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Abstract
Background: Cost-related prescription nonadherence is a prominent barrier that may affect health outcomes in Black communities in Canada. We aimed to assess the prevalence of cost-related prescription nonadherence among Black adults in Canada and to investigate racial disparities in comparison to White adults, accounting for demographic, socioeconomic, and insurance coverage factors as potential mediators.
Methods: We conducted a cross-sectional study using pooled data from 5 cycles of the Canadian Community Health Survey. The outcome was self-reported cost-related prescription nonadherence. We used a hierarchical framework and applied multivariable Poisson regression to estimate weighted adjusted prevalence ratios (PRs) with 95% confidence intervals (CIs). We used weights provided by Statistics Canada to provide estimates representative of the Canadian population.
Results: Respondents to the survey included 2997 Black and 178 514 White adults; after weighting, the average population size was 16 544 715, 3.6% of whom identified as Black. Among Black adults, the prevalence of cost-related prescription nonadherence declined from 15.3% in 2015 to 9.5% in 2022, compared with a decrease from 6.0% to 5.5% among White adults. Prescription medication coverage among Black adults was 71.6% in 2015 and 72.5% in 2022, compared with 83% and 80% among White adults, respectively. The prevalence of cost-related prescription nonadherence was 75% higher among Black adults than among their White counterparts (average 12.2% v. 5.8%; adjusted PR 1.75, 95% CI 1.43 to 2.14), while prescription medication coverage was less frequent among Black adults. After adjusting for potential mediators, Black cultural or racial background remained associated with cost-related prescription nonadherence (adjusted PR 1.36, 95% CI 1.13 to 1.64). Prescription medication coverage was associated with a lower likelihood of cost-related prescription nonadherence (adjusted PR 0.44, 95% CI 0.41 to 0.46).
Interpretation: Cost-related prescription nonadherence was significantly higher among Black adults in Canada, both before and after adjusting for potential mediators. Addressing disparities in prescription medication coverage and associated barriers is essential to promoting equitable access to health care.
The Black population in Canada is growing, reaching 1 547 870 inhabitants in 2021 and projected to surpass 3 million by 2041.1,2 Black people in Canada experience health disparities, including comparatively high rates of diabetes, hypertension, and HIV/AIDS mortality.3,4 Health care access is often hindered by social barriers — such as racism, discrimination, language barriers, financial constraints, geographic limitations, and mistrust of providers — leading to hesitancy in seeking care and difficulties accessing services. 5–7 Less is known about how financial stress affects prescription medication use among Black people in Canada. Cost-related prescription nonadherence is defined as the inability to fill a prescription or delaying, splitting, or skipping doses because of financial constraints.8 It represents a prominent barrier for Black people in Canada, with overall prevalence estimates of cost-related prescription nonadherence in the past year ranging from 5.1% to 10.2%.9 Patient-related, socioeconomic, health system, and health care provider factors have been shown to contribute.8,10 In Canada, cost-related prescription nonadherence has been associated with younger age, female sex, belonging to a racial or ethnic minority group, immigration status, being unmarried, low income, lack of medication insurance, perceived poor health status, having multiple chronic conditions, and irregular employment.9,11–13
Canada is the only high-income country with a public health insurance program that does not provide universal coverage for prescription medications.14,15 Instead, pharmaceutical coverage policies vary by province, leading to differences in out-of-pocket expenses and catastrophic drug costs.14,15 The lack of universal prescription coverage exacerbates health inequalities. In Ontario, private medication insurance is positively associated with health service use.16 The likelihood of having private drug insurance has been shown to increase with annual household income, with those earning $20 000 to $39 999 being 1.55 times, and those earning more than $80 000 being 3.22 times, more likely to have private drug insurance than those earning less than $20 000.17 However, these studies did not specifically examine trends among Black people. Recently, disparities by sex in prescription medication insurance coverage have been documented in Canada, including among people identifying as Black.18 Although existing evidence highlights racial disparities in prescription medication insurance coverage in Canada, the specific relationship between Black racial or cultural identity and cost-related prescription nonadherence has not been adequately explored. To address this gap, we aimed to estimate the prevalence of cost-related prescription nonadherence and prescription medication insurance coverage among Black adults in Canada, compare these rates with those of White adults, and examine potential mediators, including prescription medication insurance coverage.
Methods
Study design and data source
We conducted a cross-sectional study using 5 cycles of the Canadian Community Health Survey (CCHS) as a secondary data source within a hierarchical framework (Figure 1).19 The CCHS is a nationally representative, repeated-measures, cross-sectional survey of people in Canada aged 12 years and older, employing a multistage sampling design. The survey does not include people living on reserves and other Indigenous settlements in the provinces, full-time members of the Canadian Forces, the institutionalized population, children living in foster care, and people living in the Quebec health regions of Nunavik and Terres-Cries-de-la-Baie-James, which collectively accounted for less than 3% of the target population. The CCHS collects information annually related to health status, health care utilization, and health determinants, and it is offered in both English and French. For adults aged 18 years and older, the sample frame is designed to serve the Labour Force Survey, and it is stratified by health region. The sampling is a 2-stage stratified cluster design and dwelling is the final sampling unit. The sample produces estimates of good quality at the national level every 3 months, at the provincial level each year, and at the health region level and the territorial level for each 2-year cycle.20
Hierarchical framework for cost-related prescription nonadherence. See Related Content tab for accessible version.
Study population
We accessed anonymized person-level microdata from 2015 to 2022, which was the information available at the time the research project was approved by the Research Data Centre (RDC) of Statistics Canada. However, we excluded data from 2017, 2020, and 2021 because cost-related nonadherence was not collected in 2017 and 2021, and the 2020 data were available only for Alberta and Nova Scotia, resulting in 86.0% missing data. Additionally, we did not include data from the 3 Canadian territories, which are available only biennially, limiting the study population to residents of the 10 Canadian provinces (Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Ontario, Prince Edward Island, Quebec, and Saskatchewan).
The final study sample included Black and White people aged 18 years and older who were surveyed in 2015, 2016, 2018, 2019, and 2022, and who reported having a prescription medication in the previous 12 months. We excluded participants without prescription data (responses of “don’t know,” “refusal,” or “not stated” to questions PEX_090, PCN2_005, or PCN_10), comprising less than 3% of the sample. The annual weighted sample size ranged from 15 684 849 to 17 810 328, with an average of 16 544 715 (Appendix 1, Table S1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.250447/tab-related-content).
Outcome
The outcome was cost-related prescription nonadherence, defined as not filling or collecting a prescription or skipping doses because of cost. For 2015 to 2019, the single-answer multiple-choice question was: “During the last 12 months, was there a time when you did not fill or collect a prescription for medicine, or you skipped doses of your medicine because of the cost?” The response options were: yes, no, not applicable (no prescription to fill in the last 12 months), don’t know, refusal, and not stated. For 2022, there were 5 questions: “In the past 12 months, did you do any of the following because of the cost of your prescriptions: not fill a prescription, not collect a prescription, skip doses of your medicine, reduce the dosage of your medication, or delay filling a prescription?” The response options for each question were: yes, no, not applicable (no prescription to fill in the last 12 months), and not stated. For consistency with previous years, we defined the outcome as positive when respondents answered “yes” to not filling a prescription, not collecting a prescription, or skipping doses of their medicine (Appendix 1, Table S2).
Independent variables
The main explanatory variable was cultural or racial background, categorized as “Black only” or “White only.” This variable was derived by Statistics Canada based on self-identification responses to the question, “You may belong to one or more racial or cultural groups on the following list. Are you … ?” The response options were: White, South Asian, Chinese, Black, Filipino, Latin American, Arab, Southeast Asian, West Asian, Korean, Japanese, and other (Appendix 1, Table S2).
In addition to cultural or racial background, we considered several factors based on the literature and relevant theoretical frameworks on cost-related prescription nonadherence, as well as their availability in the CCHS data. These included respondent-related factors such as age, sex at birth, education level, marital status, underlying health conditions, and perceived mental and physical health; socioeconomic factors such as employment status, personal income, and family income; and health system–related factors, including having a health care provider and medication insurance.8–11,21,22 These variables were grouped in 5 hierarchical levels (Figure 1).
We included nonmodifiable demographic characteristics in the first hierarchical level, namely age (18 to 39 yr, 40 to 59 yr, 60 to 79 yr, and ≥ 80 yr), sex at birth (female or male), sexual orientation (heterosexual or other [homosexual, bisexual, or pansexual]), Canadian-born status (yes or no [landed immigrant or nonpermanent resident]), and language (English, French, or both; English, French, or both, and another language; other language; no information). The second hierarchical level included modifiable demographic characteristics, such as having a spouse or common-law partner (yes or no), family arrangement (living alone, living with a spouse or partner, living with a spouse or partner and children, single parent, other), educational attainment (less than secondary school graduation; secondary school graduation without postsecondary; postsecondary certificate, diploma, or university degree), work status over the past 12 months (no, yes at any time, older than 75 yr), and access to a regular health care provider (yes or no).
The third level focused on income (personal and household) and health-related variables, including history of cancer diagnosis, chronic conditions, and smoking status (categorized into 7 groups, used as a representative of lifestyle behaviours). Personal income was divided into 5 categories (< $9999, $10 000 to $29 999, $30 000 to $59 999, $60 000 to $89 999, ≥ $90 000). Household income was represented by a derived variable constructed by Statistics Canada at the national level, the household income ratio, categorized into deciles. Chronic conditions were identified based on 9 conditions reported in the survey across the 5 analyzed cycles: Alzheimer disease, arthritis, diabetes, high blood pressure, high blood cholesterol or lipids, heart disease, effects of a stroke, mood disorders, and anxiety disorder. Participants were classified as having a chronic condition if they reported any of these diseases.
The fourth level included self-perceptions of health, mental health, and life satisfaction. Health and mental health perceptions were categorized as poor, fair, good, very good, or excellent. Life satisfaction was categorized as very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, or very dissatisfied. The fifth and most proximal hierarchical level to the outcome considered insurance coverage for prescription medications (yes or no). In 2018 and 2019, respondents were asked to consider any private, government, or employer-paid plans that covered all or part of the respondent’s prescription medications; for the other years, the question related to prescription insurance coverage was less specific (Appendix 1, Table S2).
To avoid excluding participants with missing data, we created a “no information” category for each variable. Appendix 1, Table S2 provides a detailed description of each variable.
Statistical analysis
We assessed the prevalence of cost-related prescription nonadherence and prescription medication insurance coverage by cultural or racial background and year, using weights provided by Statistics Canada to account for the sampling design and nonresponse bias, and to produce estimates representative of the Canadian population covered by the CCHS sample.23 In 2022, cost-related prescription problems were evaluated across 5 categories: filling a prescription, collecting a prescription, skipping doses, reducing medication dosages, and delaying prescription fills. For 2022 data, the prevalence of each issue was calculated using the respective survey weights.
To enhance statistical power, we combined data from all 5 CCHS cycles using a pooled estimation method recommended by Statistics Canada.24 We calculated weighted percentages for each category of each variable within the study population. To estimate prevalence ratios (PRs) and 95% confidence intervals (CIs), we conducted univariable and multivariable analyses within a hierarchical framework using Poisson regression,25 with robust variance estimation based on 1000 bootstrap weights provided by Statistics Canada (svy bootstrap: poisson in Stata). We constructed separate models for each hierarchical level of the framework, including all variables considered in each level (Appendix 1, Tables S3 to S6).
We considered the model adjusting for variables at hierarchical level 1 to be an estimate of the association between Black cultural or racial background and cost-related prescription nonadherence. We treated these nonmodifiable demographic variables as potential confounders of the relationship between Black cultural or racial background and cost-related prescription nonadherence (Figure 1).26 To further explore this relationship, we incorporated potential mediator variables across hierarchical levels 2 through 5. The full hierarchical model also provided estimates of the association between prescription medication insurance coverage and cost-related prescription nonadherence, including all variables according to the hierarchical framework, except Canadian-born status and primary language.
We conducted all analyses using Stata (version 18.0) within the RDC of Statistics Canada at the University of Calgary, adhering to Statistics Canada’s requirements for data release, including the fact that all descriptive results presented are weighted.
Ethics approval
This research was conducted at a Statistics Canada RDC under microdata research contract 11013. According to Article 2.2 of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, this research was exempt from research ethics board review because it exclusively relied on information that is publicly available through a mechanism set out by legislation or regulation and that is protected by law.
Results
The total unweighted sample included 2997 Black adults and 178 514 White adults (Figure 2 and Appendix 1, Table S7). In the study population (average weighted size of 16 544 715 people), 3.6% identified as Black. The most frequent age group was 40 to 59 years (33.7%), and 54.8% of respondents were female. Most participants identified as heterosexual (93.8%); were born in Canada (85.5%); spoke English, French, or both languages at home (93.6%); and reported having a regular health care provider (89.3%). Regarding marital status, 61.5% of participants were married or in a common-law relationship, and for family arrangement, 19.5% lived alone. For health status, 58.1% had at least 1 chronic condition and 10.2% had been diagnosed with cancer at some point in their lives. When asked about health perceptions, 14.2% rated their overall health as fair or poor, and 9.6% reported fair or poor mental health. Despite these challenges, 89.4% reported being very satisfied or satisfied with their life (Table 1). At least 1 category of each variable in the hierarchical framework was associated with cultural or racial background, except for mental health perception (Appendix 1, Table S8).
Flow diagram of the unweighted sample. See Related Content tab for accessible version.
Characteristics of the study population and results of weighted univariable analyses of cost-related prescription nonadherence*
The annual prevalence of cost-related prescription nonadherence was significantly higher among Black adults than among White adults. Among Black adults, the prevalence ranged from 15.3% (95% CI 10.1 to 22.4) in 2015 to 9.5% (95% CI 5.9 to 15.1) in 2022, whereas among White adults, it ranged from 6.0% (95% CI 5.6 to 6.5) to 5.5% (95% CI 5.2 to 5.9) over the same period (Figure 3A and 3B). Prescription medication insurance coverage was consistently lower among Black adults than among White adults. Coverage prevalence among Black adults was 71.6% (95% CI 64.8 to 77.5) in 2015 and 72.5% (95% CI 66.2 to 78.0) in 2022, and was 83.0% (95% CI 82.3 to 83.6) in 2015 and 80.0% (95% CI 79.4 to 80.7) in 2022 among White adults (Figure 3C and 3D).
Annual prevalence of cost-related prescription nonadherence among (A) Black and (B) White adults, and of insurance coverage for all or part of the cost of prescription medications among (C) Black and (D) White adults, among all adults in Canadian provinces who received a prescription in the previous 12 months. Note: CI = confidence interval.
In 2022, the CCHS evaluated 5 types of cost-related prescription problems. Among Black adults, the problem with the highest reported prevalence was not filling a prescription (7.3%, 95% CI 3.9 to 13.1), followed by delaying prescription fills (6.4%, 95% CI 4.3 to 9.3) and not collecting a prescription (3.3%, 95% CI 1.9 to 6.0). Among White adults, the highest reported prevalences were for delaying prescription fills (4.5%, 95% CI 4.1 to 4.8), not filling a prescription (3.7%, 95% CI 3.4 to 4.0), and skipping doses (2.5%, 95% CI 2.3 to 2.8). The prevalence of not filling a prescription was statistically higher among Black adults than among their White counterparts (PR 1.99, 95% CI 1.00 to 3.95). Considering all 5 types of cost-related prescription problems as a single outcome, the prevalence in 2022 was 14.4% among Black adults and 8.9% among White adults (Appendix 1, Figure S2).
The overall prevalence of cost-related prescription nonadherence was significantly higher among Black adults than among White adults (PR 2.11, 95% CI 1.73 to 2.58). Conversely, adults with prescription insurance coverage were significantly less likely to experience this outcome than those without coverage (PR 0.35, 95% CI 0.32 to 0.37). Univariable analysis indicated that at least 1 category of each variable in the hierarchical framework was associated with cost-related prescription nonadherence. For instance, older age was associated with a lower prevalence, whereas being female was associated with a higher prevalence of cost-related prescription nonadherence (Table 1). Although we observed a downward trend in the prevalence of cost-related prescription nonadherence over time among Black adults (Figure 3A), none of the other years showed a statistically significant decrease compared with 2015, and the interaction term of year–racial background was also not statistically significant (Wald test χ24 = 1.76, p = 0.8).
In the multivariable model of hierarchical level 1, which included Canadian-born status and primary language, these variables were not associated with the outcome (p > 0.05) and were therefore excluded from subsequent models. A post hoc analysis assessed whether the exclusion of these variables influenced the results and confirmed that their exclusion did not affect the findings (Appendix 1, Table S9 to S10). All other variables remained independently associated and were included in subsequent models (Appendix 1, Table S11). Black adults experienced more than twice the prevalence of cost-related prescription nonadherence as White adults (PR 2.11, 95% CI 1.73 to 2.58). After adjusting for nonmodifiable demographic factors, cost-related prescription nonadherence among Black adults remained 75% higher than among White adults (adjusted PR 1.75, 95% CI 1.43 to 2.14). After adjusting for all potential mediators across levels 2 to 5 (Figure 4), a significant association persisted, indicating that racial disparities in cost-related prescription nonadherence could not be fully explained by these variables (adjusted PR 1.36, 95% CI 1.13 to 1.64). Additionally, the analysis confirmed that having insurance coverage for prescription medication was strongly associated with a lower prevalence of cost-related prescription nonadherence (adjusted PR 0.44, 95% CI 0.41 to 0.46), even after adjusting for confounders across all levels of the hierarchical model (Table 2). These findings remain consistent in a post hoc analysis after adjusting for province of residence and survey year (Appendix 1, Table S12).
Estimation of the association between Black cultural or racial background and cost-related prescription nonadherence using the hierarchical framework, with White adults as the reference group. Note: CI = confidence interval.
Multivariable models of cost-related prescription nonadherence by hierarchical level
Interpretation
We found a significantly higher annual prevalence of cost-related prescription nonadherence among Black adults who reported receiving a prescription in the last year in Canada, compared with White adults. In line with this, the annual prevalence of insurance coverage for prescription medications was lower among Black adults. After adjusting for nonmodifiable characteristics, the association between Black cultural or racial background and cost-related prescription nonadherence remained significant. Furthermore, this association persisted after accounting for several potential mediator factors, including prescription insurance coverage. Additionally, having insurance coverage was significantly associated with a lower prevalence of cost-related prescription nonadherence, even after adjusting for potential confounders.
This study provides national-level estimates of the prevalence of cost-related prescription nonadherence among Black adults in Canada. Similar disparities have been documented in the United States, where 35.1% of Black Medicare beneficiaries reported cost-related prescription nonadherence. This higher prevalence may be explained by the focus on noninstitutionalized people aged 65 years and older, whereas our study included individuals aged 18 years and older.21 Another study among insured adults with diabetes found 17% of African American participants reported cost-related prescription nonadherence, compared with 13% of White participants.27 However, after adjusting for age, sex, and income, the racial disparity was no longer significant.27 This prevalence among African American people was comparable to that observed among Black adults in our study.
Population-based studies in Canada have estimated the prevalence of cost-related prescription nonadherence to range from 4.9% to 10.2%.9,13 Among specific populations, such as patients on hemodialysis or people with multiple chronic conditions, prevalence estimates have ranged from 12.9% to 16.6%.28,29 Despite differences in definitions of cost-related prescription nonadherence and population characteristics, the prevalence of this outcome among White adults in our study aligned with rates previously reported in population-based studies. In contrast, the prevalence of cost-related prescription nonadherence among Black adults appeared to align more closely with rates observed in disease-specific groups.28,29 Additionally, our findings on prescription medication insurance coverage align with a Statistics Canada analysis using CCHS data from 2015, 2016, and 2019, which reported that 73.3% of Black females and 72.5% of Black males had drug insurance, compared with 83.6% and 82.5%, respectively, in the nonracialized population aged 12 years and older.18 Our findings of factors that were significantly associated with cost-related prescription adherence — such as age, sex, sexual orientation, marital status, income, self-perceived health, life satisfaction, chronic conditions, and insurance coverage — align with previous reports using CCHS data.12,13,22
Recently, a study using CCHS data from 2015 to 2020 reported race and ethnicity, including Black ethnicity (adjusted odds ratio 1.67, 95% CI 1.61 to 1.76), as a predictor of cost-related nonadherence among people aged 12 years and older.13 However, a strength of our study is that we specifically examined the relationship between Black cultural or racial background and cost-related prescription nonadherence in the adult Canadian population, using a hierarchical approach that accounted for various confounders and potential mediators, including insurance coverage. In the US, a national survey of older adults found an association between Black race or ethnicity and cost-related prescription nonadherence, partially mediated by factors such as age and insurance coverage. However, this association disappeared when income was considered.21 In our study, the association between Black cultural or racial background and cost-related prescription nonadherence persisted after adjustment, although it was partially mediated by factors like income.
Other unassessed factors, including perceptions specific to Black individuals — such as health knowledge, treatment beliefs, distrust in the health care system, and health care provider interactions — may also play a role. These factors were not considered in this study given the lack of available data. Therefore, further qualitative and quantitative research is needed to address these gaps and develop strategies to reduce disparities in cost-related prescription nonadherence. Such information will be valuable for developing strategies to reduce disparities in cost-related prescription nonadherence. By improving understanding of this issue in Black communities, this research can inform policies and interventions that promote equitable access to medications, ultimately contributing to more inclusive and equitable health care systems in Canada.
Limitations
The results are restricted to the 10 provinces. However, given that only 0.14% of the Black population resides in the territories,1 this exclusion is unlikely to substantially alter the conclusions. Since we included only people aged 18 years and older, these results are not generalizable to children. The CCHS did not evaluate delaying prescription filling or reducing doses before 2022. Considering that delaying prescription filling was the second most prevalent issue among Black adults (6.4%) and reducing doses had a prevalence of 2.2%, the observed prevalence of cost-related prescription nonadherence among Black adults may be an underestimate. The CCHS is a self-reported survey; therefore, recall bias may be present, given that the outcome is measured over the previous 12 months. In addition, social desirability bias may also be present. We used a hierarchical approach to account for confounders and potential mediators in the relationship between Black cultural or racial background and cost-related prescription nonadherence. However, we did not employ a formal mediation model to assess the specific mediation effect of any individual factor. Information on the type of prescription medication insurance coverage was not collected in the 2022 CCHS. As a result, we were unable to distinguish between government-sponsored plans, employer-sponsored benefit plans, privately purchased plans, and other types of coverage; therefore, we modelled prescription medication insurance as a binary variable in the analyses. The CCHS does not collect information on certain factors that could help better understand cost-related prescription nonadherence, such as the type of medication prescribed and the availability of a pharmacy near the respondent’s residence, which may be important contributors, as previously reported. For example, medications for mental health conditions were the most commonly mentioned by people reporting cost-related prescription nonadherence in Canada.30 Additionally, distance to the pharmacy has been associated with difficulty obtaining medications among patients with epilepsy in the US.31 Access to and cost of transportation have also been discussed as potential barriers to medication adherence.32
Conclusion
Cost-related prescription nonadherence was significantly higher among Black adults than among White adults during the study period in Canada. Although factors such as education, income, chronic conditions, health perceptions, and insurance coverage partially mediated this association, Black racial or cultural background remained independently associated with a higher prevalence of cost-related prescription nonadherence. Furthermore, having insurance coverage significantly reduced the prevalence of cost-related prescription nonadherence among both Black and White adults. Further research is essential to explore the underlying factors contributing to these disparities and to develop interventions for equitable medication access. Additionally, the Pharmacare Act (C-64), which provides publicly funded, single-payer, first-dollar coverage (i.e., health care services fully paid by public insurance, with no upfront costs to the patient) for prescription drugs for the treatment of diabetes, received royal assent on Oct. 10, 2024, and is currently in the initial implementation phase. Further research is required to assess the effect of this legislation and public prescription medication coverage on cost-related prescription nonadherence in Black populations, and to investigate the reasons behind the higher prevalence in cost-related prescription nonadherence among Black adults in Canada.
Footnotes
Competing interests: Ato Sekyi-Otu is co-chair of the health working group with the Black Opportunity Fund. Oluwabukola Salami is co-chair of the Public Health Agency of Canada Advisory Committee on Science, a member of the Governing Council of the Social Sciences and Humanities Research Council of Canada, and an advisory board member with the Canadian Institutes of Health Research (CIHR) Institute for Human Development, Child and Youth Health. No other competing interests were declared.
This article has been peer reviewed.
Contributors: Ruth Martínez-Vega, Andre Renzaho, Maria Ospina, Marie-Françoise Mégie, Ato Sekyi-Otu, and Oluwabukola Salami contributed to the conception and design of the work. Oluwabukola Salami acquired the data. Ruth Martínez-Vega analyzed the data. Aloysius Maduforo, Adebola Adetiba, Andre Renzaho, Maria Ospina, Marie-Françoise Mégie, Ato Sekyi-Otu, and Oluwabukola Salami contributed to data interpretation. Ruth Martínez-Vega drafted the manuscript. All of the authors revised it critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.
Funding: This research is funded by Alberta Innovates through the LevMax program (no. 242505979) and by the Canada Research Chairs Tier 1 program awarded to Oluwabukola Salami, with support from the CIHR (no. CRC-2022-00289). The funders had no role in the conception, data analysis, or writing of the manuscript.
Data sharing: The data used in this study are not publicly available. The analyses were conducted at the Statistics Canada Research Data Centre (RDC) at the University of Calgary under microdata research contract 11013, in accordance with Statistics Canada confidentiality requirements. The authors do not have direct access to the data outside the RDC environment.
Disclaimer: Oluwabukola Salami is an associate editor for CMAJ and was not involved in the editorial decision-making process for this article.
- Accepted January 9, 2026.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
References
- 1↵Visible minority by gender and age: Canada, provinces and territories. Ottawa: Statistics Canada; 2023. Available: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=9810035101 (accessed 2025 Feb. 21).
- 2↵The daily — Canada in 2041: A larger, more diverse population with greater differences between regions. Ottawa: Statistics Canada; 2022. Available: https://www150.statcan.gc.ca/n1/daily-quotidien/220908/dq220908a-eng.htm (accessed 2025 Feb. 21).
- 3↵VeenstraGPattersonAC. Black–White health inequalities in Canada. J Immigr Minor Health 2016;18:51–7.
- 4↵Mortality inequalities of Black adults in Canada. Ottawa: Statistics Canada; 2023. Available: https://www150.statcan.gc.ca/n1/pub/82-003-x/2023002/article/00001-eng.htm (accessed 2025 Feb. 21).
- 5↵BoakyePNPrendergastNBandariB. Obstetric racism and perceived quality of maternity care in Canada: voices of Black women. Womens Health (Lond Engl) 2023;19:17455057231199651.
- 6HusbandsWLawsonDOEtowaEB. Black Canadians’ exposure to everyday racism: implications for health system access and health promotion among urban Black communities. J Urban Health 2022;99:829–41.
- 7↵MoscouKBhagalooAOniludeY. Broken promises: racism and access to medicines in Canada. J Racial Ethn Health Disparities 2024;11:1182–98.
- 8↵BriesacherBAGurwitzJHSoumeraiSB. Patients at-risk for cost-related medication nonadherence: a review of the literature. J Gen Intern Med 2007;22:864–71.
- 9↵HolbrookAMWangMLeeM. Cost-related medication nonadherence in Canada: a systematic review of prevalence, predictors, and clinical impact. Syst Rev 2021;10:11.
- 10↵RezaeiSPeikanpourMZareiL. An adapted model of cost-related medication nonadherence among older adult patients with chronic diseases: an Iranian qualitative study. BMC Geriatr 2023;23:208.
- 11↵GuptaSMcCollMAGuilcherSJ. Cost-related nonadherence to prescription medications in Canada: a scoping review. Patient Prefer Adherence 2018;12:1699–715.
- 12↵Abdel-RahmanONorthS. Patterns of cost-related medication underuse among Canadian adults with cancer: a cross-sectional study using survey data. CMAJ Open 2021;9:E474–81.
- 13↵RebićNChengLLawMR. Predictors of cost-related medication nonadherence in Canada: a repeated cross-sectional analysis of the Canadian Community Health Survey. CMAJ 2024;196:E1331–40.
- 14↵MorganSDawJLawMR. Rethinking pharmacare in Canada. SSRN 2013 June 13. Available: http://www.ssrn.com/abstract=2303892 (accessed 2025 Feb. 21).
- 15↵HajizadehMEdmondsS. Universal pharmacare in Canada: a prescription for equity in healthcare. Int J Health Policy Manag 2020;9:91–5.
- 16↵AntonipillaiVGuindonGESweetmanA. Associations of health services utilization by prescription drug coverage and immigration category in Ontario, Canada. Health Policy 2021;125:1311–21.
- 17↵BolatovaTLawMR. Income-related disparities in private prescription drug coverage in Canada. CMAJ Open 2019;7:E618–23.
- 18↵Exploring gaps in prescription drug insurance coverage among men and women in Canada using an intersectional lens. Ottawa: Statistics Canada; 2024. Available: https://www150.statcan.gc.ca/n1/pub/75-006-x/2024001/article/00001-eng.htm (accessed 2025 Feb. 21).
- 19↵VictoraCGHuttlySRFuchsSC. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997;26:224–7.
- 20↵Statistics Canada. Canadian Community Health Survey - Annual Component (CCHS) [Internet]. 2022 [cited 2025 Aug 10]. Available from: https://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&Id=1383236
- 21↵GelladWFHaasJSSafranDG. Race/ethnicity and nonadherence to prescription medications among seniors: results of a National study. J Gen Intern Med 2007;22:1572–8.
- 22↵LawMRChengLDhallaIA. The effect of cost on adherence to prescription medications in Canada. CMAJ 2012;184:297–302.
- 23↵Canadian Community Health Survey: public use microdata file, 2017/2018– archived. Ottawa: Statistics Canada. Available: https://www150.statcan.gc.ca/n1/en/catalogue/82M0013X2020001 (accessed 2025 Aug. 10).
- 24↵ThomasSWannellB. Combining cycles of the Canadian Community Health Survey. Health Rep 2009;20:53–8.
- 25↵BarrosAJHirakataVN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003;3:21.
- 26↵Diaz-QuijanoFASantos de MeloLR. The total effect of ethnicity on COVID-19 outcomes is underestimated when conditioning for comorbidities: response to Learoyd et al. J Clin Epidemiol 2024;170:111261.
- 27↵TsengC-WTierneyEFGerzoffRB. Race/ethnicity and economic differences in cost-related medication underuse among insured adults with diabetes: the translating research into action for diabetes study. Diabetes Care 2008;31:261–6.
- 28↵HirthRAGreerSLAlbertJM. Out-of-pocket spending and medication adherence among dialysis patients in twelve countries. Health Aff (Millwood) 2008;27:89–102.
- 29↵LabaTLChengLKolhatkarA. Cost-related nonadherence to medicines in people with multiple chronic conditions. Res Social Adm Pharm 2020;16:415–21.
- 30↵LawMRChengLKolhatkarA. The consequences of patient charges for prescription drugs in Canada: a cross-sectional survey. CMAJ Open 2018;6:E63–70.
- 31↵WeltyTEWillisSLWeltyEA. Effect of limited transportation on medication adherence in patients with epilepsy. J Am Pharm Assoc (2003) 2010;50:698–703.
- 32↵LearnihanVSchroersRDCooteP. Geographic variation in and contextual factors related to biguanide adherence amongst Medicaid enrolees with type 2 diabetes mellitus. SSM Popul Health 2021;17:101013.
