Reflections of Homeless Women and Women with Mental Health Challenges on Breast and Cervical Cancer Screening Decisions: Power, Trust, and Communication with Care Providers

Abstract

This study conducted in Toronto, Canada, explored the perceptions of women living in homeless shelters and women with severe mental health challenges about the factors influencing their decision-making processes regarding breast and cervical cancer screening. Twenty-six in-depth qualitative interviews were conducted. The objectives of this research were (i) to provide new insights about women’s decision-making processes, (ii) to describe the barriers to and facilitators for breast and cervical cancer screening, and (iii) to offer recommendations for future outreach, education, and screening initiatives developed specifically for under/never-screened marginalized women living in urban centers. This exploratory study utilized thematic analysis to broaden our understanding about women’s decision-making processes. A constructed ontology1 was used in an attempt to understand and describe participants’ constructed realities. The epistemological framework was subjective and reflected co-created knowledge. The approach was hegemonic, values-based, and context-specific. The aim of the analysis was to focus on meanings and actions with a broader view to identify the interplay between participants’ narratives and social structures, medical praxis, and policy implications. Results from 26 qualitative interviews conducted in 2013–2014 provided insights on both positive and negative prior cancer screening experiences, the role of power and trust in women’s decision-making, and areas for improvement in health care provider/patient interactions. Outcomes of this investigation contribute to the future development of appropriately designed intervention programs for marginalized women, as well as for sensitivity training for health care providers. Tailored and effective health promotion strategies leading to life-long cancer screening behaviors among marginalized women may improve clinical outcomes, decrease treatment costs, and save lives.

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

“…Within the literature, across all health states, personalized care was broadly characterized as representing respectful behaviour toward the patient, providing care in a preferred language, healthcare provider (HCP) awareness about the needs of vulnerable populations and delivery of care that considered both social and medical needs ( 25 , 27 , 31 , 33 , 39 , 45 , 50 , 53 – 55 , 57 , 62 , 68 , 69 , 74 , 77 , 79 – 81 , 82 , 85 , 88 , 90 , 94 , 99 , 100 , 102 , 106 – 109 , 111 , 114 , 116 , 118 , 119 , 122 , 124 , 134 , 135 , 136 , 141 , 142 , 147 , 150 , 154 , 156 , 158 , 163 , 165 , 169 , 172 , 174 , 176 , 179 , 184 , 192 , 193 , 195 – 204 , 208 , 209 ). Consistent within the reviewed literature, patients and caregivers identified a preference for care that was holistic, individualized and culturally competent ( 19 , 28 , 53 , 69 , 74 …”

“…These supports were preferred to overcome barriers to accessing care among the walking well; those with chronic conditions; those with mental, cognitive and addiction-related issues; and those with acute life-threatening illnesses ( 19 , 28 , 39 , 55 , 72 , 76 , 90 , 94 , 99 , 116 , 121 , 124 , 129 , 132 , 134 , 147 , 150 , 154 , 168 , 169 , 172 , 178 , 195 , 198 , 200 , 201 , 208 ). The relationship between HCPs and patients was important across all of these health states.…”

“…In terms of variations across patient groups, for the walking well group, holistic care meant being able to access non-Western approaches to healthcare free of financial barriers, including traditional Chinese medicine ( 28 , 74 , 76 , 94 , 99 , 116 , 121 , 124 , 129 , 132 , 162 , 168 , 178 , 195 , 201 , 208 ). For the mental and cognitive health groups, holistic care specifically meant being able to access spiritual and culture-based services ( 39 , 55 , 72 , 90 , 147 , 150 , 169 , 172 , 189 , 198 , 200 ).…”

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

“…For example, people with severe mental illness have 92% higher odds of an advanced cancer at diagnosis than those without mental illness, while cancer-related deaths are two times higher among homeless adults and 1.7 times higher among individuals with severe mental illness compared to the general population [ 6 , 8 ]. Such outcomes are linked to the compounding effects of stigma and discrimination, often unintentional, 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 [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ].…”

“…For example, in our experiences as researchers and clinicians, we have seen how people who experience significant inequities are not able to access or proceed with appropriate treatment because they are unable to adhere to highly rigid schedules of chemo- or radiation therapy [ 17 , 29 ]. Moreover, within the current structure of the cancer care system, services are typically not designed to foster a sense of trust or emotional safety, align with the social-emotional needs of patients, or work in ways that explicitly aim to make patients who experience marginalization feel accepted and respected [ 17 , 19 , 25 , 28 ].…”