Perspectives on cancer health disparities in West Virginia.
Abstract: "Perspectives on Cancer Health Disparities in West Virginia" provides an overview of the factors that lead to health disparities in general, to the burden of breast and other cancers in our state, and highlights the deep-rooted values and characteristics that will help communities and their partners achieve parity.
Subject: Oncologic nursing (Demographic aspects)
Cancer (Care and treatment)
Cancer (Methods)
Cancer (Demographic aspects)
Authors: Brown, Pamela K.
Heady, Hilda R.
Gainor, Sara Jane
Harrison, Diana
Daven, Morgan
Pub Date: 10/01/2009
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: Oct, 2009 Source Volume: 105 Source Issue: S1
Product: Product Code: 8000432 Cancer Therapy NAICS Code: 621 Ambulatory Health Care Services
Geographic: Geographic Scope: West Virginia Geographic Code: 1U5WV West Virginia
Accession Number: 218949143
Full Text: Objectives

The objectives of this paper are to discuss:

1) the factors that lead to health disparities in general; 2) how health disparities relate to the excess burden cancer in our state; 3) the deep-rooted values and characteristics that will help communities and their partners reduce and/or eliminate cancer health disparities in West Virginia.

Perspective on Cancer Health Disparities

"There is a critical disconnect between what we discover in cancer research and what we deliver to all American people. This 'discovery to delivery disconnect' is a key determinant of the unequal burden of cancer."(1) The "disconnect" occurs when we, as health care providers and educators, fail to understand the relationship between historical and cultural factors and the attitudes, beliefs, and behavior of our communities. Understanding why cancer disproportionately impacts some West Virginians must be linked to the ability to translate that understanding into effective interventions. Bridging the disconnect requires health care providers to be culturally competent and patients to have access to high-quality health care services. Failure to bridge the disconnect results in an unequal burden of cancer in our communities, causing a cancer health disparity.

Cancer health disparities are population-specific differences in incidence, disease outcomes, and access to high-quality care throughout the cancer continuum. These health disparities negatively challenge the well-being of our communities. An overarching theme, health disparities occur for many reasons but, in general, only impact a select segment of the population--those who have the least resources, human and material, to cope with disease. The concept of 'health disparities' is complex and constantly under refinement, but includes;

* the systemic barriers that block access to cancer education and optimal screening, treatment, and survivor services,

* the reasons people don't comply with lifestyle recommendations that will keep them healthy,

* the reasons some people get and/or die of certain cancers because of their race, ethnicity, socioeconomic status, genes, and geographic location, and

* the way people with cancer are treated differently depending on their class, race and ethnicity.

For all people, the main contributors to the unequal burden of cancer are lack of education and poverty. (2) Also, underserved populations have poorer health status and outcomes because of inequities in access to care; limited adoption of healthy behaviors; life-long gaps in access to routine preventive care; limited English proficiency; miscommunication in patient-provider interactions; and the prevalence of co-morbidities such as obesity, diabetes, and heart disease. (3) In West Virginia, health disparities also relate to lack of health insurance, having limited literacy skills, living in a poor, rural county, and, in our predominantly white population, being a racial or ethnic minority. (4)

Definitions of "access" must address both "knowing" something needs to be done and having the resources to get it done. Lack of access to care, especially lack of insurance, contributes greatly to a disproportionate vulnerability of underserved populations nationally and in our state. West Virginia ranks among the highest in the nation for people living below the poverty level and a quarter of residents between the ages of 18 and 64 are uninsured. (5) Uninsured adults in West Virginia are more likely to not see a doctor when needed due to cost than adults with coverage (6). Those uninsured who do see a doctor may not receive the same level of care as insured patients. This inequity may be a result of health practice "guidelines for cost containment." "Medical profiling" may also be a factor, meaning the care provider may assume a poor, rural patient will not comply with a treatment regime, may not understand medical or drug-taking directives, or may not be able to travel for more specialized care. Not only is the patient denied the opportunity to participate in decision-making regarding his/her own health, but the patient may not even be aware that there are treatment options. (7)

West Virginia ranks high among the states in the percentage of adults at the lowest literacy level. People with limited literacy skills report poorer overall health; are less likely to be screened; present in later stages of disease; are more likely to be hospitalized; have poorer understanding of treatment, and have lower adherence to medical regimens. (8) Physicians, nurses, and other health care professionals have an opportunity to improve health by communicating with people in clear, uncomplicated terms and in a manner that is respectful of their cultural background. Lack of knowledge about potential communication barriers exacerbates health disparities and negatively impacts health outcomes. By taking the time to consider who a patient is in a cultural context, the physician, nurse or other health care provider can make a significant difference in the patient's experience. Making a commitment to understanding the role of communications in the care and treatment of patients from diverse populations can improve the quality of care they receive and positively contribute to equality of care they receive. (9)

Summary

When national cancer data show that certain populations or groups of people have disproportionately high incidence rates or are at higher-than-average risk of death or prolonged illness, they are termed a "special or underserved population."(10) In West Virginia, the incidence rate for breast cancer is lower than the U.S. rate, but the mortality rate for breast cancer in West Virginia is higher. (11) The high breast cancer mortality rate in our state is evidence of a health disparity. Some women may not be getting regular mammograms, they may be diagnosed with breast cancer at a later stage, and/or they are not receiving timely and appropriate treatment.

With limited resources and copious challenges, collaborations and partnerships are essential to improving cancer care in West Virginia. And these partnerships must include community advisors in every phase of development and delivery of programs and services. The Bureau for Public Health West Virginia Breast and Cervical Cancer Screening Program (BCCSP) provides screening to more than sixteen thousand women per year who are uninsured or under-insured and pays for further diagnostic tests and treatment when needed. Funded by the Centers for Disease Control and Prevention, it is an example of public, academic and community partnerships that come together to improve the rate of breast and cervical cancer screening. Another example of the state's academic and community partnerships is the robust grassroots, community based rural health training program. Through the West Virginia Rural Health Education Partnerships/Area Health Education Centers, all state supported health science students complete rural rotations and service learning projects in rural communities. Students engage in cancer prevention and screening projects and serve as they learn. The students learn in an integrated holistic manner the clinical, population-based, and cultural skills that are needed to practice in rural areas. The WV Department of Health and Human Resources in collaboration with Cancer Prevention and Control (CPC) at the Mary Babb Randolph Cancer Center supports the WV Comprehensive Cancer Coalition, "Mountains of Hope." Partners in this effort include the American Cancer Society, Marshall University Edwards Comprehensive Cancer Center, the BCCSP and the Bureau for Public Health Comprehensive Cancer Control Program, the NCI Cancer Information Service, the Appalachia Community Cancer Network, Susan G. Komen for the Cure, the WV Ovarian Cancer Initiative and "Agents of Hope" community volunteers, most of who are cancer survivors. This coalition, a model for other rural states, developed a comprehensive state cancer plan, which clearly identifies the needs for prevention, early detection, and quality of life for all cancers. Community-based cancer coalitions gain support and encouragement from the larger organization to provide prevention and screening programs for the people in their community.

An understanding of the history of rural people and how their receptiveness to health care is influenced by their history and culture can help to eliminate the disparities that perpetuate themselves in our culture. In order to reduce the unequal burden of cancer, issues such as quality of health care, adequate infrastructure and resources, transportation barriers, insurance coverage for all, increasing health literacy, and improving quality of life must be addressed. Financial limitations, transportation problems, and lack of insurance may appear to be barriers to early detection and treatment, when sensitivity to those issues can create an environment of openness to help stimulate creative thinking about options. To impact cancer health disparities, prevention, early detection, and treatment for all must be the focus with an eye to providing such services in a way rural West Virginians can welcome and embrace.

CME Post-Test

34. What is the key determinant of the unequal burden of cancer?

a. race

b. the discovery to delivery disconnect

c. lack of access to care

35. What are the two main contributors to the unequal burden of cancer?

a. Cost of and access to care

b. Lack of insurance and high co-pays

c. Poverty and lack of education

36. T or F Health literacy and cultural competence impact cancer health disparities in West Virginia

37. What is the role of partnership in reducing cancer health disparities in West Virginia?

a. Maximizing resources

b. Reducing duplication of effort

c. Building political influence

References

(1.) Freeman HP (Chairman), President's Cancer Panel. Voices of a Broken System: Real People, Real Problems. Bethesda, MD: National Cancer Institute, 2002.

(2.) Freeman HP, "Voices of a Broken System: Real People, Real Problems," President's Cancer Panel--Report of the Chairman 2000-2001, National Cancer Institute, National Institutes of Health, September 2001.

(3.) Agency for Healthcare Research and Quality (AHRQ). 2006 National healthcare disparities report (AHRQ Pub. No. 070012). Rockville, MD: U.S. Department of Health and Human Services.

(4.) Lengerich EJ, Bohland JR, Brown PK, Dignan MB, Paskett NE, Schoenberg NE, and Wyatt SW. "Images of Appalachia." Prev Chronic Disease 3, No. 4 (2006): A112.

(5.) US Census Bureau 2004 American Community Survey. Data profile highlights: West Virginia. Washington, DC: U.S. Census Bureau.

(6.) Lavizzo-Mourey, R. "A Tree in the Storm: Philanthropy and the Health of the Public." In Robert Wood Johnson Foundation Annual Report, 2005.

(7.) Freeman HP, "Voices of a Broken System: Real People, Real Problems," President's Cancer Panel--Report of the Chairman 2000-2001, National Cancer Institute, National Institutes of Health, September 2001.

(8.) Effects of Public Information in Cancer (Epic). University of Pennsylvania Annenberg School for Communication. Centers of Excellence in Cancer Communications Research. In http://ceccr. asc.upenn.edu/index.asp.

(9.) Matthews-Juarez, P., Weinberg, A.D. (2006). Cultural competence in cancer care: A health care professional's passport. Waco, TX. Intercultural Cancer Council, Baylor College of Medicine.

(10.) Freeman HP, "Voices of a Broken System: Real People, Real Problems," President's Cancer Panel--Report of the Chairman 2000-2001, National Cancer Institute, National Institutes of Health, September 2001.

(11.) 1999-2005 United States Cancer Statistics: Incidence and Mortality web-based report. Centers for Disease Control and Prevention, National Cancer Institute. Available at http://surveillance.cancer.gov/ joint report.html.

Pamela K. Brown, MPA [1] Hilda R. Heady, MSW [2] Sara Jane Gainor, MBA [3] Diana Harrison, BS [4] Morgan Daven, MA [5]

[1] Associate Director, Mary Babb Randolph Cancer Center, West Virginia School of Medicine, West Virginia University, Morgantown, WV

[2] Associate Vice President for Rural Health, Health Sciences Center, West Virginia School of Medicine, West Virginia University, Morgantown, WV

[3] Director, NCI Cancer Information Service, MidAtlantic Region, Mary Babb Randolph Cancer Center, West Virginia School of Medicine, West Virginia University, Morgantown, WV

[4] Rural Health Initiatives Director, American Cancer Society, South Atlantic Division, Charleston, WV

[5] Vice President, Health Disparities Reduction, American Cancer Society, South Atlantic Division, Asheville, NC
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