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

Traditionalism and Colorectal Traditionalism and Colorectal Cancer Screening among Cancer Screening among

Reservation American IndiansReservation American Indians

David G. Perdue MD MSPHDavid G. Perdue MD MSPH

University of MinnesotaUniversity of Minnesota

Division of GastroenterologyDivision of Gastroenterology

Background: Colorectal Cancer Background: Colorectal Cancer In Indian CommunitiesIn Indian Communities

Colorectal CancerColorectal Cancer

Normal Colon Colon CancerPolyp

Polypectomy Colon Cancer Prevented!

Current Screening OptionsCurrent Screening Options

FOBT (on 3 consecutive stools) YearlyAND

Flexible Sigmoidoscopy Every 5 Years

Colonoscopy every 10 years

OR

OR

Barium Enema Every 5 Years

Invasive colorectal cancer incidence by region, Invasive colorectal cancer incidence by region, 1999-2002 AI/AN in CHSDA counties and All Races 1999-2002 AI/AN in CHSDA counties and All Races

Combined in RegionCombined in Region Age 50 and OverAge 50 and Over

359.0

250.7

206.1

148.1 144.5

59.4

205.6190.3

166.3189.4

164.1154.0

0

50

100

150

200

250

300

350

400

Alaska NothernPlains

SouthernPlains

East PacificCoast

Southwest

Ag

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dju

ste

d (

US

20

00

) ra

te p

er

10

0,0

00

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AI/AN

All Races

AI/AN Cases 211 272 435 65 278 176AI/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

32% Higher Incidence in Northern Plains American Indians

AK/SW6 foldDifference

Barriers Can Lead to CancerBarriers Can Lead to Cancer

Individual and Community BarriersIndividual and Community Barriers-Unaware of Risk or Denial-Unaware of Risk or Denial-Fear of Pain or Embarrassment-Fear of Pain or Embarrassment-Cultural Beliefs-Cultural BeliefsFinancial BarriersFinancial Barriers

-No insurance-No insurance-Fear of liability-Fear of liability-Need to miss work-Need to miss work-Need for a ride-Need for a ride

Institutional BarriersInstitutional Barriers -Discomfort with medical -Discomfort with medical

systemsystem -Physician not recommending-Physician not recommending -Unclear of risk-Unclear of risk -Competing priorities-Competing priorities -Time constraints-Time constraints

-Endoscopic capacity-Endoscopic capacity-Distance to services-Distance to services

No ScreeningNo Preventative PolypectomyLater Stage Diagnoses??

Traditionalism and Colorectal Cancer Traditionalism and Colorectal Cancer Screening among American IndiansScreening among American Indians

University of MinnesotaUniversity of Minnesota David G. Perdue, MD, MSPHDavid G. Perdue, MD, MSPH

Black Hills Center for American Indian HealthBlack Hills Center for American Indian HealthJeffrey A. Henderson, MD, MPH Jeffrey A. Henderson, MD, MPH

University of WashingtonUniversity of WashingtonAndrew Bogart, MSAndrew Bogart, MSYang Wen, MSYang Wen, MSJack Goldberg, PhDJack Goldberg, PhDDedra Buchwald, MDDedra Buchwald, MD

Education and Research Towards Health Education and Research Towards Health (EARTH)(EARTH)

5 yr multi-center prospective cohort5 yr multi-center prospective cohortDetermine how diet, physical activity, and other Determine how diet, physical activity, and other lifestyle and cultural factors relate to the development lifestyle and cultural factors relate to the development and progression of chronic diseases, including cancerand progression of chronic diseases, including cancerPIs:PIs:

Black Hills Center for American Indian Health: Black Hills Center for American Indian Health: Jeff Henderson MD MPHJeff Henderson MD MPH

Alaska Native Tribal Health Consortium:Alaska Native Tribal Health Consortium:Anne Lanier MD MPHAnne Lanier MD MPH

University of UtahUniversity of UtahMarty Slattery PhD MPHMarty Slattery PhD MPH

Traditionalism & Colorectal Cancer Screening among Traditionalism & Colorectal Cancer Screening among Reservation American IndiansReservation American Indians

AIMsAIMsDescribe the self-reported CRC screening test Describe the self-reported CRC screening test utilization among AIs > 51 years of ageutilization among AIs > 51 years of age

Test hypothesis that AIs who maintain their Test hypothesis that AIs who maintain their traditional culture are less likely to have had traditional culture are less likely to have had CRC screeningCRC screening


SubjectsSubjects

BHCAIH Cohort: n= 5,212BHCAIH Cohort: n= 5,212

Age 51 or over: n= 867Age 51 or over: n= 867

Complete data, no history CRCComplete data, no history CRC FOBT: n= 717FOBT: n= 717 Endoscopy: n= 751Endoscopy: n= 751


CRC Screening Questions:CRC Screening Questions:Based on BRFSSBased on BRFSS

““Did you ever have a test to see if there is blood in Did you ever have a test to see if there is blood in your bowel movement also called a fecal occult blood your bowel movement also called a fecal occult blood test or FOBT?” test or FOBT?”

““Did you ever have a colonoscopy or sigmoidoscopy? Did you ever have a colonoscopy or sigmoidoscopy? These are tests in which a tube is inserted in the These are tests in which a tube is inserted in the rectum to view the bowel.” rectum to view the bowel.”


Traditionalism Constructs:Traditionalism Constructs:Traditional Healing PracticesTraditional Healing Practices

Cultural IdentityCultural Identity


Traditional healing practices questions Traditional healing practices questions

““Have you ever been treated by a traditional Native Have you ever been treated by a traditional Native healer” healer”

““Do you use traditional Native remedies and or Do you use traditional Native remedies and or practices to remain healthy (prevent illness)?” practices to remain healthy (prevent illness)?”

““Do you use traditional Native remedies and or Do you use traditional Native remedies and or practices when you are sick or ill?”practices when you are sick or ill?”


Cultural Identity Questions:Cultural Identity Questions:

““What language do you usually speak at home, your What language do you usually speak at home, your own American Indian language, English, or both?” own American Indian language, English, or both?”

““How much do you identify with your own tribal How much do you identify with your own tribal tradition?”tradition?”

““Do you ever participate in Native dances, powwows, Do you ever participate in Native dances, powwows, potlatches, chicken scratch dances, sweats, or other potlatches, chicken scratch dances, sweats, or other such traditional events as a dancer, drum member, such traditional events as a dancer, drum member, organizer, or other active participant?” organizer, or other active participant?”


Adjustment covariates:Adjustment covariates:AgeAgeEducationEducationEmployment, Employment, Single caregiverSingle caregiverMarital statusMarital statusSmoking historySmoking historyReservation of residence Reservation of residence Status as a current driver Status as a current driver


Statistical AnalysisStatistical Analysis

Frequencies and proportionsFrequencies and proportionsSociodemographic: age, income, dependents, education, employment Sociodemographic: age, income, dependents, education, employment and marital status.and marital status.Ecological: reservation, driving status, single care giverEcological: reservation, driving status, single care giverTraditional healing practicesTraditional healing practicesCultural identity Cultural identity

Association between traditional healing practices and cultural Association between traditional healing practices and cultural identity with the receipt of CRC screening identity with the receipt of CRC screening

logistic regression analysis. logistic regression analysis. Adjusted odds ratios and 95% confidence intervalsAdjusted odds ratios and 95% confidence intervals

Association of our summary (ordinal) measures of traditional healing Association of our summary (ordinal) measures of traditional healing and cultural identify with CRC screening and cultural identify with CRC screening

test for trend from logistic regression. test for trend from logistic regression.


ResultsResultsAny CRC screening: 35%Any CRC screening: 35%

FOBTFOBTArizona: 23% (versus state BRFSS 31%)Arizona: 23% (versus state BRFSS 31%)

South Dakota: 20% (versus state BRFSS 27%)South Dakota: 20% (versus state BRFSS 27%)

EndoscopicEndoscopicArizona: 22% (versus state BRFSS 52%)Arizona: 22% (versus state BRFSS 52%)

South Dakota: 21% (versus state BRFSS 50%) South Dakota: 21% (versus state BRFSS 50%)


Factors Associated with ScreeningFactors Associated with ScreeningAssociated with FOBT Associated with FOBT

Education Level Education Level (p =0.02)(p =0.02)

Former or non-smoker Former or non-smoker (p <0.01)(p <0.01)

Associated with EndoscopyAssociated with EndoscopyIncome Income (p < 0.01)(p < 0.01)

Education Level Education Level (p < 0.01)(p < 0.01)

MarriedMarried (p < 0.01)(p < 0.01)

Former or non-smokerFormer or non-smoker (p < 0.01)(p < 0.01)

Current DriverCurrent Driver (p = 0.02)(p = 0.02)


Unadjusted Summary ComparisonsUnadjusted Summary Comparisons

Traditional Healing Use QuestionsTraditional Healing Use QuestionsFOBT: FOBT: None significantNone significant

EndoscopyEndoscopy None SignificantNone Significant

Cultural Identity QuestionsCultural Identity QuestionsFOBTFOBT None SignificantNone Significant

Endoscopy Native Language at home p<0.01Endoscopy Native Language at home p<0.01


Logistic RegressionLogistic Regression FOBT Endoscopy

Traditional Healing

Adjusted

OR 95%CIAdjusted

OR 95%CI

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



Number of traditional healing practices endorsed

Adjusted OR

95%CI Adjusted OR

95%CI

0 1.0 -- 1.0 --

1 0.6 (0.3, 1.0) 1.0 (0.6, 1.6)

2 0.7 (0.4, 1.4) 0.6 (0.3, 1.2)

3 0.6 (0.3, 1.2) 0.9 (0.5, 1.8)

p trend 0.06 0.41



Cultural Identity

AdjustedOR

95% CIAdjusted

OR95% 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)



Number of cultural identity factors endorsed

Adjusted OR

95% CIAdjusted

OR95% CI

0 1.0 -- 1.0 --

1 0.6 (0.3, 1.2) 1.1 (0.6, 2.1)

2 0.6 (0.3, 1.0) 0.7 (0.4, 1.2)

3 0.7 (0.4, 1.3) 0.6 (0.3, 1.1)

p trend 0.36 <0.01


Summary Results:Summary Results:FOBT and endoscopic screening are lower in FOBT and endoscopic screening are lower in AI than non-AIs living in the same stateAI than non-AIs living in the same state

Those with higher education attainment and Those with higher education attainment and former smokers had the highest likelihood of former smokers had the highest likelihood of reporting FOBT and endoscopyreporting FOBT and endoscopy

Higher incomes, married, and current drivers Higher incomes, married, and current drivers where more likely to have had endoscopy where more likely to have had endoscopy


Summary ResultsSummary ResultsThose who spoke their Native language at Those who spoke their Native language at home where less likely to have had home where less likely to have had endoscopyendoscopy

None of the other traditionalism questions met None of the other traditionalism questions met statistical significancestatistical significance

However, the direction of association all However, the direction of association all questions was away from screeningquestions was away from screening


Trend AnalysisTrend AnalysisA significant trend A significant trend awayaway from FOBT was seen from FOBT was seen with increasing positive responses to the with increasing positive responses to the traditional medicine use questionstraditional medicine use questions

A significant trend A significant trend awayaway from endoscopic from endoscopic screening was seen with increasing positive screening was seen with increasing positive responses to the cultural identity questionsresponses to the cultural identity questions


LimitationsLimitationsTraditionalism is a complex metric that varies Traditionalism is a complex metric that varies by tribe and geographyby tribe and geography

CRC screening was self-reportedCRC screening was self-reportedProbable many tests were for symptoms, not Probable many tests were for symptoms, not screeningscreening

Lack of data on factors known to alter odds of Lack of data on factors known to alter odds of screeningscreening

Having a primary physician who recommends Having a primary physician who recommends screeningscreening

Insurance statusInsurance status


ConclusionsConclusionsAmerican Indians experience disparities in CRC American Indians experience disparities in CRC burdenburden

Screening disparities likely play an important roleScreening disparities likely play an important role

Constructs of traditionalism affect CRC screening Constructs of traditionalism affect CRC screening participation in complex waysparticipation in complex ways

More work is needed to understand the individual, More work is needed to understand the individual, community, and institutional barriers to and community, and institutional barriers to and determinants of CRC screening participation so determinants of CRC screening participation so durable, culturally-specific CRC screening programs durable, culturally-specific CRC screening programs can be developedcan be developed


Questions?Questions?

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

Documents

american indian healthjeffrey

current screening optionsfobt

traditional native remedies

traditional native healer

traditional culture

msphblack hills center

history crc fobt

region age