Standing Rock Indian Reservation Women's and Men's Cancer Screening Program

State: ND Type: Model Practice Year: 2004

The Standing Rock Indian Reservation Women's and Men's Cancer Screening Program provides cancer screening and education for women 20 and older and men 40 and older. 2500 women ages 20 and older reside on the reservation, and 737 received breast and cervical cancer screening in 2003, which compares to 475 in 1997 before program inception. 1034 men 40 and older live on the reservation, with 147 men receiving colorectal and prostate cancer screenings in 2003-04. In comparison, 37 men were screened in 2001-2002 before program inception. The outcomes achieved have been a result of the partnerships developed between Standing Rock Indian Health Services (service provider), Tribal Health-Community Health Representatives (CHRs) (outreach component), and Custer Health, the local public health unit (program management). The program's initial focus was breast and cervical cancer screening, and in 2003 men's cancer screening was added following community request. Prior to program implementation, there was little consistency with yearly cancer screening for women. This has improved significantly as there is now a greater than 50% return rate for annual screening. The men's program increased screening from less than 1% to 14% within the first year. The key elements identified to replicate the practice are as follows: program partners must have specific roles, community education and outreach must be provided by providers and caregivers who are known and trusted, community needs must be evaluated and incorporated into the plan to reach the program goal, health exams need be comprehensive with a provider who preferably of the same gender. Goals for the 2004 women's program and 2003-2004 men's program are as follows: 750 women will receive breast and cervical cancer screening; 70-80 men will receive prostate and colorectal screening; and an additional 400-500 women and men will receive education.
During the beginning stages of the program, staff quickly identified the following secondary and equally important needs of the clients: the client's exam needs to be comprehensive as breast and cervical cancer screening may not be the incentive for coming into the clinic; and a provider of the same gender is preferred and in some cases demanded before a woman would consent to breast and cervical cancer screening. Staff subsequently incorporated comprehensive exams and female providers into the program plan. Once the women's health program was established, the community requested replication of the program for men's health, which was added in 2003. To promote interest in screening a special day was designed for women at the clinic. Only women were scheduled for exams on this day. To make the event more festive, gifts and food were provided for the participants. This special event created a social aspect to the screening day, which was well received. The clinic provides clinical breast exams and pap tests during regular clinic days, but at least half of the screening now occurs on the women's health days. The women receive comprehensive care with their breast and cervical cancer screening exams because this may be the only time during the year when the woman comes to the clinic for care. Staff provide a variety of different screenings and education in addition to their exam. The program is unique in that the health department has a strong partnership with a variety of entities at the federal, state, and tribal levels, local public health, and local businesses. By working together, a strong program has been built. This partnership is now expanding into other areas of health care, including men's cancer screening and children's health.
Agency Community RolesThe role of Custer Health is to serve as program facilitator by managing the grants, coordinating program activities, and working with the partners in providing case management and community education. Since Custer Health was perceived as an outside agency to the Standing Rock community, the health department needed to develop a means for program recognition and trust. Health department staff began by working with the Standing Rock Tribal Health CHRs providing one to one and small group contacts, encouraging women to screen and educating them about screening guidelines. The CHRs were identified as a primary partner because their role in the community is as a health advocate helping the people of the reservation by identifying needs, accessing health care, providing support and health education. The primary partners meet at least two to three times per year to plan and evaluate program activities to ensure that program goals are on track for the year. Custer Health also serves in the role of educator to nursing students from the local college and university. The special women’s health day is used to provide an opportunity for the students to work in a different setting to promote an understanding of working with different cultures. To foster collaboration with the partners, Custer Health has organized educational opportunities for the CHRs to increase their knowledge about women’s and men’s health and cancer screening. This improves the CHRs ability to provide credible health information. Custer Health assisted Indian Health Services in obtaining a mobile mammography provider and facilitated the meeting where a contract was completed for on-site mammography services.  Costs and ExpendituresThe Custer Health program costs for the Women's Health program are $55,566 for this year. This amount is funded by the Women's Way and Avon Foundation Breast Care Fund grants. This money is used for staff salaries, staff transportation to Standing Rock, mammography transportation, outreach activities, partial coverage of screening incentives and educational material. The men's health program practice costs were $19,887.30. This money was used for salaries, transportation to the Standing Rock Reservation, incentives for screening educational material and outreach activities. Since this program is new, the major emphasis was on outreach and education. Local colleges and universities provide students to assist with screening events for clinical experience, and this time is counted as in-kind contribution of $3,750 per year. Prairie Knights Casino provided the in-kind contribution of food for screening events and this amount is approximated at $3,000. KLND radio provides one radio Public Service Announce (PSA) for every three paid PSAs, which amounts to approximately $500 for all the screening events. The local newspaper offers an in-kind contribution of 15% off each newspaper ad to advertise screening events at $294 per year. Standing Rock Tribal Health provides the salary and mileage for 11 CHRs to do the community outreach and education for the program. Standing Rock Indian Health Services provides funding for the services for screening as well as education and outreach for patients that come to the clinic. All partners are committed to this program evidenced by program growth and strategies implemented to overcome obstacles that prohibit screening. Commitment is ensured by continuously evaluating program activities and community needs, then implementing the activities to meet the goal.  ImplementationThe 2003 Women’s Health Program objectives are to plan 12 women’s health days; screen 350 to 400 women at all Indian Health Services clinics during regular clinic hours; educate women about cancer screening guidelines; provide educational material that is specific to the Standing Rock community; assist women with scheduling appointments, determine if there are barriers that prevent women from screening and assist with eliminating barriers; educate women about women’s health and family issues at special screening days and with other community settings; and evaluate all screening and education activities. Women’s Health Program objectives and activities for 2004 are to provide transportation for trips to Bismarck for mammography, assist Indian Health Services with scheduling mammograms, identify women due for mammograms when they present at the Women’s Health Days, provide education to women 40 and older about mammogram screening guidelines and encourage them to discuss mammography with their provider, monitor status of appointments kept and missed and reschedule appointments for women who have missed their appointments, educate medical providers to screen for need of mammograms when women present at the clinic for non-breast related concerns, and evaluate all mammography activities by the partners. Men’s Health Program objectives and activities from April 2003 to March 2004 include screening 70 to 80 men 40 and older for prostate and colorectal cancer with all health care needs addressed with each visit, holding two men’s health days planning to screen 25 to 30 men per day, assisting with scheduling appointments for exams, providing education to men and women about the importance of prostate and colorectal cancer screening, encouraging men in the community to screen by providing a prostate cancer survivor testimonial on the local radio and in the newspaper, educating men at men’s health days about healthy living and other health issues, and evaluating all screening and education activities.
PROCESS EVALUATION The partners work together in development of the yearly objectives, and then meet at least three times per year to evaluate the program progress. One of the largest challenges faced with the women's program was the loss of the mobile mammography unit in 2000. The number of mammograms declined by more than one half in 2001. Since the program was unable to get a mobile mammography unit, staff looked at alternative measures and received grant funding from the Avon Foundation Breast Care Fund to allow the CHRs to provide transportation for mammography and also to assist Indian Health Services with their mammography program as they did not have a staff person dedicated to contacting women and scheduling mammograms. Screening numbers improve every year and will increase significantly when mobile mammography becomes available, which will occur later this year. Funding for the mobile unit comes from a grant obtained by Aberdeen Area Indian Health Services. OUTCOME EVALUATION Evaluation is one of the key elements to the program. The program asks participants, staff and volunteers to evaluate the education and exam process with each special screening day. The program partners then review participant and staff evaluations after each screening day and make adjustments as needed to ensure that they are providing quality care and are meeting the needs of program participants. The positive unintended consequence of the program was the inclusion of men's health after the women's health program became established. The practice does achieve most program goals and in some instance, such as the men's health program, has far exceeded the goals. Lack of on-site mammography is the biggest barrier to achieving mammography goals, but the program will continue to work toward meeting this goal as well.
SustainabilityStaff are very optimistic about the future years for screening, as more community members are expecting annual screening as the norm and are sharing this information with their friends and family. The practice is definitely worth the resources invested in the program. The program has more than six years invested and is still growing and working to meet the goals. There has been a difference in community attitude about yearly cancer screening. Lessons LearnedOne of the major lessons learned in this program is that community trust is critical to program growth. Community trust is a process that takes years to develop. Local involvement by trusted and known people in the community is also an important component to have on the team to ensure connections within the community. Persistence and patience are key elements with this program. Offering complete health care at the time of the special clinic days is critical for getting people to come into the clinic. The one stop shop philosophy does make a difference for people deciding to screen for cancer if they can have all their other health care needs addressed at the same time. Before beginning a screening program it is important to spend time in the community to understand the needs of the people. It is necessary to determine what the community identifies as important and implement this into the program. Outreach and community education is vital to getting people into the clinic for screening. It often takes multiple contacts before a person may come into the clinic for screening.  Key Elements ReplicationThe key elements identified to replicate the practice are as follows: program partners must have specific roles; community education and outreach must be provided by providers and caregivers who are known and trusted; community needs must be evaluated and incorporated into the plan to reach the program goal; and health exams need be comprehensive with a provider, preferably of the same gender.