Expanding practice horizons: learning from American Indian patients

Disappearing, displaced, and undervalued: a call to action for Indigenous health worldwide

"What sets worlds in motion is the interplay of differences, their attractions and repulsions. Life is plurality, death is uniformity. By suppressing differences and peculiarities, by eliminating different civilisations and cultures, progress weakens life and favours death. The ideal of a single civilisation for everyone implicit in the cult of progress and technique, impoverishes and mutilates us. Every view of the world that becomes extinct, every culture that disappears, diminishes a possibility of life!"

Participation of minorities in cancer research: the influence of structural, cultural, and linguistic factors

Overall, participation rates in cancer clinical trials are very low, ranging from 3 to 20% of eligible participants. However, participation rates are especially low among the socially disadvantaged and racial/ethnic minority groups that have been historically underrepresented in clinical research. Structural factors such as study duration, treatment or intervention schedule, cost, time, followup visits, and side effects represent more of a barrier to participation among these groups compared with white, non-Hispanics. Attitudes, beliefs, perceptions, and knowledge regarding clinical research, and cultural characteristics of underrepresented minorities pose additional barriers to participation. This article focuses on the structural, cultural, and linguistic factors that affect participation in clinical cancer research for each major U.S. racial/ethnic group. Low socioeconomic status, speaking a primary language other than English, differences in communication styles, mistrust of research and the medical system, fear, embarrassment, and lack of knowledge about the origin of cancer appear to have a negative impact on clinical cancer research participation rates. Much of the information about these factors comes from studies of cancer screening because little data is available on the factors that prevent and facilitate participation of minorities in clinical cancer trials specifically. Such research is needed, and, given the heterogeneity within and between minority populations, should occur in several different geographic settings and with as many different minority subpopulations as possible.

Pap smear screening among urban Southwestern American Indian women

BACKGROUND

American Indian women have among the highest incidence and mortality rates of cervix cancer in the United States. The incidence of cancer of the cervix among American Indians is 19.5/100,000 versus 7.8/100,000 in U.S. whites, and comparison by geographic region/tribe indicates that the rate is four to six times higher in some tribes. Papanicolaou cytological testing (Pap smear) permits the detection of cervical lesions before they become cancerous, effectively reducing the incidence of cervical cancer by 75-90%. The American Cancer Society recommends a Pap smear every year beginning at age 18 years or when sexually active, and more frequent screening in high-risk populations.

METHODS

A random household cross-sectional survey was conducted in Phoenix, Arizona, to assess cervical cancer screening rates among 519 adult urban American Indian women. Logistic regression was used to identify predictors of Pap smear use.

RESULTS

Three-quarters (76.1%) of urban women American Indian surveyed received a Pap smear within the past 3 years, but only 49.5% received a Pap smear within the last year. Women over age 50 years were significantly less likely to have received a recent Pap smear in comparison to younger women.

CONCLUSIONS

The results of this study indicate that limited access to health care and lack of knowledge about the procedure were important barriers to Pap smear use. Improving cervix cancer screening participation rates is an important step in reducing the disease burden in this high-risk population.

Influence of health care, cost, and culture on breast cancer screening: issues facing urban American Indian women

BACKGROUND

Breast cancer is the second leading cause of cancer death among American Indian women. Southwestern American Indian women are more likely to have distant spread of the disease, and 5-year survival from breast cancer is poor in comparison to U.S. whites. Mortality from breast cancer could be reduced by more than 30% in American Indian women if current recommendations for screening were followed.

METHODS

A random household cross-sectional survey was conducted among 519 adult American Indian women in Phoenix, Arizona. Logistic regression was used to identify predictors of recent clinical breast examination and mammogram among those women aged 40 years and older.

RESULTS

Just more than half (53.0%) of the women surveyed reported they had received a clinical breast examination in the last year, and 35.7% indicated they had received a mammogram in the last 2 years. Access to care, knowledge of the examinations, and health beliefs were positively associated with breast cancer screening in the multivariate analyses.

CONCLUSIONS

The cancer screening rates observed in urban American Indian women are far below current national estimates and Healthy People 2000 Objectives. This study confirms the limited access of urban Indians to preventive health services, and supports a role for cancer education in improving screening participation in this special population.

Cancer prevention among urban southwestern American Indian women: comparison to selected Year 2000 national health objectives

PURPOSE

The health issues which have historically faced American Indians are related to infectious disease, but today many chronic diseases play a large role in the health status of this special population. For example, existing data indicate that American Indians have the poorest cancer survival of any group in the U.S. (34% vs. 50% for U.S. Whites). Regular participation in cancer screening and lifestyle factors such as smoking, diet, and alcohol have been found to significantly contribute to cancer risk. However, available information about these behaviors is sparse and suffers from limitations. The purpose of this study was to assess the prevalence of cancer risk behaviors and provider recommendation for cancer screening among urban American Indian women.

METHODS

A random household cross-sectional survey was administered to 519 adult American Indian women in Phoenix, Arizona. Smoking and weight status, alcohol consumption, physical activity, and provider referral were assessed by self-report.

RESULTS

The results indicate that weight (69.6% were overweight) and excessive alcohol consumption (12.1 reported chronic drinking) were significant health issues in this population. The prevalence of provider referral for smoking cessation (14.9% among ever smokers) and breast as well as cervical cancer screening (30.1% and 55.5%, respectively) were below the 75% level set forth in the Year 2000 Goals.

CONCLUSIONS

The results of this study suggest that increased cancer prevention and control efforts are needed in this special population to address the link between diet, weight, and long-term disease prevention.

Diabetes and Canada's aboriginal peoples: the need for primary prevention

The high prevalence of non-insulin-dependent diabetes mellitus (NIDDM) in Canada's native communities corresponds with high diabetes prevalence rates in other populations of indigenous peoples that have undergone changes associated with acculturation. Behavioural risk factors can be particularly amenable to public health action. There exists a need to develop, implement and test in collaboration with native people, interventions aimed at reducing the incidence and impact of NIDDM, by reducing the risk of its onset, and by early detection and treatment. Intervention programmes should be conceived with sensitivity to the overall health, social, economic, educational and cultural environment within a community. Although this review focuses specifically on diabetes in Canada, many of the points relating to the need for primary prevention of the disease will be appropriate in other situations.

Evaluating written patient education materials

Evaluation, the last component in the process of patient education, is the most frequently omitted step in producing informative material. Yet, it is essential that program/material evaluation be conducted to determine the impact and success or failure of the program or material. It is vital to be aware of this need and possess knowledge about types of evaluation and those areas that must be included to provide a comprehensive evaluation.