Barriers To Cancer Screening

Jeanne Duquette, RNChronic Care Coordinator

Iowa/Nebraska Primary Care AssociationNovember 27,2007

Facts and Figures about Iowa Community Health Centers

• General Community: 89,622, which is 94% of those we serve.

• Homeless: 3,538 or 4% • Migrant/seasonal 1,500 or 2%• Uninsured: 36,953 or 39% of those we serve• Medicaid/SCHIP: 27,942 or 29%• Medicare: 7,493 or 8%• Private Insurance: 22,422 or 24%

Facts and Figures about Iowa Community Health Centers

• 100% Federal Poverty Level: 53,381- 57%

• 101-150% FPL: 13,427 -- 14%

• 151-200% FPL: 6,021 -- 6%

• Over 200% FPL: 8,470 -- 9%

Poverty Level

•A full 86% of our population served is between 100 and 200% of poverty!

Breakdown of Ethnicities

• Caucasian: 57,633 -- 62%

• Hispanic/Latino: 19,126 -- 20%

• Black/African American: 13,715 -- 14%

• Asian: 1,744—2%

Poverty

Patterns of generational poverty

• Oriented in survival: discussion of academic topics not prized. One must have a job to make enough money just to survive.

• Woman’s identity is role of martyr: woman is expected to take care of her man and her children

• Man’s identity: To be a “man”-expectation that he will work hard physically

Patterns of generational poverty

• Belief in fate: Destiny and fate. Choice is seldom considered.

• Time: Occurs only in the present. The future does not exist.

• Lives in the moment: Does not consider future ramifications-being proactive, setting goals, and planning ahead are not considered. Most of what occurs is reactive and in the moment. Future implications of present actions are seldom considered.

How to reduce barriers

• Be non-judgmental and genuine• A sense of humor is a plus• Ask about job and family commitments to

find the right time to be tested• Consider a friend or family member to

come with client for support• Consider resources if tests are positive• Bring consequences down to impact on

“present” time

HOMELESS

Homeless

Homeless

• Adults, families, youth, shelter users, chronic street dwellers, doubled-up

• Psychiatric problems

–Mental Illness

–Substance abuse

–Often victims of abuse

Homeless Issues

• Lack of :– comprehensive care– Primary care– Preventive care– Immunizations– Specialty care– Psychiatric Care– Safety net

Homeless Issues

• Results in:

– Increased inappropriate use of ER Dept.

– Increased hospitalizations

– Increased death rate: 10 x the rate of general public

How to reduce barriers

• Provide care that is trauma informed– Allow client to have a friend in the exam room– Always ask before proceeding with each step of

procedure– Client needs to be told he/she can call off the

procedure if they stop feeling safe• Outreach and Engagement

– If patients walk in for a visit, try to do all cancer screening then

• Bring services to the patient– Nurse with outreach teams, Clinics in shelters– Availability of specialty services

Migrant/Mobile populations

Migrant/Mobile Issues

• Language differences and low literacy levels• Unreliable transportation• Unfamiliar with local resources• Legal status/fear• Limited formal education• Lack of funds• No health insurance• No disability/ no pay when sick

How to reduce barriers

• Provide walk in or same day services• Have ability to speak their language• Have literature available in low literacy level• Attempt to provide all services in a single visit• Assist with transportation• Provide services using sliding fee scale • Offer service when the client is off work or bring

services to them• Develop tools to help navigate client through

follow-up and referrals

Camp Health Aids/promotoras

• Teach breast and prostate self-exam techniques and about exam procedures

• Stress importance of yearly check-ups• Assist clients in overcoming barriers to

making/keeping appointments• Teach and advocate for safe working and

living conditions (pesticide safety)• Go with patient to appointment to reduce

fears and arrange follow up connections

Hispanic Cancer Risks

• Hispanic Americans:– have higher rates of stomach, liver, cervix,

and gallbladder due to infectious agents– Less likely to be screened for female breast,

cervical, colorectal and prostate cancers– More likely to be diagnosed at a later stage

for cancers of lung, colon, rectum, prostate, breast and skin

African American

Health Risk

• Overall breast cancer incidence is lower in black women than white women but– Breast cancer survival rates are lower in black

women– Black women also have a higher incidence of

breast cancer at younger ages and tends to be diagnosed at later stages

– Breast cancer in black women is less likely to be diagnosed in the local stage compared to whites

Health Risks

• Black men have a higher incidence of prostate cancer than whites after the age of 40.

• The mortality rate is higher and survival rate is lower for blacks.

• For both men and women, blacks have a higher incidence of colorectal cancer, and develop it at younger ages than whites.

Health Risks

• For men 50 and older, blacks are more likely to never have received a fecal occult blood test, sigmoidoscopy or colonoscopy than whites

• Black women have higher incidence of cervical cancer than white women and the survival rate is lower.

• Black women are less likely than whites to be diagnosed in the local stages

How to reduce barriers

• Have health fairs, perhaps in work sites• Include the religious community in the

process• Have health navigators to help with

teaching• Have literature available that culturally

appropriate and of a low literacy level• Have options available for relief from

young children or elderly adults.

Asian

Health Risk

• Cancer is a major cause of death• Different groups prone to different types of

cancer– Recent immigrants: liver and stomach cancers

caused by chronic infections– Those in the country longest develop cancers that are

most common here: breast and colorectal cancers– Vietnamese: incidence and death rates from liver

cancer 7 times greater than in whites – Korean men and women 5-7 times more likely to

develop stomach cancer than whites

Health Risk comparing Asians

• Chinese women and Vietnamese women have a higher incidence of death from lung cancer, though smoking rates are low

• Filipino men have higher rates of prostate cancer

• Filipino women have a higher death rate from breast cancer

• Japanese Americans have higher rates of colorectal, stomach, prostate and breast cancer

Health Risk comparing Asians

• Vietnamese and Korean women have higher rates of cervical cancer AND lower rates of Pap test screening.

• Several of the Asian groups had low rates of breast and colorectal cancer screening

How to reduce barriers

• Overcome language obstacles

• Look at payment issues-lack of insurance

• Consider a navigator/health coach to break through cultural barriers

• Assist with transportation obstacles

• Provide written materials below sixth grade reading level in their native language

Over-arching barriers for all

• Affordability of screening tests and follow-up services

• Fear, lack of knowledge, unclear instructions

• Competing priorities with scarce financial resources

• Lack of knowledge of state resources or local resources to pay for screening

• Importance of prompts and reminders

Resources/Bibliography

• “Increasing Cancer Survivorship in Mobile Underserved Populations Survey Results” Andrea Caracostis, MD; 2007

• Cancer Incidence, Mortality, and Associated Risk Factors Among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese Ethnicities on the internet at: http://CAonline.AmCancerSoc.org

• “Improving Rates of Colorectal Cancer Screening” From focus group

results and discussions- Health Disparities Collaboratives, 2007 Summit

• “Studies Shed New Light on Breast Cancer, Treatment” HealthDay News Thurs, Sept.6,2007

• “System overhaul key to reducing breast cancer deaths for black women” Chicagotribune.com, October 18,2007

• “Hispanics Have Unique Cancer ‘profile” HealthDay News, Wednesday, sept.13,2007

Resources/Bibliography

• Several power points on Migrant and Homeless from Sharon Morrison , Homeless Clinicians Network and anecdotal information from a short interview with Sharon

• Several power points from Migrant Clinicians Network and anecdotal information on migrant barriers to cancer screening.

• “Disparities in Colon Cancer Screening in the Medicare Population” Arch Intern Med. 2007; 167:258-264

• “HRSA HDC Cancer IT Faculty Reflections” Mar.2006 by David Rollason, PA-C; Elizabeth Magenheimer, MSN, APRN; Ann Camp, MD

Resources/Bibliography

• “Are All Latinas the Same?:Perceived Breast Cancer Screening Barriers and Facilitative Conditions” Psychology of Women Quarterly,v28 n4 p400-411 Dec 2004

• “Chronic Illness Often a Taboo Subject:Survey” washingtonpost.com Thursday, Oct.11,2007

• Racial Differences in Cancer Pfizer Pharmaceuticals, July 2005• “Overcoming Barriers to Healthcare for the Homeless Population”

Dr. Brenda MerrittBridges Out of Poverty strategies for Professionals and Communities,

Ruby > Payne, PhD; Philip E.DeVol; Terie D.Smith 2006