A Failed Public Health Approach To Improve Colorectal Cancer Screening Among African-Americans - Roxane Handel
Colorectal cancer is the third leading cause of cancer-related deaths among African American men and women. Despite the lingering high death toll, early diagnosis has effectively decreased the number of deaths related to colorectal cancer throughout the years by identifying abnormal growths, or polyps, before they turn into cancer. However, post-diagnosis survival rates are lower for African Americans than for white Americans. From 1992 to 1999 African Americans diagnosed with colorectal cancer had a 53 percent five-year survival rate, compared with a 63 percent survival rate in whites (1). Why the discrepancy? Experts pointed at the lack of access to colorectal cancer screenings among the African American population. To address this problem many insurance companies expanded coverage for colorectal cancer screenings (2,3). Some states such as
One of the underlying causes behind the low rate of colorectal cancer screening among African Americans is their mistrust in the medical system. The stigma attached to the medical environment stems mainly from the injustices of the forty year
Another reason behind the failure of medical interventions to increase the screening rate of colorectal cancer among African Americans is the lack of knowledge among the population that they are more susceptible to colorectal cancer than other races and their view of cancer as an incurable disease. The stigma around colorectal cancer among this population is detrimental because it instills a sense of futility in the colorectal cancer screening. Furthermore, not understanding their elevated risk exacerbates the situation because no sense of urgency exists. In a study that investigated risk perceptions and screening patterns for colorectal cancer among predominately low-income African Americans age 50 or above, 36% of respondents rated their risk as below average and 37% did not know their risk for colon cancer (8). While this study found that more studies need to be done to more accurately determine the perceived risk, it is clear that enough of the population does not understand that they are at greater risk of developing colorectal cancer than whites. This ultimately affects their decisions to get screened and leads to deaths that could have been prevented. Another study conducted with blacks, Hispanics, and whites also suggests that minority groups particularly lack knowledge of cancer, colon cancer screening tests, and screening in general (9). They had difficulty understanding the simplified medical terms and procedures, and although were hopeful about early cancer diagnosis were still reluctant to get tested if they were symptom free. Thus, the intervention has not significantly increased colorectal cancer screening rates among African Americans in part because it does not simultaneously educate this population on their risk of acquiring the disease, the benefits of screening early, and the details of the procedures that need to be done that could help decrease the incidence of colorectal cancer. If African Americans do not perceive that they are at risk to begin with and do not realize that options exist that could prevent and cure the disease, they will not take action. Ofcourse, recognizing that colorectal cancer is curable and understanding ones risk does not guarantee a change in behavior as the health belief model implies. Nevertheless, the problem of perceived risk must be addressed in conjunction with other social and behavioral issues in order for the situation to improve.
Another social element that public health officials must tackle is the discrimination existent among the caregivers. Many African Americans understand their high risk of developing colorectal cancer and have access to care yet do not get screened early enough because of the issue of discrimination. The reason is linked to a stigma created by the caregivers themselves who discriminate against the African American patient. Recent studies have shown that blacks and whites with equal medical insurance and co-morbidities have unequal colorectal cancer survival rates (10). The differences in mortality are not due to biological differences either. Peter Bach, a pulmonologist and epidemiologist at
Racial discrimination is reflected through the level of communication and the amount of time spent between the doctor and the African American patient compared to the white American. Physicians often do not communicate with the African Americans in the same manner as they do with their white patients. In addition, African Americans claim that the time they spend with doctors is minimal compared the time the doctors spend with their white patients. Both the lack of communication and the reduced amount of time result in low quality care among the African American population. Studies suggest that African American patients receive low quality care compared to white Americans, and that only high quality healthcare can ensure adequate procedures and screening recommendations (16). Often it is information on prevention, available screenings, and risky behaviors that physicians choose not to discuss with their African American patients during their ten minute appointments. This selectiveness creates a sense of neglect among African Americans and denies them of information that could help them improve their behaviors and attitudes towards colorectal screenings. Why are physicians selective? Perhaps the physicians see African Americans as less of a law-suit threat than white patients, and thus feel the need to be more explicit and detailed with their white patients. Or maybe physicians don’t feel the obligation to delve into details when it comes to their African American patients because they believe that the African American patient simply won’t understand or won’t take action either way? Although the reasoning behind physicians’ discriminatory behavior is unclear, it definitely clear that communication and time spent with the African American patient is hindered because of discrimination. Studies have shown how communication can improve colorectal cancer screening and survival rates (11). Therefore, the lack of communication and low quality care resulting from discrimination was a critical element that the medical intervention failed to target. Consequently, African Americans still forgo colorectal cancer screening and get diagnosed too late.
In all, the stigma attached to the medical environment, the colorectal cancer disease, and the African American race has greatly influenced the distribution of life chances of blacks particularly by decreasing their colon cancer survival rates in comparison to other races. These stigmas all feed into a low self- esteem cycle and a feeling of inferiority among African Americans. The stigmatized individual has a low self-esteem because they the situations in which they find themselves have consistently negative implications on the self (17). The prejudices and stereotypes exemplify situations surrounding African Americans that affect their self-esteem. As a result they do not stand up for themselves nor care for themselves. This has a negative implication on their health which they often neglect along with their school, and later their careers. Consequently, their family members enter the same cycle of poverty and low self-esteem, both factors having repercussions on the African Americans’ health-related behavior. Therefore, the issue of stigma deserves attention not only because stigma directly affects behavior, but also because stigma indirectly affects ones self-esteem, which ultimately influences behaviors.
Interventions designated to improving colorectal cancer screening rates among African Americans must keep in mind the social and behavioral elements that can influence an individual’s behavior. It is precisely the social stigma attached to the medical field, the disease, and the black race that caused the medical intervention to fail to improve the colon cancer screening among African Americans. Just because a screening exists, and there is access to it does not mean that people will actually participate. Many other issues need to be addressed in order to help educate and change the mindset of both African Americans and caregivers in order for a successful outcome to ensue and for less African Americans to die from a preventable disease.
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