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Breast and Cervical Cancer Screening in women of American Samoa
– Reported, April 02, 2012
Following approval from the Office of Samoan Affairs, we conducted four focus group sessions, in which a total of 55 women from urban and rural sites participated. Women were asked about their perceptions regarding barriers, knowledge, and past utilization of available cancer screening services.
Among the participants, professional women were more aware and had higher utilization rates of age-specific screening services. Barriers to health care services included lack of awareness and fears regarding poor confidentiality.
Our findings, which have been reviewed by participants, highlight the further need for outreach and education about female cancers. Screening rates could be increased and all services may benefit from increased collaboration between the American Samoa Department of Public Health and Lyndon B. Johnson (LBJ) Tropical Medical Center. Our findings underline a need for additional staff training in professionalism, particularly in the areas of confidentiality and respect for patients.
Cancer is the second leading cause of death among Samoans,1 and breast and cervical cancer are among the most common types of cancers affecting Samoan women. Although data are not available from American Samoa, breast cancer accounts for about 22% of all cancers diagnosed among Samoan women in Hawai’i and about 27% of all cancers of those in Los Angeles.2,3 Samoan women are more likely than are Caucasian women in the United States to receive a diagnosis of cancer at a younger age and to be diagnosed with cancer (all cancers) after metastasis has occurred.Of those women diagnosed with invasive cervical cancer, over 50% have not received Papanicolau (Pap) smear screening within the previous five years.
Mammograms and Pap smears are effective screening tools in the detection and prevention of invasive breast and cervical cancers. However, many barriers exist in providing these services to women in American Samoa. Previously identified barriers include differences in the level of awareness of the health benefits of screening, a shortage of adequately trained health care professionals (especially females), lack of supplies, and a lack of resources for the appropriate evaluation of specimens and radiological studies. Culturally based barriers including modesty and fear of the stigma associated with visiting an Obstetrics and Gynecology clinic, popularly associated with family planning and birth control, are significant.
In this article, we provide background on the United States relationship with American Samoa and report on our effort to gain more information about the barriers to breast and cervical cancer screening in the territory.
American Samoa is located in the South Pacific 2,600 miles south of Hawaii. It has a total land area of 76 square miles and a population of approximately 55,000, of which females number around 30,000. Female life expectancy is 78 years, compared with 80 for women in the United States.9 About 50% of the population is under the age of 20 and nearly 60% of the population is below the poverty level. It has been governed by the United States since World War II and is currently a US territory, with representation but no vote in Congress. Residents of American Samoa hold US passports and are free to migrate to Hawaii and other states. All residents are considered insured as all are eligible for Medicare and Medicaid services; there are no other insurance providers.
The American Samoa Department of Public Health, with support from the US Centers for Disease Control and Prevention (CDC), operates the Breast and Cervical Cancer Early Detection Program (BCCEDP). This program supports nursing and administrative staff offering free yearly screening mammograms to all women over age 50 and free Pap smears to all women. Pap smear specimens are sent to Hawaii for interpretation, and mammograms are read by LBJ radiologists. Program staff provides initial screenings in clinics and travel to two rural villages on Tutuila, the main island of Samoa, to perform Pap smears and arrange for appointments and transportation for mammograms. Screenings are also performed at the public health clinic in the village of Tafuna. From January 2003 through December 2007, the BCCDEP program reports that 1837 women received Pap smears and 717 mammograms.10 When abnormal Pap smears are detected patients are contacted and referred to the physician gynecologist, while patients with abnormal mammograms are referred for possible surgery, as mastectomy is the only treatment option for breast cancer in American Samoa.
A total of 55 women participated in these focus groups, held on the main island of Tutuila. In each session, the authors conducted open-ended ethnographic explorations of issues that may prevent women in American Samoa from using available cancer screening resources. A bilingual research assistant was present for note-taking and all group sessions were audio-taped. To maximize the number of women participating in our study, the only exclusion criteria was age less than 18 years old. The four groups of women represented various socioeconomic backgrounds. Most participants in the two village groups did not work outside the home. The two groups of professional women were a group of nursing students and a group of business professionals from a communications company. These participants have all had education beyond high school. We included our younger cohort of professional women to gauge whether their education and involvement in the medical field would affect their awareness of recommended screening practices. The facilitator was not present during these two professional groups as participants were fluent in English. The women in the village groups received a small honorarium for their participation, recommended as culturally appropriate by the local facilitator. Both rural meetings were initiated by village chiefs, who being male, were then asked by the participants to leave before the discussion began, as did the male researcher. The nursing students and women in the communications firm did not receive monetary compensation, but instead were provided with refreshments. All participants signed a consent form, available in both English and Samoan, which was explained to participants in the rural groups in both languages by the professional facilitator and in English to the professional groups. A summary of our findings was prepared in both English and Samoan and distributed to all participants.
Only 16% of all 55 participants had undergone mammography . Awareness of mammography was 100% in both professional groups compared to 57% and 75% in the village groups. Similarly, more women in the two professional groups than the village groups were aware of Pap smear screening and had undergone Pap smear screening. Utilization rates of clinical breast exam (CBE) and mammography in village groups were higher than that of our professional groups. Fifty percent of women from our village focus groups versus 15% from our professional group had utilized CBE and 25% vs. 7% had utilized mammography.
Overall 78% of the participants responded that they had some knowledge of mammographic screening for breast cancer. Only nine of those interviewed were over the age of 50, the age at which free mammograms are offered by the Department of Public Health and nine participants reported having had a mammogram themselves. Not all nine of the women who received mammograms were older than 50, possibly because it may have been a diagnostic rather than a screening mammogram, a distinction not explored. Twenty-five percent of the village group participants had utilized mammography compared to 7% of women in the professional groups. However, 100% of the professional group was aware of mammography compared to 57% of the village group women. Seventy-one percent of the women had heard of a CBE and 33% had undergone a CBE, though it may be noted that the US Preventive Services Task Force no longer recommends teaching CBE, rating it a D – moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. As with mammography, more women in the professional group were aware of the clinical breast exam than the village group (70% vs. 64% respectively) but a greater number of village women reported having had a clinical breast exam (15% in the professional group vs. 56% in the village group).
Cervical Cancer: Eighty-seven percent of the women interviewed reported that they were aware of the Pap smear screening test for cervical cancer, and 71% responded that they had undergone a Pap smear test themselves. Participants reported that Pap smears are routinely obtained during prenatal care, which is fairly well attended.
Traditional practices: Prayer was cited as the most common non-medical method used to improve a serious medical condition. Most women were familiar with traditional Samoan medicine in the form of drinks and bandages made from medicinal plants, but none reported practicing these methods or knowing how to prepare them. Unlike participants in a previous study, no one suggested that cancer might result from departing from the traditional Samoan way of life (Faa Samoa).12
Health Care: Participants expressed frustration when asked to describe past experiences with the health care system in American Samoa. Many reported significant concerns regarding the confidentiality of personal health information in the medical clinics. Exam tables in the OB/GYN clinic are partitioned only by curtains; everyone in the room can overhear the patient’s conversation with her doctor. Inappropriate, vulgar language was reportedly used by nurses and staff. Also cited were complaints of long waits for clinic appointments and poor communication between doctors and patients. Women felt that some doctors did not listen to their histories adequately, did not explain their medical problems to them or give them information on the medications they were being prescribed. In addition, many women reported a lack of confidence in the quality of the care offered. Participants felt that certain people received preferential treatment by the hospital staff depending on their status. Most women reported that if their families could afford the costs, they preferred to travel to Hawaii, California, or New Zealand for medical care. Some participants were pleased with the care from certain physicians in the area, but had difficulties arranging appointments with specific doctors.
Credits:Lisa Wu, MD, Elaine Colby, MD, Alisi Iongi-Filiaga, and Gregory G Maskarinec, PhD
More Information at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3123153/
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