Barriers To Cancer Screening

1
Barriers To Cancer Screening

• Jeanne Duquette, RN
• Chronic Care Coordinator
• Iowa/Nebraska Primary Care Association
• November 27,2007

2
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

3
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

4
Poverty Level

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

5
Breakdown of Ethnicities

• Caucasian 57,633 -- 62
• Hispanic/Latino 19,126 -- 20
• Black/African American 13,715 -- 14
• Asian 1,7442

6
Poverty
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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.
• Womans identity is role of martyr woman is
  expected to take care of her man and her children
• Mans identity To be a man-expectation that he
  will work hard physically

8
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.

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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

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HOMELESS
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Homeless
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Homeless

• Adults, families, youth, shelter users, chronic
  street dwellers, doubled-up
• Psychiatric problems
• Mental Illness
• Substance abuse
• Often victims of abuse

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Homeless Issues

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

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Homeless Issues

• Results in
• Increased inappropriate use of ER Dept.
• Increased hospitalizations
• Increased death rate 10 x the rate of general
  public

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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

16
Migrant/Mobile populations
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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

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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

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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

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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

21
African American
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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

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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.

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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

25
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.

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Asian
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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

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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

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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

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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

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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

32
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

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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 167258-264
• HRSA HDC Cancer IT Faculty Reflections
  Mar.2006 by David Rollason, PA-C Elizabeth
  Magenheimer, MSN, APRN Ann Camp, MD

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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 SubjectSurvey
  washingtonpost.com Thursday, Oct.11,2007
• Racial Differences in Cancer Pfizer
  Pharmaceuticals, July 2005
• Overcoming Barriers to Healthcare for the
  Homeless Population Dr. Brenda Merritt
• Bridges Out of Poverty strategies for
  Professionals and Communities, Ruby gt Payne, PhD
  Philip E.DeVol Terie D.Smith 2006