A fresh approach to preventive care is overdue to make health outcomes more fair. Inequities based on racialization, income and gender mean that we need to urgently change the way care is provided. Lives hang in the balance, especially for those who face barriers to care.
We worked with a national panel of colleagues and patients, all knowledgeable about health equity and many with lived experience of disadvantages, to develop guidance on how to ensure everyone gets the preventive care they need, like cancer screening. It’s easy to bemoan inequities and idly suggest things should be different — our focus was on the specific actions that need to be taken.
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Home testing
Outdated ways of providing care — like expecting patients to attend a clinic for a pelvic exam that is, at best, uncomfortable, and at worst, traumatizing, for cervical cancer screening — can lead to poor outcomes. In the case of cervical cancer screening, those outcomes can include delayed diagnosis of cervical cancer.
Self-testing for the virus that causes cervical cancer is at least as accurate as the traditional approach of Pap tests that require a pelvic exam. Some patients avoid pelvic exams due to the inconvenience and discomfort, and survivors of sexual abuse might opt out of screening to avoid being re-traumatized.
The technology needed for self-testing has been around for years. Studies have shown that it helps connect people with care in addition to being cost-effective. While the main benefit of self-testing is better access to screening for patients, avoiding visits also frees up physician time.
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Skin testing for tuberculosis exposure — which requires an initial visit to implant the test in the forearm, and a return visit two or three days later to read the test — is another example of an old practice that can take a back seat to a more efficient approach.
Many people who have made two trips for a skin test might be surprised to learn there is a blood test that is likely more accurate, especially for those who have been vaccinated. The test is not expensive or new. It can be done today. But, like self-testing for cervical cancer, it needs to be publicly funded for everyone.
Self-testing for HIV can also remove the need for patients to attend an appointment and wait to receive a result. The answer can be available in minutes and with tests that are available from vending machines as part of a pilot program.
With self-testing, there is also no need for patients to worry about being asked leading questions or being judged by a doctor when they request a test. Self-testing for HIV is an example of an innovation that can help both individuals and the population by reducing the spread of HIV.
Better access to screening
Current guidelines in Canada assume that people will receive periodic assessments of their mental health. But we know that many people do not receive routine primary care. We also know that income, as well as other social factors such as racialization and gender identity, can determine access to care, in part because some face discrimination within the health-care system.
For these reasons, we recommend routine screening for depression for people experiencing disadvantages.
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Likewise, we suggest that people experiencing disadvantages be screened for colorectal cancer starting at age 45 years, while the recommendation for the general population is to start at age 50.
Our recommendation for an earlier start is based on the fact that earlier screening prevents deaths, there are disparities in cancer outcomes based on social factors, and screening does not always start when patients are first notified.
High blood pressure is sometimes referred to as a “silent killer” because it usually causes no symptoms but it can result in a heart attack or a stroke. We recommend blood pressure checks every three to five years — together with a comprehensive assessment of cardiovascular risk — to ensure people have appropriate access to life-saving medicines that have helped to extend life expectancy.
Justice in access to care
In an ideal world, guidance that prioritizes the health of those facing discrimination and disadvantages would not be needed. Life would be fair, care would be equitable and health outcomes would be level. But our world is not ideal.
We can actually achieve something better than “equal” treatment; we can achieve justice when it comes to access to life-saving preventive care by reaching out to those who need the most support.
One part of that is empowering patients and members of the public by informing them about the care they should be offered. You can visit screening.ca to be provided with a custom list of recommended interventions based on your age and answers to some yes-or-no questions.
Focusing on the needs of those who are treated unfairly could ultimately lead to improvements for everyone. Once the capacity of HPV testing is increased, self-testing will likely become a standard approach to cervical cancer screening, as it already has in Australia. We could start with preventive care in redesigning health care for those who need it the most.
We also need to reflect on why the unfair status quo has persisted for so long. Governments and large health-care institutions have all made grand statements about the need to tackle sexism, racism, ableism and other forms of discrimination. It is long past time for those institutions to fund and support specific actions to help those who have been disadvantaged by previous inaction.
Nav Persaud receives funding from the Canadian Institutes of Health Research, the Canada Research Chairs program and the Ontario SPOR Support Unit.
Aisha Lofters receives funding from the Canadian Institutes of Health Research, the Canadian Cancer Society, the Peter Gilgan Centre for Women’s Cancers at Women’s College Hospital, and Pfizer/ReThink Breast Cancer.
