A “Tea and Cookies” Approach: Co-designing Cancer Screening Interventions with Patients Living with Low Income

  • Aisha K. LoftersEmail author
  • Natalie A. Baker
  • Andree Schuler
  • Allison Rau
  • Alison Baxter
  • Nancy N. Baxter
  • Edward Kucharski
  • Fok-Han Leung
  • Karen Weyman
  • Tara Kiran
Original Research



In our primary care organization, we have observed income gradients in cancer screening for our patients despite outreach. We hypothesized that outreach strategies could be improved upon to be more compelling for our patients living with low income.


To use co-design to adapt our current strategies and create new strategies to improve cancer screening uptake for patients living with low income.


An exploratory, qualitative study in two phases: interviews and focus groups.


For interviews, we recruited 25 patient participants who were or had been overdue for cancer screening and had been identified by their provider as potentially living with low income. For subsequent focus groups, we recruited 14 patient participants, 11 of whom had participated in Phase I interviews.


To analyse written transcripts, we took an iterative, inductive approach using content analysis and drawing on best practices in Grounded Theory methodology. Emergent themes were expanded and clarified to create a derived model of possible strategies to improve the experience of cancer screening and encourage screening uptake for patients living with low income.

Key Results

Fear and competing priorities were two key barriers to cancer screening identified by patients. Patients believed that a warm and encouraging outreach approach would work best to increase cancer screening participation. Phone calls and group education were specifically suggested as potentially promising methods. However, these views were not universal; for example, women were more likely to be in favour of group education.


We used input from patients living with low income to co-design a new approach to cancer screening in our primary care organization, an approach that could be broadly applicable to other contexts and settings. We learned from our patients that a multi-modal strategy will likely be best to maximize screening uptake.



We would like to thank Anne Crassweiler, Sam Davie, Jean Wilson and all other members of our community advisory committee for their guidance, input and support throughout this study. AL is supported by a Chair in Implementation Science at Women’s College Hospital.

Funding Information

This study was funded by an Academic Health Sciences Centre Alternate Funding Plan Innovation Fund from St. Michael’s Hospital. AL is supported by a Canadian Institutes for Health Research (CIHR) New Investigator Award. Both AL and TK are supported as Clinician Scientists by the Departments of Family & Community Medicine at St. Michael’s Hospital and the University of Toronto. TK is also supported by CIHR and Health Quality Ontario as an Embedded Clinician Scientist and as the Fidani Endowed Chair in Improvement and Innovation at the University of Toronto.

Compliance with Ethical Standards

Ethics approval for the study was provided by the St. Michael’s Hospital Research Ethics Board.

Conflict Of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Aisha K. Lofters
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    Email author
  • Natalie A. Baker
    • 5
    • 7
  • Andree Schuler
    • 1
    • 2
  • Allison Rau
    • 7
  • Alison Baxter
    • 1
  • Nancy N. Baxter
    • 4
    • 5
    • 8
  • Edward Kucharski
    • 9
  • Fok-Han Leung
    • 2
    • 3
  • Karen Weyman
    • 2
    • 3
  • Tara Kiran
    • 1
    • 2
    • 3
    • 4
    • 10
    • 11
  1. 1.MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute St. Michael’s HospitalTorontoCanada
  2. 2.Department of Family and Community MedicineSt. Michael’s HospitalTorontoCanada
  3. 3.Department of Family and Community MedicineUniversity of TorontoTorontoCanada
  4. 4.ICESTorontoCanada
  5. 5.Dalla Lana School of Public HealthTorontoCanada
  6. 6.Women’s College HospitalTorontoCanada
  7. 7.Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt. Michael’s HospitalTorontoCanada
  8. 8.Department of Surgery, Li Ka Shing Knowledge InstituteSt. Michael’s HospitalTorontoCanada
  9. 9.Cancer Care OntarioTorontoCanada
  10. 10.Health Quality OntarioTorontoCanada
  11. 11.Institute of Health Policy, Management and EvaluationTorontoCanada

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