Traditionalism and Colorectal Cancer Screening among Reservation American Indians

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Traditionalism and Colorectal Cancer Screening
among Reservation American Indians

• David G. Perdue MD MSPH
• University of Minnesota
• Division of Gastroenterology

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(No Transcript)
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Background Colorectal Cancer In Indian
Communities
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Colorectal Cancer
Normal Colon
Colon Cancer
Polyp
Colon Cancer Prevented!
Polypectomy
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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
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Invasive colorectal cancer incidence by region,
1999-2002 AI/AN in CHSDA counties and All Races
Combined in Region Age 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.No
te All races combined not limited to CHSDA
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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
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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

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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

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Traditionalism Colorectal Cancer Screening
among Reservation American Indians

• AIMs
• Describe the self-reported CRC screening test
  utilization among AIs gt 51 years of age
• Test hypothesis that AIs who maintain their
  traditional culture are less likely to have had
  CRC screening

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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

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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.

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Traditionalism Colorectal Cancer Screening
among Reservation American Indians

• Traditionalism Constructs
• Traditional Healing Practices
• Cultural Identity

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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?

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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?

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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

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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.

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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)

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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 lt0.01)
• Associated with Endoscopy
• Income (p lt 0.01)
• Education Level (p lt 0.01)
• Married (p lt 0.01)
• Former or non-smoker (p lt 0.01)
• Current Driver (p 0.02)

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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
  plt0.01

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Traditionalism Colorectal Cancer Screening
among Reservation American Indians
Logistic Regression FOBT FOBT Endoscopy Endoscopy
Traditional Healing Adjusted OR 95CI Adjusted OR 95CI
Has ever been treated by a Traditional Native Healer 0.7 (0.4, 1.1) 1.1 (0.7, 1.8)
Uses traditional Native remedies/practices when ill 0.7 (0.5, 1.1) 0.6 (0.4, 1.0)
Uses traditional Native remedies/practices to prevent illness 0.7 (0.4, 1.1) 0.9 (0.6, 1.4)
None meet significance
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Traditionalism Colorectal Cancer Screening
among Reservation American Indians
Logistic Regression FOBT FOBT Endoscopy Endoscopy Endoscopy
Number of traditional healing practices endorsed Adjusted OR 95CI Adjusted OR Adjusted OR 95CI
0 1.0 -- 1.0 -- --
1 0.6 (0.3, 1.0) 1.0 (0.6, 1.6) (0.6, 1.6)
2 0.7 (0.4, 1.4) 0.6 (0.3, 1.2) (0.3, 1.2)
3 0.6 (0.3, 1.2) 0.9 (0.5, 1.8) (0.5, 1.8)
p trend 0.06 0.06 0.41 0.41 0.41
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Traditionalism Colorectal Cancer Screening
among Reservation American Indians
Logistic Regression FOBT FOBT Endoscopy Endoscopy
Cultural Identity Adjusted OR 95 CI AdjustedOR 95 CI
Uses American Indian language at home 0.8 (0.6, 1.2) 0.6 (0.4, 0.9)
Identifies with tribal tradition 0.9 (0.6, 1.5) 0.7 (0.4, 1.1)
Actively participates in tribal events 0.9 (0.6, 1.3) 0.8 (0.5, 1.2)
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Traditionalism Colorectal Cancer Screening
among Reservation American Indians
Logistic Regression FOBT FOBT FOBT Endoscopy Endoscopy Endoscopy
Number of cultural identity factors endorsed Adjusted OR 95 CI Adjusted OR Adjusted OR Adjusted OR Adjusted OR 95 CI
0 1.0 -- -- 1.0 -- --
1 0.6 (0.3, 1.2) (0.3, 1.2) 1.1 (0.6, 2.1) (0.6, 2.1)
2 0.6 (0.3, 1.0) (0.3, 1.0) 0.7 (0.4, 1.2) (0.4, 1.2)
3 0.7 (0.4, 1.3) (0.4, 1.3) 0.6 (0.3, 1.1) (0.3, 1.1)
p trend 0.36 0.36 0.36 lt0.01 lt0.01 lt0.01
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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

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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

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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 away from endoscopic
  screening was seen with increasing positive
  responses to the cultural identity questions

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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

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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

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Questions?