had clinical signs and symptoms of CRC, and higher relative risk of advanced neoplasia among indigenous individuals. These findings and the involvement of end-users, informed the simulation model study. Under the parameters of the model, we estimate that colonoscopy demand with a CRC screening program would surpass capacity within 1-2 years, and continue to increase over the next 10-15 years due to adenoma surveillance. If this colonoscopy demand is met, we estimate screen detected cancers would increase by 110%, and clinically detected cases reduce by 26%. Increasing the phase-in period or revising adenoma follow-up guidelines would reduce demand and still improve cancer detection and prevention. A framework for a CoP, and consensus on priorities among stakeholders were established. Conclusion: Participatory simulation modeling was a useful method of informing CRC screening delivery in a remote northern population. The simulated scenarios provide decision-makers with strategies to enhance programmatic screening while conserving colonoscopy resources. The findings of this thesis helps to characterize the current outcomes of CRC screening in the NWT, and identifies opportunities to improve CRC screening effectiveness for a remote and, largely indigenous population.

The widespread use of highly active antiretroviral therapy (HAART) has resulted in longer lifespans for HIV seropositive women in the United States, during which preventive health care is recommended. Failing to complete recommended cancer screening tests can result in cancer being diagnosed at a later stage with a poorer prognosis. The purpose of the study, based on the ecosocial theory, was to describe the sociodemographic and clinical variables of HIV seropositive women who failed to complete recommended screening tests for breast, cervical, and colorectal cancers, and determine if the presence of hypertension, obesity, diabetes, depression, or tobacco use impacted the completion of these screening tests. The electronic medical records of 142 HIV seropositive women were reviewed. Univariate analysis, bivariate analysis, and logistic regression were conducted to create a model associated with the completion of preventive health care screening tests. For breast cancer, cervical cancer, and colorectal cancer, 69%, 71.8%, and 69.7% failed to complete screening, respectively. Number of years living with HIV infection and HIV stage were associated with breast cancer screening; distance between residence and health care facility, and HIV stage were associated with cervical cancer screening; and age and marital status were associated with colorectal cancer screening. Addressing issues related to the completion of cancer screening tests over the lifespans of HIV seropositive women can result in positive social change by preventing disease and disability, which can negatively impact these women, their families, and their communities.

Lung cancer affects many individuals each year and accounts for many deaths around the globe. Lung cancer screening is a preventative health measure that has the ability to detect lung cancer earlier. The purpose of this project was to focus on the education of nursing staff within a community health system, with subsequent implementation of an electronic health record clinical decision support system, to create a direct referral pathway to lung cancer screening, delivered through patient education. The concept of prevention was the framework for this project design, which was further organized around the plan-do-study -act model, while taking into consideration the health belief model and theory of interpersonal relations. Using systemized dashboard reports within the electronic health record software, specific variables were targeted for data collection and analyzed for the purpose of this project. Final data demonstrated an increase of triple the programmatic volume of the previous year, directly following the implementation of the above initiative. Further comparative statistics bespeak to the significant needs of the community regarding tobacco dependence and lung cancer screening. High-risk individuals who are current or former smokers will benefit from this initiative by receiving education about lung cancer screening and tobacco dependence treatment while within the care of the community based health system. A nursing-driven pathway to preventative care could also serve other cancer screening programs effectively, as well as be applied to a variety of chronic disease comorbidities to make a significant positive social change.

Zimbabwean men at risk of developing prostate cancer (PC) are diagnosed late or not at all. A cross sectional, quantitative study was done in Zimbabwe to establish physicians' attitudes and beliefs towards PC screening and diagnosis. Descriptive statistics were obtained to determine physicians' beliefs and attitudes using the Physician Attitudes and Beliefs Questionnaire Survey. The instrument incorporated validated instruments, the Burns' Cancer Belief Scale and Physician Survey on Prostate Cancer Screening, and demographic questions to measure specific independent variables, potentially influencing attitudes and beliefs. Means and standard deviations were conducted for continuous variables for beliefs and attitudes, and frequencies and percentages for categorical variables were calculated. Data from 206 respondents were analyzed utilizing multiple regression and MANOVA analysis to determine significance. The average Belief score was 3.96 (SD = 1.04), which reflected an overall belief score falling in the neutral range of response options. Linear regression results were significant, F(19, 178) = 2.09, p = 0.007, R2 = 0.18, suggesting that screening, stage of cancer, gender, training location, culture, total years in practice, and specialty accounted for 18% of the variance in Belief score. Attitude score predicted by screening (p = .000), stage of cancer (p = .005), race (p = .000), and culture (p = .020), was also significant. Screening and training location were significant predictors. Results will benefit physicians improve their attitudes using suggested continued education, resulting in improved screening practices and PC diagnosis. The public health system will potentially see PC death rates decline over time increasing life expectancy.

Minority women groups in the United States have the highest incidence and mortality rates of cervical cancer. Hispanic women have the highest incidence rate and the second highest mortality rate of the disease. Researchers have examined the lower rates of cervical cancer screening among Hispanic women, as compared to other groups of U.S. women, but researchers have not examined the extent to which socioeconomic status, acculturation, and sexual activity impact Hispanic women's compliance with screening. The purpose of this study was to examine the association between compliance with cervical cancer screening and acculturation, socioeconomic status, and sexual activity among U.S. Hispanic women. The framework for investigating the extent of association between these identified barriers and willingness to comply with screening was the behavioral model for vulnerable populations. Chi-square tests and logistic regression were used to analyze data from the National Health Interview Survey for 2011, 2012, and 2013, focusing on U.S. Hispanic women ages 21 - 65 (N = 739). The findings from this study revealed that educational level was significantly associated with U.S. Hispanic women's cervical cancer screening; however, no statistically significant associations were found for socioeconomic status, acculturation, and sexual activity and screening rates for this group. Findings from this study can better inform researchers and others of the lower rate of screening for cervical cancer among U.S. Hispanic women. The findings will also promote positive social change by targeting U.S. Hispanic women and other minority women groups for programs that promote cervical cancer screening.

Prostate cancer is the second most often diagnosed cancer and internationally the sixth foremost cause of cancer death in males, as of 2011. Within the United States it is the most common form of cancer in men with 186,000 new cases and with an overall 28,600 deaths in 2008, and it is the second leading kind of cancer-related death in men. The widespread threat that prostate cancer poses against men across the globe cannot be understated, and its initiation and progression must be understood in order to truly comprehend its implicated risks and possible forms of treatment. As its name implies, prostate cancer is a form of cancer that develops in the prostate gland located in the male reproductive system. Its progress starts when standard semen-secreting prostate gland cells mutate into cancer cells. Although its developments may start at the prostate gland, cancer cells may metastasize to other parts of the body through circulation systems such as the lymph nodes. The main sites of metastasis for prostate cancer include the adrenal gland, the bones, the liver and the lungs. Although there are treatments available for prostate cancer, there is no definitive cure. The primary goal of this project was to find an alternative form of treatment, which is what will be necessary to combat this cancer.

Indiana University-Purdue University Indianapolis (IUPUI) / Colorectal cancer (CRC), the third leading cause of cancer-related death in the U.S., could largely be prevented if more people had polyps removed via colonoscopies. Embarrassment has been identified as one important barrier to colonoscopy, but little is known about embarrassment in this context. Further, there is no instrument available to measure this construct. Therefore, the purpose of this study was to develop a reliable and valid instrument to measure colonoscopy-related embarrassment. The study aims were to: 1) estimate reliability and validity of a new instrument, the Colonoscopy Embarrassment Scale (CES); 2) examine relationships among demographic/personal characteristics, health beliefs, and CES scores; 3) examine relationships among demographic/personal characteristics, physician recommendation, health beliefs, and colonoscopy compliance; and 4) evaluate participants’ perceptions of aspects of having a colonoscopy that are most embarrassing and their suggestions for reducing embarrassment. The Health Belief Model and Transtheoretical Model of Change provided theoretical support for this study. Participants were HMO members aged 50-65 years (n=234). Using a cross-sectional, descriptive research design, data were collected using a mailed survey. The response rate was 56%. Data were analyzed using independent samples t-tests, correlations, Chi Square, and regression. Results showed that the six-item CES had internal consistency (Cronbach’s alpha of .89) and construct validity. Lower income, higher BMI, lower CRC knowledge, higher barriers, and lower self-efficacy were related to higher CES scores (or more embarrassment). Higher CRC knowledge, lower barriers, higher self-efficacy, and a physician recommendation for the test were related to higher compliance with colonoscopy. Lower barriers, higher self-efficacy, and a physician recommendation were predictive of compliance with colonoscopy. In conclusion, embarrassment is a significant barrier to colonoscopy, yet there are steps that can be taken to reduce embarrassment such as increasing privacy and limiting bodily exposure. The CES is a tool that can be used to measure colonoscopy-related embarrassment and the results could be used in developing further interventions to reduce embarrassment, leading to increased colonoscopies and lower mortality.

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