Assessing Patient Barriers to Cancer Screening in Safety-Net Health Systems Open Access

Cotter, Megan (2016)

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Objective: We assessed patient needs and resources for colorectal cancer (CRC) and breast cancer screening at nine safety-net health systems that participated in the Community Health Initiatives CHANGE Grant program run by the American Cancer Society. Methods: Fifty-two key informant interviews were conducted by ACS staff during routine site visits to each of the nine safety-net systems in the summer of 2013. Questions were asked about intervention implementation, including successes, challenges, and lessons learned. A team of researchers from ACS and the Emory Preventive Research Center (EPRC) used constructs from the Consolidated Framework for Implementation Research (CFIR) to code transcripts and examine emerging themes using each primary care setting as a case. Segments on patient needs and resources were further analyzed using a constant comparative approach. Results: The needs and resources of patients varied by system and by type of cancer screening. Common patient barriers to screening included cost of services, lack of knowledge, fears of testing and diagnosis, transportation, language differences, and low literacy levels. To address these barriers, health systems made changes to informational materials, provided referrals and partnered with organizations providing free or low-cost services, or employed patient navigators or community health workers to help patients understand and navigate the health system. Conclusions: Patient barriers to accessing and receiving preventive care services arise at all levels of health care delivery, including patient, provider, organizational, and policy levels. CFIR constructs are useful for capturing this information, but changes to construct definitions could improve the data analysis process. By addressing patient barriers, safety-net health systems can play a critical role in improving access to cancer screening for underserved populations, thereby helping to reduce the burden of disease on underserved populations and potentially lowering cancer mortality rates.

Table of Contents

Chapter 1: Introduction 1

Colorectal Cancer 2

Breast Cancer 2

Importance of Cancer Screening 3

Colorectal Cancer Screening 4

Breast Cancer Screening 7

Disparities in Cancer Burden and Access to Screening 8

Safety-Net Health Systems 13

The Consolidated Framework For Implementation Research 14

Research Question 15

Chapter 2: Literature Review 16

Patient Barriers to Cancer Screening Services 16

Barriers to Colorectal Cancer Screening 17

Barriers to Breast Cancer Screening 21

Barriers to Cancer Screening for Disadvantaged Populations 23

Innovations for Improving Access to Cancer Screenings 27

Role of Safety-Net Systems in Addressing Patient Barriers to Screening 29

Federally Qualified Health Centers 31

Patient Centered Medical Homes 34

Consolidated Framework For Implementation Research 38

Patient Needs and Resources 40

Chapter 3: Methods 45

Introduction 45

Program Description 45

Study Sample 48

Data Analysis 50

Chapter 4: Results 55

Introduction 55

Cost 55

Knowledge 59

Fears 62

Transportation 64

Scheduling 66

Language 67

Literacy 69

Culture 70

Patient Navigation 71

Summary 73

Chapter 5: DISCUSSION 74

Financial Barriers 74

Knowledge Barriers 75

Patient Fears 76

Patient Navigation 77

Use of CFIR Construct to Assess Patient Needs and Resources 78

Limitations 80

Implications and Recommendations 81

References 84

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