Priorities and Community Need

1. Screening and Diagnostic Access. Evidence-based programs that provide access and reduce barriers to breast cancer screening and/or diagnostic services.  Example programs include the provision of free or low-cost screening and diagnostic services (e.g., clinical breast exams, screening mammograms, diagnostic mammograms, ultrasound, MRI, biopsies), mobile mammography, transportation assistance, expansion of clinical hours and co-pay/deductible assistance.

All programs should include the following elements:

a. Strong outreach component to serve rarely and never screened women
b. Plans to connect those who qualify to existing programs like Breast and Cervical Cancer Control and Navigation Program and Healthy Michigan Plan.
c. Education about personal and inherited risk informing a decision to get screened according to individual risk
d. Needs assessment to identify any barriers to moving through the continuum of care
e. Plans for resources and referrals to remove any barriers (may include, but not limited to transportation, childcare, physical access via mobile mammography, low cost mammography for uninsured, locating an in-network provider, or understanding insurance for insured)
f. Verification of completion of screening of each individual
g. Provide further diagnostics navigation as necessary
h. Verification of resolution of any follow up diagnostic testing
i. Navigation to treatment options
j. Address the target communities and counties. Highest scores will go to programs designed to serve the greatest proportion of target communities (e.g. 80% of caseload will be target population):

i. African Americans (Berrien, Jackson, Muskegon),
ii. Hispanic/Latinos (Kent, Ottawa, Van Buren),
iii. Rural counties (Cass, Montcalm, Livingston), and/or
iv. Low-income (under 350% FPL), uninsured and underinsured, men and high-risk women who do not qualify for BCCCNP.

2. Culturally Appropriate Education and Community Navigation. Community-based navigation programs focused on connecting women to screening services and providing referral and supportive transition to follow-up services (diagnostics and treatment) as needed. Programs should reduce barriers to care and provide evidence-based community education that dispels myths and reduces fears. The focus is bringing healthcare into the community and increasing the number of women who have not been screened in the last two years who receive screening services. Priority populations include (in no particular order): African American, Hispanic/Latino, rural. All programs should include the following elements:

a. Education about personal and inherited risk informing a decision to get screened according to individual risk
b. Needs assessment to identify any barriers to screening
c. Plans for resources and referrals to remove any barriers (may include, but not limited to transportation, childcare, free or low cost services for uninsured, locating an in-network provider or understanding insurance for insured, out-of-pocket costs for insured, genetic testing, financial assistance, lymphedema and other treatment supplies)
d. Verification of completion of screening of each individual
e. Referral and supportive transition to further diagnostics navigation as necessary
f. Address the target communities and counties. Highest scores will go to programs that designed to serve the greatest proportion of target communities (e.g. 80% of caseload will be target population):

i. African Americans (Berrien, Jackson, Muskegon),
ii. Hispanic/Latinos (Kent, Ottawa, Van Buren), and/or
iii. Rural counties (Cass, Montcalm, Livingston).

3. Survivorship Programs. Increase availability of evidence-based programs serving survivors with a focus on social and emotional wellbeing, wellness programs, and lifestyle intervention strategies.

a. Address the target communities and counties. Highest scores will go to programs designed to serve the greatest proportion of target communities (e.g. 80% of caseload will be target population):

i. African Americans (Berrien, Jackson, Muskegon),
ii. Hispanic/Latinos (Kent, Ottawa, Van Buren), and/or
iii. Rural counties (Cass, Montcalm, Livingston).

These priorities are the result of an in depth needs assessment, the 2015 Komen Michigan Community Profile. The Community Profile examined the cancer burden in Michigan and found that disparities exist for some populations. Grant making priorities are designed to meet the breast health needs in our community and reduce disparities in outcomes.

The Community Profile uncovered several key insights with regard to Black/African-American women’s access to services. Women and providers alike saw barriers to access as being transportation, affordability (including health insurance), systems knowledge/trust, and simply not knowing what services may be available to them. Transportation issues included navigational complexities of public transit in urban areas and lack of a reliable personal vehicle in suburbs and outskirts. Medical systems are complex and intimidating, especially when health insurance is a concern. Deeply-ingrained historical experiences of institutional racism is a barrier impacting trust in a provider. A common thread in the dialogues with key informants and focus group participants was the need for more community-based navigation. Several women cited lay health ministers or parish nurses as trustworthy resources and others cited individuals that are well-known within the community who informally serve as navigators helping to reduce fear, dispel myths, and connecting women to resources for services. While there are multiple barriers, community-based navigation provides a great opportunity and direction for improvement of systems and outreach.

Hispanic/Latina women face similar barriers to Black/African-American women, though they experience these barriers differently. One key informant pointed out that both populations are negatively impacted by the frequent changes in the American health care landscape especially with screening recommendations and insurance coverage procedures. Having insurance is a privilege that many Hispanic/Latinas do not have. According to the Pew Research Center, 20 percent of Michigan’s overall Hispanic/Latino population is without health insurance with this number climbing to 45 percent for foreign-born Hispanics. In Kent County alone, 36 percent of Hispanics go without doctor visits due to lack of insurance or inability to pay. Van Buren and Ottawa Counties are home to large numbers of migrant Hispanic/Latino farmworkers who are transient and tend to not stay in one area for long, impeding progression through the continuum of care. While many of these workers are documented, some are not, adding barriers to eligibility for services. Regardless of documentation status, Hispanic/Latina women are less likely to seek health care for themselves due to culturally-ingrained fear of systems. Another culturally-specific barrier is language, a difference from the other two populations of interest. Hispanic/Latinos who speak limited or no English face difficulties when attempting to relate to doctors, especially when a language line is used in lieu of bilingual medical staff. Although translation lines help reduce language barriers, it does not eliminate them and may impede the medical professional’s ability to pick up on subtle cues that could improve care.

Rural counties of Montcalm, Cass, and Livingston are areas lacking in breast health resources for women, regardless of race. The isolated nature of rural culture is a barrier in itself with many women preferring to stay within their county of residence, which usually have limited breast health services. Women who live in these more rural areas are also more likely to undergo drastic medical procedures such as mastectomy rather than breast-sparing procedures like chemotherapy due to lack of adequate transportation and rough driving conditions in the snowy Michigan winters. This makes access to services a multi-dimensional issue that transcends obvious socioeconomic factors. Montcalm County, the northernmost county in Komen Michigan’s service area, has a lower proportion of residents receiving mammograms than the state average, likely contributing to the rising death rate in this area. Transportation to and from health services is a challenge for residents of rural areas as public transit doesn’t typically extend far past small city limits—if it exists at all. Systems fear is a concern for rural women, though their experience of systems differs from Black/African-American or Hispanic/Latina women. This fear is related to travel to urban areas and the navigation of complex medical campuses which often resemble small cities. One key informant indicated that rural women tend to feel “forgotten” by health systems and nonprofits because they exist so far outside of metropolitan areas. With this group, it is important to actively engage by acting as a resource to connect to care.

Black/African-American, Hispanic/Latina, and rural women all face disparities in their access to breast health services. Though many challenges and barriers are similar, needs are unique and must be addressed in a culturally-appropriate manner that is reflective of the community. Programs for these populations must move beyond one-size-fits-all approaches and emerge with fresh ideas to reach out to women in need.

It is evident through examination of the health systems analysis, quantitative and qualitative data that disparities exist based on race, ethnicity, and geographical location which contribute to social determinants of health. Utilizing the information obtained through this study, the Affiliate recognizes that the following needs are present:

  • Hispanics/Latinas may experience difficulty accessing health care services due to language, cost, and/or documentation barriers;
  • Black/African-American women are less likely overall to be diagnosed with breast cancer though more likely to be diagnosed with breast cancer at a late-stage and more likely to die from the disease;
  • Women in rural areas are less likely to leave their area for services due to lack of reliable transportation or fear of larger cities. Furthermore, rural breast cancer survivors are more likely to die of breast cancer;
  • Black/African-Americans and Hispanics/Latinas report higher levels of medical mistrust which makes them less likely to seek medical care including preventative services;
  • Breast cancer survivors across the Komen Michigan service area lack access to survivor support programs that include wellness and lifestyle interventions, particularly services for rural residents and programs that are linguistically inclusive and culturally competent.

As community partners and grantees have noted, simply offering free mammograms is no longer bringing women in the door for services. Many of the women served in prior Komen programs are now covered through other resources like Healthy Michigan Plan and expanded services from the Breast and Cervical Cancer Control and Navigation Program. As the State Innovation Model directs, health care must be brought into the community. By focusing on creating a pipeline of support from community-based education and navigation into clinical services and follow up care, Komen Michigan will support a stronger, more connected cancer care community.

Utilizing this information as a lens, the Affiliate analyzed common themes to identify Mission priorities. First, across all communities of interest, the Affiliate recognizes a need for screening and diagnostic programs to fill the gaps in existing programs. Second, culturally competent navigation and education programs will help address the specific needs of the population to be served, including reducing fear and dispelling myths. Third, there is a need for survivor support programs that incorporate lifestyle interventions like exercise and nutrition. The Affiliate has proposed several priorities to address these needs across all communities it serves, as set forth above.