Strengthening preventive cancer screening in Northern Ontario, Canada: Structural supports and systemic barriers with the all nations health partners Ontario health team

Abstract

Objective

Northern Ontario populations experience significant health disparities, particularly in rural and remote areas. This study examined the supports and barriers to preventive health care services, specifically cancer screening, in the Kenora, Ontario, Canada, All Nations Health Partners Ontario Health Team (ANHP OHT).

Methods

Participants included project team members, administrators, program leads, and clinicians from organizations involved in the planning, delivery, and reporting of cancer screening, recruited through purposive and snowball sampling. Data were collected in Kenora, ON, Canada, between July & August 2023. Interviews were transcribed and thematically coded.

Results

Four key themes emerged: (1) healthcare data integration, emphasizing governance, trust, and improved Electronic Medical Record (EMR) interoperability; (2) enhanced care coordination to streamline preventive services and optimize resource use; (3) infrastructure, funding, and incentive challenges across multiple regulatory bodies affecting screening delivery; and (4) the need for contextualized, culturally safe cancer screening incorporating trauma-informed approaches.

Conclusions

We developed contextualized recommendations to strengthen the evidence base for high-quality primary care preventive service delivery. This work identifies systemic barriers to cancer screening, offers practical recommendations for improvement, and advances understanding of preventive service delivery in a geographically distinct region.

Highlights

• •Northern Ontario faces significant and ongoing barriers to cancer screening.
• •Poor electronic medical record interoperability limits effective data integration.
• •System challenges reduces efficiency of service delivery.
• •Contextualized, culturally safe care incorporates trauma-informed approaches.
• •Covid-19 has intensified existing challenges in preventative care service delivery.

1. Introduction

Northern, rural, and remote populations experience disparities in health and health care compared to their urban counterparts (Health in the North: A Report on Geography and the Health of People in Ontario's Two Northern Regions, 2017). These disparities are often compounded for Indigenous populations (Katz et al., 2021; Phillips-Beck et al., 2020). In these rural and remote regions, primary care is sometimes the only available point of contact with the healthcare system (Government of Canada SC, 2023). Primary care provider shortages, fragmented information systems, and other systemic challenges within the health system can lead to missed screenings, delayed diagnoses, and ultimately poorer health outcomes among patients (Chowdhury, 2022; Grewal and Varner, 2024). National attention to the “healthcare crisis” unintentionally distracts from the realities that northern, rural, remote and Indigenous communities have been facing for decades (Gillespie, 2023; Rabeneck et al., 2023). The COVID-19 pandemic also exposed and exacerbated the fragility of Canadian primary health care systems. As demand for care increased and provider capacity declined (Shen et al., 2024), access to essential services was disrupted, including preventive care services, such as cancer screening (Alkatout et al., 2021; Flood et al., 2023).

Ontario Health Teams (OHTs) coordinate integrated healthcare delivery for their attributed population (Health, 2025) and have a mandate to demonstrate improvements in cancer screening participation within their populations (Primary Care Networks in Ontario Health Teams: Guidance Document, 2024). In Northwestern Ontario, there are four OHTs, including the Kenora Ontario's All Nations Health Partners Ontario Health Team (ANHP OHT). The ANHP OHT includes Indigenous and municipal leaders, in partnership with sixteen local organizations, with a collective aim to provide the right service, at the right time, in the right setting, for everyone in the Kenora region (About Us – All Nations Health Partners Ontario Health Team [Internet], 2026).

The primary aim of this study was to identify facilitators and barriers to the delivery and improvement of cancer screening in the ANHP OHT, from the perspectives of primary care providers and decision-makers. Understanding the challenges and barriers to preventive health screening in Kenora can be applied to improve cancer screening in the numerous rural and remote regions in Canada, where 15% of the population lives (Government of Canada SC, 2026).

2. Methods

2.1. Study design and population

In this socially accountable research project, clinicians and decision-makers from the ANHP OHT in Kenora Ontario, Canada, partnered with researchers from NOSM University's Research Toward Health Hub (NORTHH). The partnership aimed to co-design and implement a quality improvement study that was meaningful to the people of Kenora, their organizations, and primary care research. A NORTHH research assistant (PS) was embedded within the ANHP OHT and was geographically based in Kenora, Ontario, during the study period. The embedded research assistant attended in-person meetings with the dedicated Cancer Screening Working Group, local planning sessions and quality improvement discussions. This approach emphasized relationship building based on mutual trust and understanding and created a basis for snowball sampling as a recruitment method.

The team held initial in-person meetings with the ANHP OHT Cancer Screening Working Group to review the proposed research and interview questions. After these initial meetings, the team used snowball sampling to recruit health professionals, including administrators, program leads, and clinicians from organizations involved in planning, delivering, and/or reporting cancer screening. The embedded research assistant emailed a letter of information to all potential interviewees and offered to schedule a sixty-minute virtual interview.

2.2. Measures

The embedded research assistant (PS) conducted 15 semi-structured interviews during July and August of 2023, with n = 19 health professionals and administrators from nine different ANHP organizational partners who are involved in planning, delivering, and/or reporting cancer screening for the OHT. In three instances interviews included more than one individual. A semi-structured interview guide included three overarching questions in the context of cancer screening can be found in Table 1.

Table 1.

Interview questions.

Question number	Question
Question 1	What do preventive care services look like in primary care here, and how are they organized?
Question 2	What are the facilitators and barriers encountered by i) patients, ii) providers, and iii) populations during the screening process?
Question 3	Are outreach programs for preventive care available, and what do they look like?

The verbatim transcription feature of Microsoft Teams was used to accurately capture the entire virtual interview, supplemented with field notes taken by the embedded research assistant.

2.3. Data analysis

Thematic analysis was used to identify common themes and gain insights into the factors influencing cancer screening in primary care settings in ANHP OHT. The embedded research assistant (PS) conducted all the interviews and independently coded the transcripts, using Braun and Clarke's six-step approach (Braun and Clarke, 2019). The developing codes, interpretations, and emerging themes were then reviewed and discussed iteratively with the research team. Through these discussions, codes and themes were refined, revised, and consolidated until consensus was reached. This ensured that the findings were relevant, applicable, and valuable for the attributed population served by the ANHP OHT.

The project received an exemption from research ethics review (Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2) - Article 2.1) and obtained a waiver from Lakehead University's Research Ethics Board.

3. Results

Participants interviewed represented a range of roles, including administrative leadership, primary care providers (physicians and nurse practitioners), nursing professionals, and allied health staff. Several participants held dual clinical and administrative responsibilities, reflecting the multidisciplinary nature of cancer screening planning, delivery, and implementation across the ANHP OHT. Participants also included representation of First Nations communities and Indigenous health service providers.

The thematic analysis generated four themes, highlighting opportunities and challenges related to cancer screening in primary healthcare settings in this OHT context. Table 2 outlines the themes and subthemes identified in interviews.

Table 2.

Summary of themes and subthemes identified from interviews with stakeholders associated with the All Nations Health Partners Ontario Health Team, in Kenora, Ontario, in 2023.

Themes	Subthemes
1.Health Care Data Integration	Inconsistent cancer screening charting in EMR's
	Fragmented EMR's
	Cross-provincial data barriers
	Inaccurate screening status
2.Care Coordination	Lack of specific medical directives
	Duplication of services and efforts
	Pathway confusion
3.Updated Infrastructure, Funding, and Incentivization	Physical infrastructure
	Transportation barriers
	Lack of preventive care incentives
	Fragmented funding structure: This has since been addressed with the RGCC
	Timely transportation of specimens
4.Contextualized, Culturally Safe and Trauma-Informed Care	Social determinants of health influencing  -Preventive care ranking low priority  -Mistrust of healthcare system
	Culturally safe promotional materials
	Sustained relationships with communities

3.1. Healthcare data integration

Primary health care providers reported a lack of a consistent, coordinated method to identify patients eligible for breast, cervical, or colorectal cancer screening. Inconsistent recording of screening encounters and results makes it impossible to determine patients' screening eligibility status at the point of care. One participant shared:“The screens are different, like when I look at (one organization), I have a harder time finding the information. There's only so much I can do legally within that chart… II can't always find that accessible information. So I think that one shared system would be definitely a huge asset.” - Participant 9.

Laboratory backlogs, exacerbated by the COVID-19 pandemic, had prolonged the processing of cancer screening results, extending wait times from 3 to 6 weeks to 3–6 months in 2023. Respondents noted that these delays frustrate both providers and patients because they limit their ability to offer opportunistic screening and receive appropriate, timely follow-up. One participant described the impact of the delays on communication with patients: “So our results are coming back six months after the fact…telling the patient because a Pap might take six months to get back.” - Participant 12.

Patient preferences, geographic proximity, and longer local wait times within the ANHP OHT prompted some residents to seek healthcare across provincial borders, often accessing cancer screening and, in particular, follow-up services, in the neighbouring city of Winnipeg in the province of Manitoba, which is 208 km away. As a result, the lack of provincial data integration excludes patient information from the OHT cancer screening indicator data. This is particularly evident in the Ontario-specific Screening Activity Report (SAR), as shared by one participant: “Majority of follow-up visits are within Manitoba, not in Ontario. So those follow-ups don't go into the SAR (Ontario's provincial screening activity report).” - Participant 11.

3.2. Care coordination

Participants described how physician shortages and the remote nature of some First Nations communities required that registered nurses perform cancer screening under an expanded scope of practice. Although participants noted that accepted regional practice approaches support these nurses, they identified that there are currently no standardized medical directives across the different organizations with the ANHP OHT. One provider shared these challenges related to a lack of clear medical directives to facilitate cancer screening, stating: “There's no process, even though we're all working under the same umbrella, there's no process yet for a streamlined approach.”- Participant 2. This fragmentation across organizations and records leads to issues with cancer screening coordination, increased workloads, and, at times, duplicated services. One provider shared this challenge, stating: “So somebody might see me on Monday for a health issue, and then they might see the (organization's name) nurse practitioner on a Wednesday for that same issue, and then they might go to emerge on a Friday. I do see the two extremes though. I see where there's so much duplication of healthcare provided, and then there's other people who are getting nothing.” - Participant 2.

3.3. Updated infrastructure, and funding and incentivization

Respondents identified infrastructure barriers to cancer screening in the OHT, including inadequate examination rooms that risk compromising patient privacy, and a shortage of health care personnel (especially female providers). The lack of accessible transportation and reliable internet for appointment booking further complicates patients' access to cancer screening. Respondents noted that inaccurate or outdated mailing addresses created challenges in communicating screening information, particularly as reminders, follow-up instructions, and abnormal results are often delivered by mail. A participant described this challenge, explaining that when patients have “an old address on file or it's no fixed address, when the cancer screen reports go to them, they don't (go to) them and it might be quite a long time before a health care provider might find them again.” - Participant 15.

Many primary care practices in the ANHP OHT region reported operating under alternative payment models that prioritize shared remuneration for healthcare providers and financial incentives tied to meeting quality targets and screening numbers. However, they also reported this creates a lack of incentive for healthcare providers to proactively follow up on patients' cancer screening test results, particularly those not administered in-office and therefore not tracked in EMRs, such as the Fecal Immunochemical Test (FIT).

Respondents identified a lack of dedicated funding from OHT's to support cancer screening initiatives within the ANHP OHT. Although cancer screening has been identified as a priority area with specific deliverables set out by OHT's, additional funding is not provided to support the resources required to advance this work. As one participant explained, “There is no additional funding provided to the ANHP to support cancer screening. The expectation is that partner Organizations will contribute in-kind resources and manpower” - Participant 11.,

Timely transportation of laboratory specimens, such as cancer screening FITs, to the appropriate facilities was another specific challenge identified. These challenges were further exacerbated during the COVID-19 pandemic, with one participant sharing: “Hours were also impacted during COVID. (Clinics were) really restricting their hours for a time. So I know it was a challenge getting FITs in during that time.” - Participant 11.

3.4. Contextualized, culturally safe and trauma-informed care

Respondents identified several interconnected patient-specific barriers to cancer screening, including limited understanding of screening or deprioritization due to other ailments. A participant reflected on this, sharing: “And then on top of trying to manage other things, addiction or trying to find food for the day or trying to find a, a couch for the night, it's [cancer screening] just not a priority,” - Participant 15. Furthermore, previous negative or traumatic experiences with healthcare institutions, such as feeling disrespected, dismissed, or discriminated against, can lead to deep mistrust of the health system. A specific example of this was shared by a participant who stated: “You have to be empathetic to where… people come from and, you know, everybody has their own tolerance of things… If anybody's had a really bad experience where, you know, they, they had their breast squished so hard that it hurts after they don't want to go back.” - Participant 7.Informational and culturally safe materials tailored to each of the diverse populations served by this OHT would be necessary. Some specific populations that respondents mentioned included Indigenous patients, those with limited literacy skills, and those for whom English is a second language. When discussing Indigenous specific barriers, a participant stated: “Communication is hard to get around. We don't have the ability to send a flyer to everybody's door, you know, to let them know what's available, like it's, you know, if they were to have a TV channel or even a radio station, that would, be able tospeak in, their language, so they could even know that that kind of stuff is available.” - Participant 16. Respondents noted some targeted outreach strategies used for individuals living on-reserve, such as mobile screening bus visits, which help overcome known barriers to cancer screening (e.g., travel times) but not necessarily all barriers.Most respondents emphasized the importance of trauma-informed approaches to care, notably to support person- and community-centred cancer screening.

Several respondents also highlighted the need for sustained relationship-building with communities, emphasizing that trust is not built through one-time interventions, but through ongoing, respectful engagement. One participant noted that this is currently a challenge, sharing: “I have different nurses every single week…if you had more consistent nursing here every week… you would get a lot more consistency in care.” - Participant 16.

Outdated health cards delayed access to cancer screening, a barrier compounded during the COVID-19 pandemic by reduced transportation access for people in distant communities. One participant noted: “People don't have up to date version codes (on their health cards), especially during COVID, a lot of people didn't get their health cards up to date. People on reserve often don't get their health cards up to date because they don't have access into town. They are having other struggles and getting a health card up to date is the last thing on their list.” - Participant 2.

4. Discussion

This study offers a comprehensive examination of cancer screening practices within the ANHP OHT by drawing on perspectives from a range of stakeholders, including providers, administrators, and representatives from Indigenous communities. The diverse representation presented here provides contextual experience and perspectives from northern, rural, and remote communities that differ significantly from those of their urban southern Ontario counterparts. Including participants from both local and regional health service delivery roles provides a thorough understanding of the systemic and operational barriers faced in this region. Findings from this study, including health care data integration, care coordination, updated infrastructure, funding and incentivization, and culturally safe and trauma-informed care, offer a structured framework for understanding the complex nature of cancer screening in rural and remote contexts. The conclusions and findings from this study are intended to inform knowledge users and policymakers, providing actionable insights to address the identified barriers and offering suggestions for implementing effective strategies to improve preventive cancer screening in isolated and diverse communities similar to the All Nations Health Partners Ontario Health Team.

Health care data integration, specifically the standardization and integration of interoperable EMRs in primary care settings, requires three crucial components in a regional health system: trust, transparency, and shared accountability (McGlynn et al., 2003). The lack of centralized or interoperable health information systems among health service providers, within and between OHTs, makes identifying eligible patients at the point of care burdensome and, at times, impossible (Petrik et al., 2023). Similar challenges have been reported in other rural and remote settings, including Alaska Native communities, where providers identified difficulties accessing previous screening information within medical charts, increasing administrative workload and creating barriers to timely cancer screening delivery (Redwood et al., 2023). Without integrated health information systems and standardized charting across systems, primary care providers must rely on manual processes that are time-consuming and error-prone. EMRs offer benefits but are limited by fragmented data from incompatible systems and varying charting models, particularly in underserved areas (Baus et al., 2020).

Northern and remote communities are particularly vulnerable to EMR fragmentation due to a combination of geographical, infrastructure, and workforce factors that hinder interoperability among points of access and across jurisdictions (Canada G of CIS, 2023). It is important to note that some northern communities rely on paper charts or outdated EMRs, which impede the capture of complete patient histories and complicate care (Canada G of CIS, 2023). Solutions to advance the establishment of interconnected EMRs include establishing robust data governance frameworks (Affleck, 2019), transparent privacy protocols, and collaborating with Indigenous stakeholders to honour data sovereignty principles. These processes are underway within the ANHP OHT to support the future development of a unified EMR, including enabling providers across organizations access between existing EMR systems, and advancing the plan to implement a single EMR database through ongoing stakeholder engagement and tailoring the system to meet the practical needs of the providers.

Despite shared goals, some organizations within the ANHP OHT operate in silos because of varying structures, payment models, and resource constraints that limit care coordination. For an OHT with multiple primary care organizations, there is an opportunity to strengthen horizontal integration of patient files through collaboration among primary care services, local hospitals, and community services (Price et al., 2015; Heeringa et al., 2020). Horizontal integration aligns with previous recommendations for primary care reform in Ontario (Price et al., 2015; Marchildon and Hutchison, 2016) and may, over time, be realized through the current focus on primary care networks (Primary Care Networks in Ontario Health Teams: Guidance Document, 2024). Standardized approaches, such as standing orders and medical directives, may support this by establishing consistent workflows across organizations and providers in different settings to initiate and complete screening more efficiently. This aligns with research from rural and tribal settings in America demonstrating that standardized processes, including standing orders and medical directives, can support more consistent cancer screening delivery (Hoover et al., 2025). Though many OHT primary care networks are in their infancy, it remains unclear whether the OHT structure, including the one in ANHP, can or will address the information-sharing challenges across primary care organizations.

Updated infrastructure, funding, and incentivization have supported cancer screening. Other systemic barriers, such as limited funding and staffing, also restrict the development of integrated cancer screening services. Financial challenges, including inadequate incentives, discourage practitioners from implementing preventive measures across care settings (Wee et al., 2001). Evidence on the effectiveness of pay-for-performance incentives is mixed, with some studies showing improved screening rates and others showing no effects (Kaczorowski et al., 2011; Kiran et al., 2012). This study suggests revising funding and payment models to incentivize providers better and recommends a “single comprehensive funding envelope” for the ANHP OHT to allow greater flexibility in resource allocation.

At the time of publication, a new funding model has been established and implemented in the ANHP OHT region called the Rural Generalist Council Care (RGCC) model. The RGCC was established to centralize and streamline processes for allocating physician resources to address the region's unique healthcare challenges and inequities (“Transformative” new health care model coming to Kenora - NWONewsWatch.com [Internet], n.d.). The model focuses on improving equitable access to primary and emergency care for all residents in the region, regardless of whether they are attached to a specific provider (Kissick and Siroishka, 2025). It represents a shift from reactive to proactive care, emphasizing timely, culturally safe, and community-driven services (“Transformative” new health care model coming to Kenora - NWONewsWatch.com [Internet], n.d.).

To achieve care coordination, integrating care delivery and improving the efficiency of preventive care are essential; however, ensuring these services are contextualized, culturally safe and trauma-informed is even more crucial. Trauma, including a history of sexual abuse, can hinder cancer screening participation due to trust, safety concerns, and fear of re-traumatization. When patients carry these emotional and psychological burdens, they may approach the healthcare system with fear or suspicion or avoid it altogether. Recognizing the unique barriers communities face is essential to providing safe and culturally appropriate care (Liberda et al., 2025). Overcoming these barriers requires improving clinical infrastructure, expanding access to screening, and increasing cultural sensitivity within communities (Nguyen et al., 2020). Encouraging practitioners to undergo trauma-informed and cultural safety training can help deliver anti-racist, trauma-sensitive care, especially for Northern, rural, remote, and Indigenous populations. However, strategic implementation methods are still required to translate such training into effective practice. For example, tribally engaged cancer screening initiatives in rural Oklahoma have highlighted the importance of community partnership and collaboration with health service partners to co-design educational materials and outreach strategies that reflect local values and priorities (Nagykaldi et al., 2025). Collaborative efforts to co-design culturally relevant materials and strengthen provider training will improve patient-centred resources and promote accessible, safe screening (First Nations, Inuit, Métis and Urban Indigenous Cancer Screening Resources | Cancer Care Ontario [Internet], n.d.).

Despite many strengths, this study has some noteworthy limitations. The findings are specific to the ANHP OHT, which may limit generalizability; however, many of the challenges the ANHP OHT faces are generalizable to other rural and remote areas in the North and beyond. Additionally, the study lacks a detailed quantitative analysis that could provide a more objective measure of the issues identified. However, qualitative analysis was appropriate for the study objective and enabled us to understand the intricacies of the limitations of cancer screening in the ANHP OHT. While the study team worked to mitigate potential bias by including members from numerous communities across Northern Ontario, the data collection process is shaped by the advantages and limitations of having an embedded researcher conduct this work. Snowball sampling may also have led to an overrepresentation of certain organizations or viewpoints. In data analysis, thematic analysis relies on interpreting conversations, which may introduce subjectivity. However, our methods followed the step-by-step process set out by Braun and Clarke, which has been widely used (Baus et al., 2020).

5. Conclusion

The current study focused on cancer screening; however, in engaging with partners across the ANHP OHT, it has become clear that similar structural and socio-political realities affect many other health outcomes. Systems and operational changes could improve outcomes in cancer screening and other areas of health care, such as chronic disease management, and our results highlight potential areas for this change. The insights from this study are applicable beyond Northwestern Ontario, with many other rural and remote regions across Canada and internationally facing similar challenges. Future directions include identifying approaches to integrate data and medical records across organizations, developing streamlined pathways for care coordination within overarching organizations such as the ANHP OHT, and developing innovative ways to promote culturally safe learning opportunities. Implementation and re-evaluation of efforts will determine the success of new strategies.

CRediT authorship contribution statement

Paige H. Stevenson: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Barbara Zelek: Writing – review & editing, Writing – original draft, Supervision, Project administration, Formal analysis, Conceptualization. Roya Daneshmand: Writing – review & editing, Writing – original draft, Supervision, Methodology, Formal analysis. Kerri Z. Delaney: Writing – review & editing, Writing – original draft, Supervision, Formal analysis. Brianne Wood: Writing – review & editing, Writing – original draft, Supervision, Methodology, Formal analysis, Conceptualization.

Funding

Funding was provided by the NOAMA AFP Grant A22–11 and supported by the ANHP OHT.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.