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Keywords:

  • community health networks;
  • medically underserved area;
  • urban population;
  • African Americans;
  • Hispanics;
  • cancer prevention and control;
  • health;
  • health promotion;
  • awareness

Abstract

  1. Top of page
  2. Abstract
  3. Factors Related to the Disproportionate Cancer Burden in EH
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

The East Harlem Partnership for Cancer Awareness (EHPCA) was formed in 1999 to reduce disparities in cancer screening and prevention among medically underserved minorities residing in a large urban community (East Harlem, New York City) by increasing awareness of cancer risk, prevention, and treatment, and promoting greater participation in breast, cervical, colorectal, and prostate cancer screening and early detection. The Partnership augments a 20-year collaboration between an academic medical center, a public hospital, and 2 community health centers. Needs assessments were conducted to inform program development. Cancer education, outreach, and screening programs were developed based on the PRECEED-PROCEED model for health education and health promotion programming. Needs assessments revealed that although the majority of the population (86%) was insured and had a source of primary care, cancer screening guidelines for breast, cervical, prostate, and colorectal cancers were not being followed. Outreach strategies, targeted curricula, educational sessions, and screening programs have been developed and implemented to improve knowledge levels and increase screening participation. The EHPCA is a model of a successful partnership among the public and private sectors to reduce disparities in cancer screening and prevention in a diverse, medically underserved, urban minority community. Future efforts to reduce cancer screening disparities in this population will include patient navigation and improved access to standard-of-care screening such as colonoscopy. Cancer 2006. © 2006 American Cancer Society.

East Harlem (EH) is a vibrant community of diverse cultures and traditions located in the northern section of the Borough of Manhattan, New York. Its population of 125,076 is 49% Hispanic (of any race), 46% African-American (AA), 6% White, and 2% Asian.1 In addition to the predominantly Puerto Rican and AA population, recent immigrants include those from Mexico, the Dominican Republic, Central America, and West Africa. A language other than English is spoken in 42% of households,1 and 39% of EH residents have incomes below the U.S. poverty level.2 Thirty-seven percent of EH residents receive Medicaid benefits.1, 2

According to American Cancer Society (ACS) and Behavioral Risk Factor Surveillance Survey3–6 data, marked disparities exist in cancer incidence and mortality among minorities when compared with the majority Caucasian population nationally. Cancer mortality and incidence rates among minorities in EH are 30% higher than elsewhere in New York City (NYC).1 For example, prostate and colorectal cancer incidence among adults aged 45-64 years living in this community is significantly higher than the average for NYC. Women in EH are diagnosed with breast cancer at later stages of disease than are women from other NYC neighborhoods. Malignant neoplasms are the second leading cause of death in EH after heart disease, with an age-adjusted rate of 147 per 100,000 when compared with 91 per 100,000 for the rest of NYC.1

Factors Related to the Disproportionate Cancer Burden in EH

  1. Top of page
  2. Abstract
  3. Factors Related to the Disproportionate Cancer Burden in EH
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

An Institute of Medicine (IOM) report recognized that race, ethnicity, socioeconomic status (SES), and geographic location influence health care, independent of patient need.7 The IOM report also noted that disparities are related to barriers and other factors not directly related to the health care system. Barriers fall into the 4 broad categories outlined here.

Sociodemographic (SES)

Minority status often is associated with lower levels of education and related lower occupational status and income.2 These problems, in turn, introduce financial constraints that limit access. Related economic barriers to health care include the need for child care space while seeking health care, inadequate transportation to get to a health care facility, lower SES,8–10 and loss of pay while obtaining care.11

Acculturation (i.e., related to culture-specific beliefs and practices)

The extent to which an individual and/or group is integrated into the dominant culture can also function as a barrier to health care. Acculturative barriers include traditional beliefs about the causes of disease (e.g., cancer is caused by bad blood or evil spirits).12 Such culture-specific attitudes, particularly fatalism, have been associated with lower levels of health care use among both AAs and Hispanics.13–15 For example, the fatalistic belief that death is inevitable if cancer is diagnosed has been associated with lower participation in screening.14 Among Hispanics, acculturation level is strongly associated with language. Lack of proficiency in English hampers acquisition of knowledge about health risks and ability to communicate with health care providers who do not speak Spanish.9

Organizational (e.g., lack of access)

Challenges in using the health care system are more common among minorities. For example, individuals in this population typically do not have adequate health insurance16, 17 or the money to pay out of pocket for health care. As a result, they are less likely to seek preventive care and are more likely to rely on emergency rooms for routine health care.18, 19

Educational (i.e., lack of information and education about cancer screening and prevention)

Studies have shown that medically underserved ethnic minorities have, in general, less knowledge about cancer than do whites20 and suggest that minorities do not get the same level of preventive care information as nonminorities. Michielutte and Diseker21 have argued that differences in knowledge are often due to differences in ways of obtaining information through the media, differences in education, and reduced access to sources of medical information and medical care. For example, more than one-third of AA men perceive their primary care physicians as providing little if any information about prostate cancer during a medical visit.22 Primary care physicians report provider forgetfulness, inconvenience, and office organizational factors as barriers to implementation of screening guidelines.23 Anecdotal reports of physician barriers include lack of knowledge, poor attitudes, and disagreement with guidelines as they pertain to colorectal cancer (CRC) screening. Similarly, patients have cited lack of physician recommendation as a major reason for not having had cancer screening.

This report summarizes the efforts of the East Harlem Partnership for Cancer Awareness (EHPCA [the Partnership]) to address cancer-related health disparities in the EH population, including development of the Partnership, its activities, successes, and future plans.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. Factors Related to the Disproportionate Cancer Burden in EH
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Formation and Organization of the EHPCA Partnership

The EHPCA was established in 1999 to reduce cancer-related health disparities in East Harlem (EH), New York, following the award of a 5-year grant from the National Cancer Institute (NCI) in response to its Request for Applications to develop Special Populations Networks. The Partnership represents the collaboration of 2 community health centers, a large city hospital, and an academic medical center. Partners include Boriken Neighborhood Health Center (Boriken), Settlement Health (SH), the Metropolitan Hospital Center (MET), and the Mount Sinai School of Medicine Medical Center (Mt. Sinai). Together, these 4 sites deliver the vast majority of primary and ambulatory care to EH residents.

Mt. Sinai is responsible for project coordination and acts as a network resource for educational materials and training. Three Mt. Sinai divisions (the Department of Community and Preventive Medicine, the Department of Community Relations, and the Center for Multicultural and Community Affairs) worked with Mt. Sinai's cancer center to initiate the Partnership effort. A high level of mutual respect and trust has characterized the Partnership from its inception. Figure 1 depicts the organizational structure of the Partnership.

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Figure 1. Organizational structure of the East Harlem Partnership for Cancer Awareness.

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Critical to the overall operation of the Partnership are 4 bilingual cancer health educators, 1 assigned to each of the 4 community sites. They provide outreach and educational services to the community and the Partnership sites and, thus, spend the majority of their time in the community. In addition, medical students, residents, and faculty from Mt. Sinai and MET assist in training sessions, community workshops, and health fairs, and act as resources to the program overall.

A Network Steering Committee was established to advise on the Partnership's service delivery and education agenda and to oversee its implementation and evaluation. The Committee includes the 2 coleaders, the Project Director, and key administrators/directors at each of the Partnership's 4 sites. Cancer specialists, epidemiologists, social scientists, and health educators also are members of the Network Steering Committee. The Community Advisory Board (CAB), composed of representatives from community-based health organizations, churches, social service agencies, senior citizen centers, and other grassroots leaders, is a critical component of the Partnership. Mechanisms for ongoing communication and evaluation include weekly meetings of the Health Educators and Program Director, monthly Network Steering Committee meetings, and quarterly CAB meetings.

Theoretical Model

The PRECEED-PROCEED model for health education and health promotion programs, developed by Green, Krueter, and colleagues,24, 25 was used as a guide in formation of the Partnership. The model facilitates understanding of health-related behaviors and the social and physical environments that support them. The application of PRECEED-PROCEED has been described in more than 900 published articles. The model is especially relevant to the Partnership's work since its primary tenet is that health promotion programs/campaigns must be community-based in order to be effective. Individuals who are targeted must actively participate in decision-making from the outset.

Strategies based on PRECEED-PROCEED focus on behavior change and the factors that affect behavior. The model takes a broad approach to behavior analysis and change and emphasizes identification of predisposing, enabling, and reinforcing factors. Specific to the Partnership's goals, predisposing factors include the personal motives of community members, including cultural beliefs and acceptance of the EHPCA as a credible force. Predisposing factors are the motives, attitudes, and beliefs that drive behavior and behavior change. Enabling factors, which facilitate behavior change, include access to care, health literacy, language, SES (including immigration status, health insurance coverage), and physician attitudes and referral patterns. Reinforcing factors include the incentives and rewards, both on a community and an individual level, to embrace new health care beliefs and behaviors.

Ongoing assessment is a key component of PRECEED-PROCEED. From the outset of a health intervention program and throughout all phases of implementation, data are collected to obtain feedback on the program's effectiveness. This information is used to refine/modify methods to ensure maximal impact.

Community Needs Assessments

Needs assessments were designed to identify population characteristics and barriers to cancer screening. Both focus group and community survey methodology were used for these assessments. Focus groups helped to identify barriers not previously considered and served to introduce community groups to the program's efforts. Surveys provided a larger, more qualitative set of data for analysis.

Focus groups

Five focus groups, held at community sites identified by the CAB, were conducted during the first year of the Partnership. Forty-three participants included 17 men and 26 women. There were 21 AAs and 22 Hispanics who ranged in age from 34 to 87 years. Sites were selected to represent different sectors of the community (AA, Hispanic, and gender and age groups. All of the groups were led by trained focus group facilitators matched by gender and language (e.g., a bilingual man facilitated a group of Hispanic men).

Community survey

A survey was developed and implemented to assess the demographic characteristics of the community, community knowledge of and participation in cancer screening, and barriers experienced by EH residents related to screening. Survey participants were recruited at clinic sites, as well as at street fairs, senior centers, and other venues. A total of 248 people agreed to participate in the survey. Informed consent, approved by Mt. Sinai's Institutional Review Board, was obtained from all participants. Face-to-face interviews were conducted with 173 (70%) participants; 75 interviews (30%) were completed by telephone.

In addition, 5 pilot projects were conducted during the course of the SPN, focusing on identifying additional barriers to screening and testing patient navigation (PN) as a method of increasing adherence to CRC screening.

RESULTS

  1. Top of page
  2. Abstract
  3. Factors Related to the Disproportionate Cancer Burden in EH
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Needs Assessment Results

Survey population characteristics

Based on self-report, 96% of those surveyed were AA (n = 109; 96% completed the interview in English) or Hispanic (n = 128; 48% completed the interview in English) (Table 1). (Nine individuals who were neither AA nor Hispanic were excluded because of small sample size.) The distribution of sociodemographic characteristics based on self-identified ethnicity and preferred language of the participant revealed significant differences in Hispanic subgroups (based on preferred spoken language). For example, Hispanics not born in the United States preferred Spanish (Spanish-language Hispanics), compared with the Hispanics who preferred to conduct the survey in English (English-language Hispanics). In addition, 100% of Spanish-speaking Hispanics vs. 44% of Hispanics who completed the interview in English and 16% of AAs, were less educated (21% with postsecondary education vs. 35% and 38%, respectively); had 3 or more children (58% vs. 34% and 46%, respectively); were less likely to be employed (87% vs. 64% and 70%, respectively); had incomes under $10,000 (71% vs. 53% and 41%, respectively); and were more likely to receive health care at the SH clinic (60% vs. 30% and 35%, respectively). Hispanics in general were more likely to be Catholic while AAs tended to be Protestant (92% of Spanish-speaking and 82% of English-speaking Hispanics vs. 23% of AAs). More Hispanics were married or had a partner when compared with AAs (38% and 43% vs. 24%, respectively). English-language Hispanics were more often interviewed in clinics rather than in the community and tended to be younger than the other 2 populations (x = 41.10, SD 14.1 vs. x = 50.99, SD 18.0 for Spanish-language Hispanics and x = 51.26, SD 18.9 for AAs). Post hoc analyses indicated that Spanish-language Hispanics were less likely to be employed and more likely to have incomes under $10,000 when compared with English-language Hispanics and AAs (P < .05).

Table 1. Sociodemographic Characteristics of African American and Hispanic Survey Respondents (n = 237)
 African American No. (%)Hispanic (English-speaking) No. (%)Hispanic (Spanish-speaking) No. (%)Significance
  1. NS indicates not significant; SD, standard deviation.

Gender
 Female91 (84)47 (77)56 (84)NS
 Male18 (16)14 (33)11 (16) 
Education
 ≤High school67 (62)39 (64)53 (79)0
 At least some college42 (38)22 (36)14 (21) 
Children
 1-254 (54)37 (66)25 (42)0
 ≥346 (46)19 (34)34 (58) 
Employed
 Yes33 (30)22 (36)9 (13)P < .01
 No76 (70)39 (64)58 (87) 
Income
 >$10,00061 (59)27 (47)17 (29)P < .001
 <$10,00043 (41)30 (53)42 (71) 
Insurance
 Government71 (70)39 (65)44 (68)NS
 Private21 (21)10 (17)6 (9) 
 None10 (10)11 (18)15 (23) 
Marital status
 Married/partner26 (24)23 (38)29 (43)P < .01
 Not married83 (76)38 (62)38 (57) 
Religion
 Catholic21 (23)44 (92)50 (82)P < .001
 Protestant69 (77)4 (8)11 (18) 
Faith
 Strong90 (83)43 (72)36 (56)P < .001
 Not strong19 (17)17 (28)28 (44) 
Born in U.S.
 Yes88 (84)34 (56)65 (100)P < .01
 No17 (16)27 (44)  
Interview language
 English105 (96)61 (100)67 (100)P < .01
 Spanish4 (4)   
Interview location
 Clinic62 (57)54 (89)41 (61)P < .01
 Community47 (43)7 (11)26 (39) 
 Settlement health20 (35)16 (30)24 (60)P < .01
 Boriken31 (54)24 (45)11 (28) 
 Metropolitan7 (12)13 (25)5 (13) 
Age (18–92 y) (mean ± SD)51.26 ± 18.941.10 ± 14.150.99 ± 18.0F (2,234) = 7.5; P < .001
Identified barriers

Those identified through the survey of community needs were grouped (using the IOM's categorization of barriers to health care) into sociodemographic, acculturation, and organizational barriers.

Sociodemographic barriers.

In spite of the low SES of this inner-city community, only 13% of participants had no health insurance. Of the total survey population, 67% had government-sponsored insurance (Medicare or Medicaid), and 10% had commercial or self-paid insurance. Age was the primary sociodemographic barrier to a number of screening behaviors, including obtaining Pap tests and performing breast self-examinations.

Acculturation barriers

Among women, barriers included a fatalistic view of breast cancer as a death sentence, and a future orientation (rather than a past or present orientation), which was associated with lower compliance with mammography guidelines. Among men, seeking medical care was viewed as a sign of weakness, and sickness was seen as a threat to one's status as a man. Additionally, fear of receiving bad news was a key reason men avoided screening for both CRC and prostate cancer. Hispanic men also felt that undergoing a digital rectal examination (DRE) was a violation of their manhood. Embarrassment was cited as a barrier to both sigmoidoscopy and colonoscopy. Having both fecal occult blood testing (FOBT) and a flexible sigmoidoscopy was predicted by primary spoken language (English) and present orientation (versus past or future). Hispanic men more often mentioned a fear of needles as a barrier to going to health care providers in general, while fear of the unknown was related to resistance to screening.

Organizational barriers

Although 83% of those surveyed had a primary care physician, knowledge levels about CRC and prostate cancer and screening for these cancers were low. Being screened was primarily related to having symptoms, not to prevention or early detection. Low levels of physician recommendation were reported for sigmoidoscopy and colonoscopy. For prostate screening, a DRE had been recommended for most men (80%), but many (45%) had not had a physician recommend a prostate-specific antigen (PSA) test. Most men older than 50 years, however, had been tested despite lack of a physician recommendation. Other organizational barriers included long waits at medical clinics and limited hours of clinic operation.

Table 2 highlights breast, cervical, colorectal, and prostate cancer screening rates compared with ACS guidelines. While the high rates of mammography screening are indicative of successful efforts to promote this cancer detection method, one-third of women surveyed were not meeting ACS guidelines for maintenance screening, thus pointing out the need for further education about the importance of continual screening. In addition, lack of knowledge about the Pap test as a means of detecting and preventing cervical cancer indicated another area of concern in terms of education. Encouragingly, most men older than 50 years had had a PSA test, but the lack of physician recommendation for this test among a predominantly minority population—including AA men at high risk for this disease—raised questions about the adequacy of physician recommendations for cancer screening in the community. Similarly, the high level of ignorance and misinformation among those surveyed likely contributes to low levels of CRC screening in this population.

Table 2. Screening Rates (%)
Type of screening (Age and gender selected)Ever screenedCurrently being screened (ACS guidelines)
  1. ACS indicates American Cancer Society; Pap, Papanicolaou; PSA, prostate-specific antigen.

Clinical breast examination93.866.3
Mammography93.364.4
Breast self-examination93.562.5
Pap test97.162.5
Fecal occult blood test and flexible sigmoidoscopy or colonoscopy48.428.6
Digital rectal exam90.070.0
PSA testing65.050.0

Outreach, Education, and Screening Activities

Outreach, education, and screening activities were informed by the needs assessment results. Principal EHPCA activities to address the cancer education and screening needs of the EH community included 1) developing a cancer education curriculum specifically tailored for minority individuals; 2) implementing community outreach activities to promote cancer education and increase screening rates; and 3) improving access to prostate, CRC, breast, and cervical cancer screening programs through the reduction of systemic and organizational barriers. In addition, to achieve its goals, the Partnership integrated PN, training for health care professionals and researchers, and community-based participatory research into these activities.

Cancer education curriculum

The health educators developed cancer education curricula for minority individuals on 12 topics ranging from general cancer information to material on specific cancers. These materials are available both in English and Spanish and have been reviewed for appropriate levels of health literacy and cultural sensitivity. The materials have been reviewed by the CAB and are regularly updated, based on comments by community members.

Community outreach, education, and access improvement efforts

Presentations and workshops have been conducted at community centers, senior centers, housing projects, community boards, faith-based organizations, and health clinics. In addition, educational materials have been provided at community health and street fairs each summer, providing up-to-date information on cancer screening guidelines and referral information. A quarterly bilingual newsletter and promotional materials have been developed and distributed to better inform the community about both the EHPCA and the cancer screening programs it conducts.

Over the past 4 years the Partnership has worked with almost 100 community-based organizations, reaching close to 3000 people per year. Pre- and postworkshop knowledge tests, administered as a metric to assess the program's effectiveness, have demonstrated knowledge increases (ranging from 5% to 22%) in each topic area, including breast, cervical, colorectal, and prostate cancer. Information about cancer screening has been distributed to over 700 people at more than 30 health fairs. Many of the individual educational sessions with 580 patients and family members have been conducted at the request of the primary care physicians at the 4 Partnership sites, thus supporting physicians' efforts to have their patients complete the recommended screenings.

Over the past 3 years, through efforts at the Partnership sites, almost 1200 people (869 women and 321 men) have been individually counseled about cancer screening tests. CRC screening (FOBT, sigmoidoscopy, and colonoscopy) has been found to be of less interest to the community when compared with breast and cervical cancer screening for women and prostate and testicular cancer screening for men.

To increase participation in prostate cancer screening, a program of free prostate education and screening was initiated in 2002, in conjunction with the ACS and the Deane Prostate Health Center at Mt. Sinai. This program is conducted monthly at SH and quarterly at Boriken. Men are encouraged to have both PSAs and DREs. Results of the DRE are recorded and disclosed immediately to the participant, while the PSA results are mailed ∼1 week after the program. All men needing follow-up care are offered appointments at the Deane Prostate Health Center, regardless of their ability to pay. To date, more than 600 men have participated in these programs; more than 20 have been referred for follow-up care, and prostate cancer has been diagnosed in 4 men.

Outreach programs developed to increase the rate of CRC screenings in EH include ongoing educational presentations about CRC at senior centers and various community sites. CRC-specific educational materials, along with standard educational materials, are also distributed at community fairs and Partnership sites. To directly improve CRC screening rates, the Partnership works with the Division of Gastroenterology of the Mt. Sinai Hospital to distribute Hemoccult cards (for FOBT testing) to individuals at selected venues for whom this screening is indicated. To date, almost 150 Hemoccult cards have been distributed and efforts are under way to improve the return rate. Unlike PSA, in which blood specimens are collected onsite, FOBT involves home participation and individual motivation, which remains an obstacle to compliance. Much of the Partnership's effort in the future will focus on establishing colonoscopy as the preferred screening test.

Training Activities

Through the EHPCA, Mt. Sinai School of Medicine is participating in the training of students from high school through postmedical school, including 6 high school students (all minorities), 2 genetic counseling graduate students, and 4 summer interns (2 medical students [one minority] and 1 college student, and 1 postbaccalaureate student [bilingual] from NYC's Department of Health and Mental Hygiene's Health Research Training program). Four postdoctoral fellows (2 minorities), 3 minority faculty, and countless medical students have received training. Many of these trainees have gone on to contribute in the field; 1 postdoctoral trainee currently is a Resident in Community and Preventive Medicine, and another has joined Mt. Sinai's faculty.

Pilot Studies

Results of the 5 pilot studies conducted in conjunction with the EHPCA are summarized in Table 3.

Table 3. EHPCA Supplements—Pilot Studies
Pilot titleCancer type addressedMethodsObjective measuresResults
  1. EHPCA indicates East Harlem Partnership for Cancer Awareness; CRC, colorectal cancer; FOBT, fecal occult blood test.

Colorectal Cancer Screening in the Emergency DepartmentColorectal cancerInterviews with medically stable patientsKnowledge, cancer pros and cons, screening adherenceAfter exploring potential demographic differences (e.g., ethnicity, gender, income), the strongest predictors of adherence to CRC screening were age, along with a positive view of CRC screening
Prostate Screening in the Emergency DepartmentProstate cancerInterviews with African American menDecision-making regarding prostate screeningProblems with recruitment made it impossible to report results
Increasing FOBT/Flexible Sigmoidoscopy Screening Among MinoritiesColorectal cancerUse of a patient navigator to increase adherence to CRC screening (FOBT and flexible sigmoidoscopy)Completion of CRC screeningPatients receiving navigation services were more likely to complete CRC screening (both FOBT and endoscopic screening)
The Witness Project® of Harlem (WPH)Breast and cervical cancerExamine the impact of the WPH on breast cancer screening among African American women nonadherent to mammographyBreast cancer screening attitudes (7 items); social influence on breast cancer screening (5 items, α = 0.90); medical mistrust (12 items, α = 0.89); racial pride (7 items, α = 0.87); spirituality (12 items, α = 0.84).While sample size was too small to test the outcome, the use of these measures was verified and are in use in other studies
Patient Navigator: An Intervention to Improve Colorectal Cancer Screening by ColonoscopyColorectal cancerDetermine whether a Patient Navigator program can help overcome patient barriers to colonoscopic CRC screeningCompletion of colonoscopic screeningPatient navigation is effective in reducing organizational barriers and improving patient compliance with screening colonoscopy in ethnic minorities

DISCUSSION

  1. Top of page
  2. Abstract
  3. Factors Related to the Disproportionate Cancer Burden in EH
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Research and experience have demonstrated that generic health promotion interventions are not successful. Interventions must be tailored to individuals' needs, values, and beliefs (i.e., predisposing factors) and resources (i.e., enabling factors), and must focus both on the barriers individuals face and the resources needed to achieve positive health change.

Lessons Learned and Future Activities

Through our involvement with the EH community, we have learned about predisposing and enabling factors affecting cancer education and screening, as well as barriers to education and screening within this community. As a result, our future activities will focus on 1) continuing to increase awareness of and appreciation for cultural differences; 2) recognizing and overcoming organizational barriers to cancer screening, including the implementation of PN as a cornerstone of our outreach efforts, and 3) continuing to address cancer education and screening needs, including those of the uninsured and underinsured through the use of creative, nontraditional avenues.

Increasing awareness

We have come to recognize that cultural sensitivity on the part of health care providers and health educators is key to any successful health intervention, especially in the EH community. Each culture has unique patterns of beliefs and styles of social interaction. To work together to eradicate health disparities, it is crucial that cultural differences in attitude, behavior, and belief are recognized and honored. Cultural sensitivity is central to our efforts. Although few would argue the importance of cultural sensitivity in our work, achieving it is far from easy. It demands ongoing self-examination, didactic and experiential training, and partnering with those targeted for intervention. We have sought to identify our own cultural ignorance, prejudice, and insensitivity and learn how to help our clients/patients understand us as we, at the same time, seek to understand them. The process of cultural sensitivity entails getting to know ourselves and getting to know those whom we hope to partner with and serve.

Organizational barriers

Community members' difficulty in completing recommended screening tests is due in part to organizational barriers. For example, navigating the system from a community health center to a hospital endoscopy unit for CRC screening involves many steps, including getting a referral, understanding where to go for the pretesting consultation, scheduling an appointment, understanding and completing the preparation for the procedure, having someone available to accompany the patient to the test, getting time off from work, locating the new facility, etc. As part of our efforts to address these barriers, we will join with our partners in the community health centers to establish referral systems so that Partnership physicians can more easily refer their patients to hospital-based screening such as mammography and colonoscopy.

Patient navigation will be a cornerstone of our future work to address organizational barriers. The health educators, already working as culturally sensitive guides, will be further trained in methods of increasing personal motivation (i.e., predisposing factors) and working to ensure that enabling factors do not hinder the completion of cancer screening; for example, to help reduce medical distrust, peer buddies will be recruited. These community members will have completed the age-specific screening tests we are encouraging others to undergo. By relating their positive experiences with the health care system, we expect to increase screening rates of those who have previously been afraid to undergo screening.

Language has long been a barrier to care in this community. Our bilingual health educators have served as a bridge for those unable to consult health care professionals in their native language. As part of the navigation system to be established, the health educators will continue to assist when language is a factor.

Other approaches to address education and service needs

Activities are planned to ensure that community members educated at sites other than the primary program sites will be reached and navigated into health centers in order to increase participation in preventive health care; for example, we will explore the use of theater as a method of enhancing health literacy and screening knowledge. Big Apple Playback Theater is a company that uses improvisational acting to ‘playback’ stories told by members of the audience. This group performs at various community settings, including church gatherings, homeless shelters, prisons, and drug rehabilitation centers. This method of communicating key ideas and messages without the need for sophisticated medical knowledge can be highly effective.

We also plan to develop a pilot health education project using feedback from community members who have had cancer or have undergone cancer screening. This approach can convey orally information that is often difficult to read (e.g., CRC screening guidelines). Lessons learned can then be presented to health care professionals, who can incorporate them into their approaches to screening.

In addition, we will explore methods to ensure that any patient having an abnormal screening test receives appropriate follow-up care. From our own work and that of others, we know that individuals often get lost in the system. Our health educators will develop ways to ensure that this does not happen as we increase the number of patients receiving cancer screening. Working with NYC's Department of Health and the ACS, we have secured funding to ensure that men and women without health insurance can receive colonoscopies. We currently make referrals to the Centers for Disease Control and Prevention-sponsored Healthy Women's Partnership for mammography and cervical cancer screening. As discussed earlier, we have initiated a program of free prostate screening, in conjunction with the ACS and the Deane Prostate Health Center at Mt. Sinai.

Further, improving access to health care services may also include connecting people with primary care. Through our partnerships with 2 community health clinics and 3 hospital-based primary care clinics, we will work to develop programs for referring individuals without a primary care physician to a convenient site. This activity may include PN to reduce personal barriers such as medical mistrust, immigration status, and/or language. Access to care has been a problem for both the uninsured and those without legal documentation. Although the community health centers have always served this segment of the population, the opening of the free East Harlem Health Outreach Partnership (EHHOP) has created an additional referral site. EHHOP is a novel approach to providing quality health care, regardless of the ability to pay or medical insurance status, with the specific objective of reaching out to un- and underinsured residents of EH. As noted, we will work closely with the clinics and EHHOP to ensure that any community member requiring medical care receives it, regardless of the ability to pay. By adding a PN component, we will be able to assess actual completion of cancer screening. We will also work with our Partnership medical directors to identify ways to assess referrals to screening by their clinical staff.

Conclusions

The EHPCA is one model of a successful partnership among the public and private sectors of the EH community brought together in mutual respect and with a clear purpose—to reduce disparities in cancer screening and prevention among the medically underserved members of this community. Much has been learned through this venture that will serve to guide future cancer education and screening endeavors.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Factors Related to the Disproportionate Cancer Burden in EH
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

We are grateful to our Network Advisory Board, the Community Advisory Board, the community of East Harlem, and the health educators who have been dedicated to this project.

REFERENCES

  1. Top of page
  2. Abstract
  3. Factors Related to the Disproportionate Cancer Burden in EH
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES
  • 1
    New York State Department of Health. Information for a healthy New York. Available at www.health.state.ny.us (accessed Sept 29, 2005).
  • 2
    US Bureau of the Census. 1990 Census of Population. Social and economic characteristics. Washington, DC: US Government Printing Office; 1990.
  • 3
    American Cancer Society. Cancer facts and figures for African Americans, 2003–2004. Atlanta: American Cancer Society; 2003.
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