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Shared and Unshared Barriers to Cancer Symptom Management Among Urban and Rural American Indians

Purpose—Before the end of the 20th century, American Indians (AIs) primarily resided in nonmetropolitan
areas. Shifting demographic trends have led to a majority of AIs now living in urban
areas, leading to new health care barriers for AIs. AIs experience the poorest survival from all
cancers combined compared to all other racial groups. Identifying and classifying barriers to
cancer care may facilitate supportive interventions and programs to improve access and treatment.

Methods—A 5-year cancer symptom management project targeted AIs in the Southwest. The
first phase of the randomized clinical trial consisted of 13 focus groups (N=126) of cancer
patients/survivors and their caregivers. Discussions explored existing and perceived barriers and
facilitators to cancer symptom management and cancer treatment.

Findings—Significant barriers to cancer-related care were found among urban AIs, as compared
to their rural counterparts. Barriers were classified within 4 sub-groups: a) structural, b) physical,
c) supportive, or d) cultural. Urban AIs reported barriers that are both structural and physical
(inadequate access to care and public transportation) and supportive (lack of support, resources
and technology, and less access to traditional healing). Rural participants reported communication
and culture barriers (language differences, illness beliefs and low levels of cancer care
knowledge), as well as unique structural, physical and supportive barriers.

Conclusion—It is important to identify and understand culturally and geographically influenced
barriers to cancer treatment and symptom management. We provide recommendations for
strategies to reduce health disparities for AIs that are appropriate to their region of residence and
barrier type.
access to care; cancer; geography; health disparities; social determinants of health
The United States’ population and geographic distribution have been rapidly changing for
decades. From 2000 to 2010 alone, the urban population has increased by 12.1%, more
rapidly than the nation’s overall growth rate.1 As the US population as a whole grows
increasingly “urban” each decade, a phenomenon, termed “metropolitanization,”2 of the
American Indian/Alaska Native (AI/AN) population follows suit. The US Census Bureau
classifies “urban” areas as having a population density of at least 1,000 people per square
mile; a classification of “rural” consists of all territories, populations, and housing units
located outside of urban areas.3 The population of AI/ANs residing in urban locations is
For further information, contact: Felicia S. Hodge, UCLA School of Nursing, 700 Tiverton Avenue, Factor Building #5-940, Los
Angeles, CA 90095;; Tel: (310) 267-2255..
NIH Public Access
Author Manuscript
J Rural Health. Author manuscript; available in PMC 2015 April 01.
Published in final edited form as:
J Rural Health. 2014 April ; 30(2): 206–213. doi:10.1111/jrh.12045.
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steadily growing, and it is currently at 60%.4,5 During the 20th century and previously, AI/
ANs primarily resided in isolated rural areas. The population shift for AIs to urban centers
was expedited during the mid 20th century for several reasons that included a government
policy of assimilation which emphasized the termination of and relocation of AIs from
reservations to major cities, economic migration, and an influx of World War II veterans
who did not return to the reservations, but instead remained in urban centers.6,7 From 1970
to 2000, AI/ANs were least likely to live in metropolitan areas, compared to all other races.
Only 20 years ago, at the time of the 1990 census, did a majority (51%) live in metropolitan
areas for the first time (Hobbs & Stoops, 2002).2 According to the US Census, only 22% of
AI/ANs now reside in tribal areas (ie, federal reservations, off-reservation trust land, state
reservations, etc.) with 5 of the 10 most populated reservations being located in Arizona.8
Unlike rural reservation populations, urban AI/AN populations tend to be more diverse,
encompassing multiple tribal groups who have diverse ethnic, cultural, and social
characteristics. The extent of acculturation into urban and mainstream culture can vary
greatly, and many traditional beliefs and practices from rural reservation living are
transplanted with individuals and families into urban areas, often over several generations.
In addition, movement around urban areas (transiency) is common, and it has been
postulated to be a result of feelings of social and cultural isolation associated with living
away from reservations.9,10
While rural populations typically fare worse on many dimensions of health compared with
populations at other levels of urbanization, urban Indian populations are less likely to live
within designated Indian Health Service (IHS) service areas where health care services are
provided by federal (IHS) and tribal health programs,10,11 raising new health care access
concerns. To provide health care for the increasingly urban Indian population, the IHS
currently funds 33 urban Indian health programs.5,10 Unfortunately, assessing health status
and even the level of health care access of the AI/AN population by area of residence is
difficult to study due to racial misclassification in state and national health databases.12
Even statistical reports generated by the IHS do not stratify health status by rural/urban
location of residence, and AI/ANs not residing in defined IHS service areas are not included
in aggregate statistical reports.12
With only limited information available characterizing the health status of AI/ANs living in
rural and urban areas, there is a dearth of research examining cancer, cancer-related
symptoms and related barriers to care in this population. AI/ANs experience the poorest
survival rate from all cancers combined compared to all other racial groups.13 Contributing
factors may include late or inadequate access to treatment, lack of access to culturally
sensitive education, language barriers, poverty, unreliable or nonexistent transportation, and
cultural beliefs surrounding cancer,14,15 all of which may be influenced by region/location
of residence. Reservation clinic clients may obtain initial screenings from providers and
referrals to IHS contract care specialists. However, because IHS clinics have limited
numbers of specialists and screening equipment, referrals to specialists at larger
metropolitan hospitals or clinics are not always approved for funding.16 Urban Indian
residents, on the other hand, may have more ready access to specialists, provided they have
sufficient insurance coverage, either through Medicaid/Medicare, private or work-related
insurance. Urban residents may also have the option of returning to their tribe’s reservation
or IHS clinic for primary care; however, they may or may not be eligible for contract health
care services and referrals by the IHS clinic due to their urban residence.16 Thus patients in
both geographic settings may experience delays in treatment and disjointed care.
Studies have demonstrated how health care disparities result from a complex interplay of
economic, social, and cultural factors.17,18 For colorectal, female breast, cervical, and
Itty et al.
J Rural Health. Author manuscript; available in PMC 2015 April 01.
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prostate cancer the proportion of cases diagnosed at a localized stage is lower and the
proportion diagnosed at a distant stage is higher in high-poverty compared with low-poverty
census tracts.19 For breast cancer, the proportion of women diagnosed with regional- and
distant-stage disease is higher among African Americans, Hispanics/Latinos, and AI/ANs
than among whites and Asian Americans/Pacific Islanders. In a study of rural-urban
differences in cancer stage at diagnosis, rural residents were twice as likely to have unstaged
cancers compared to urban residents, and tended to have more advanced disease than urban
patients.10,20 Results suggested that differences in access to or utilization of early detection
methods at urban sites may contribute to the rural-urban differential in the extent of disease
at diagnosis.10,20
This paper describes the results of the first phase of a large randomized intervention study
designed to reduce/overcome barriers to cancer-related symptom management among AIs
residing in the Southwest United States. The goal of the project was to identify and
categorize illness beliefs and barriers to symptom management faced by AI cancer patients/
survivors and family members, and to better understand how these constructs impact the
cancer experience. Structural barriers, such as extent of health insurance and financial
support; physical barriers, including geographical distance to health care facilities and
limited access to transportation; cultural barriers, such as illness beliefs and practices, and
distrust of the health care system; as well supportive barriers, were examined in this study.

Adult male and female AI cancer patients/survivors, along with caregivers/family members
(n=126), participated in 13 focus group discussions on cancer symptom management.
Participants were recruited for focus groups through the use of flyers posted at community/
health sites and word of mouth. Inclusion criteria were: (1) self-identify as AI, (2) age 18
years or older, (3) experience as a cancer patient (with active disease, before, during or after
treatment) or survivor (not currently experiencing active disease), or experience as a family
member (immediate or extended family) or caregiver (typically relatives, also including
close friends or home health care workers) of an AI patient/survivor. Focus groups were
held in conference rooms at 2 urban AI clinics and one community center at a reservation
site in eastern Arizona. Rural sites were classified as such if the population density was less
than 1,000 persons per square mile.3 Each participant was consented prior to enrolling by
trained project facilitators with experience working with AIs. The sessions, 1 to 2 hours in
length, were audio-recorded with permission from the group members who were asked to
use pseudonyms or numbers instead of names during discussion for confidentiality purposes.
Thirty-five-dollar gift cards were offered as incentives for participation. Focus group
discussions centered on the following areas: cultural constructs and personal experiences
with cancer, barriers to self-management of cancer symptoms, and cancer beliefs, myths and
fears. The study received Institutional Review Board approval from the University of
California, Los Angeles and the Phoenix Area Indian Health Service.
At the beginning of each focus group session, following consenting and enrollment, the
facilitators explained ground rules for focus group discussions, emphasizing speaking in turn
and respectful listening. Focus group topics included the identification of cancer etiology,
barriers, treatment and experience with cancer-related symptoms and their management.
Facilitators followed a focus group protocol with prompts to guide open-ended discussion.
The facilitators audiotaped the sessions, but participants were allowed to request the
audiotape to be turned off at any time, during which case the facilitators would take notes.
All participants were given the opportunity to speak, but all were not required to do so.
Itty et al.
J Rural Health. Author manuscript; available in PMC 2015 April 01.
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Research staff transcribed the audio-recordings of focus groups verbatim. The transcriptions
were analyzed by 3 members of the research team and coded following constructivist
Grounded Theory techniques21 to identify major codes and categories in the data.
Transcripts were read in their entirety by one investigator, and then excerpt-by-excerpt
coding was conducted to capture the meaning expressed in each excerpt. Codes were
reviewed and grouped by importance, similar concepts, and frequency in order to identify
major themes emerging from the data. A second investigator independently reviewed the
categorized codes and key themes. Community representatives reviewed excerpts from
transcripts and evaluated the developing framework to assess accuracy of interpretation and
provided validation of the codes and themes. Code description and categorization were
discussed and modified until agreement among the entire research team was achieved. A
matrix listing final codes and excerpts was created to synthesize data. Results from this
study were shared with participating tribes and urban sites, and a review of findings was
completed by the Phoenix Area Indian Health Service prior to publication.

The study sample included 81 urban (64.3%) and 45 rural participants (35.7%).
Additionally, 20.6% were urban and 9.5% were rural cancer patients/survivors. The majority
of participants were female (89 females, 37 males). Further details of sample characteristics
have been reported elsewhere.22 Through the application of qualitative analysis numerous
common—and several significantly different—barriers to cancer symptom management
were identified among urban and rural Southwest AIs. Both groups reported experiencing
physical barriers, such as transportation difficulties and lack of cancer care services. Within
major categories of common (shared) barriers and differing (unshared) barriers, factors were
further categorized within sub-groups of structural, physical, supportive, and cultural
Common (shared) barriers to cancer symptom management
Study participants reported common barriers in their cancer symptom management
experience, which although distinguishable by varying geographic, lifestyle or cultural
constructs, are still fundamentally similar. (See Tables 1 and 2 for qualitative data on
barriers identified for rural and urban Southwest American Indians.)

1) Structural Barriers—Structural barriers include those factors beyond one’s personal
control and involve the system’s organization and provision of care. Both the urban and
rural groups described lengthy time between appointments and among service providers
(appointments for a nutritionist, oncologist, etc., were often scheduled on different days).
Native language translational services, largely available for rural groups—were non-existent
for urban groups. The availability of and access to advanced technical cancer screening and
treatment modalities and equipment was reported to be sparse in the rural areas, as compared
to urban sites, often leading to reported inadequate treatment/misdiagnosis or late diagnosis
among rural AI patients/survivors.

2) Physical Barriers—Physical barriers, described as distance to cancer care services and
transportation difficulties, were experienced by both groups; however, the limitations that
define these barriers are due to 2 major defining experiences. For the urban Indian group,
living in a city presented difficulties in transportation— not because of distance factors—but
due to traffic congestion and the expense and time burden of using the public transportation
system. While reservation or rural-based Indians did not report experiencing such
difficulties in transportation, they did note a lack of transportation options (such as not
having a vehicle, no public transportation, or needing to rely upon relatives to provide rides
Itty et al.
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to appointments). In addition, rural groups described dealing with complications of
coordinating transportation with others in light of the extremely long distance from isolated
rural-reservation sites to medical care services. Long distances, coupled with numerous
appointments, often necessitated overnight stays (added expense) and increased reliance on
others for help with rides, childcare, etc., while away obtaining care, which introduced other
significant issues described below.

3) Supportive Barriers—A third common barrier described was the lack of supportive
services and care for cancer patients/survivors and their families. Both urban and rural
Indian residents reported a general lack of access to appropriate information about cancer
care and treatment. In addition, they noted that they often did not receive the attention of
cancer advocates. This lack of support has been explained as the limited number of patient
advocates or “navigators” employed on or near reservations or in urban settings. When
available, advocates were not typically perceived as culturally competent or knowledgeable
about the cancer patients’/survivors’ support needs. Many urban and rural participants noted
that they have access to Community Health Representatives (CHRs) who can help with such
tasks as transportation, picking up prescriptions and other health-related services.
Unfortunately, not all sites have CHRs, and those that do may experience limited availability
of CHRs who are overwhelmed tending to the needs of AI residents who have type 2
diabetes, heart disease, or other chronic diseases.

A lack of social or emotional support of family and friends was noted by both groups. The
practice of “not bringing one’s troubles home” appeared to lead to increased social isolation
and low support for cancer patients/survivors. AI cancer patients/survivors alike discussed
the inability to “bring home” information about their cancer diagnosis, treatment, and
survivorship experience. “We don’t talk about it,” was a common view voiced by
participants regardless of geographic region of residence, as to do so would bring even more
stress, problems, and grief to an overburdened family. The inability to turn to family and
friends and share the cancer experience served to isolate the cancer patients/survivors in
many instances.

Differing (unshared) barriers to cancer symptom management
While level of acculturation may vary among AIs of different tribal affiliations regardless of
geographic setting, a number of barriers identified in this study typified cultural differences
between urban participants holding more acculturated view points, and more traditionally
minded rural AI participants. These differing or unshared barriers were more evident among
the rural/reservation group than the urban group. (See Tables 1 and 2 for qualitative data on
barriers identified for rural and urban Southwest American Indians.)

1) Cultural Barriers—Culture played a significant role in the management of such cancerrelated
symptoms as pain, depression, fatigue, and loss of function among rural/reservation
participants. Difficult patient-provider communication, language differences, illness beliefs,
disagreement regarding/lack of access to Native healing practices and low levels of cancer
care knowledge were reported as barriers to cancer symptom management more frequently
among rural residents. Because rural focus group participants for the most part did not have
access to patient advocates, there was frequent noting of the inability to understand and
communicate with the doctor. Patients and survivors reported that it was not unusual for the
doctor to complete the visit without responding to the patient’s questions. Additionally, the
rural participants felt that the providers did not understand the culture of American Indians,
medical terms and discussions were not understandable, and language differences
contributed to misunderstandings and poor communications. These challenges may have
also contributed to the patients’/survivors’ low level of knowledge regarding cancer
Itty et al.
J Rural Health. Author manuscript; available in PMC 2015 April 01.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
screening, diagnosis, treatment and survivor issues, as well as the management of cancer
symptoms. Rural participants typically reported levels of cancer knowledge and awareness
of the cancer diagnosis, treatment and potential outcomes on the lower end of the spectrum,
compared to a decent command of the terminology, diagnosis and treatment options more
commonly reported among the urban group.
The use of traditional healers among the rural group was evident in their discussion of
treatment preferences and healing ceremonies. Knowledge of traditional healers and
ceremonies were voiced, and the use of both Western and traditional medicine was
explained as a way to “maintain balance.” Urban groups discussed the use of Western
medicine, sometimes in combination with traditional healing. Distance barriers appeared to
place urban Indians farther away from traditional medicine resources, which although
sometimes available in urban locations are more prevalent on reservations. Rural
participants’ experience with traditional healers often included family and community
members in the healing process. Urban Indians reported it was more typical to visit Western
doctors, who are more easily accessible in urban locations, on an individual basis; with
privacy regulations and hospital rules, the inclusion of family members is more inhibited.
Discussion indicated that urban Indian communities may struggle to balance a desire for
traditional cultural practices with available medical services.

2) Structural Barriers—Rural/reservation participants reported greater financial stress, as
well as unique structural, physical and supportive barriers. Because of the isolation of rural
reservation sites, employment opportunities are scarce and the financial stress of cancerrelated
treatment and care can become unmanageable. Even with the availability of the IHS
clinic and hospital services, participants voiced that they are often without the needed
specialized care, and referrals to outside agencies or to specialized care become financially
unobtainable. Not only are these services more apt to be located in larger cities, having little
or no insurance other than the care provided by the IHS left some rural patients/survivors
vulnerable for refusal due to the inability to pay. Those who did find a way to enter a
“support group” or to find a patient advocate told of uncomfortable meetings, long wait
times, and rapid discussions regarding illness, loss of function and even death—a taboo
topic among many tribes.
Both rural and urban AIs demonstrated unique, yet significant, structural barriers. Distance
and systems barriers were perceived as more understandable barriers—it was the lack of
social and family support, coupled with the cultural-related barriers, which were noted as
major problems.

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