Health Affairs

Please contact cancer@apamsa.org in advance if you will be organizing a screening program and would like to participate in the national APAMSA effort to increase community access to cancer screening and education.

A full list of links to find healthcare access aid resources in your local area along with multi-language materials to utilize at your event can be found here.   

Step-by-step protocol:

1. Identify your population or community of focus. We highly recommend reaching out to local community organizations to discuss partnership.
2. Identify a local physician (primary care, dermatologist, oncologist) who will serve as your mentor and oversee the screening. 
   1. Important point: It is absolutely imperative you work with a physician for your program. Reports given to screened subjects must be signed by a physician. 
   2. The American Cancer Society offers a list of databases to help allocate physicians in your area. 
3. Determine the cancer outreach and language needs in your area. Refer to this collection of multi-language cancer awareness pamphlets for examples of resources.
   1. Note: It is important to implement resources and an action plan that are inclusive of diverse skin tones and colors.
4. Identify materials needed for the screening: Feel free to refer to this Materials List as a guide. Quantity and costs are subject to change. 
   1. Secure funding to cover the cost of materials. APAMSA is setting up a Cancer Screening Grant application, so stay tuned for opportunities to gain funding.
5. Research the following questions. 
   1. Where can insured screening-positive clients obtain care? 
      1. Provide referral information for physicians who see clients with suspicious skin lesions. The client’s own PCP is also sufficient. 
   2. Where can uninsured screening-positive people obtain care? 
      1. Provide information regarding clinics for the uninsured – find community health locations using this link.
   3. Are interpreters needed for your event?
      1. You may need to seek peer educators or AANHPI advocacy groups to recruit multi-lingual volunteers to serve as patient navigators, since many community health clinics do not have resources for interpreters for many Asian languages. 
      2. Refer to the Additional Resources document for interpreter resources if needed. 
6. Develop a client follow-up plan
   1. How will you ensure that clients who need further follow-up are able to contact any referrals made?
      1. E.g. additional phone calls to make sure the clients have contacted a primary care provider or have made an appointment.
7. Identify an appropriate screening location. 
   1. This can be at a clinic that sees Asian patients, a cancer institute, a church, community center, or your local campus. For your screening event to go smoothly and efficiently, it is recommended that your venue has a waiting area, an area for check-in, at least two or more private rooms with seating, an area for check-out, and plenty of hallway space for multiple people to walk through. 
8. Obtain educational materials in English and Asian languages regarding skin cancer to distribute to the clients who come to your screening. Use existing materials from the CDC, American Cancer Society, The Skin Cancer Foundation, the American Academy of Dermatology, etc. 
   1. Refer to this collection of multilanguage cancer awareness pamphlets for examples of resources.
9. Print and organize all necessary forms: Our cancer screening toolkit contains examples of release forms and patient health info forms that you may utilize. 
   1. If applicable, consider the need for translated versions of these forms based on the population you serve. 
10. Recruit and train volunteers; these may be students or members of community partner organizations. For a screening event that lasts multiple hours, you may assign hourly shifts to volunteers. 
    1. These volunteers will be responsible for turning over rooms, serving as navigators, working at check-in and check-out stations, and some may participate in performing skin exams with a physician’s oversight. Assign a lead volunteer to be in charge of rooming and collecting forms. 
11. Advertise your event to members of the local community. Create registration forms that request contact information of clients who are scheduling an appointment. You may also request contact information of the client’s primary care provider (if applicable) to send results directly to them after your screening event. Distribute fliers to communal areas like grocery stores, churches, or recreational centers. See examples of fliers provided in our toolkit. 
12. Send out a reminder to all registered participants a week to a couple days in advance of their appointment time and event location. 

1. 1. Have student volunteers ready at different stations.
      1. a. Check-in: Have clients fill out a health info form and a release form – see examples in our toolkit. Inform the client to take these two forms with them to the exam room. Keep an organized log of every client, their appointment times, and contact information to keep track of all clients who present to the screening. Have seating, clipboards, and pens available for those who are filling forms or are waiting to be seen. 
      2. b. Screening Station: Each room should be turned over and prepped for every new client to be seen. A complete room should have all necessary PPE (gloves, masks, hand sanitizers), measuring tape for recording suspicious lesions, a clipboard and pen for the examiner, and a fresh gown for the client. Make sure each client is given plenty of time to change before being seen by an examiner. 
         1. Use colored indicators on doors to track the status of each room: (1)vacant and ready for a new client, (2)occupied with a client who has yet to be seen, (3)occupied with both client and examiner, (4)vacant but needs to be turned over. You can use a binder ring with four different colored construction papers placed on a hook or doorknob. 
         2. You should assign a volunteer as a lead who is in charge of rooming. This person assigns clients to vacant rooms and allocates an examiner to each client who needs to be seen. After each visit is complete, the lead should collect all Release forms from the client, and direct the client to a navigator to be escorted to check-out. The client should have only their Patient Info Form with them at check out. 
         3. You should assign additional volunteers as navigator or room turnovers. Navigators are to escort clients from check-in to their screening station and back to check-out. Navigators should also double check that all client forms are handed to the lead. Room turnovers are to keep all rooms stocked with supplies and prepare a new gown for each client. 

• Check-out: It should be recorded when each client has finished their screening and left the facility. Make sure to scan a photocopy of each client’s Health Info Form; they can take the physical copy with them for their own records or if they choose to present it to their provider at a follow up visit. At this point, volunteers can double check with the client that their logged contact information is correct in case you would like to follow up with them. Also confirm with the client that their PCP information is correct, or if they require referrals based on their insured status. Inform the client that their screening results will be sent to their established provider if they have one. 

Overview of Screening Responsibilities:

• Positive for a suspicious lesion

• • • Recommendation: further testing, referral to a primary care physician, or follow-up at a clinic that accepts uninsured clients.
      • For insured clients:
        • Identify a physician/physicians in your area who specialize in skin cancer (dermatologists). Refer clients to these physicians, or encourage them to make follow-up appointments with their own primary provider. 
      • For uninsured clients:
        • Ideally, identify and refer clients to a community health center dedicated to the Asian population.
        • If unavailable, refer to a community health center, a clinic for the uninsured that provides Asian language services, an established navigator system, or a student run free clinic affiliated with your institution. Be aware of what referral systems and services are offered at your student run clinic.

• Negative for suspicious lesions

• Recommendation: Encourage education and promote awareness.

• • • Educate clients that a negative screening result does not eliminate the possibility of skin cancer. Inform them of risk factors and prevention methods. Emphasizing sunscreen use is crucial. They should also be encouraged to perform self-examinations at home to identify any new or changing skin lesions which they can bring up to their primary care physician. 

Client Follow-up Protocol:

• All clients with an established primary care physician should have their Health Info Form sent over to their provider’s office. 
• It is ideal to follow up with everyone who participates in your screening to educate them about skin cancer and direct them to appropriate avenues for treatment.
• Important point: simply telling clients at your screening event to go see their primary care physician is not as effective as calling and writing to them directly. 
  • With direct communication, we can ensure that 1) clients understand what they need to do, and 2) they understand the reasons for doing so. 

Examples of Client Follow-up Systems:

1. Letters
   1. If you send out letters to your clients, make sure they are in English and appropriate Asian languages. 
   2. Ensure that the language you use is readable and accessible to people with all levels of literacy. Avoid unnecessary jargon.
   3. Make sure your letters are customized with information regarding clinics, referrals, and skin cancer info. 
   4. TIP: When you register people for the cancer screening, have them self-address an envelope to themselves that you will use to send them their results. This will minimize mistakes in mailing addresses.
2. Letters and Phone calls
   1. Sending letters and following up with phone calls is a better way of making sure the people understand their screening results. 
   2. Make sure that if you make phone calls you have people who can speak the language of the person you’re calling, either through recruiting volunteers who speak other languages or using phone interpreter services. 
   3. If you mail a letter, try to follow up with a phone call 2 weeks later to make sure they understand the letter and encourage follow-up. Then, make a follow-up call 3 months later to see if action was taken. The downside to making phone calls is that you can’t give medical information to anyone except for the person you screened, so you may have to call back several times.

Handling Patient Info:

• You should keep all physical copies of signed Release Forms on file for proof of HIPAA compliance. Any client is allowed to request a copy of their Release Form. 
• All clients should leave the event with the physical copy of their Health Info Form after you scan a photocopy and store it digitally in a private location. Ensure that only your institution, club executive board, and/or partnered organization’s administrative members have access to these documents. You may send copies of Health Info Forms to your clients’ primary care physicians with each client’s permission. 
• Make sure to discard all physical copies of sensitive documents appropriately if they are no longer needed (i.e. by paper shredding). 

It is recommended before you proceed with anything to talk to your schools and partnered organizations regarding the best way to handle this. 

While there is very little risk involved with skin cancer screening, every institution and health organization has different policies which you must understand before proceeding with any service that informs patient care. This is another reason why the first and most important step is to secure a licensed faculty/ physician advisor to oversee your screening.

Please contact hepatitis@apamsa.org in advance if you will be organizing a screening program and would like to participate in the national APAMSA effort to collect hepatitis B data.

Resources to find information about your local areas:

• Hepatitis B Foundation physician directory: https://www.hepb.org/treatment-and-management/physician-directory/

• US Department of Health & Humans Services – Find a Health Center: https://findahealthcenter.hrsa.gov/

• American Liver Foundation resource center directory: https://liverfoundation.org/resource-center/

Steps:

1. Identify a local hepatologist or other physician who will serve as your mentor and oversee the screening. Important point: It is absolutely imperative you work with a physician for your program. Lab tests have to be ordered by a physician, and reports given to screened subjects must be signed by a physician.

   1. We also recommend you contact your local American Liver Foundation contacts, who will likely be able to provide you with more information and direct you to physicians who would be willing to help you.

2. Determine the hepatitis B outreach and language needs in your area.

3. Identify resources needed for the screening (i.e. labs, phlebotomist, etc…).

4. Discuss with your mentor the need for obtaining IRB approval/waivers as needed. IRB approval will be needed if there are plans to analyze and report the data.

5. Secure funding.

   1. Research the following questions. Send completed research to National APAMSA for databasing.
      Where can insured hepatitis B positive people obtain care?

      1. Provide referral information for physicians who see hepatitis B clients.

   2. Where can uninsured hepatitis B positive people obtain care?

      1. Provide information regarding clinics for the uninsured

      2. You may need to seek peer educators or community health advocates to function as a patient navigator, since many indigent clinics do not have resources for interpreters for many Asian languages.)

   3. Where can hepatitis B antibody negative people obtain the vaccine?

      1. Provide information about where they can go to get the hepatitis B vaccine, either through their primary care physician or through a free/discounted vaccination program.

   4. Where can other family members be screened?

      1. Provide information regarding places to be screened for hepatitis B.

6. Develop a client follow-up plan

   1. How are you going to notify clients of their results?

      1. E.g. phone calls, letters, both, educational session, or something else.

   2. How will you ensure that clients who need further follow-up are able to contact any referrals made?

      1. E.g. additional phone calls to make sure the clients have contacted a primary care provider or have made an appointment to get vaccinated.

7. Identify an appropriate screening location.

   1. This can be at a clinic that sees Asian patients, a church, community center, a hepatitis B screening in the Asian community, a hepatitis B screening that’s part of a more comprehensive health screening for the community, or many other options.

8. Secure a phlebotomist + appropriate supplies to draw blood.

9. Find a laboratory that will process your samples. When signing the contract, find out how long it takes for results to be processed and sent back to the ordering physician. You can also request the results to be sent to you in a spreadsheet.

   1. Ask your physician mentors for suggestions.

   2. Most commercial labs will provide phlebotomist, and blood drawing kits and also dispose of sharps and biohazard materials. Quest Diagnostics gives a good rate but will not provide phlebotomists on Sundays.

   3. Some cities such as Chicago provide free hepatitis B screening through their health departments as well.

10. Obtain educational materials in English and Asian languages regarding hepatitis B to distribute to the clients who come to your screening. Use existing materials from the CDC, American Liver Foundation, Hep B Foundation, or Asian Liver Center. Please see the resources page for more information.

11. Create a waiver/consent form for clients to sign. This should also include a description about what will happen to their samples. This needs to be in English and Asian Languages.

12. Recruit and train student volunteers.

1. Have student volunteers ready at different stations.

   1. Education station: provide educational materials to clients about hepatitis B. Encourage people to get screened.

      1. TIP: Having clients sit through an educational presentation as a ticket into the free screening is an effective educational method.

   2. Screening registration station: have clients fill out health info form and consent form. Assign a unique ID number to each person for your records. This ID number will be used to label their samples and also for subsequent data analysis. Keep these records that link client names with ID numbers in a secure location. Review with your clients what will happen to their samples and when they will be contacted.

      1. : Have each person write their own address on an envelope or address label during registration. This significantly improves your chances of sending the letters to the right place.

   3. Blood drawing station: managed by a licensed phlebotomist, ideally with a physician present.

2. All this seems like a daunting task for medical students, but there is help for you! The best and most effective way to conduct a screening is to connect yourself with local groups that already have many of these resources already developed.

Lab results will be returned generally 2-3 weeks following the screening.

Overview of Screening Responsibilities:

• Hepatitis B Surface Antigen Positive

  • Recommendation: further testing, referral to a primary care physician, or follow-up at a clinic that accepts uninsured clients.

    • For insured clients:

      • Identify a physician/physicians who specialize in hepatitis B. Refer clients to these physicians or their own primary provider.

    • For uninsured clients:

      • Ideally, identify and refer clients to a community health center dedicated to the Asian population.

      • If unavailable, refer to a community health center, a clinic for the uninsured that provides Asian language services, an established navigator system, or a student run free clinic affiliated with your institution. Be aware of what referral systems and services are offered at your student run clinic.

• Hepatitis B Surface Antigen Negative, Hepatitis B Surface Antibody Negative

  • Recommendation: get immunized with the hepatitis B vaccine.

    • Refer clients to the appropriate places to get the vaccine such as their primary provider, and also provide recommendations for where clients might go to get free vaccinations if they are uninsured, such as free/discounted vaccination programs.

• Hepatitis B Surface Antigen Negative, Hepatitis B Surface Antibody Positive

  • Client has antibodies to hepatitis B and is immune. Encourage them to have their family members screened.

Client Follow-up Protocol:

• Simply sending clients a letter notifying them that they are hepatitis B positive is not effective. This is one of the best areas for students to get involved because you can help develop tracking programs and follow-up with both your hepatitis B surface antigen positive and negative clients.

• It is ideal to follow up with everyone who participates in your screening to educate them about hepatitis B and direct them to appropriate avenues for treatment.

• Hepatitis B surface antigen positive persons need to see a physician even if they have no symptoms.

• Hepatitis B negative persons, who also are hepatitis B surface antibody negative, need to get the hepatitis B vaccine.

• Important point: simply telling clients to go see their doctor or handing them a voucher to get a vaccine is not as effective as calling and writing to them directly.

  • With direct communication, we can ensure that1) understand what they need to do, and 2) they understand the reasons for doing so.

Examples of Client Follow-up Systems:

1. Letters

   1. If you send out letters to your clients, make sure they are in English and appropriate Asian languages.

   2. Make sure your letters are customized with information regarding clinics, referrals, vaccines, and other hepatitis B services.

   3. TIP: When you register people for the hepatitis B screening, have them self-address an envelope to themselves that you will use to send them their results. This will minimize mistakes in mailing addresses.

2. Letters and Phone calls

   1. Sending letters and following up with phone calls is a better way of making sure the people understand the test results.

   2. Make sure that if you make phone calls you have people who can speak the language of the person you’re calling, either through recruiting volunteers who speak other languages or using phone interpreter services.

   3. If you mail a letter, try to follow up with a phone call 2 weeks later to make sure they understand the letter and encourage follow-up. Then, make a follow-up call 3 months later to see if action was taken. The downside to making phone calls is that you can’t give medical information to anyone except for the person you screened, so you may have to call back several times.

3. Educational Session, Letters, and Phone Calls

   1. Inform all clients to return a week or two later to receive their results and participate in an educational session. Call and leave messages reminding them of this educational session, and avoid giving out medical information over the phone. During the educational session, explain the various possibilities of their screening results. Before or after the educational session, provide each client a letter with their results. Consider also providing food. Make sure your speaker is able to communicate in the language of the community.

   2. This is the most time consuming method of notifying the screening participants, but has proven effective for some screening programs, and allows for face-to-face communication. However, this method may not be amenable to all client schedules and may result in a gap in the follow-up care if you do not also ensure to write and call clients.

It is recommended before you proceed with anything to talk to your schools regarding the best way to handle this.

While there is very little risk involved with drawing blood, every institution has different policies which you must check before proceeding with anything. This is another reason why one of the first steps is to secure a faculty/community physician advisor.