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Topic

Towards Advancing Health Equity in Cancer Care: Understanding the Barriers to Accessing Cancer Treatment for People who Experience Structural Vulnerability in Canada

School of Nursing

Date & location

• Thursday, March 26, 2026
• 4:00 P.M.
• Virtual Defence

Examining Committee

Supervisory Committee

• Dr. Kelli Stajduhar, School of Nursing, ̽��ϵ�� (Supervisor)
• Dr. Marilou Gagnon, School of Nursing, UVic (Member)
• Dr. Tara Horrill, College of Nursing, University of Manitoba (Outside Member)
• Dr. Leah Lambert, Nursing and Allied Health Research and Knowledge Translation, BC Cancer (Outside Member)

External Examiner

• Dr. Patsy Yates, Faculty of Health, Queensland University of Technology

Chair of Oral Examination

• Dr. Julian Lum, Department of Biochemistry and Microbiology, UVic

Abstract

Current estimates suggest that one half of all Canadians will be diagnosed with cancer in their lifetime, and one in every four will die from the disease. Yet the cancer burden is not evenly distributed and inequitable access to healthcare leads to differences in health outcomes for certain groups. Despite a universal, publicly funded healthcare system in Canada, there are challenges in achieving equitable access to healthcare, and those who are impacted by structural vulnerability face significantly poorer cancer outcomes. Structural vulnerability encompasses a diverse range of social disadvantages and locations; however, the focus of this dissertation is primarily concerned with inequities related to extreme socioeconomic status such as poverty and homelessness. Population health studies suggest that people who such disadvantage have higher cancer incidence and mortality, and are less likely to receive timely, high-quality treatment. These disparities signal the need for more comprehensive understanding of the barriers to accessing cancer treatment in order to inform the development of models of care that promote equitable access and improve cancer outcomes. At the time of embarking on this dissertation, little was known about barriers to cancer treatment for people who experience structural vulnerability in the Canadian context. Therefore, the overall goal of this dissertation research was to better understand barriers to cancer treatment for people who experience structural vulnerability in Canada. To achieve this goal, a multiple-methods manuscript-based dissertation was employed.

The format of this dissertation is organized into seven Chapters. Chapter 1 is an introduction which further details the aims of this dissertation. Chapter 2 presents a review of the literature with a focus on the cumulative upstream inequities across the cancer care continuum that lead up to treatment—from etiology, prevention, and early detection to diagnosis—that contribute to barriers to accessing cancer treatment among people who experience structural vulnerability. Chapter 3 outlines the multiple methods utilized in this dissertation and describes my dual positioning as a nurse practitioner and novice researcher. All studies in this dissertation are informed by critical perspectives of social justice and health equity, including an expanded discussion of structural vulnerability, are described in Chapter 3. Intersectionality has also been employed as an analytic lens to deepen my understanding of barriers. The multiple methods for the findings Chapters 4 through 6 are also detailed in Chapter 3. Because the methods for Chapters 4 and 5 have already been well described in their published manuscripts, greater attention is given to the focused ethnography stronger emphasis on the focused ethnography utilized in Chapter 6.

Chapter 4 is a scoping review that examines barriers to cancer treatment for people who socioeconomic disadvantage in high-income countries. This Chapter includes the manuscript published in BMC Health Services Research. This scoping review included 20 studies. Most were conducted in the United States (n = 16), with additional publications from Canada (n = 1), Ireland (n = 1), the United Kingdom (n = 1), and one scoping review. Across the literature, the most frequently reported barriers included inadequate insurance coverage and financial constraints (n = 16), unstable housing (n = 5), limited availability and geographic distribution of services and transportation barriers (n = 4), insufficient resources to address social care needs (n = 7), communication challenges (n = 9), system fragmentation (n = 5), implicit bias (n = 4), advanced disease or comorbidities at diagnosis (n = 8), psychosocial stressors (n = 6), and constrained social support networks (n = 3). These barriers often intersected and compounded one another, resulting in poorer access to cancer treatment across diverse social locations of socioeconomic disadvantage. While the majority of studies were conducted in the United States, the findings have relevance for other high-income countries, including Canada. At the same time, this scoping review highlighted the need for more nuanced research on barriers to cancer treatment within the Canadian context.

Chapter 5, has also a manuscript published in International Journal for Equity in Health, is a secondary analysis of ethnographic data which aimed to understand barriers to cancer treatment from participants who faced structural vulnerability with advanced cancer in one Western Canadian city. This secondary analysis draws from 30 months of repeated interviews (n = 147) and 300 h of observational fieldwork with people experiencing health and social inequities at the end-of-life, their support persons, and service providers. An interpretive thematic analysis identified four themes presenting as 'modifiable' barriers to inequitable access to cancer treatment: (1) housing as a key determinant for cancer treatment; (2) impact of lower health literacy; (3) addressing social care needs is a pre-requisite for treatment; and (4) intersecting and compounding barriers reinforce exclusion from cancer care. These findings illuminate the contextual and structural factors that contribute to inequitable access to cancer treatment within the Canadian health care system. In particular, findings from this emphasized the importance of identifying and addressing social care needs as integral to treatment assessment and delivery, alongside biomedical considerations.

The final findings Chapter 6 is a focused ethnography examining the impact of homelessness and access to cancer treatment in one Western Canadian city. The manuscript “Making Cancer Treatment Work”: A Focused Ethnography to Understand the Impact of Homelessness and Access to Cancer Treatment has been drafted to submit for publication. Findings from Chapters 4 and 5 further emphasized housing as a critical social determinant of health, and people who experience homelessness face remarkably greater barriers to cancer treatment resulting in more frequent delays to receiving a timely diagnosis or initiating treatment, interrupted treatment, or exclusion from care altogether. Data collection for this focused ethnography was embedded within a larger ethnographic study on the topic of examining caregiving in the context of inequities at the end-of-life (H22-00313-A001; PI: Stajduhar). Data were generated through more than 100 hours of participant observation and 28 in-depth interviews with individuals with cancer and their informal caregivers experiencing homelessness, community-based health and social service providers, and healthcare professionals working within a cancer treatment facility. An interpretive thematic analysis informed by a socioecological framework was used to examine the data. Findings revealed four intersecting themes that illustrate how homelessness constrains cancer treatment access across multiple levels: (1) ‘Is this the right choice?’: Weighing the competing priorities of unstable housing with cancer treatment; (2) ‘It takes somebody’: How non-traditional support networks sustain access to cancer treatment amid housing precarity; (3) Attending to cancer treatment without a fixed address: How cancer, community health, and housing organizations contribute to the ecosystem of care; and (4) ‘Housing as healthcare’: The structural role of policy in cancer treatment access. Overall, the findings demonstrate that improving equitable access to cancer treatment for individuals experiencing homelessness requires coordinated, cross-sectoral approaches that integrate cancer care, housing, and community-based health and social services.

In closing, Chapter 7 is a discussion and is the final chapter in this multiple-methods manuscript-based dissertation. A summary of the collective findings is provided, which emphasize that barriers to cancer treatment for people who experience structural vulnerability in Canada are multifaceted and shaped by the complex intersections of unmet social determinants of health, fragmented health and social care systems, and cancer treatment structures that are not designed to consistently respond to complex social care needs. Across studies, unmet social care needs such as safe and stable housing, income supports, and transportation (among others) were implicit prerequisites for engaging in cancer treatment, placing individuals who experience structural vulnerabilities at greater risk for falling through gaps in the cancer treatment, often compounded by the need to independently navigate disintegrated health and social care systems without sustained support. Recommendations for advancing equity in cancer care therefore requires coordinated policy and organizational commitment, strengthened intersectoral partnerships, and the expansion of equity-oriented, mobile, and community-based models of care that integrate social and health supports rather than relying on individual capacity alone. This chapter concludes by examining implications for oncology nursing policy, practice, education, and research, highlighting how nursing’s longstanding social justice mandate positions the profession to contribute meaningfully to leadership and innovation in advancing more equitable cancer care.