Background: This thesis is composed of three studies testing the effect of the Colon Cancer Check (CCC) program, the organized screening program for colorectal cancer in Ontario, on screening participation. In the first paper, we described the trends of participation to Fecal Occult Blood Test (FOBT) and endoscopy, and the trend of ‘up-to-date’ consistent with guidelines, overall and stratified by demographic characteristics between 2005 and 2011. In the second paper, we tested the effect of physician’s recommendation on FOBT participation and disparities in participation. In the third paper, we measured the effect of the CCC program on FOBT participation using an interrupted time series. Methods: We identified six annual cohorts of individuals eligible for CRC screening in Ontario between 2005 and 2011 by linking the Registered Persons Database to Ontario Health Insurance Plan and 2006 Census from Statistics Canada. We used descriptive statistics to describe the trends of participation. The effect of physician’s recommendation on screening participation was tested using multiple logistic regression analysis. The effect of the CCC program on FOBT participation was tested using segmented regression analysis. Results: An increasing trend in FOBT participation and ‘up-to-date’ status was observed across all demographic characteristics. The disparity gaps persisted over time by gender, income, recent registrant and age. The rural/urban gap was removed. Physician’s recommendation tripled the likelihood of FOBT participation (prevalence rate ratio=3.23, CI= 3.22-3.24) and mitigated disparities. The CCC led to a temporary increase in level (8.2‰ person-month) in FOBT participation followed by a decline in trend and then a plateau. The increase in level was significant across all population sub-groups. Conclusions: We found that CRC screening has increased in Ontario across all subgroups of the population but remained suboptimal. Disparities in screening participation were identified. Proposed strategies to improve performance include interventions to increase the rate of physician’s recommendation at the practice level, tailored interventions to motivate under-users and public media campaigns.

Background: This thesis is composed of three studies testing the effect of the Colon Cancer Check (CCC) program, the organized screening program for colorectal cancer in Ontario, on screening participation. In the first paper, we described the trends of participation to Fecal Occult Blood Test (FOBT) and endoscopy, and the trend of ‘up-to-date’ consistent with guidelines, overall and stratified by demographic characteristics between 2005 and 2011. In the second paper, we tested the effect of physician’s recommendation on FOBT participation and disparities in participation. In the third paper, we measured the effect of the CCC program on FOBT participation using an interrupted time series. Methods: We identified six annual cohorts of individuals eligible for CRC screening in Ontario between 2005 and 2011 by linking the Registered Persons Database to Ontario Health Insurance Plan and 2006 Census from Statistics Canada. We used descriptive statistics to describe the trends of participation. The effect of physician’s recommendation on screening participation was tested using multiple logistic regression analysis. The effect of the CCC program on FOBT participation was tested using segmented regression analysis. Results: An increasing trend in FOBT participation and ‘up-to-date’ status was observed across all demographic characteristics. The disparity gaps persisted over time by gender, income, recent registrant and age. The rural/urban gap was removed. Physician’s recommendation tripled the likelihood of FOBT participation (prevalence rate ratio=3.23, CI= 3.22-3.24) and mitigated disparities. The CCC led to a temporary increase in level (8.2‰ person-month) in FOBT participation followed by a decline in trend and then a plateau. The increase in level was significant across all population sub-groups. Conclusions: We found that CRC screening has increased in Ontario across all subgroups of the population but remained suboptimal. Disparities in screening participation were identified. Proposed strategies to improve performance include interventions to increase the rate of physician’s recommendation at the practice level, tailored interventions to motivate under-users and public media campaigns.

Colorectal rectal cancer (CRC) is the 3rd most common cancer in men, the 2nd most common cancer in women, and the 4th leading cause of cancer death. Lack of screening or delayed screening for CRC is the major cause of undiagnosed cancers that become malignant and eventually become fatal. Nurses at the project site are not in compliance with CRC screening guidelines due to inadequate knowledge of the screening guidelines recommended by the American Cancer Society, which creates a gap in practice. The purpose of this project was to develop staff education on CRC screening guidelines. The practice focused question addressed if evidence-based education regarding CRC screening could be an effective means for nurse education, according to a panel of local experts. A pre-test evaluation of knowledge regarding CRC screening was administered to nursing staff from the site. The John Hopkins evidence-based practice model guided the development of the staff education program, using the results of the pre-test, evidence-based practice literature and guidelines. The project team, consisting of a physician and medical support staff, evaluated the education program, plan for delivery, and plan for evaluation of learning through an anonymous Likert-style evaluation survey. The 3 team members also completed program evaluation surveys, and 100% agreed or strongly agreed that the program objectives were met. The project was limited to planning only and the education program materials, along with plans for later implementation and evaluation of learning through pre- and post-tests, were handed over to the project site for delivery at a later date. The CRC screening education will become part of the yearly staff competencies, leading to appropriate screening of the site’s patient population. This education project has the potential to promote positive social change by saving lives and improving the quality of those lives.

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.

Colorectal cancer is a serious malignant disease with an incidence of over 1.8 million new cases per year worldwide. There are about 8 000 patients diagnosed with CRC in the Czech Republic each year, and about half of them present with an advanced disease. Screening program identifies patients in the early stages of CRC resulting in overall better prognosis and survival. There is also a lack of biomarkers of early CRC detection and of response to treatment. The first aim of our project was to conduct a national multicentre prospective observational study to evaluate the impact of CRC screening within the framework of a Czech population screening programme. Between March 2013 and September 2015, a total of 265 patients were enrolled in 12 centres across the Czech Republic. Patients were divided into screening and control groups and compared for pathology status and clinical characteristics. Screening was defined as a primary screening colonoscopy or a colonoscopy after a positive FOBT in an average-risk population. The distribution of CRC stages was significantly favourable in the screening group compared with the control group (stages 0, I and II, 63% versus 43.3%; p <0.001). The presence of distant (M1) and local metastases (N1 and N2) was significantly less prevalent in the screening group (0%,...

Indiana University-Purdue University Indianapolis (IUPUI) / Men’s adherence to masculinity norms has been implicated as a risk factor for unhealthy behaviors (e.g., drinking to intoxication, having unprotected sex with multiple, simultaneous partners) and lack of engagement in healthy behaviors (e.g., blood pressure screening, cholesterol screening, wearing protective clothing while in the sun, receipt of annual medical and dental exams) (Boman & Walker, 2010; Courtenay, 2000a, 2000b, 2011; Hammond, Matthews, & Corbie-Smith, 2010; Iwamoto, Cheng, Lee, Takamatsu, & Gordon, 2011; Locke & Mahalik, 2005; Mahalik, Lagan, & Morrison, 2006; Mahalik et al., 2003; Nicholas, 2000; Pachankis, Westmaas, & Dougherty, 2011; Pleck, Sonenstein, & Ku, 1993; Wade, 2009). Masculinity has been defined as behaviors, beliefs, and personality characteristics associated more often with men than women as well as characteristics and behaviors that society prescribes and reinforces in men (Thompson, Pleck, & Ferrera, 1992). Rooted in geographical, cultural, and temporal environments, diverse masculinities have emerged throughout the United States and the world (Connell, 1995; Courtenay, 2011). Traditional masculinity beliefs and behaviors in the United States include the sturdy oak (men should be tough, self-reliant, stoic, and confident), no sissy stuff (men should avoid feminine characteristics and behaviors), the big wheel (men should strive for success and status), and give ‘em hell (men should embrace aggressiveness, daring, and violence) (Brannon, 1976). Numerous qualitative studies have suggested that some men find cancer screening examinations involving the rectum (i.e., endoscopy for colorectal cancer [CRC] screening or digital rectal examination [DRE] for prostate cancer screening) an affront to their masculinity (see Table 1 for quotations from these studies) (Bass et al., 2011; Beeker, Kraft, Southwell, & Jorgensen, 2000; Getrich et al., 2012; Goldman, Diaz, & Kim, 2009; Harvey & Alston, 2011; Holt et al., 2009; Jilcott Pitts et al., 2013; Jones, Devers, Kuzel, & Woolf, 2010; Rivera-Ramos & Buki, 2011; Thompson, Reeder, & Abel, 2011; Wackerbarth, Peters, & Haist, 2005; Winterich et al., 2009). However, to the author’s knowledge, no quantitative studies have considered the role of masculinity in CRC screening adherence. Unfortunately, current CRC screening rates fall below the 70.5% Healthy People 2020 screening objective (U.S. Department of Health and Human Services, 2012).Research is needed to better understand relationships between men’s masculinity norms and CRC screening adherence so that interventions may be developed to reduce barriers to screening, improve screening rates, and, ultimately, decrease men’s mortality from CRC. The present study will address this gap in the literature by examining the masculinity norms and CRC screening adherence of male veterans aged 51-75 years who are at average CRC risk (Levin et al., 2008). First, the prevalence of CRC, its risk factors and warning signs as well as CRC screening techniques, screening rates, and characteristics of individuals who are adherent and non-adherent to CRC screening guidelines are summarized. Next, the concept of masculinity, theoretical and empirical support for studying masculinity norms within the context of CRC screening, and potential relationships between masculinity norms and colorectal cancer screening behaviors are described. Finally, the study methods, results, and future directions and limitations of this research are described.

Colorectal cancer (CRC) screening in the form of self-sampling enhances participation and early cancer detection. However, CRC screening participation in Sweden is marked by inequality. Moreover, individuals are relatively uninformed about screening procedures, with existing informational channels all exhibiting various limitations. Hence, this project was initiated in collaboration with KI and KTH to develop a digital decision aid for individuals called into CRC screening. This study aims to mark an initial stage of development, with the overarching goal being to improve CRC screening participation rates and support informed decision making aligned with patient values and preferences. Using an approach rooted in the shared decision-making (SDM) model, the study investigates user attitudes and preferences concerning health, digital healthcare services and cancer screening through conducting semi-structured interviews and a thematic analysis. These insights inform user requirements, which are integrated with stakeholder requirements and the current informational landscape to shape the digital decision aid’s information architecture and design. The research identifies various challenges and opportunities for the development of the digital decision aid in a Swedish context, underscoring the importance of adapting the decision aid to user needs and preferences. In subsequent stages of development, the prototype produced by this study should be evaluated through usability testing, and further user research should be conducted to generate more specific user requirements concerning visual and interactional elements.

African American (AA) men in the state of Alabama are affected by colorectal cancer (CRC) more than all other races. The purpose of this phenomenological study was to gain understanding of colorectal cancer screening health benefits in AA men in Mobile, Alabama. The health beliefs model (HBM) developed by Hochum, Rosemstock, and Kegels was used to to explore the barriers and facilitators to CRC screening in AA men with health insurance in Mobile, Alabama. The research questions explored knowledge, perceptions, and facilitators to CRC screening among AA men age 40 to 75. Participants were selected using purposive sampling and data were collected through face-to-face individual interviews with 13 participants living in Mobile, Al. Data were inductively coded and subjected to a thematic analysis procedure. The study findings revealed that participants had a general knowledge of cancer but a low awareness of CRC screening. Findings also revealed a perceived gap in CRC screening education from participants' doctors. Few reported understanding or remembering a conversation about the need for CRC screening during their last doctor's visit. There was no indication that age or level of education played a meaningful role in participants' knowledge or perception of CRC screening requirements. Positive social change implications stemming from this study include recommendations to Alabama public health officials and policy makers to invest in the development of intervention and education efforts to increase CRC screening among AA men, which in turn, may reduce CRC related morbidity and mortality.

Dans quelle mesure le concept de genre constitue-t-il une clé de lecture pertinente aux rapports entre dynamiques territoriales et dynamiques sanitaires ? Cette thèse propose de répondre à cette interrogation en analysant la participation au dépistage organisé du cancer colorectal et sa promotion dans les Hauts-de-Seine (92). Les villes de Boulogne-Billancourt et de Gennevilliers, ainsi que deux quartiers populaires de chacune d’elles sont comparés à partir de données quantitatives (taux de participation au dépistage) et qualitatives (observations, entretiens semi-directifs). Il apparaît que les disparités spatiales (inter ou infra-communale) et sexuées de participation au dépistage du cancer colorectal se déclinent différemment selon les territoires étudiés et ne reflètent pas l’inégale répartition spatiale des classes sociales. L’analyse des trajectoires de recours au médecin généraliste, acteur clé du programme, révèle des représentations et pratiques territoriales spécifiques aux contextes gennevillois et boulonnais, mais aussi aux hommes et aux femmes de ces espaces. L’étude de la promotion de ce dépistage permet de mieux comprendre les modes d’organisations et de développement des communes et quartiers ciblés (types et réseaux d’acteurs politiques, professionnels ou associatifs). Elle révèle également la nécessité de prendre en compte le genre dans l’analyse des déclinaisons locales d’une politique nationale de santé publique. Enfin, les représentations et les pratiques des médecins généralistes s’ancrent dans des parcours professionnels, des normes sociales dominantes et des dynamiques territoriales originales. / To which extent does the concept of gender can be a strategic concept to understand links between health and territorial dynamics? The following study aims to investigate this topic by analyzing the attendance at colorectal cancer screening sessions and its promotion in the Hauts-de-Seine (Paris region). We draw a comparison between the towns of Boulogne-Billancourt and Gennevilliers, and two of their popular districts, based on quantitative (attendance rates to screening sessions) and qualitative data (observations, semi-directive interviews). Among the findings, it appears that spatial and gendered disparities regarding colorectal cancer screening vary depending on the places studied and do not reflect the unequal distribution of social classes. The analysis of health-seeking behaviors to a general practitioner – a key actor of this screening program – highlights spatial representations and practices which are specific to the contexts in Boulogne-Billancourt and in Gennevilliers, as well as to women and men. The study of the promotion of colorectal cancer screening also enables us to better understand the ways these towns and districts are developed and organized (type and network of political, professional and associative stakeholders). In addition, the study stresses on the necessity to take gender into account when it comes to the analysis of local implementations of a national public health policy. Lastly, professional backgrounds, dominant social norms and spatial dynamics are an integral part of general practitioner’s representations and practices.

L’objectif de ce travail est d'explorer et comprendre les principaux freins et leviers psychologiques à la démarche de dépistage du cancer colorectal (CCR) par Hemoccult-II®. Plus particulièrement, nous cherchons à préciser le rôle spécifique du concept d’anxiété envers la santé dans le processus qui conduit à prendre la décision de participer au dépistage du CCR.Une étude qualitative exploratoire basée sur la méthodologie des focus groups, suivie d’une étude quantitative ont été menées auprès d’individus âgés de 50 à 74 ans, ayant un risque moyen de développer un CCR. Les individus ayant déjà participé au dépistage ont de meilleures connaissances concernant le test Hemoccult-II®, surestiment davantage les leviers envers le test Hemoccult-II®, sont plus anxieux envers la santé, et mobilisent davantage de stratégies d’ajustement de type vigilant que les individus n’ayant jamais participé au dépistage. Les principaux prédicteurs de la participation au dépistage du CCR sont le degré de connaissances envers le dépistage du CCR, la surestimation des leviers au test Hemoccult-II®, la peur de la maladie et les stratégies d’ajustement de type vigilant.Ces résultats suggèrent que certains facteurs psychologiques, dont l’anxiété envers la santé, jouent un rôle essentiel dans la participation au dépistage du CCR par Hemoccult-II®. / The aim of this study is to investigate and to understand the main psychological barriers to and facilitators of colorectal cancer screening (CRC) by Hemoccult-II®. More specifically, we try to clarify the specific role of the concept of health anxiety in the decision making process which influences participation in CRC screening.An exploratory qualitative study, based on the methodology of focus groups, followed by a forward-looking quantitative study were led with people from 50 to 74 years old, with an average risk of developing a CRC. People having already participated to CRC screening have better knowledge about the Hemoccult-II® test, overestimate facilitators of the Hemoccult-II® test, are more anxious about health, and use more monitoring coping strategies than individuals having never participated to CRC screening. Main predictors of the participation to CRC screening are knowledge about CRC screening, overestimation of facilitators of Hemoccult-II® test, fear of disease and monitoring coping strategies.Results suggest that psychological factors, including health anxiety, play an important role in the participation in CRC screening by Hemoccult-II®.