New guideline to promote health equity in Canada

A comprehensive new guideline with 16 preventive care recommendations aims to promote health equity for people disadvantaged because of racism, sexism and other forms of discrimination.

The guideline, created by a diverse team of clinicians from across Canada with patient involvement, is published in CMAJ (Canadian Medical Association Journal).

Preventive care includes screening for certain cancers and heart conditions, blood testing for tuberculosis, self-testing for diseases like HIV and other practices to detect a condition before it progresses. However, many people face barriers to accessing preventive care, such as Indigenous people, racialized people, people who identify as 2SLGBTQI+ (2-spirit, lesbian, gay, bisexual, transgender, queer or questioning and intersex), people with functional limitations and those with low incomes.

"Preventive care such as screening for certain cancers can save lives, but access to this care is not equitable for many reasons, including poor connections with primary care, limited availability to attend appointments, mistrust of health care and discriminatory practices in the health system," said guideline co-lead Dr. Nav Persaud, Canada Research Chair in Health Justice at the University of Toronto and a family physician at Unity Health Toronto, Toronto, Ontario.

"Stigmatization related to mental health, substance use, HIV and other infectious diseases is a barrier to care, especially for people experiencing disadvantages."

The authors make 15 screening and preventive care recommendations for primary care as well as one policy recommendation aimed at government to improve primary care for people experiencing disadvantages.

"By prioritizing people who are disadvantaged in the health care system for preventive care like cancer and heart disease screening, we can promote health and make health outcomes more equitable or fair," said Dr. Aisha Lofters, a scientist and family physician at Women's College Hospital and associate professor, University of Toronto, Toronto, Ontario.

The authors also recommend removing cost barriers, such as costs for bowel preparations for colorectal cancer screening, tests for HPV, tuberculosis and other diseases, and costs for treatment, counseling and any other out-of-pocket health expenses.

"The 16 recommendations focused on health equity represent perhaps the largest change to preventive care in decades, including changes in the starting age for colorectal cancer screening, depression screening, how cervical cancer screening and tuberculosis testing is done," said Dr. Lofters. "As well, we recommend new screening aimed at providing evidence-based health care interventions to address serious threats to health such as intimate partner violence."

Some key recommendations include:

• Colorectal cancer—prioritize colorectal cancer screening for patients starting at age 45 years (rather than the current recommendation of 50 years)
• Cervical cancer—offer self-testing to people eligible for cervical cancer screening
• Tuberculosis—use a blood test to screen for latent tuberculosis (rather than a skin test that requires several visits)
• Depression—screen for depression along with providing appropriate supports in adolescents and adults
• Poverty—in all families with children, screen for social risk factors, such as poverty or the ability to afford basic necessities, and connect with resources and supports
• Primary care access—prioritize connection to primary care, with automatic enrollment in a primary care practice similar to the way children are automatically enrolled in local schools

Find an easy-to-read table with all 16 recommendations and the guideline here.

A decision tool, http://www.screening.ca, can help primary care professionals prioritize people for preventive care.

The guideline is based on the latest evidence and also includes input from people with lived experience and studies on patient values and preferences.

To ensure equitable implementation, government funding is needed. "Some long overdue changes will require government action," urges Dr. Persaud. "This includes publicly funding blood (IGRA) testing for tuberculosis, HPV self-testing as cervical cancer screening, and major investments to ensure everyone has a family doctor (or primary care provider)."