Integrated access to cancer screening: expanding access for cervical and colorectal cancer screening in rural and remote Northern Alberta, Canada using a mobile service to bring cancer screening closer to home

Abstract

Background

The goal of the Integrated Access to Cancer Screening (IACS) initiative was to help reduce the disparity in cancer screening participation across Alberta by implementing an integrated mobile service delivery model for breast, cervical, and colorectal cancer screening in rural and remote communities in Northern Alberta, performed by Nurse Practitioners (NPs) that addressed barriers to access. The aim of this study was to evaluate the outcomes and impact the IACS initiative had on the communities and residents of Northern Alberta. This article describes the initiative design, implementation, outcomes, and impact of the initiative.

Methods

The IACS model was implemented in a total of 36 visited communities in Northern Alberta from December 2020 to December 2021. The impact of the IACS initiative was measured using a mixed methods approach. The participation rate, cancer screening overdue status, and connection to a PCP were assessed using quantitative data collected through the existing clinical information system. Patient and provider feedback were collected from opened-ended surveys, and all data was analyzed by the research team. This study evaluated the impact the IACS initiative had on patient cancer screening participation and cancer screening knowledge, addressing known barriers to service delivery in rural and remote Northern Alberta, and to understand how this service might be sustained for future operation.

Results

Six hundred fifty-three people participated in screening offered through the IACS initiative. 99% of Pap screenings offered to patients were accepted, and 98% of FIT kits were accepted from the NPs, with a completion rate of 84%. The clinical data and survey responses from patients and providers indicated support for sustaining the IACS initiative. The IACS model of screening was favoured by most female patients. It also increased screening uptake in the communities we visited in the North Zone of Alberta, where screening rates are low.

Conclusion

These findings highlight that the IACS initiative was well-received and brought value to underserved communities in Northern Alberta. The IACS model effectively facilitated screening for those who were overdue or have never been screened before. The reach of the IACS model was broader than anticipated, with those who are attached to a PCP also finding the integrated mobile screening model beneficial, bringing the services closer to home.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-12392-7.

Background

Cancer screening remains an important tool for detecting breast, cervical, and colorectal cancers early, when treatment works best [1, 2]. In Alberta, Canada, organized cancer screening programs exist for breast, cervical, and colorectal cancer screening. Despite the wide reach of screening programs in Alberta, disparities in cancer screening exist among sub-populations [3]. Close to one-fifth of the population in Alberta lives rurally (16%), where participation rates are typically lower than the general population. For example, participation rates for breast, cervical, and colorectal cancer screening in the North Zone of Alberta were 57.3% (2018–2019), 56.2% (2017–2019), and 51.3% (2018–2019), compared to 65.2%, 63.6%, and 55.7%, respectively across the entire province (AHS internal data).

The IACS initiative aspired to remove barriers and improve access to cervical and colorectal cancer screening services for people living in rural and remote Northern Alberta by raising awareness about and promoting cervical and colorectal cancer screening services in these communities while encouraging those who were unscreened and overdue to take part in the mobile screening clinics. The objectives of the evaluation were to understand how this approach: influenced the target population in terms of participation and knowledge; addressed known limitations of service delivery in rural and remote Northern Alberta; might be sustained for future operation.

The factors influencing cancer screening participation are complex and multifaceted, encompassing patient, provider, and health-system levels [4, 5]. Notably, rural areas in Canada and worldwide exhibit lower screening rates [6–8]. Structural barriers include access to timely cancer screening services due to the geographic distance of these Northern communities from clinics and health care providers (HCPs), and low numbers of primary care attachments (AHS internal data, 2016–2018) [9, 10]. In addition, there also exist psychosocial barriers, including health literacy and health knowledge, which tend to be lower among residents in rural and remote communities and preferences from female patients for female HCPs in screening, especially for breast and cervical cancers [11].

In 1991, a mobile mammography service, known as Screen Test (ST), was implemented to facilitate breast cancer screening in rural Alberta. This program provides access to screening mammography by visiting 120 rural communities throughout the province each year. However, the program does not offer screening for cervical or colorectal cancers. This gap has meant that many living in Northern Alberta would still need to travel to access primary care providers (PCPs) for these services. From 2013 to 2015, AHS implemented a pilot: the ‘Enhanced Access to Cancer Screening’ (EACS) initiative. The EACS pilot added cervical and colorectal cancer screening to ST’s mobile mammography services by utilizing dedicated public health nurses from the local communities to complement the travelling clinics. EACS served 28 communities and screened 697 patients, of which 117 had multiple screenings. The results showed promise, indicating an increase in the overall utilization of cervical and colorectal cancer screening among patients from rural and remote communities in Northern Alberta, where EACS was implemented, compared to those communities that received standard mobile mammography services [10]. However, there were several limitations to the EACS model, including administrative barriers, capacity for cancer screening in local communities, lack of facilitated follow-up, and continuity of care.

This pilot, entitled the Integrated Access to Cancer Screening (IACS) initiative, built upon the learnings from the previous pilot (EACS), addressed several of its limitations, and used the infrastructure of ST for booking patients and scheduling community visits. For example, the IACS initiative added a community mobilization coordinator to facilitate the communication process through local knowledge and relationships in the communities to be visited by the IACS. The IACS initiative also introduced dedicated female Nurse Practitioners (NPs) to ST team. ST performed screening mammography as they always have, however, with the addition of NP led cervical and colorectal cancer screening services, the ST service delivery model was modified and streamlined by allowing patients to bypass a visit to a PCP to get a referral to screening and to facilitate diagnostic follow-up if needed. This was an important addition as there is data suggesting that about 15% of Albertans do not have a PCP [12] — a well-known systemic barrier to screening. In Canada, the NP role has been in place for about two decades. NPs in Alberta are registered nurses with advanced education and training who play a key role in the province’s primary health care system. They are regulated by the College and Association of Registered Nurses of Alberta [13]. NPs can assess, diagnose, and treat a range of health conditions and minor injuries. They can also order and interpret diagnostic tests, prescribe medications, and make referrals to specialists [14]. NPs are well-positioned to provide high-quality care and fill the primary care service gap in cancer screening access, given their expanded scope of practice and holistic approach; they are highly utilized in the health care system.

Methods

The intervention

From December 2020 to December 2021, Alberta Health Services (AHS) Screening Programs operated the Integrated Alberta Cancer Screening (IACS) initiative, offering multiservice cancer screenings in rural and remote Northern Alberta communities using the established ST mobile mammography service delivery model, with the addition of female NPs who provided cervical and colorectal cancer screening (Pap tests and Fecal Immunochemical Test [FIT] kits), while the mobile mammography service team conducted mammograms. The IACS model further streamlined the screening process by allowing patients to book all appointments through the existing ST toll-free number, reducing the need for multiple bookings.

A community mobilization coordinator worked with local partners and primary care groups to promote the service and schedule appointments, using communication methods like social media, newsletters, and face-to-face meetings. The IACS initiative also provided a clear engagement plan to ensure consistency and success across communities. Detailed records of all correspondence were kept, ensuring consistency and applying lessons learned from one community to another. A visual of the process pathway (Fig. 1) briefly describes the key actions required to implement the IACS initiative.

Fig. 1.

The actions required to implement the IACS initiative are described in the process pathway

During the clinic visits, the ST mammography technologists performed screening mammography on the mobile unit while the NPs offered cervical and colorectal screening to eligible patients in a clinic space close to the location of the mammography trailer. Complications of the COVID-19 pandemic hindered NPs’ access to space; however, the North Zone administration accommodated IACS sites in many local facilities. In a few instances, the ST mobile unit and the IACS clinic locations did not coincide, and as a result, the NPs held the clinics separately.

Setting

IACS clinics were scheduled in conjunction with the mobile mammography service’s visits. Local PCPs were notified, and patients received information through reminder letters and community promotions. The mobile service visited 36 communities in the North Zone (Fig. 2) and served numerous adjacent communities making the screening process more accessible to residents of the rural and remote Northern Alberta.

Fig. 2.

This map of Alberta depicts the 36 IACS clinic locations as white dots within the North Zone of AHS as indicated in black

Target population

Participants were eligible for cervical and colorectal cancer screening based on Alberta’s Clinical Practice Guidelines: Pap tests for those aged 25–69 (every three years) and FIT tests for those aged 50–74 (every 1–2 years). While men were eligible for colorectal screening, the initiative focused primarily on recruiting those eligible for mammography.

Recruitment

Existing ST patients were notified of IACS when they received their reminder letter. When patients called to book a mammography appointment, they were offered an appointment with the NP for the additional screenings for which they were eligible.

Data sources

The research team used a mixed-methods approach for data collection. Quantitative data collected through the AHS clinical information system – Meditech. This system allowed the team to pull reports on who was seen, assess their eligibility, and determine the screening test(s) provided, the screening results, and the follow-up clinical services provided. Netcare was used to obtain the dates that individuals were last screened (provided it was completed in Alberta), to understand who was overdue for breast, cervical, and colorectal cancer screening.

Patient and provider information was gathered using qualitative data collected via open-ended patient and provider surveys that were developed specifically for the IACS initiative and implemented through the survey platform, SelectSurvey [see additional files 1 and 2]. Following each clinic, a debrief report was circulated to local HCPs involved in the IACS initiative and included an invite to the feedback survey developed for the IACS initiative with an accompanying SelectSurvey link in which providers selected themselves for participation in the feedback survey. Patient surveys gathered information on the clinic experience, while provider surveys focused on the effectiveness of the initiative.

Variables

Objectives of the evaluation

The primary objectives of this evaluation were to: (1) assess the impact of the integrated approach on the target population in terms of participation and knowledge; (2) address known limitations of service delivery in rural and remote Northern Alberta; and (3) understand the sustainability of this approach for future operations.

Screening participation

Screening participation was defined as the occurrence of no-shows and eligible multiscreen participants. It was measured by calculating the ratio of completed appointments to booked appointments, using data from the IACS booking system and NP clinic records.

Patient knowledge

Patient knowledge was defined as the change in patients' understanding of cancer screening after attending the IACS clinic. This variable was measured using Likert scale responses from the IACS patient feedback survey.

Addressing service delivery limitations

Addressing known limitations of service delivery in rural and remote Northern Alberta was defined as the ability of the IACS service delivery model to identify and address barriers to access. This variable was measured using responses from patient and healthcare provider (HCP) feedback surveys.

Sustainability

Sustainability was defined as the level of support for the continued operation and funding of the integrated, NP-led service delivery model in rural and remote Northern Alberta. This variable was measured using responses from patient and HCP feedback surveys.

Data analysis

Quantitative data was analyzed using MS Excel, while qualitative data underwent thematic analysis with NVivo.

To determine the ethical risk of this initiative, a Project Ethics Community Consensus Initiative (ARECCI), [15] an online ethics screening tool was applied. This tool is widely accepted across Alberta and in many jurisdictions across Canada as a pre-curser to health projects and initiatives where the decision is made to whether a formal ethics review is required or not. As a result of the ARECCI assessment, it was determined that the IACS initiative carried minimal risks, thus an institutional review board ethics approval was not required. Informed consent was obtained from all individual participants included in the study.

Results

Main findings

• Patients were thrilled to have services come to their communities. • Some reported difficulty getting appointments with their local physicians and long wait times. • The inability to find female physicians or physicians they did not work with or attend gatherings with was a barrier to screening in rural/remote communities. • Many women told us they would have signed up their husbands for FIT had they known that men could go. Instead, many assumed it was just for patients getting mammograms because IACS was booked through Screen Test’s mobile mammography services. • Over 80% of patients were overdue for cervical and/or colorectal cancer screening or had never been screened. • 90% of survey respondents felt their understanding of cancer screening improved because of IACS. • 59% revealed they learned of the clinics from their mammography screening reminder letters. • 100% of health care providers felt that these integrated screening clinics should be sustained in their community. • 100% of health care providers believe these integrated screening clinics benefit their community. • 98% of patients stated they would participate in this type of integrated screening clinic.

Quantitative

Over the 13 months the IACS initiative was implemented, 720 patients registered for screening clinics and 653 patients were seen. Clinics took place in 36 locations reaching residents in 156 different communities, including 20 Indigenous communities. There were 66 people who did not show for their appointments.

Of the 653 patients screened through IACS, 99% identified as female (n = 650) and 1% identified as male (n = 4). The average age of patients was 56 years, which was in the target age range for all three screening programs. The youngest age of patients seen was 25 and the oldest age was 74. Age trends between the sexes were unable to be determined as there were few male patients who participated in the clinics. Table 1 provides the number of IACS participants seen across different age groups through the duration of the initiative.

Table 1.

Age range of patients who took part in the IACS initiative

Age of IACs participants	Number of participants
25–35	29
36–45	54
46–55	149
56–65	264
66–74	100
Total #	653

Primary care attachment

IACS accepted people regardless of their attachment to a PCP. We anticipated that most participants of IACS would not have a PCP because they are the most underscreened population. However, most (78%) IACS participants were attached to a PCP, as stated on their intake with the NP.

Cervical cancer screening participation

84% (n = 550) of patients who attended the IACS clinics were eligible (overdue or never screened) for cervical cancer screening and were offered Pap tests. The NPs performed 546 Pap tests; the remaining 4 participants decided not to participate in cervical screening.

Overdue for cervical cancer screening

Those who had not had a Pap test in the past 36 months were considered overdue for screening according to the Alberta Cervical Cancer Screening Program guidelines (allowing for a 6-month leeway in screening eligibility where patients can be screened before they are overdue). Of those who were screened for cervical cancer (n = 546), 79% were overdue (n = 433), 2% (n = 9) had never been screened, and 9% (n = 104) were screened appropriately but were not overdue. Five of the nine patients who had never been screened upon attending the IACS clinic were newly eligible (ages 25 and 26), while the remaining four were between ages 54 and 60. All nine overdue had a 100% acceptance rate and normal results.

Out of the 653 patients screened, 97% (n = 527) had a normal result, 3% (n = 18) had an abnormal result, and only a single patient (< 1%) had an unsatisfactory result. Results were communicated to both patient and provider through mail. Patients with an abnormal result were referred for colposcopy—continuing through the screening pathway as appropriate with a local health care provider – either one the patient was already attached to or another local PCP.

Colorectal cancer screening participation

In total, 317 patients attended the IACS clinics and were eligible (overdue or never screened) for colorectal cancer screening and thus were offered a FIT by the NPs. This accounted for almost half of all patients (48%). Overall, 98% (n = 312) of FIT kits offered were accepted/dispensed by the NPs, and 263 FITs were completed, indicating an 84% completion rate. The completion rate is noteworthy because they got up to three reminder calls contributing to such high return rates.

Overdue for colorectal cancer screening

Everyone who is at average risk and had not completed a FIT in the past 24 months or colonoscopy in the past 10 years was considered overdue for colorectal cancer screening according to the Alberta Colorectal Cancer Screening Program guidelines, 53% (n = 178) of people were overdue for colorectal cancer screening, and 37% (n = 96) had never been screened for colorectal cancer. These numbers validated the need of the IACS initiative because there were so many people in rural Alberta who had never been screened for colorectal cancer.

Out of the 312 FIT kits that were offered, 92% (n = 241) had a normal result, and 8% (n = 22) had an abnormal result. Results were communicated to both patient and provider through mail. Patients with an abnormal result were referred for colonoscopy through their local PCP or through another local provider – continuing through the screening pathway as appropriate.

Multi-screen appointments

When eligible, most patients (76%, n = 497) elected to screen for cervical cancer, colorectal cancer, or both following their mammogram during the IACS clinics.

Patient survey participation

• 88% (n = 575/653) of all patients agreed to participate in a feedback survey.

• 61% (n = 398/653) of IACS patients completed the survey (online or mailed back to screening programs)

• 79% (n = 229/291) return rate for paper surveys

• 60% (n = 169) return rate for electronic survey

Qualitative findings: patient surveys

Based on open-ended survey responses, various themes emerged regarding the benefits of the IACS clinics. The two most prominent themes were as follows: eliminating barriers to accessing screening and preference for female HCPs. Other themes which emerged included positive experiences with staff, and simplicity of IACS services.

Patients who participated in the survey were asked what influenced their decision to book their cervical and/or colorectal cancer screening with the IACS initiative. In total, 386 survey participants responded to this question, with some giving more than one reason as to why they booked, for a total of 417 responses. The most common reason provided was they were due or overdue for screening with 40% (n = 168), followed by the ease of access and convenience of the services (21%, n = 88), then the reason of integrated access, meaning they could be screened for more than one cancer in one stop (13%, n = 54).

When asked, 98% (n = 373) of patients reported they would participate in this integrated screening clinic again, and 235 provided reasons for this. The most common reason reported by 62% (n = 145) of participants was the convenience of the screening services, including how easy it was to book. This was followed by the fact that the NPs were female (18%), the option for integrated screening services (15%), and finally because they had no family doctor (5%).

Barriers to Access (n = 192)

It was noted that patients had difficulty rearranging their lives to get to the closest city or community for screening and that simply finding an HCP is frustrating for rural and remote communities. For example, in Fairview, a community in Northern Alberta, only 69% of residents have a family doctor (well below the provincial average of 87%).

“This was great that I didn't have to travel 2 1/2 h one way for an appointment. Being I did all 3 screenings which would of taken 3 days, only took 1 h of my time, which is awesome!” – IACS Patient

“Please continue this valuable rural screening. It helps those who cannot travel and gives anonymity in rural settings. Thank you for coming to town!!” – IACS Patient

Preference for Female HCPs (n = 43)

Forty-three women reported not having Pap tests for 20–30 years as they had male physicians and did not want to be screened by a male.

“I felt comfortable talking to you and I’m glad you’re a female.” – IACS patient

“I never did a Pap as I always had a male doctor and didn’t feel comfortable.” – IACS patient

In addition, there were over 200 positive comments regarding the IACS clinics. Appreciation for the staff (32%, n = 74), the services (28%, n = 65), and the simplicity of the process (10%, n = 23) was shared by survey participants, in addition to the understanding of the benefits integrated screening brings to rural areas (12%, n = 29), and the stated desire for the travelling IACS clinics to continue (18%, n = 43).

“I hope this continues, as so many patients have difficulty retaining a family physician, and appointments during regular working hours are not always ready to attend if you have to take off work. The flexible hours, easy access, and knowledgeable practitioners make this a great program which will benefit many.” – IACS Patient.

“This is a great program for women who don't have a gyno and in a smaller community, you don't want your male GP doing it and then meeting him on the street the next day. That is just very embarrassing. This screening is done by a woman and I'm so much more comfortable with that. I hope this is a yearly event and it will help so many women.” – IACS Patient.

Patients who participated in the patient feedback survey could share final comments; 60% (n = 139) of the comments showed appreciation: 32% for the staff who helped them along their screening journey and 28% appreciated the integrated screening services offered.

“Unfortunately, I got lazy and didn't do my FIT test when my doctor gave it to me. Have the Nurse Practitioner keeping watch over whether or not I have done my FIT test has been an incentive to do my FIT test! Many friends have recently got bowel cancer, and they discovered it by a FIT test! Had breast cancer 4 1/2 years ago, and it was through government AHS program/mammogram screening that I found I had cancer.” – IACS Patient.

HCP surveys

A debrief email report after each clinic went to each community administrator, which included a link directing them to the HCP feedback survey. HCPs who participated in the survey (n = 32) identified as registered nurses (28%, n = 9), administrative staff (28%, n = 9), physicians (12%, n = 4), or other (31%, n = 10, e.g., health promotion, LPN, manager, etc.). The HCPs survey’s main themes included that the convenience of the clinic (minimal travel) and shortages of PCPs, predominantly female physicians, were the main benefits of the integrated mobile screening; in addition, the screening was used by more people than expected, including those who have primary care attachment.

When HCPs were asked if they thought the IACS clinic in their community allowed for increased access to cancer screening, 25 (93%) responded that it did, and two participants were indifferent. It was mentioned by these HCPs that the clinics were very popular in some communities and filled up quickly and therefore many were unable to book an appointment. When prompted for reasons why the clinics increased access, several reasons were revealed: almost half (46%, n = 5) of the responses indicated the convenience of the clinics coming right to the community, followed by the shortage of physicians in rural areas (35%, n = 4), and finally the presence of the female practitioners connected with the IACS clinics (18%, n = 2) all contributed to the increased access to integrated screening for their community members.

Regarding their perspectives of the benefits of integrated screening, 97% (n = 29) felt that IACS was a benefit to their community due to the fact that travel was minimal (44%, n = 27), access to physicians in their communities is limited (26%, n = 7), clinics were multiservice screening opportunities (19%, n = 5), and the HCPs were female (11%, n = 3).

“Finding a family physician in this area is very difficult, and it is even harder to find a female one. Having the clinic helped remove the barrier to not getting a Pap done because of lack of family Dr and lack of female Dr for those who are not comfortable with a male performing such an invasive procedure.” – Health care provider.

HCPs were provided with a final opportunity to share any final comments about the integrated screening clinics, with most responses showing appreciation for the services coming to their communities (45%, n = 10), followed by the sentiment that the clinics are beneficial to rural and remote communities (32%, n = 7). Additional comments appealed for the services to continue (14%, n = 3).

“This type of clinic in all rural communities is a great screening tool as well as a terrific way to teach individuals about the importance of screening and early detection. I do feel the bus and the IACS clinic should be twice a year to a lot of rural communities.” – Health care provider.

Discussion

The introduction of this mobile service delivery model for cancer screening allowed for a streamlined screening process and gave autonomy to the NPs whose scope of practice ranged from performing risk assessment and eligibility for screening, performing the screen, discussing the results, and providing a referral if diagnostic follow-up was needed. Adding an NP increased the efficiency of the screening pathway and provided continuity of care. Previous research has shown that integrating NPs into cancer screening increases participation of under screened patients by removing barriers to screening (e.g., rural and remote environments, minorities, female care providers, no access to regular HCP, lack of education and awareness) [16, 17]. In addition, NPs providing care via mobile clinics provide on-the-spot primary cancer care for people in underserved communities [16, 18].

IACS was not designed to replace local primary care services but to complement what is available in rural and remote communities, allowing overburdened HCPs to focus on the more urgent needs of their patients. It was unexpected that 78% of patients would be attached to a PCP and yet participate in cancer screening services from the IACS initiative; this suggests the integrated model was appealing to those who have successfully navigated the system, have primary care attachment, and had been screened in the past, while also reaching those who have never been screened. As a participant noted in her survey response, it is time-saving and appropriate even for the “well-educated” and “health-conscious” women living in rural areas of Alberta. It cuts down travel time, time off work, the expense of travelling to out-of-town screening appointments, and arranging childcare. It also reduces the likelihood of running into those who screened you in social settings, which can be embarrassing for some due to the sensitive nature of the screenings for breast, cervical, and colorectal cancers.

IACS enhanced effectiveness with a streamlined screening process for both patients and the health care system for those participating in the initiative; Introducing a dedicated community mobilization coordinator created greater organization of the program, freeing up other HCPs from administrative tasks and improving engagement with screening through the relationships built in the community. Having three screens completed in one location at one time eliminated the need for three separate appointments. The commitment to screening was reflected in the low incidence of no-shows and cancellations; No-shows and cancellations were few overall, with 30 and 38, respectively, indicating that more than 90% of registered patients attended the clinic. In addition, the convenience of the multi-screen appointment was utilized by 76% of patients choosing to have a multi-screen appointment (Pap/FIT/mammogram).

The convenience of screening highlights the practicality of integrated screening for three cancers for everyone living in rural and remote regions of Alberta. It is an important addition to the community, not only to the most underscreened, but to everyone eligible. Overall, this innovative approach to cancer screening utilizing NPs within a mobile service delivery framework, resulted in an increase in screening uptake in participating communities in the North Zone of Alberta. If implemented in consultation with local advisors, it has the potential to positively influence cancer screening behaviors in similar regions within Alberta, Canada, and beyond, especially amongst those who are vulnerable to low screening rates due to barriers of access [6, 19]. Integrated screening is a benefit to patients based on the results presented, and its potential impact on the larger healthcare system should not be overlooked.

Limitations

The limitations of the IACS initiative are primarily due to its short duration. As a one-year pilot initiative, it was not possible to assess the long-term impact on participation rates in Northern Alberta. The initiative's reliance on mammography as the entry point for integrated screening meant it was more likely to engage female patients for breast and cervical screening, even though the FIT test was available to all sexes of average risk. Only four of the 653 patients who attended the IACS clinics were male. Improved community communication and media messaging has potential to create an integrated mobile screening clinic suitable for everyone. Survey responses indicated that women did not encourage their male spouses to attend the IACS clinic, believing it was only for those getting mammograms. The high number of people in rural Alberta who have never been screened for colorectal cancer underscores the importance of marketing this service to all sexes.

The COVID-19 pandemic presented additional challenges. Government restrictions required the IACS initiative to be flexible, leading to unforeseen issues such as difficulty securing space in rural facilities due to COVID-19 testing and vaccine clinics. Many health services staff were redeployed or had competing priorities, complicating local coordination. From a patient perspective, there were cancellations due to COVID-19 symptoms and anecdotal reports of patients being reluctant to visit healthcare facilities for cancer screening due to the virus.

Conclusions

Despite these limitations, the results showed the benefits of the program and an appreciation from the patients accessing the care and benefits to the health care system. The IACS clinics brought preventative care closer to home for patients with limited access, especially those living in rural and remote locations in Northern Alberta.

Using an IACS model demonstrates an effective way to address barriers to cancer screening in rural and remote areas, such as geography (lack of services locally), number of people unattached to a PCP, and the preference for female physicians. The IACS initiative expanded upon work from the EACS pilot to deliver cervical and colorectal cancer screening to Albertans who may have otherwise not had access. The initiative demonstrated that there is an interest in the integrated service and that it facilitates screening for those who are overdue or have never been screened before. These results illustrate the need for such programs and show evidence that they serve everyone, including but not limited to those lacking screening the most, thereby maximizing the potential benefits of screening. Feedback about the program showed that it was both desired and utilized by community members and HCPs, with requests for future IACS clinics being received after the initiative had wrapped. Health care systems looking to utilize a similar model should consider the long-term viability of such an initiative because of its potential effectiveness in increasing cancer screening in rural and remote communities by addressing barriers to access.

Abbreviations

AHS

Alberta Health Services

COVID-19

Coronavirus disease 2019

EACS

Enhancing Access to Cancer Screening

FIT

Fecal immunochemical test

HCP

Health care provider

IACS

Integrated Access to Cancer Screening

NP

Nurse practitioner

PCP

Primary care provider

ST

Screen test

Authors’ contributions

JW prepared the initial draft of this manuscript, she was involved in designing the methodology, collecting, and analyzing the data. KP was the project lead for the IACS initiative, from the grant proposal, through implementation and analysis. KP managed all human and financial resources associated with IACS and contributed to the writing of the manuscript. GK created the Cervical and Colorectal care pathways and was involved in operationalizing the project grant with ongoing consultation to the nurse practitioners as they were new to cancer screening and required support with Colposcopy referrals. GK assisted in addressing the triage of positive cervical screens and was also responsible for pulling the quantitative data from MediTech. Finally, GK co-wrote the section in the journal article pertaining to the Nurse Practitioner roles in the project. MM was the Community Mobilization Coordinator for the IACS initiative and strengthened relationships with Northern Alberta communities and coordinated each of the screening initiatives. SMP, JN, and SL were involved in writing of the manuscript. JH supported the design of the IACS initiative particularly where the project aligned with Screen Test processes and workflows. JH oversaw all processes for recruiting patients and scheduling community visits. MS oversaw the IACS initiative as a director of Screening programs. HY was the Principal Investigator of the IACS initiative. All authors reviewed the manuscript.

Funding

The initiative was funded by Alberta Innovates through the Cancer Screening Research and Innovation Opportunity grant.

Data availability

The data used in this paper is available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

To determine the ethical risk of this initiative, a Project Ethics Community Consensus Initiative (ARECCI),(15) an online decision-support tool was applied. This tool is widely accepted across Alberta and in many jurisdictions across Canada as a pre-curser to health projects and initiatives where the decision is made to whether a formal ethics review is required or not. As a result of the ARECCI assessment, it was determined that the IACS initiative carried minimal risks, thus an institutional review board ethics approval was not required.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.