TAIBU Community Health Centre executive director Liben Gebremikael, left, and Dr. Onye Nnorom have helped reach out to the Black community to get them routinely screened for breast, cervical and colorectal cancers.Carlos Osorio/The Globe and Mail
An east Toronto community health centre that primarily serves Black patients went from having abysmal screening rates for breast, cervical and colorectal cancers to ones that surpassed provincial averages in just a few years. The secret to this turnaround? An approach that advocates for health-care providers’ “cultural humility,” which can include anything from using Black models in informational posters to avoiding the word “cancer” when trying to get patients to schedule appointments.
The seven-year efforts of staff at TAIBU Community Health Centre, which are documented in a new paper in the journal Canadian Family Physician, drastically improved rates of screenings for breast, colorectal and cervical cancers. (In Ontario, screening rates are reported by offers made to patients, rather than tests completed. Offers increased from 17 per cent to 72 per cent, 18 per cent to 67 per cent, and 59 per cent to 70 per cent, respectively, between 2011 and 2018; the peer-reviewed paper’s authors document in detail why this is a reliable proxy for completed tests.)
The paper’s authors conclude that simple, culturally appropriate and community-led interventions can have dramatic results with Black and immigrant populations, groups whose low screening rates put them at increased risk.
Though comparable data are not available in Canada, American research has found that Black women are 40-per-cent more likely to die from breast cancer than white women – and experts attribute that in large part to delayed screenings.
“We know screening can save lives,” says Liben Gebremikael, the executive director at TAIBU, which serves a population in the Malvern area of Scarborough that is 85-per-cent foreign-born and 59-per-cent Black. “Even when it comes to cost, by doing this prevention and early identification and early intervention, you are really saving the system lots of investments and services down the line.”
In 2013, after a review of its low testing rates, TAIBU created a program to address barriers its patients faced structured around the Afrocentric principle of Ubuntu, which in Bantu means “I am because we are” and stresses the well-being of the collective.
The first step of the program was getting the health centre’s administrative assistants to call all patients who were overdue for a breast, colorectal or cervical cancer screening and, crucially, avoiding the term “cancer” on the phone when doing so.
It’s a word that carries a lot of stigma in some Black communities, explained Onye Nnorom, a family physician who helped develop the program at TAIBU and is Black Health Theme Lead for the University of Toronto’s Temerty Faculty of Medicine.
“With cancer, sometimes there’s a belief that perhaps God is punishing you, or something terrible is happening, or it’s a death sentence,” said Dr. Nnorom, who is also president of the Black Physicians’ Association of Ontario. “The recommendation was that if we were talking about cancer screening, to frame it as ‘preventive care’ if we’re talking to people over the phone, so that they don’t panic or don’t have kind of a visceral reaction to the word.”
Once they came in for an appointment, nurses and physicians’ assistants would explain more about the screenings and why they were important. At that point it would be safer to use the word cancer, when it could be better contextualized. Since it was nurses and physicians’ assistants – rather than overextended primary-care physicians – who were usually having these conversations with patients, there wasn’t the usual rush of a doctor’s appointment or the one-issue-per-visit rule to adhere to.
In its efforts to destigmatize cancer screenings, TAIBU staff put up posters, developed informational pamphlets and shared videos that featured racialized models.
Central to this new program was learning “cultural humility,” says Dr. Nnorom. When doctors, nurses and physicians’ assistants provide an emotionally safe space for their patient, without making judgments or assumptions about them, the patient feels empowered to share their opinion.
“You’re not going to get that if it’s an environment where a patient feels like the provider doesn’t care or is going to mock them or shame them,” she said.
TAIBU’s primary focus is on Black patients, a population that is extremely diverse and required different approaches, Mr. Gebremikael said.
He found that some patients who were newcomers, often immigrants from the African continent, were completely unfamiliar with a health care system such as Canada’s and had many concerns about the implications of getting tested. “Sometimes it’s the concern of, ‘What if my screening comes up positive?’” he said, because they would then have to navigate new terrain that could feel overwhelming.
When designing this program, staff learned that many Muslim patients declined screening appointments if they were offered during Ramadan. Simply shifting the program dates to fall helped clear that barrier, and had the added benefit of getting patients immunized against influenza when they came in for a visit.
As important as improving screening rates is, it’s not enough to close the gap in outcomes between white and racialized patients who are diagnosed with cancer.
A major data set in the U.S. found the seven-year survival rate from breast cancer for African-American women was significantly worse than it was for white women, even when the cancer was detected at Stage 1, points out Ophira Ginsburg, a Canadian oncologist and global women’s health expert who is currently a senior visiting scientist at the International Agency for Research on Cancer.
That, she said, speaks to issues beyond screening that are often tied to poverty – that apply even to Canada’s publicly funded health care system. Access to treatment could be complicated by language barriers, lack of drug insurance coverage and having to travel a long way to reach a hospital. At TAIBU, for example, 55 per cent of the patient population earn less than $35,000 a year.
“Our own studies showed that there are still differences in the ability for somebody to ‘adhere’ to the clinical-care pathway, for reasons that aren’t usually captured unless you have an interaction with a social worker in a cancer centre and learn that, ‘Oh, this woman doesn’t have added benefits so she can’t take time off work, or she has children at home and there’s nobody to help,’ ” she said.
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