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Traditionalism and Colorectal Cancer Screening among Reservation American Indians

Traditionalism and Colorectal Cancer Screening among Reservation American Indians. David G. Perdue MD MSPH University of Minnesota Division of Gastroenterology. Background: Colorectal Cancer In Indian Communities. Colorectal Cancer. Normal Colon. Polyp. Colon Cancer.

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Traditionalism and Colorectal Cancer Screening among Reservation American Indians

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  1. Traditionalism and Colorectal Cancer Screening among Reservation American Indians David G. Perdue MD MSPH University of Minnesota Division of Gastroenterology

  2. Background: Colorectal Cancer In Indian Communities

  3. Colorectal Cancer Normal Colon Polyp ColonCancer Colon Cancer Prevented! Polypectomy

  4. Current Screening Options Colonoscopy every 10 years OR FOBT (on 3 consecutive stools) Yearly AND Flexible Sigmoidoscopy Every 5 Years OR Barium Enema Every 5 Years

  5. Invasive colorectal cancer incidence by region, 1999-2002 AI/AN in CHSDA counties and All Races Combined in RegionAge 50 and Over 32% Higher Incidence in Northern Plains American Indians AK/SW 6 fold Difference AI/AN Cases 211 272 435 65 278 176 AI/All Races RR 1.75 1.32 1.24 0.78 0.88 0.39 Source: Prelim_NPCR_SEER_AgeGroups_08_17_06.doc.Note: All races combined not limited to CHSDA

  6. Barriers Can Lead to Cancer • Individual and Community Barriers • -Unaware of Risk or Denial • -Fear of Pain or Embarrassment • -Cultural Beliefs • Financial Barriers • -No insurance • -Fear of liability • -Need to miss work • -Need for a ride No Screening No Preventative Polypectomy Later Stage Diagnoses?? • Institutional Barriers • -Discomfort with medical system • -Physician not recommending • -Unclear of risk • -Competing priorities • -Time constraints • -Endoscopic capacity • -Distance to services

  7. Traditionalism and Colorectal Cancer Screening among American Indians • University of Minnesota • David G. Perdue, MD, MSPH • Black Hills Center for American Indian Health • Jeffrey A. Henderson, MD, MPH • University of Washington • Andrew Bogart, MS • Yang Wen, MS • Jack Goldberg, PhD • Dedra Buchwald, MD

  8. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Education and Research Towards Health (EARTH) • 5 yr multi-center prospective cohort • Determine how diet, physical activity, and other lifestyle and cultural factors relate to the development and progression of chronic diseases, including cancer • PIs: • Black Hills Center for American Indian Health: • Jeff Henderson MD MPH • Alaska Native Tribal Health Consortium: • Anne Lanier MD MPH • University of Utah • Marty Slattery PhD MPH

  9. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • AIMs • Describe the self-reported CRC screening test utilization among AIs > 51 years of age • Test hypothesis that AIs who maintain their traditional culture are less likely to have had CRC screening

  10. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Subjects • BHCAIH Cohort: n= 5,212 • Age 51 or over: n= 867 • Complete data, no history CRC FOBT: n= 717 Endoscopy: n= 751

  11. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • CRC Screening Questions: • Based on BRFSS • “Did you ever have a test to see if there is blood in your bowel movement also called a fecal occult blood test or FOBT?” • “Did you ever have a colonoscopy or sigmoidoscopy? These are tests in which a tube is inserted in the rectum to view the bowel.”

  12. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Traditionalism Constructs: • Traditional Healing Practices • Cultural Identity

  13. Traditionalism & Colorectal Cancer Screening among Reservation American Indians Traditional healing practices questions • “Have you ever been treated by a traditional Native healer” • “Do you use traditional Native remedies and or practices to remain healthy (prevent illness)?” • “Do you use traditional Native remedies and or practices when you are sick or ill?”

  14. Traditionalism & Colorectal Cancer Screening among Reservation American Indians Cultural Identity Questions: • “What language do you usually speak at home, your own American Indian language, English, or both?” • “How much do you identify with your own tribal tradition?” • “Do you ever participate in Native dances, powwows, potlatches, chicken scratch dances, sweats, or other such traditional events as a dancer, drum member, organizer, or other active participant?”

  15. Traditionalism & Colorectal Cancer Screening among Reservation American Indians Adjustment covariates: • Age • Education • Employment, • Single caregiver • Marital status • Smoking history • Reservation of residence • Status as a current driver

  16. Traditionalism & Colorectal Cancer Screening among Reservation American Indians Statistical Analysis • Frequencies and proportions • Sociodemographic: age, income, dependents, education, employment and marital status. • Ecological: reservation, driving status, single care giver • Traditional healing practices • Cultural identity • Association between traditional healing practices and cultural identity with the receipt of CRC screening • logistic regression analysis. • Adjusted odds ratios and 95% confidence intervals • Association of our summary (ordinal) measures of traditional healing and cultural identify with CRC screening • test for trend from logistic regression.

  17. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Results • Any CRC screening: 35% • FOBT • Arizona: 23% (versus state BRFSS 31%) • South Dakota: 20% (versus state BRFSS 27%) • Endoscopic • Arizona: 22% (versus state BRFSS 52%) • South Dakota: 21% (versus state BRFSS 50%)

  18. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Factors Associated with Screening • Associated with FOBT • Education Level (p =0.02) • Former or non-smoker (p <0.01) • Associated with Endoscopy • Income (p < 0.01) • Education Level (p < 0.01) • Married (p < 0.01) • Former or non-smoker (p < 0.01) • Current Driver (p = 0.02)

  19. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Unadjusted Summary Comparisons • Traditional Healing Use Questions • FOBT: None significant • Endoscopy None Significant • Cultural Identity Questions • FOBT None Significant • Endoscopy Native Language at home p<0.01

  20. Traditionalism & Colorectal Cancer Screening among Reservation American Indians None meet significance

  21. Traditionalism & Colorectal Cancer Screening among Reservation American Indians

  22. Traditionalism & Colorectal Cancer Screening among Reservation American Indians

  23. Traditionalism & Colorectal Cancer Screening among Reservation American Indians

  24. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Summary Results: • FOBT and endoscopic screening are lower in AI than non-AIs living in the same state • Those with higher education attainment and former smokers had the highest likelihood of reporting FOBT and endoscopy • Higher incomes, married, and current drivers where more likely to have had endoscopy

  25. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Summary Results • Those who spoke their Native language at home where less likely to have had endoscopy • None of the other traditionalism questions met statistical significance • However, the direction of association all questions was away from screening

  26. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Trend Analysis • A significant trend away from FOBT was seen with increasing positive responses to the traditional medicine use questions • A significant trend awayfrom endoscopic screening was seen with increasing positive responses to the cultural identity questions

  27. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Limitations • Traditionalism is a complex metric that varies by tribe and geography • CRC screening was self-reported • Probable many tests were for symptoms, not screening • Lack of data on factors known to alter odds of screening • Having a primary physician who recommends screening • Insurance status

  28. Traditionalism & Colorectal Cancer Screening among Reservation American Indians • Conclusions • American Indians experience disparities in CRC burden • Screening disparities likely play an important role • Constructs of traditionalism affect CRC screening participation in complex ways • More work is needed to understand the individual, community, and institutional barriers to and determinants of CRC screening participation so durable, culturally-specific CRC screening programs can be developed

  29. Questions?

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