Cycles of silence: First Nations women overcoming social and historical barriers in supportive cancer care

Use of photo methods in research studies with cancer survivors and their caregivers: a scoping review

PURPOSE

Photo methods such as photo-elicitation and photovoice have traditionally been implemented as knowledge-generation techniques; however, they have also been conceptualized as tools for community impact and as interventions in and of themselves. We performed a scoping review to document how photo methods have been used in studies of cancer, to describe participant populations, and to identify opportunities for future directions for the use of photo methods in cancer.

METHODS

An a priori search strategy was implemented across health-related databases with the following inclusion criteria: (1) study participants were diagnosed with cancer and/or were caregivers of those with cancer; (2) study participants were asked to take and/or respond to photographs as part of the study protocol; (3) articles were published in peer-reviewed journals; (4) articles were written in English.

RESULTS

Eighty non-duplicative articles were identified; of these, 30 articles describing 24 individual studies were included for review. All but one (95.8%) of the studies utilized photovoice solely as a knowledge-generation technique without participant outcome measurement or analysis. Across all included studies, participants were largely women with breast cancer; other demographic and cancer-related variables (e.g., race and cancer stage) were not consistently reported. Caregivers were included in 37.5% of studies.

CONCLUSION

Photo methods are most frequently used in order to capture qualitative data in cancer populations; however, there are missed opportunities in their lack of use for intervention and systemic change. In addition, inconsistent reporting of demographics and cancer characteristics limits our ability to synthesize these data across studies.

Examining structural factors influencing cancer care experienced by Inuit in Canada: a scoping review

Inuit face worse cancer survival rates and outcomes than the general Canadian population. Persistent health disparities cannot be understood without examining the structural factors that create inequities and continue to impact the health and well-being of Inuit. This scoping review aims to synthesise the available published and grey literature on the structural factors that influence cancer care experienced by Inuit in Canada. Guided by Inuit input from Pauktuutit Inuit Women of Canada as well as the Joanna Briggs Institute scoping review methodology, a comprehensive electronic search along with hand-searching of grey literature and relevant journals was conducted. A total of 30 papers were included for analysis and assessment of relevance. Findings were organised into five categories as defined in the a priori framework related to colonisation, as well as health systems, social, economic, and political structures. The study results highlight interconnections between racism and colonialism, the lack of health service information on urban Inuit, as well as the need for system-wide efforts to address the structural barriers in cancer care.

Health and healthcare equity within the Canadian cancer care sector: a rapid scoping review

BACKGROUND

Despite a publicly-funded healthcare system, alarming cancer-related health and healthcare inequities persist in Canada. However, it remains unclear how equity is being understood and taken up within the Canadian cancer context. Our objective was to identify how health and healthcare equity are being discussed as goals or aims within the cancer care sector in Canada.

METHODS

A rapid scoping review was conducted; five biomedical databases, 30 multidisciplinary websites, and Google were searched. We included English-language documents published between 2008 and 2021 that discussed health or healthcare equity in the Canadian cancer context.

RESULTS

Of 3860 identified documents, 83 were included for full-text analysis. The prevalence of published and grey equity-oriented literature has increased over time (2008-2014 [n = 20]; 2015-2021 [n = 62]). Only 25% of documents (n = 21) included a definition of health equity. Concepts such as inequity, inequality and disparity were frequently used interchangeably, resulting in conceptual muddling. Only 43% of documents (n = 36) included an explicit health equity goal. Although a suite of actions were described across the cancer control continuum to address equity goals, most were framed as recommendations rather than direct interventions.

CONCLUSION

Health and healthcare equity is a growing priority in the cancer care sector; however, conceptual clarity is needed to guide the development of robust equity goals, and the development of sustainable, measurable actions that redress inequities across the cancer control continuum. If we are to advance health and healthcare equity in the cancer care sector, a coordinated and integrated approach will be required to enact transformative and meaningful change.

Health care utilization differences between First Nations people and the general population with inflammatory bowel disease: a retrospective cohort study from Saskatchewan, Canada

BACKGROUND

Indigenous people in Canada often face barriers to access specialized care, with limited data in evaluating health care utilization among Indigenous people with inflammatory bowel disease (IBD). We aimed to compare health care utilization between First Nations patients and those in the general population diagnosed with IBD in Saskatchewan.

METHODS

We conducted a patient-oriented, population-based, retrospective cohort study by linking administrative health databases of Saskatchewan between fiscal years 1998/99 and 2017/18. We designed and completed this study in partnership with Indigenous patients and family advocates. We applied a validated algorithm to identify IBD incident cases and then used the self-declared First Nations status variable to divide those cases. We applied a 1:5 ratio for age and sex matching and used Cox proportional models to assess associations. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported.

RESULTS

We created a matched cohort with 696 IBD incident cases: 116 First Nations patients and 580 patients in the general population. We observed differences between the groups for IBD-specific hospital admissions (HR 1.33, 95% CI 1.01-1.75), IBD-related hospital admissions (HR 1.55, 95% CI 1.20-2.01), medication claims for IBD (HR 0.52, 95% CI 0.41-0.65) and 5-aminosalicylic acid claims (HR 0.56, 95% CI 0.45-0.71) adjusting by rural or urban residence and diagnosis type. There were no significant differences in the hazard rate of outpatient gastroenterology visits (HR 1.13, 95% CI 0.90-1.41), colonoscopies (HR 1.14, 95% CI 0.92-1.41) and surgeries for IBD (HR 1.14, 95% CI 0.80-1.64).

INTERPRETATION

We identified that First Nations patients diagnosed with IBD had a higher rate of hospital admissions owing to IBD than patients in the general population diagnosed with IBD. We also found an inverse association between First Nations status and having prescription medication claims for IBD.

Risk Stratification and Cancer Follow-Up: Towards More Personalized Post-Treatment Care in Canada

After treatment, cancer survivors require ongoing, comprehensive care to improve quality of life, reduce disability, limit complications, and restore function. In Canada and internationally, follow-up care continues to be delivered most often by oncologists in institution-based settings. There is extensive evidence to demonstrate that this model of care does not work well for many survivors or our cancer systems. Randomized controlled trials have clearly demonstrated that alternate approaches to follow-up care are equivalent to oncologist-led follow-up in terms of patient outcomes, such as recurrence, survival, and quality of life in a number of common cancers. In this paper, we discuss the state of follow-up care for survivors of prevalent cancers and the need for more personalized models of follow-up. Indeed, there is no one-size-fits-all solution to post-treatment follow-up care, and more personalized approaches to follow-up that are based on individual risks and needs after cancer treatment are warranted. Canada lags behind when it comes to personalizing follow-up care for cancer survivors. There are many reasons for this, including difficulty in determining who is best served by different follow-up pathways, a paucity of evidence-informed self-management education and supports for most survivors, poorly developed IT solutions and systems, and uneven coordination of care. Using implementation science theories, approaches, and methods may help in addressing these challenges and delineating what might work best in particular settings and circumstances.

Sâkipakâwin: Assessing Indigenous Cancer Supports in Saskatchewan Using a Strength-Based Approach

Given that the health care system for Indigenous people tends to be complex, fragmented, and multi-jurisdictional, their cancer experiences may be especially difficult. This needs assessment study examined system-level barriers and community strengths regarding cancer care experiences of Indigenous people in Saskatchewan. Guided by an advisory committee including Indigenous patient and family partners, we conducted key informant interviews with senior Saskatchewan health care administrators and Indigenous leaders to identify supports and barriers. A sharing circle with patients, survivors, and family members was used to gather cancer journey experiences from Indigenous communities from northern Saskatchewan. Analyses were presented to the committee for recommendations. Key informants identified cancer support barriers including access to care, coordination of care, a lack of culturally relevant health care provision, and education. Sharing circle participants discussed strengths and protective factors such as kinship, connection to culture, and spirituality. Indigenous patient navigation, inter-organization collaboration, and community relationship building were recommended to ameliorate barriers and bolster strengths. Recognizing barriers to access, coordination, culturally relevant health care provision, and education can further champion community strengths and protective factors and frame effective cancer care strategies and equitable cancer care for Indigenous people in Saskatchewan.

Understanding culturally safe cancer survivorship care with inuit in an urban community

Cancer is a leading cause of death among Inuit. A legacy of colonialism, residential schools, and systemic racism has eroded trust among Inuit and many do not receive culturally safe care. This study aimed to explore the meaning of culturally safe cancer survivorship care for Inuit, and barriers and facilitators to receiving it in an urban setting in Ontario Canada. As Inuit and Western researchers, we conducted a descriptive qualitative study. We held two focus groups (n = 27) with cancer survivors and family members, and semi-structured interviews (n = 7) with health providers. Data were analysed using thematic content analysis.Three broad themes emerged as central to culturally safe care: access to traditional ways of life, communication, and family involvement. Family support, patient navigators, and designated spaces were facilitators; lack of support for traditional ways, like country food, was a barrier. Participants were clear what constituted culturally safe care, but major barriers exist. Lack of direction at institutional and governmental levels contributes to the complexity of issues that prevent Inuit from engaging in and receiving culturally safe cancer care. To understand how to transform healthcare to be culturally safe, studies underpinned by Inuit epistemology, values, and principles are required.

A critical exploration of nurses' perceptions of access to oncology care among Indigenous peoples: Results of a national survey

Inequities in access to oncology care among Indigenous peoples in Canada are well documented. Access to oncology care is mediated by a range of factors; however, emerging evidence suggests that healthcare providers, including nurses, play a significant role in shaping healthcare access. The purpose of this study was to critically examine access to oncology care among Indigenous peoples in Canada from the perspective of oncology nurses. Guided by postcolonial theoretical perspectives, interpretive descriptive and critical discourse analysis methodologies informed study design and data analysis. Oncology nurses were recruited from across Canada to complete an online survey (n = 78). Nurses identified a range of barriers experienced by Indigenous peoples when accessing oncology care, yet located these barriers primarily at the individual and systems levels. Nurses perceived themselves as mediators of access to oncology care; however, their efforts to facilitate access to care were constrained by the dominance of biomedicine within healthcare. Nurses' constructions of access to oncology care highlight the embedded narrative of individualism within nursing practice and the relative invisibility of racism as a determinant of equitable access to care among Indigenous peoples. This suggests a need for oncology nurses to better understand and incorporate structural determinants of health perspectives.

Canadian Resources, Programs, and Models of Care to Support Cancer Survivors' Transition beyond Treatment: A Scoping Review

(1) Background: One in two Canadians will be diagnosed with cancer in their lifetime, but as a result of the progress in diagnosis and treatment, more individuals are surviving cancer than ever before. However, the impact of cancer does not end with treatment. The objectives of this review are to (1) provide a broad overview of the supportive care interventions and models of care that have been researched to support Canadian post-treatment cancer survivors; and (2) analyze how these supportive care interventions and/or care models align with the practice recommendations put forth by Cancer Care Ontario (CCO) and the Canadian Association of Psychosocial Oncology/Canadian Partnership Against Cancer (CAPO/CPAC). (2) Methods: An electronic search was completed in MEDLINE, Embase, PsycINFO, and CINAHL in January 2021. Included studies described supportive care interventions or models of care utilized by adult Canadian cancer survivors. (3) Results: Forty-two articles were included. Survivors utilized a multitude of supportive care interventions, with peer support and physical activity programs being most frequently cited. Four models of follow-up care were identified: primary care, oncology care, shared-care, and transition clinics. The supportive care interventions and models of care variably aligned with the recommendations set by CCO and CAPO/CPAC. The most commonly followed recommendation was the promotion of self-management and quality resources for patients. (4) Conclusions: Results indicate an inconsistency in access to supportive care interventions and the delivery of survivorship care for cancer survivors across Canada. Current efforts are being made to implement the recommendations by CCO and CAPO/CPAC; however, provision of these guidelines remains varied.

Interventions to improve cancer survivorship among Indigenous Peoples and communities: a systematic review with a narrative synthesis

PURPOSE

The purpose of this systematic review is to synthesize the evidence on the types of interventions that have been utilized by Indigenous Peoples living with cancer, and report on their relevance to Indigenous communities and how they align with holistic wellness.

METHODS

A systematic review with narrative synthesis was conducted.

RESULTS

The search yielded 7995 unique records; 27 studies evaluating 20 interventions were included. The majority of studies were conducted in USA, with five in Australia and one in Peru. Study designs were cross-sectional (n=13); qualitative (n=5); mixed methods (n=4); experimental (n=3); and quasi-experimental (n=2). Relevance to participating Indigenous communities was rated moderate to low. Interventions were diverse in aims, ingredients, and outcomes. Aims involved (1) supporting the healthcare journey, (2) increasing knowledge, (3) providing psychosocial support, and (4) promoting dialogue about cancer. The main ingredients of the interventions were community meetings, patient navigation, arts, and printed/online/audio materials. Participants were predominately female. Eighty-nine percent of studies showed positive influences on the outcomes evaluated. No studies addressed all four dimensions of holistic wellness (physical, mental, social, and spiritual) that are central to Indigenous health in many communities.

CONCLUSION

Studies we found represented a small number of Indigenous Nations and Peoples and did not meet relevance standards in their reporting of engagement with Indigenous communities. To improve the cancer survivorship journey, we need interventions that are relevant, culturally safe and effective, and honoring the diverse conceptualizations of health and wellness among Indigenous Peoples around the world.

Putting the Patient First: A Scoping Review of Patient Desires in Canada

Patient-centred care is a key priority for governments, providers and stakeholders, yet little is known about the care preferences of patient groups. We completed a scoping review that yielded 193 articles for analysis. Five health states were used to account for the diversity of possible preferences based on health needs. Five broad themes were identified and expressed differently across the health states, including personalized care, navigation, choice, holistic care and care continuity. Patients' perspectives must be considered to meet the diverse needs of targeted patient groups, which can inform health system planning, quality improvement initiatives and targeting of investments.

Seizing the Means of Reproduction? Canada, Cancer Screening, and the Colonial History of the Cytopipette

In recent years, self-sampling has emerged as a compelling way of increasing cervical cancer screening rates within First Nations, Inuit and Métis communities. By allowing women to take their own samples in private, when and where they are most comfortable, home testing kits have been framed as a new, unequivocally feminist technology, and a panacea in Indigenous health. But are these techniques really as ethical and empowering as they have been made out to be? To answer this question, this article traces the history of the uptake and use of cervical cancer screening technologies in Canada. By tracing the mechanics and motivations of two state-sponsored cervical cancer screening studies carried out by Canada's Department of Indian Health Services during the mid to late twentieth century, this piece explores the settler-colonial roots of cancer surveillance, and shows how the implementation of both Pap-testing and DIY forms of screening within Indigenous communities has, at least historically, been more about enacting biopolitical regimes than promoting feminist ideals or improving health outcomes.

Comparing cancer incidence, stage at diagnosis and outcomes of First Nations and all other Manitobans: a retrospective analysis

Background

Globally, epidemiological evidence suggests cancer incidence and outcomes among Indigenous peoples are a growing concern. Although historically cancer among First Nations (FN) peoples in Canada was relatively unknown, recent epidemiological evidence reveals a widening of cancer related disparities. However evidence at the population level is limited. The aim of this study was to explore cancer incidence, stage at diagnosis, and outcomes among status FN peoples in comparison with all other Manitobans (AOM).

Methods

All cancers diagnosed between April 1, 2004 and March 31, 2011 were linked with the Indian Registry System and five provincial healthcare databases to compare differences in characteristics, cancer incidence, and stage at diagnosis and mortality of the FN and AOM cohorts. Cox proportional hazard regression models were used to examine mortality.

Results

The FN cohort was significantly younger, with higher comorbidities than AOM. A higher proportion of FN people were diagnosed with cancer at stages III (18.7% vs. 15.4%) and IV (22.4% vs. 19.9%). Cancer incidence was significantly lower in the FN cohort, however, there were no significant differences between the two cohorts after adjusting for age, sex, income and area of residence. No significant trends in cancer incidence were identified in either cohort over time. Mortality was generally higher in the FN cohort.

Conclusions

Despite similar cancer incidence, FN peoples in Manitoba experience poorer survival. The underlying causes of these disparities are not yet understood, particularly in relation to the impact of colonization and other determinants of health.

Spirituality in cancer survivorship with First Nations people in Canada

BACKGROUND

Advancements in cancer survivorship care have shown that holistic approaches, tailored to people's unique survivorship needs, can decrease cancer burden and enhance well-being and quality of life. The purpose of this study was to explore the meanings of spirituality in cancer survivorship for First Nations people, the largest Indigenous population in Canada, and describe how spiritual practices are incorporated into healing.

METHODS

This study is part of a larger arts-based project about cancer survivorship with First Nations people. Thirty-one cancer survivors discussed spirituality as part of their cancer survivorship experiences. Data were generated through sharing sessions (n = 8) and individual interviews (n = 31). Qualitative descriptive analysis was conducted.

RESULTS

Three themes emerged about the meaning of spirituality in cancer survivorship. Spirituality was expressed as a complex phenomenon that (1) interconnected self with traditional roots and culture, (2) merged the body and mind, and (3) gave meaning, strength, and faith in the cancer journey. First Nations people incorporated spirituality into cancer survivorship by giving thanks, attending places of spiritual connectedness, singing, praying, speaking to the Creator, and engaging the sun and moon.

CONCLUSION

First Nations cancer survivors have viewed cancer as an opportunity for emotional and spiritual growth that enabled healing. Understanding the role of spirituality in cancer survivorship is important to develop and deliver culturally safe health services that reduce the burden of cancer and ultimately improve outcomes for First Nations people in Canada.

Cancer Services and Their Initiatives to Improve the Care of Indigenous Australians

Indigenous Australians continue to experience significantly poorer outcomes from cancer than non-Indigenous Australians. Despite the importance of culturally appropriate cancer services in improving outcomes, there is a lack of awareness of current programs and initiatives that are aimed at meeting the needs of Indigenous patients. Telephone interviews were used to identify and describe the Indigenous-specific programs and initiatives that are implemented in a subset of the services that participated in a larger national online survey of cancer treatment services. Fourteen services located across Australia participated in the interviews. Participants identified a number of factors that were seen as critical to delivering culturally appropriate treatment and support, including having a trained workforce with effective cross-cultural communication skills, providing best practice care, and improving the knowledge, attitudes, and understanding of cancer by Indigenous people. However, over a third of participants were not sure how their service compared with others, indicating that they were not aware of how other services are doing in this field. There are currently many Indigenous-specific programs and initiatives that are aimed at providing culturally appropriate treatment and supporting Indigenous people affected by cancer across Australia. However, details of these initiatives are not widely known and barriers to information sharing exist. Further research in this area is needed to evaluate programs and initiatives and showcase the effective approaches to Indigenous cancer care.