Health Equity in National Cancer Control Plans: An Analysis of the Ontario Cancer Plan

Using the Power Wheel as a transformative tool to promote equity through spaces and places of patient engagement

BACKGROUND

Patient engagement is the active collaboration between patient partners and health system partners towards a goal of making decisions that centre patient needs-thus improving experiences of care, and overall effectiveness of health services in alignment with the Quintuple Aim. An important but challenging aspect of patient engagement is including diverse perspectives particularly those experiencing health inequities. When such populations are excluded from decision-making in health policy, practice and research, we risk creating a healthcare ecosystem that reinforces structural marginalisation and perpetuates health inequities.

APPROACH

Despite the growing body of literature on knowledge coproduction, few have addressed the role of power relations in patient engagement and offered actionable steps for engaging diverse patients in an inclusive way with a goal of improving health equity. To fill this knowledge gap, we draw on theoretical concepts of power, our own experience codesigning a novel model of patient engagement that is equity promoting, Equity Mobilizing Partnerships in Community, and extensive experience as patient partners engaged across the healthcare ecosystem. We introduce readers to a new conceptual tool, the Power Wheel, that can be used to analyse the interspersion of power in the places and spaces of patient engagement.

CONCLUSION

As a tool for ongoing praxis (reflection +action), the Power Wheel can be used to report, reflect and resolve power asymmetries in patient-partnered projects, thereby increasing transparency and illuminating opportunities for equitable transformation and social inclusion so that health services can meet the needs and priorities of all people.

Patient-reported mental health and well-being trajectories in oncology patients during radiation therapy: an exploratory retrospective cohort analysis using the Ontario Cancer Registry

PURPOSE

Mental health and well-being trajectories are not expected to be homogeneous in diverse clinical populations. This exploratory study aims to identify subgroups of patients with cancer receiving radiation therapy who have different mental health and well-being trajectories, and examine which socio-demographic, physical symptoms, and clinical variables are associated with such trajectories.

METHODS

Retrospective analysis of radiation therapy patients diagnosed with cancer in 2017 was conducted using data from the Ontario Cancer Registry (Canada) and linked with administrative health data. Mental health and well-being were measured using items from the Edmonton Symptom Assessment System-revised questionnaire. Patients completed up to 6 repeated measurements. We used latent class growth mixture models to identify heterogeneous mental health trajectories of anxiety, depression, and well-being. Bivariate multinomial logistic regressions were conducted to explore variables associated with the latent classes (subgroups).

RESULTS

The cohort (N = 3416) with a mean age of 64.5 years consisted of 51.7% females. Respiratory cancer was the most common diagnosis (30.4%) with moderate to severe comorbidity burden. Four latent classes with distinct anxiety, depression, and well-being trajectories were identified. Decreasing mental health and well-being trajectories are associated with being female; living in neighborhoods with lower income, greater population density, and higher proportion of foreign-born individuals; and having higher comorbidity burden.

CONCLUSIONS

The findings highlight the importance of considering social determinants of mental health and well-being, in addition to symptoms and clinical variables, when providing care for patients undergoing radiation therapy.

"Healthcare should be the same for everyone": perceived inequities in therapeutic trajectories of adult patients with lung cancer in Chile, a qualitative study

Background

Globally, it has been reported that different social determinants of health affect health outcomes in lung cancer (LC). Research on the therapeutic trajectories of patients (TTP) is a novel field for identifying barriers and facilitators in health. The objective of this study was to reveal perceived differences in TTP with LC in Chile according to selected social determinants of health (SDH) and the experiences of patients, health professionals, and civil society leaders.

Methods

This is a qualitative paradigm, one case-study design. Online semi-structured interviews were conducted with patients with LC, health professionals, and civil society leaders. The strategies for the recruitment process included social networks, civil society organizations, health professionals, and the snowball technique. A thematic analysis was carried out.

Results

Selected SDH impact LC's TTP in Chile, particularly concerning health system access, health services, information, and patient navigation experiences. The analysis of the experiences of the participants allowed us to identify barriers related to the selected SDH in three stages of the TTP: initiation, examinations, and diagnosis and treatment. Individuals with limited education, those residing outside the capital, women, and those in the public health system encountered more barriers throughout their TTP.

Discussion

Study findings suggest that being a woman with low education, from the public health system, and not from the capital might represent one of the most powerful intersections for experiencing barriers to effective healthcare in LC in Chile. It is necessary to monitor the TTP from an SDH perspective to guarantee the rights of access, opportunity, quality, and financial protection.

Interventions Designed to Increase the Uptake of Lung Cancer Screening: An Equity-Oriented Scoping Review

Introduction

Participation in lung cancer screening (LCS) is lower in populations with the highest burden of lung cancer risk (through the social patterning of smoking behavior) and lowest levels of health care utilization (through structurally inaccessible care) leading to a widening of health inequities.

Methods

We conducted a scoping review using the Arksey and O'Malley methodological framework to inform equitable access to LCS by illuminating knowledge and implementation gaps in interventions designed to increase the uptake of LCS. We comprehensively searched for LCS interventions (Ovid Medline, Excerpta Medica database, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus from 2000 to June 22, 2021) and included peer-reviewed articles and gray literature published in the English language that describe an intervention designed to increase the uptake of LCS, charted data using our previously published tool and conduced a health equity analysis to determine the intended-unintended and positive-negative outcomes of the interventions for populations experiencing the greatest inequities.

Results

Our search yielded 3572 peer-reviewed articles and 54,292 pieces of gray literature. Ultimately, we included 35 peer-reviewed articles and one gray literature. The interventions occurred in the United States, United Kingdom, Japan, and Italy, focusing on shared decision-making, the use of electronic health records as reminders, patient navigation, community-based campaigns, and mobile computed tomography scanners. We developed an equity-oriented LCS framework and mapped the dimensions and outcomes of the interventions on access to LCS on the basis of approachability, acceptability, availability, affordability, and appropriateness of the intervention. No intervention was mapped across all five dimensions. Most notably, knowledge and implementation gaps were identified in dimensions of acceptability, availability, and affordability.

Conclusions

Interventions that were most effective in improving access to LCS targeted priority populations, raised community-level awareness, tailored materials for sociocultural acceptability, did not depend on prior patient engagement/registration with the health care system, proactively considered costs related to participation, and enhanced utilization through informed decision-making.

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.

Disparities in the survival of endometrial cancer patients in a public healthcare system: A population-based cohort study

OBJECTIVE

Social determinants of health (SDH) have been shown to correlate with adverse cancer outcomes. It is unclear if their impact goes beyond behavioral risk or healthcare access. We aimed to evaluate the association of SDH with endometrial cancer outcomes in a public healthcare system.

METHODS

A retrospective cohort study of endometrial cancer patients diagnosed between 2009 and 2017 in Ontario, Canada. Clinical and sociodemographic variables were extracted from administrative databases. Validated multifactorial marginalization scores for domains of material deprivation, residential instability and ethnic concentration were used. Associations between marginalization and survival were evaluated using log-rank testing and Cox proportional hazards regression.

RESULTS

20228 women with endometrial cancer were identified. Fewer patients in marginalized communities presented with early disease (70% vs. 76%, p < 0.001) and received surgery (89% vs. 93%, p < 0.001). Overall survival was shorter among marginalized patients (p < 0.001). On multivariable analysis adjusted for patient and disease factors, overall marginalization (HR = 1.22, 95% CI 1.03-1.08), material deprivation (HR = 1.22, 95% CI 1.10-1.35) and residential instability (HR = 1.32, 95% CI 1.19-1.46) were associated with increased risk of death (p < 0.001).

CONCLUSIONS

Socioeconomic marginalization is associated with an increased risk of death in endometrial cancer patients. Targetable events in the cancer care pathway should be identified to improve health equity.

FUNDING

This study was supported by a grant (#RD-196) from the Hamilton Health Sciences Juravinski Hospital and Cancer Center Foundation.

Access Denied: Nurses' Perspectives of Access to Oncology Care Among Indigenous Peoples in Canada

Inequitable access to oncology care is a significant issue among Indigenous Peoples in Canada; however, the perspectives of oncology nurses have not been explored. Guided by an interpretive descriptive methodology, we explored nurses' perspectives on access to oncology care among Indigenous Peoples in Canada. Nurses described the health care system as "broken" and barriers to accessing oncology care as layered and compounding. Lack of culturally safe care was articulated as a significant issue impacting equitable access, while biomedical discourses were pervasive and competed with nurses' attempts at providing culturally safe and trauma- and violence-informed care by discounting the relational work of nurses.

EQUIP emergency: can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?

Background

Despite a publicly funded system, health care in Canada has been shown to be deeply inequitable, particularly toward Indigenous people. Based on research identifying key dimensions of equity-oriented health care as being cultural safety, harm reduction and trauma- and violence-informed care, an intervention to promote equity at the organizational level was tested in primary health care, refined and adapted, and tested in Emergency Departments (EDs).

Methods

In partnership with clinical, community and Indigenous leaders in three diverse EDs in one Canadian province, we supported direct care staff to tailor and implement the intervention. Intervention activities varied in type and intensity at each site. Survey data were collected pre- and post-intervention from every consecutive patient over age 18 presenting to the EDs (n = 4771) with 3315 completing post-visit questions in 4 waves at two sites and 3 waves (due to pandemic constraints) at the third. Administrative data were collected for 12 months pre- and 12 months post-intervention.

Results

Throughout the study period, the participating EDs were dealing with a worsening epidemic of overdoses and deaths related to a toxic drug supply, and the COVID 19 pandemic curtailed both intervention activities and data collection. Despite these constraints, staff at two of the EDs mounted equity-oriented intervention strategies; the other site was experiencing continued, significant staff shortages and leadership changeover. Longitudinal analysis using multiple regression showed non-significant but encouraging trends in patient perceptions of quality of care and patient experiences of discrimination in the ED. Subgroup analysis showed that specific groups of patients experienced care in significantly different ways at each site. An interrupted time series of administrative data showed no significant change in staff sick time, but showed a significant decrease in the percentage of patients who left without care being completed at the site with the most robust intervention activities.

Conclusions

The trends in patient perceptions and the significant decrease in the percentage of patients who left without care being completed suggest potential for impact. Realization of this potential will depend on readiness, commitment and resources at the organizational and systems levels.

Trial registration

Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).

"My Cancer Is Worth Only Fifteen Weeks"? A Critical Analysis of the Lived Experiences of Financial Toxicity and Cancer in Canada

BACKGROUND

Cancer patients experience financial hardship due to rising expenses related to cancer treatment and declining income levels associated with reduced employability. Employment Insurance Sick Benefits (EI-SB) is a social income support program which provides temporary income replacement to Canadians when they fall ill. Although EI-SB is designed to maintain continuity of income during an illness, little is known about the perspectives of cancer patients who receive EI-SB. This knowledge can inform the development of public policies which are responsive to the needs and priorities of cancer patients.

METHODS

We conducted a theory-informed thematic analysis of data collected from twenty semi-structured interviews with participants who were receiving care in a cancer centre in Cape Breton, Nova Scotia and had received EI-SB. A coding framework was developed using Taplin and colleagues' intermediate outcomes of patient care across the cancer care continuum. Interpretation of findings was guided by the synergies of oppression theoretical lens.

RESULTS

Three overarching themes describe the experiences of cancer patients receiving social income support: Economic exclusion, in which the structure of the labour market and social welfare system determine access to workplace benefits and continuity of reasonable income; financial toxicity, a vicious cycle of financial burden and increasing financial distress; and constrained choices, where cancer influences employability and lowered income influences the need to be employed.

CONCLUSION

Cancer patients need income support programs that are tailored to match their healthcare priorities. In addition, policies which strengthen working conditions and facilitate a reintegration to work when possible will be important in addressing the structural drivers of income insecurity experienced by cancer patients.

Distinguishing symptom patterns in adults newly diagnosed with cancer: a latent class analysis

CONTEXT

Socio-demographic differences, including place of residence, socio-economic status, ethnicity, and gender, have been associated with various inequities in cancer care outcomes.

OBJECTIVES

The aims were to distinguish subgroups of patients with different symptom patterns at the time of the initial oncology visit and determine which clinical and socio-demographic variables are associated the different symptom patterns.

METHOD

Responses to the Edmonton Symptom Assessment Scale- revised and clinical and socio-demographic variables were obtained via the Ontario Cancer Registry and linked health data files. Latent class analyses were conducted to identify and compare the subgroups.

RESULTS

The cohort (n = 216,110) with a mean age of 64.5 years consisted of 54.1% women. The analyses identified six latent classes (proportions ranging from 0.09 to 0.31) with distinct symptom patterns, including: 1) many severe symptoms, 2) many less severe symptoms, 3) predominantly mild symptoms, 4) severe psychosocial symptoms, 5) severe somatic symptoms, 6) few symptoms. The subgroups were associated not only with clinical differences (diagnoses and functional status), but also with various socio-demographic (age, sex) and community characteristics (neighborhood income, proportion of foreign born, rurality).

CONCLUSION

The results indicated that there were substantial differences in symptom patterns at the time of the initial oncology visit, which were associated with both clinical diagnoses and socio-demographic differences. These results point to the importance of taking the social situation of patients into account, and not just diagnosis, to better understand differences in symptom patterns of people living with cancer.

Toward equitable access to oncology care for Indigenous Peoples in Canada: Implications for nursing

As a result of overlapping social, economic, historical, and political influences, and intersecting experiences of racism, stigma and discrimination within healthcare, Indigenous Peoples in Canada experience inequitable access to healthcare and oncology care. The aim of this paper is to highlight some of the barriers contributing to inequitable access to oncology care, research examining oncology nurses' perspectives on these barriers and their roles in addressing barriers, and implications for nursing practice. Importantly, the role of nurses is not often considered in relation to healthcare access. By highlighting recent research evidence, I aim to open space to see the valuable work of oncology nurses, and to consider where and how we, as a profession, could better address inequities in access to oncology care for Indigenous Peoples.

Vers un accès équitable aux soins oncologiques pour les peuples autochtones du Canada : implications pour la pratique infirmière

Les peuples autochtones du Canada ne disposent pas d’un accès équitable aux soins de santé et aux soins oncologiques à cause de facteurs sociaux, économiques, historiques et politiques qui se recoupent tous les uns les autres, et auxquels s’ajoutent éventuellement le racisme, les préjugés et la discrimination qu’ils subissent dans le système de santé. Le but du présent article est de faire ressortir certains des obstacles empêchant un accès équitable aux soins oncologiques, de présenter les recherches portant sur ces mêmes obstacles vus selon la perspective des infirmières en oncologie et le rôle qu’elles jouent pour les abolir, et de décrire les implications pour la pratique infirmière. Plus important encore, la question de l’accès aux soins est rarement abordée sous l’angle du rôle des infirmières. Cet article se veut un espace pour souligner le précieux travail des infirmières en oncologie et pour examiner comment et où nous pourrions, comme profession, mieux combattre les inégalités d’accès aux soins oncologiques pour les peuples autochtones.

Toward equity-oriented cancer care: a Strategy for Patient-Oriented Research (SPOR) protocol to promote equitable access to lung cancer screening

BACKGROUND

Screening for lung cancer with low dose CT can facilitate the detection of early-stage lung cancers that are amenable to treatment, reducing mortality related to lung cancer. Individuals are considered eligible for lung cancer screening if they meet specific high-risk criteria, such as age and smoking history. Population groups that are at highest risk of lung cancer, and therefore, the target of lung cancer screening interventions, are also the least likely to participate in lung cancer screening. This can lead to a widening of health inequities. Deliberate effort is needed to both reduce lung cancer risk (through upstream interventions that promote smoking cessation) as well as midstream interventions that promote equitable access to lung cancer screening.

METHODS

This protocol paper describes an equity-informed patient-oriented research study. Our study aims to promote equitable access to lung cancer screening by partnering with patients to co-design an e-learning module for healthcare providers. The learning module will describe the social context of lung cancer risk and promote access to lung cancer screening by increasing equity at the point of care. We have applied the Generative Co-Design Framework for Healthcare Innovation and detail our study processes in three phases and six steps: Pre-design (establishing a study governance structure); Co-design (identifying research priorities, gathering and interpreting data, co-developing module content); and Post-design (pilot testing the module and developing an implementation plan).

DISCUSSION

Patient engagement in research can promote the design and delivery of healthcare services that are accessible and acceptable to patients. This is particularly important for lung cancer screening as those at highest risk of developing lung cancer are also those who are least likely to participate in lung cancer screening. By detailing the steps of our participatory co-design journey, we are making visible the processes of our work so that they can be linked to future outcomes and related impact, and inform a wide range of patient co-led processes.

Equity-Oriented Healthcare: What It Is and Why We Need It in Oncology

Alarming differences exist in cancer outcomes for people most impacted by persistent and widening health and social inequities. People who are socially disadvantaged often have higher cancer-related mortality and are diagnosed with advanced cancers more often than other people. Such outcomes are linked to the compounding effects of stigma, discrimination, and other barriers, which create persistent inequities in access to care at all points in the cancer trajectory, preventing timely diagnosis and treatment, and further widening the health equity gap. In this commentary, we discuss how growing evidence suggests that people who are considered marginalized are not well-served by the cancer care sector and how the design and structure of services can often impose profound barriers to populations considered socially disadvantaged. We highlight equity-oriented healthcare as one strategy that can begin to address inequities in health outcomes and access to care by taking action to transform organizational cultures and approaches to the design and delivery of cancer services.

Building Equitable Patient Partnerships during the COVID-19 Pandemic: Challenges and Key Considerations for Research and Policy

The unequal social and economic burden of the COVID-19 pandemic is evident in racialized and low-income communities across Canada. Importantly, social inequities have not been adequately addressed and current public policies are not reflective of the needs of diverse populations. Public participation in decision-making is crucial and there is, therefore, a pressing need to increase diversity of representation in patient partnerships in order to prevent the further exclusion of socially marginalized groups from research and policy making. Deliberate effort and affirmative action are needed to meaningfully engage and nurture diverse patient partnerships by broadening the scope of the patient community to include excluded or underrepresented individuals or groups. This will help us co-develop ways to enhance access and equity in healthcare and prevent the systematic reproduction of structural inequalities that have already been heightened by the COVID-19 pandemic.

Interventions designed to increase the uptake of lung cancer screening and implications for priority populations: a scoping review protocol

BACKGROUND

When designing any health intervention, it is important to respond to the unequal determinants of health by prioritising the allocation of resources and tailoring interventions based on the disproportionate burden of illness. This approach, called the targeting of priority populations, can prevent a widening of health inequities, particularly those inequities which can be further widened by differences in the uptake of an intervention. The objective of this scoping review is to describe intervention(s) designed to increase the uptake of lung cancer screening, including the health impact on priority populations and to describe knowledge and implementation gaps to inform the design of equitable lung cancer screening.

METHODS

We will conduct a scoping review following the methodological framework developed by Arksey and O'Malley. We will conduct comprehensive searches for lung cancer screening promotion interventions in Ovid Medline, Embase, the Cochrane Library, Cumulative Index to Nursing & Allied Health (CINAHL) and Scopus. We will include published English language peer-reviewed and grey literature published between January 2000 and 2020 that describe an intervention designed to increase the uptake of low-dose CT (LDCT) lung cancer screening in the Organization for Economic Cooperation and Development countries. Articles not in English or not describing LDCT will be excluded. Three authors will review retrieved literature in three steps: title, abstract and then full text. Three additional authors will review discrepancies. Authors will extract data from full-text papers into a chart adapted from the Template for Intervention Description and Republication checklist, the Consolidated Standards of Reporting Trials and a Health Equity Impact Assessment tool. Findings will be presented using a narrative synthesis.

ETHICS AND DISSEMINATION

The knowledge synthesised will be used to inform the equitable design of lung cancer screening and disseminated through conferences, publications and shared with relevant partners. The study does not require research ethics approval as literature is available online.

Disparities in surgical management of endometrial cancers in a public healthcare system: A question of equity

OBJECTIVE

Timely surgery has been shown to impact outcome in endometrial cancer patients. Social determinants of health (SDH) are associated with adverse cancer outcomes. We sought to evaluate the association of SDH with surgical treatment indicators in endometrial cancer patients in a public healthcare system.

METHODS

Endometrial cancer patients in Ontario, Canada, diagnosed between 2009 and 2017 were identified, and clinical, social and demographic variables were extracted from administrative databases. Validated community marginalization scores that include material deprivation, residential instability and ethnic concentration were used for stratification. Surgical treatment features were compared across marginalization quintiles using chi-square, Fischer exact or Wilcoxon rank sum tests as appropriate. Predictors of timely surgical treatment were evaluated with logistic regression.

RESULTS

20228 patients were identified of whom 14,423 had primary hysterectomy for a preoperative diagnosis of endometrial cancer. Fewer patients in marginalized communities received surgery (89% vs. 93%, p < 0.001). Surgical delay was longer among marginalized patients and 78% had surgery within 12 weeks compared to 84% of those least marginalized (p < 0.0001). Other quality indicators of surgical treatment were not negatively associated with marginalization. On multivariable analysis adjusted for patient and disease factors, marginalization was independently associated with increased odds of delayed surgery (OR = 0.94/quintile, CI 0.91-0.97, p < 0.001).

CONCLUSIONS

Social marginalization is associated with decreased likelihood of having surgery and with delayed surgery among endometrial cancer patients in Ontario. This may be mediated by delayed presentation and real or perceived barriers to access. Reducing surgical wait times among marginalized cancer patients is an important deliverable in public healthcare.