Comparative Analysis of Breast and Cervical Screening Adaptability at a Federally Qualified Health Center

Structural barriers to cancer screening at federally qualified health centers (FQHC) have contributed to lower screening rates than those among the broader populace, which were exacerbated by the COVID-19 pandemic. We apply the complex adaptive systems (CAS) theory to understand how one FQHC system in California reshaped its breast and cervical cancer screening programs to minimize health disruptions during the pandemic. This qualitative study, conducted between March 2022 and January 2023, consisted of interviews with clinic leadership and first-line staff, asking them to retrospectively reflect on the clinic's experiences with breast and cervical cancer screening delivery both immediately before and during the pandemic. Interviews were recorded and transcribed, and we performed content analysis and then applied the CAS theory. Participants (n = 20) ranged in age from 26 to 56 years, were mostly female (85%), and held leadership positions (65%). Participants indicated that cervical cancer screening rebounded more quickly than breast cancer screening programs. Results suggest that this difference could potentially be associated with new workflows that were in process prepandemic in the cervical cancer program to address existing screening barriers, as well as the FQHC's flexible approach to pandemic barriers, which included bolstering screening registries, hiring additional female providers, and bundling Pap smears into routine visits. In contrast, breast cancer screening relied on external radiology vendors, which may have reduced its flexibility to adjust to care disruptions. We highlight how healthcare delivery is shaped by interactions among diverse agents and nonlinear processes that occur in a dynamic and interconnected healthcare system.

We apply the CAS theory to better understand the trajectory of FQHC preventive cancer screening programs during the COVID-19 pandemic. By extending beyond the identification of stand-alone barriers and facilitators, we highlight the ways in which healthcare delivery is shaped by interactions among diverse agents and nonlinear processes.