For Latinas, the United States health care system has often failed to provide safe, culturally-sensitive treatment. In the 1950s, in a scenario that echoes the Tuskegee syphilis experiment on African Americans, American researchers developed the first oral contraceptives by testing the pills on Puerto Rican women without their full consent. The human trials perfected the pill, but many of the women suffered serious complications including blood clots, extreme dizziness, and in the case of three women, death.
As part of the national movement to eliminate racially and ethnically inappropriate medical care and address health disparities, many new initiatives have emerged to help, rather than harm, the Latina population. A new study, conducted by The New York Academy of Medicine, shows the impact and value of one such program—a project linking women with patient navigators trained to offer health education and other forms of support to help reduce disparities in cancer prevention and screening for Latina women.
High death rates from cervical cancer among Latinas—a disease that can be prevented in more than 90 percent of cases—are a prime example of how women of color continue to fall through the cracks of the health care system. In 2015, it was predicted that 2,000 Latinas would be diagnosed with cervical cancer with 600 of those cases being fatal. The cervical cancer incidence rate is 44 percent higher among U.S. Hispanic women than among non-Hispanic whites. The numbers are even more devastating because these trends are preventable. Pap smears effectively detect cancer early when treatment is most successful and human papillomavirus (HPV) vaccinations can effectively reduce HPV-related infections, which often cause cervical cancer. Yet these services, which are covered by insurance, are underutilized; nearly 85 percent of women who die of cervical cancer never received a Pap smear.
What causes so many women to forego the relatively quick and easy cervical cancer prevention test? Research shows that cervical cancer incidence and mortality are influenced by many barriers to care, one of the broader determinants of health beyond prevention, especially among Latinas. The barriers include: a poor understanding of the need for a Pap test, fear of embarrassment and pain during the procedure, language differences between provider and patient, and often, confusion about insurance coverage.
Transportation and concerns about provider cultural sensitivity may also interfere with access to cervical cancer screening among vulnerable populations. Yet, some studies have shown that Hispanic women are particularly likely to benefit from patient navigation, because it helps them overcome many of these barriers to utilizing health care. Several studies have shown that patient navigation increases patient satisfaction, alleviates anxiety associated with the screening process, and improves screening rates.
For these reasons, addressing this range of health determinants with navigators was the focus of an innovative, three-year, multi-level, community-based patient navigation program aiming to increase cervical cancer screening rates for the underserved Hispanic female population, 18 years or older, enrolled in CareLink, a financial assistance program for the uninsured, conducted at The University Health System in San Antonio, Texas. The study targeted a group at especially high risk for cervical cancer—only about 33 percent of women 18 years or older enrolled in CareLink had actually gotten their recommended Pap test within the past three years.
The program engaged the women by going beyond just recommending that they get a Pap smear. Study participants were given the opportunity to talk over their concerns and questions about cervical cancer screening with bilingual, female patient navigators. The navigators also provided health literacy coaching, focusing on the concept of prevention and the value of the test. The program included a culturally-competent mass media health promotion campaign and provided free screening tests as an incentive for participants. By emphasizing behavioral aspects and cultural sensitivity, the program was able to navigate 4,500 women in the target population and increase the screening rate from 65 percent to 80 percent in just three years.
Even more important, a new study and evaluation of the program, conducted by researchers in the Academy’s Center for Health Innovation, reports that the program may extend life. The research is published in the July 2017 issue of the American Journal of Managed Care. Using computer simulation to determine the impact of the program, the Academy team found the program increased the life expectancy of the target population by 0.2 years. It was also highly cost-effective. Further sensitivity analyses showed that even if the implementation cost of the program increased nearly 10 times—from $311 to $3,312 per person—the program would still be cost-effective in the long term.
The computer simulation model used to evaluate the program employed unique methods of simulating a target population—capturing the potential disease progression of each individual studied—to predict the long-term consequences of cervical cancer screening within a virtual environment. Computer simulation models like the Academy’s cervical cancer model offer a flexible, cost-effective approach to conducting economic evaluations and making informed decisions, compared with studies based on actual behavioral observations, especially in complex, urban environments like San Antonio, where data collection and follow-up may be difficult and expensive.
Overall, the study suggests that patient navigation programs are a culturally-sensitive, cost-effective and powerful method of helping women see the value of cervical cancer screening. And, in this case, a way of offering long overdue and greatly improved high-quality care to a population facing a life-threatening health disparity.
Tania Calle and Talitha Kumaresan are research interns at the Center for Health Innovation