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ca/GHAR

RESEARCH ARTICLE

Strategies For Improving Access To Cancer Screening

Services For Indigenous Women In Canada: A Scoping
Review

Bhajan Gill, Western University; Maren Kimura, Western University; Nikita Singh,
Western University; Esohe Ogbomo, Western University; Chantal Gillett, Western
University; Zihuang Zhang, Western University; Yue Jia, Western University.

ABSTRACT

High cancer rates among Indigenous women are associated with barriers to accessing cancer screening
programs. The purpose of this scoping review is to uncover the social, political, and economic barriers that
negatively impact Indigenous women’s access to cancer screening services. Peer-reviewed literature was
screened, yielding 21 studies that met the inclusion criteria. The studies found that many structural barriers
affecting Indigenous women are primarily rooted in pre-existing sociohistorical conditions established
through colonization and forced cultural assimilation. Barriers include mistrust in the healthcare system,
limited access to healthcare services and information, and other healthcare inequities. Health literacy and
cultural competency were identified as having the most significant impact on addressing health disparities
related to cancer screening uptake. Moving forward, health systems must build upon the existing strengths
of Indigenous communities to improve health literacy and incorporate cultural competence into care
delivery.

INTRODUCTION funding [1]. Additional barriers include complex

healthcare navigation, historical trauma, and limited
In Canada, Indigenous women experience culturally safe and accessible care [5,6].
disproportionate barriers to accessing cancer
screening services, resulting in higher incidence and Indigenous women are more likely to be diagnosed
mortality rates from common cancers (e.g., breast with late-stage cancer than non-Indigenous women
and cervical cancers) compared to non-Indigenous [1]. Through effective cancer screening programs,
individuals [1-3]. Despite significant breakthroughs early detection can target cases at their most
in cancer research, screening, and treatment, these treatable stages and is among the most effective
advancements are not accessible to all populations, ways to reduce cancer-related morbidity [1]. A multi-
and disparities persist [1,4]. These disparities stem faceted approach is needed to address these
from intersecting factors related to historical and historical and structural injustices and understand
ongoing colonial policies such as residential schools, the breadth of this issue. This scoping review was
lack of on-reserve screening services, and limited conducted to identify the social, political, and
trained healthcare professionals, resources, and economic barriers that impact cancer screening

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accessibility among Indigenous women in Canada. RESULTS

METHODOLOGY The search strategy yielded 145 peer-reviewed

articles. After screening, 21 studies met the inclusion
Two electronic databases, PubMed and Medline criteria, and 124 studies were excluded (Figure 1).
(OVID), were screened for peer-reviewed articles Included studies were conducted across Canada
using key search terms (Table 1). Reviewers applied and reflected data from various Indigenous groups.
the eligibility criteria to a 10-year period to capture Studies used a variety of qualitative, quantitative,
the most recent and applicable sources for inclusion and mixed methodologies, and some included
(Table 2). The search strategy was not limited by international groups for comparison [7]. Additionally,
study design, and “cancer screening” was kept broad three reviews were included [1,6,7]. A variety of
due to limited literature investigating cancer female health screening services were examined,
screening related to Indigenous female health. with fourteen studies focusing on cervical cancer
Additionally, broad search terms were used to [2,3,7-18], one study focusing on breast cancer [4],
include several Indigenous groups across Canada. and six studies focusing on multiple types of female
cancer screening [1,5,6,19-21]. Studies also
Table 1: Key Search Terms investigated program implementation to examine
community uptake of screening services
[5,10,12,13,18]. Furthermore, several studies explored
strategies for tackling barriers affecting Indigenous
women’s ability to access cancer screening services
[1,2,6,10,13,17].

Table 2: Inclusion and Exclusion Criteria

Figure 1: Source selection process

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DISCUSSION Areas of Impact

Multiple studies revealed that Indigenous women Health Literacy

experience significantly more health inequities
compared to the general population, especially Multiple studies highlighted low health literacy as a
related to cancer screening [9,13,19,20]. This review prominent barrier to accessing cancer screening
uncovered several barriers faced by Indigenous services for Indigenous women. Tratt et al. indicated
women accessing cancer screening services and that the greatest barrier Indigenous women face
highlighted improving health literacy and cultural towards obtaining screening services was an
competency in cancer care as impactful strategies insufficient understanding of health information [15].
to reduce inequities. Low health literacy included issues of language
barriers, inadequate communication, disparities in
Barriers to Care accessing technology, and stigmas and sensitivities
surrounding sexual health promotion and treatment
This review indicated that Indigenous women face [7]. Improving health literacy requires a greater focus
several social, economic, and political barriers to on education and disseminating screening
accessing cancer screening services in Canada. information to support health system navigation for
Many structural barriers affecting Indigenous Indigenous women [5]. Several studies emphasized
women are rooted in pre-existing sociohistorical that providing education through storytelling and
conditions and government policies established visual communication (e.g., pictures) indicated
through colonization and forced cultural higher levels of screening service engagement [5,10].
assimilation of Indigenous Peoples [2]. For example, Additionally, hosting activities such as community-
mandatory relocation to residential schools for tailored screening events has been shown to
Indigenous children contributed to power improve attitudes towards cancer screening [13,12].
imbalances that hindered Indigenous women's
abilities to access proper healthcare services [13]. Cultural Competency
Moreover, policies that created jurisdictional
divisions between on- and off-reserve Indigenous Another area of impact was increasing access to
communities further reduced access to healthcare culturally competent care for Indigenous women,
information [13,11]. These factors have contributed to whereby awareness campaigns and screening
women’s experiences of discrimination and feelings initiatives were common methods of providing
of mistrust towards the healthcare system, deterring effective and accessible messaging [13]. Screening
cancer screening service utilization and initiatives that account for cultural preferences can
exacerbating healthcare disparities [5,13]. Alongside empower Indigenous women to take initiative over
intergenerational trauma associated with their health care and increase their trust in
colonization, studies identified other structural healthcare systems [16]. Furthermore, multiple
barriers faced by Indigenous women, including lack studies highlighted the need for educational
of culturally competent healthcare providers and programs for healthcare professionals to increase
services, poor health literacy, socioeconomic understanding of culturally competent care and
inequalities, geographical barriers, constraints on structural barriers faced by Indigenous women
resources, and a lack of recall-based screening [8,16,17]. Moreover, these programs are more
systems [14,8,5]. effective when led or developed in partnership with
Indigenous communities [1,17].

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Historical factors associated with cultural genocide Residence, healthcare information, ethnicity, and
and experiences of abuse or violence should also be status [1]. Finally, many study methodologies were
acknowledged, as they can lead to reluctance in subject to self-report bias [3,4,8,9,17,19,20].
accessing cancer services [14]. Evidence indicates
screening rates improve when policies and services CONCLUSION
promote and respect the experiences and values of
Indigenous women [11,17]. Additionally, patient- This review has exposed core social, political, and
provider trust is a necessary element for fostering economic barriers that can reduce Indigenous
patient acceptance of screening processes that may women’s access to cancer screening services and
be potentially unfamiliar or invasive (e.g., Pap tests) perpetuate health inequities. Moving forward, health
[5,11,16]. A key component of trusting relationships is systems must build upon the existing strengths of
effective communication. Tratt et al. indicated that Indigenous communities to improve health literacy
effective healthcare provider communication, and incorporate cultural competence into care
specifically visual communication, acknowledged delivery. Future policies, programs, and research
cultural competencies were highly influential must aim to reduce the overall burden of cancer
towards Inuit women accessing cancer screening within Indigenous communities and strive toward
services [15]. Other strategies for promoting effective eliminating structural barriers. To address the
communication included using traditional limitations of current cancer screening initiatives,
storytelling methods, hosting face-to-face collaborative efforts must be made to challenge
workshops, and collaborating with a community systemic biases within our healthcare system and
liaison to address language and cultural barriers incorporate diverse perspectives of Indigenous
[5,10]. communities into future program implementation.

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