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The Declaration of Helsinki was adopted in 1964 and has been amended six times, most recently at the United Nations General Assembly in October 2008. This is now the only official version and it supersedes all previous ones, which should not be used or cited, except for historical purposes.

Testing treatments: Better research for better health care. This book, published by the James Lind Library, is a collection of essays addressing the question: How do we know whether a particular drug, therapy, or operation really works, and how well?

Pautas éticas internacionales sobre investigación en seres humanos (International Guidelines on Bioethics), Acta Bioethica 2004; 10(1), published in SciELO.



pahorig

The Research Promotion and Development unit's Research Interest Group (RIG) is an informal and collegial discussion space fostering the exchange of information about research needs and interests. It is a space for discussing challenges, best practices, and novel ideas in research. Aimed towards inspiring innovation and collaboration in PAHO's work, the group seeks to tap into the network of diverse knowledge and experiences, both individual and collective, represented by PAHO staff.

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Improving equitable access to Breast Cancer Screening for First Nations in Manitoba (Canada)

Imagine you are a woman living in the Canadian province of Manitoba as part of the First Nations indigenous population. Living in the rural North you have to travel long distances to access medical services. The costs for traveling in the North are very high. There are known benefits to screening for breast cancer. However, given your socio-economic barriers, how and when could you find the time to get screened for breast cancer?

What's the issue? Breast cancer in a Canadian First Nations Population

Within Manitoba there is a significant population of indigenous people in the northern part of the province. In 1996, 128,910 Aboriginal people lived in Manitoba, accounting for 11.7% of Manitoba's total population. The Aboriginal proportion of the population has been increasing rapidly over the past 20 years.1 Breast cancer is the most commonly diagnosed cancer among Manitoba women and the second most common cause of cancer-related deaths among women. From 1995 to 2004, the incidence of cancer among First Nations women doubled, from 178/100,000 to 391/100,000. During the same time, the incidence of cancer among non-First Nations women increased by just 1.5%.2

Research to Practice: Making Breast Cancer Screening Mobile

Manitoba has a publicly funded Breast Screening program which operates in four cities and towns. Breast cancer screening with a mammogram, a specialized x-ray of the breasts, is a way of detecting cancer. Access to breast cancer screening plays a major role in the timely detection and treatment of cancers in women. Monitoring breast screening participation rates showed the inequities for northern and rural women and the mobile program was introduced to address the disparities.

Ensuring Canada's First Nations have access to breast cancer screening, specifically the "geographically isolated" Manitoban Aboriginal women, and adapting it to cultural context is an example of how investment in research for health can be beneficial in promoting health equity with regards to gender, ethnicity, and socio-economic status. Mobile screening units have been created to reach women who live outside of the four cities and towns housing the screening program. To date, mobile screening programs operate in over 80 rural and northern communities every year and in 10 Winnipeg city locations.

The breast screening program works with First Nation communities to address cultural issues. The program developed posters that include aboriginal women and invitation letters are translated when needed. The local health workers arrange the appointments as some women don't have phones. The clinics are advertised over the local community radio station and the local health workers often visit women to explain the program.

This example makes clear that to achieve health equity, access to the products of research, such as cancer screening technologies, need to consider the social determinants of health. Outreach initiatives should be culturally appropriate, as shown in the example of the Aboriginal Cancer Strategy.3 The guiding principles include a physical, mental, emotional and spiritual approach to health in conjunction with a grass-roots approach that gives voice to the community.

What next: Improving Access to Breast Cancer Screening by Promoting Innovation

Despite the universal screening program, access remains a challenge. For example, mobile units have rigid schedules making it difficult to switch dates when bad winter weather or equipment failure interrupt schedules and it is not always possible to accommodate changes. The mobile unit may not return for another year or two, leading to wide variability in the use of mammograms among eligible Manitoba women. In the two year period from April 1, 2003 to March 31, 2004, just 60% of women aged 50 to 69 years had a mammogram. Women in the rural south were most likely (63%), and women in the north were least likely (53%), to have had a mammogram. In fact, all Regional Health Authorities in the rural south had higher participation rates in mammography than did Winnipeg (59%).4

These differences in breast screening participation can be related to income, jobs, children, high travel expenses and long travel times due to an inadequate infrastructure that make it difficult for northern women to travel, especially from isolated communities in the North. Thus, even reaching a mobile screening unit is perceived as an obstacle for some women. Also, competing socio-economic health issues and immediate needs such as daily bread and shelter are often considered more important. In addition, some women have family members affected by breast cancer. Such bias sometimes results in increased likelihood towards cancer screening, but sometimes also in aversion due to fear.

It is in the hands of the community health workers to raise awareness. The challenge for research is to find ways to expand equitable access to breast cancer screening for all under-screened indigenous women. This can be achieved by enhancing the favorable balance between the benefits and risks of screening and by finding ways to make the units more mobile and flexible. Looking into the future, new technologies such as more compact digitalized mammography or blood testing for cancerous cells should be at the forefront.

For further information:

Footnotes:

  1. Province of Manitoba, Demographics,
  2. Cancer Care Manitoba. 2007. Custom Tabulation. in: PAHO; A gender and ethnicity analysis of cancer: Cancer in Manitoba, Canada, p.6,
  3. Ontario. Aboriginal Cancer Strategy. Honouring the Aboriginal Path to Well-being.
  4. Fransoo R, Martens P, Burland E. 2005. Sex differences in health status, health care use, and quality of care: A Population-Based analysis for Manitoba's Regional Health Authorities. Winnipeg: Manitoba Centre for Health Policy. 435 p, in: PAHO; A gender and ethnicity analysis of cancer: Cancer in Manitoba, Canada, p.16,

  • Procedimientos normalizados de trabajo para presentar propuestas de investigación
  • Procedimientos Operacionais Padrão pela apresentaçâo das propostas de pesquisa 
  • Standard Operating Procedures for submitting research proposals