Despite a publicly funded health system in Canada, participation in population-wide screening programs has not been universal. Differences in screening uptake are associated with income, education and immigrant status (4). Individuals who live with greater degrees of social disadvantage have a higher risk of some cancers and poorer overall survival; this is directly correlated with the social determinants of health and how they intersect across the cancer care continuum (25). Therefore, new interventions such as lung cancer screening must take into consideration differences in utilization and needs, which are based on social location. This is key to preventing an inadvertent widening of the health equity gap that already exists between population group. Our study sought to fill this knowledge gap in the context of lung cancer screening which is currently being pilot tested in the province of Ontario. Specifically, we wanted to understand the perspectives on choice for lung cancer screening in patients living with low income in order to inform the design and delivery of lung cancer screening as an organized program.
Through semi-structured interviews with individuals living with low income who chose to undergo or not undergo lung cancer screening, we found that participants’ interest in screening depended on the availability of adequate housing, which subsequently empowered participants to seek care to advance their health and wellbeing. Further, clinical encounters created a space that needed to be navigated without personal bias and with sociohistorical sensitivity. Participants who recounted their clinical encounters as places of judgment-free care had meaningful relationships with their physicians, and they subsequently trusted their physicians’ judgement and recommendations.
All participants in our study initiated smoking at a very early age, recounting cigarettes as being available, accessible and, “the thing to do”. Much of this context is related to the mass-marketing campaigns that ran across media stations and sensationalized smoking in the 1950’s and 1960’s (26). Since then, policies enacted to limit the marketing and use of tobacco products in public spaces have led to decreases in smoking rates across Canada. However, this distribution is skewed such that individuals living with socioeconomic disadvantage are more likely to smoke and less likely to cease smoking (27); this finding is closely reflected in our study, given that all 18 participants had attempted smoking cessation at least once, yet only three had quit successfully.
Given the homogenous nature of our study participants, gender-based differences in choice were not readily apparent. In Canada, females are less likely to smoke on a daily basis compared to men (28). Further, studies illuminate that smoking trajectories are different for women, with peer relationships (29) and educational disadvantage (30) profoundly affecting the initiation of smoking, patterns of daily consumption as well as the ability to succeed at smoking cessation (31). Data also points to the differences in smoking patterns for Lesbian, Gay, Bisexual, Trans, Two Spirit, Queer and other sexual and gender minority individuals (LGBT2SQ+), such that they are more likely to report nicotine dependence and higher rates of cigarette consumption beginning from early adolescence (32–34).
Recent studies have highlighted that willingness to quit smoking is equal across social classes; however, socially-disadvantaged smokers are more likely to: (i) live in an environment where they socialize and work with other socially-disadvantaged people for whom smoking is considered acceptable (35); (ii) use smoking as a way to relax and cope with high daily stress levels (36); and (iii) report experiences of disadvantaged childhood, educational and employment trajectories that shape the pattern and frequency of cigarette consumption (30).
In our study, the three participants who had successfully quit smoking reportedly quit because they became more proactive towards their own health once they had found housing; all three took part in LDCT lung cancer screening. Participants identified living conditions (housing) to be a key determinant of health and wellbeing, particularly in the context of a preventative health check such as lung cancer screening. Significantly, only those participants who had their own place to call home felt empowered enough to seek opportunities to advance their health and then take action to utilize the service of screening. Participants who chose not to undergo screening lived in diverse housing situations that were generally less secure (subsidized housing; homeless shelter). For these participants, lack of adequate housing was one barrier to care.
Another barrier was the attitude and influence of treating physicians, which determined participants’ willingness to continue to engage with the health system. For lung cancer screening, physicians are typically gatekeepers to and proponents of the service, and therefore have a critical role in ensuring equitable healthcare delivery. Our findings suggest that physicians and other healthcare practitioners must learn how to deliver care that is free of personal biases to prevent the perpetuation of oppression and the systemic reproduction of health inequities.
According to the “inverse equity hypothesis” (37) population-based health interventions are more rapidly adopted by the wealthy, a term described as “top inequality” (38). This is in contrast to “bottom inequality” which refers to the lag in adoption experienced by the poorest when the intervention has reached high coverage across the remainder of the population (Victora et al., 2005). Thus, individuals developing health interventions must recognize patterns of health inequality and adapt policies and processes to mitigate these effects (39) and prevent a widening of the health equity gap between socially advantaged and disadvantaged population groups (40). Midstream interventions (41, 42) geared at reducing cigarette consumption in the socially-disadvantaged are only likely to be truly successful if incorporated into a broader program that addresses the social context of smoking behavior. As a standalone intervention, nicotine replacement therapy is unlikely to be highly effective in influencing smoking behavior and reducing lung cancer risk for those who are socially-disadvantaged. Similarly, lung cancer screening as a midstream public health program may inadvertently increase health inequities unless proactive and multipronged strategies are in place to increase uptake. Screening programs may also neglect the underlying social context of smoking behavior, such that even if individuals are screened for lung cancer, they may continue to face increased lung cancer risk due to the daily stressors that influence their choice to continue smoking. This approach to care is ignorant of the lived realities of those at high-risk of developing lung cancer, the target population of the lung cancer screening program. An equity-focused approach to screening programs therefore, would demand attention to the social context of cancer risk and utilization rates based on social location.
Health systems can determine how to respond best to inequitable health intervention uptake by engaging with patients to identify strategies that enhance intervention effectiveness (43). Conducting future patient-oriented research that incorporates the lived experience of those at high-risk for lung cancer to guide the development of a multipronged approach (such as education, resources, and tools) can maximize the availability and accessibility of the intervention to the target population (44). This approach, called targeting within universalism implies that a universally available intervention must be accompanied by specific uptake strategies that positively discriminate towards those at highest risk (45).