Barriers and Facilitators to CRC Screening in Southwestern Native Americans

Barriers and Facilitators to Barriers and Facilitators to CRC Screening in Southwestern CRC Screening in Southwestern

Native AmericansNative Americans

Navajo Nation Human Research Navajo Nation Human Research Review Board Conference Review Board Conference

November 16, 2011November 16, 2011

Christina Getrich, PhDChristina Getrich, PhDRobert Rhyne, MDRobert Rhyne, MD

Funded by NIH-NCI Funded by NIH-NCI Grant 5R21CA121066Grant 5R21CA121066

BackgroundBackground

• National incidence rates for colorectal cancer (CRC) decreasing

• In New Mexico:

Rates for whites decreasing

Rates for Native Americans and Hispanics increasing

Background

• US CRC screening rate = 57%

• NM overall CRC screening rate = 50%

NM Native Americans = 30%

60% Native Americans have never been screened

(BRFSS: 2006)

• NM’s primary care, practice-based research network (PBRN)

• Voluntary collaboration of 275 clinicians serving medically underserved and culturally diverse communities

• Focused on health disparities & translational research

Study Setting: RIOS NetStudy Setting: RIOS Net

Study MethodsStudy Methods• Rigorous qualitative

research design

• Data collection in 5 IHS (2 Navajo) & 6 CHC (Hispanic) sites

• Semi-structured interviews conducted with 1-2 providers, 1 nurse/staff & ~10 patients per site

• Surveys administered to patients

• Translators provided for patients as needed

Interview & Survey Topics

•Interviews focused on: Cancer causation and

prevention Experiences/impressions

of CRC screening tests Barriers to CRC screening

•Surveys focused on: Health literacy Exposure to info sources Prior cancer prevention

Patient-provider communication

Patient decision-making Recommendations to

improve CRC screening

Knowledge about CRC & CRC risk reduction

Access to health care system

Data AnalysisData Analysis• Interview data

– Interviews digitally recorded and transcribed

– Multidisciplinary team reviewed transcripts

– Interviews coded: identified themes explaining barriers and facilitators to CRCS

• Survey data– Descriptive statistics with stratification– Hypothesis testing as appropriate (↓ sample size)

Data CollectionData Collection

1) Northern Navajo Medical Center August 17 & 18, 2009

2) Tohatchi Medical Center October 26 & 27, 2009

• Research conducted at Native American sites from June 09 - March 10

• Navajo sites:

Results: Demographics

Language15 conducted in English4 needed some translation

Gender10 (52.6%) female9 (47%) male

Age Mean = 60 yearsRange 52-79 years

Education level 5 (26.3%) had <HS education 2 (10.6%) had a BA/BS

5 providers + nurses interviewed

19 Navajo patients interviewed

Results: Patient, Provider & Practice Barriers

I. Patient Barriers

• Lack of terminology (prevention, cancer, colon)

• Cancer not a topic of discussion (taboo)o “Everything’s always hush, hush. You don’t talk

about nothing [like that]; it’s just the Navajo way.” –Male patient

• Concern that others will know (privacy)o “I would get embarrassed to bring the [FOBT

cards] here, I don’t know. I would be embarrassed because they know you, like the staff.” –Female patient

I. Patient Barriers• Personal shame/privacy

o “It’s embarrassing to look through your rectum or to get a pap smear, you know, male doctors, I don’t want them to see me.” –Female patient

• Fearo “I don't think I want to know if I have something like

a cancer. Most people if they find out something is wrong with them, they get more depressed and they think about it, ‘Well, I'm going to die,’ or ‘No, I'm not gonna live long.’” –Male patient

• Dietary restrictions: not eating meat (FOBT)

I. Addressing Patient BarriersI. Addressing Patient Barriers

• Patient education important– Posters around the clinic, take-home educational

materials, workshops at the Chapter Houses & Senior Centers

• Use of pictures (to address lack of knowledge, literacy & language barriers)

• Depersonalize screening to get around taboo – Frame test positively: “making sure you’re healthy”

& “taking care of yourself”

– Use humor (to address shame & embarrassment)

II. Provider Barriers• Providers don’t bring topic up• Provider turnover• Competing demands

o “In a doctor’s visit…you only have a certain amount of time to do certain things. It all depends on how much they can get [in]…a lot of times [nurses] have to explain it.” –Female nurse

• Dealing with other illnesses (no time for prevention)o “Preventive health is pretty much always last…because

there are very few people who have nothing the matter with them. So there definitely are things that have gone by the wayside.” –Female provider

II. Addressing Provider BarriersII. Addressing Provider Barriers

• Establishing trust important (intimate topic)• Multiple subsequent description of tests helpful

(first the clinician, then nurse in Navajo)

• Bundle discussion of CRC into cancer prevention discussions/visits

• Schedule CRCS during regular visits (e.g., diabetes)

• Be open to blending of Western & traditional approaches

III. System Barriers

• Difficult referral system – patients forced to be passiveo “I talk to people and get them to agree. Then I fill out this

form and send it to the surgery office. And 3 months later they contact the patient. Well, 3 months later, it’s too late.” –Male provider

• Capacityo Broken equipmento Patients forced to wait: “I wouldn’t go through the

process that my aunt went through. The day of the exam when she went in she said they didn’t get to her ‘til the afternoon.” –Female patient

• No screening colonoscopies (no additional insurance)

III. System Barriers

• Contract health• Communication capabilities (spotty cell service,

no voicemail, distant mailboxes)• Rural setting / transportation:

o “A lot of people here on the reservation have a rough time trying to get transportation to get to the provider. So there’s times that they miss appointments or reschedule to where it’ll fit.” –Male patient

o Distance to clinic (avg: 27 minutes)o Not having a driver for a colonoscopyo Lack of indoor plumbing for some

III. Addressing System BarriersIII. Addressing System Barriers

• Collaborate with auxiliary staff– Nurses/staff can explain tests effectively

and bridge language/cultural barriers

• Respond to key barriers such as travel and arrange for transportation

• Use active CHR program as potential resource for education and transportation

Next Steps

• Different levels of engagement/planning (patient-provider-system):

Patient: Development of new educational materials (simple language & pictures); use of storytelling to connect with patients

Provider: Use collaborative approach (provider + nurse + CHR)

System: Tracking and navigation systems need improvement

THANK YOU!!!THANK YOU!!!

Christina Getrich

chgetrich@salud.unm.edu

505-272-3489