Perceived Experiences of Discrimination in Health Care: A Barrier for Cancer Screening Among American Indian Women with Type 2 Diabetes

Abstract

Purpose

Breast and cervical cancer-mortality disparities are prominent among American Indian women. These disparities, in part, may result from patients perceived experiences of discrimination in health care. This report evaluates the impact of perceived discrimination on screening for breast and cervical cancer in a sample of 200 American Indian women with type 2 diabetes.

Methods

Data were collected from patient report and medical records. Prevalence of breast and cervical cancer screening were assessed. Unadjusted and adjusted logistic regression analyses were used to assess associations between perceived discrimination, cancer screening status, and patients' health care-seeking behaviors.

Findings

Substantial proportions of AI women in our sample were behind the recommended schedules of screening for breast and cervical cancer. Adjusted estimates revealed that perceived discrimination was significantly associated with not being current for clinical breast examination and Pap test, and was close to statistical significance with not being current for mammography. The number of suboptimal health care-seeking behaviors increased with higher mean levels of perceived discrimination.

Conclusions

Among AI women, perceived discrimination in health care may negatively influence use of breast and cancer screening services, and health care-seeking behaviors. More research is needed among AIs to examine features of health care systems related to the phenomenon patients perceived experience of discrimination.

Introduction

American Indian (AI) women have higher mortality rates from breast and cervical cancer than non-Hispanic Whites (Espey, Paisano, & Cobb, 2005; Northwest Portland Area Indian Health Board, 2011). One factor that helps to explain these disparities is that AI women are more likely than their non-Native counterparts to be diagnosed with cancer at later stages (Clegg, Hankey, Chu, & Edwards, 2002). Among AI women, a late-stage cancer diagnosis strongly correlates with unmet cancer screening. AI women delay use of cancer screening services and generally receive fewer screenings than other groups (Eberth, Huber, & Rene, 2010; Giuliano, Papenfuss, de Guernsey de Zapien, Tilousi, & Nuvayestewa, 1998). Prominent barriers associated with cancer screening in AI women include availability of services and medical access (Coughlin, Leadbetter, Richards, & Sabatino, 2002; Eberth et al., 2010; Schumacher, Slattery, & Lanier et al., 2008); however, these factors do not entirely explain why AI women underuse cancer screening services.

Reducing cancer mortality rates among AI women may a require better understanding of patient experiences and their influence on patient engagement. For example, two recent studies demonstrate that, among AI women, a positive patient–provider relationship is associated with more favorable Pap test experiences and being current on breast and cervical cancer screening (Simonds, Christopher, Sequest, Colditz, & Rudd, 2011; Smith, Chriostopher, Lafromboise, Letiecq BL, & McCormick, 2008). However, little is known about the specific features of the patient experience for AI women that may undermine engagement in cancer screening.

A promising area of the research that links patient experiences and medical engagement is patients' perceived experiences of discrimination when obtaining health care (Bird & Bogart, 2001; Call et al., 2006; Johansson, Jacobsen, & Buchwald, 2006;Kressin, Raymond, & Manze, 2008). Perceived discrimination in health care (hereinafter “perceived discrimination”) is broadly defined as the belief that one has experienced unfair treatment in a medical setting based on characteristics including race, ethnicity, or other demographic or socioeconomic attributes (Kressin et al., 2008). Perceived discrimination has been associated with lower patient engagement, receipt of fewer health care services, and poorer health (Kressin et al., 2008; Shavers et al., 2012). The associations between perceived discrimination and cancer screenings, however, have been inconsistently demonstrated (Crawley, Ahn, & Winkleby, 2008; Hausmann, Jeong, Bost, & Ibrahim, 2008; Dailey, Kasl, Holford, & Jones, 2007; Shariff-Marco, Klassen, & Bowie, 2010; Simonds, Colditz, Rudd & Sequist, 2011).

In this report, we use a multi-item measure to evaluate the impact of perceived discrimination on screening for breast and cervical cancer in a sample of AI women with type 2 diabetes, a group previously characterized to have low cancer screening despite routine access to health care (Giroux et al., 2000). We hypothesized that perceived discrimination is associated with cancer screening status among AI women. Specifically, we examined 1) status for breast and cervical cancer screening, 2) correlates associated with not being current on cancer screenings, 3) whether perceived discrimination is independently associated with cancer screening status, and 4) associations between perceived discrimination and health care–seeking behaviors.