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Challenging Care Disparities

Nursing professor's award-winning research probes why different groups make different choices

By Kevin Foley Article published March 24, 2004

Mary Canales
Mary Canales, associate professor of nursing, recently won a Howard University award for her research. (Photo: Bill DiLillo)

Mary Canales loves the qualitative side of her research into disparities in health care. She finds sitting down with her subjects and interviewing them in depth about their lives and about why they do or do not seek diagnosis both enjoyable and intellectually stimulating.

But recently, the associate professor of nursing has become convinced that analyzing carefully directed conversations isn’t enough.

“I’ve gotten to a point in my thinking where I see that to really make a difference I need to move past qualitative studies. I can’t have the impact I want to have when I talk with 20 women,” she says. “I can write and present and speak at conferences with that individual data, but I can’t challenge societal problems.”

Canales is currently pursuing a four-year project investigating mammography decision making among American Indian women in Vermont funded through the National Cancer Institute and the NIH Cure program. The study, one of very few to focus on off-reservation women in the Northeast, looks at a population with a relatively high incidence of death from breast cancer, but with mammography screening rates below the national average.

The resonance of that project, as well as other work Canales has done around mammography, breast cancer and breast health among Latina women, contributed to her designation as an “emerging nursing star” in health disparities research, an honor she accepted on March 11 at a Howard University event.

Culture and disparity
Canales is in the midst of a second quantitative phase of her mammography work. After first reviewing literature and conducting interviews to grasp the contours of the issue — the different ways that members of a non-homogenous group frame their decisions to receive (or not receive) mammograms — she’s now nearing completion of a survey that will offer some harder data on the subject and offer insight into the accuracy of the decision-making theory she developed using her qualitative data.

The survey applies a widely used model, called “Stages of Change,” which looks at how individuals make decisions about health issues like quitting smoking (slowly, and in stages), to mammography. The model hasn’t been applied to minority women before, and Canales’s aim is to relate her subjects’ thinking about mammography, their “slot” in the “Stages of Change” model, to their complex sense of their ethnic identities, a measure Canales calls “traditionality.”

“Women think about their native identity in different ways. … Some women check the box on a form, but they don’t really think of themselves as American Indians. Other women didn’t think of it growing up, but as they get older, they develop an interest in their identity. Others grow up with it, and move out of touch as they age,” Canales says. “How do these factors affect decision making? We make lots of assumptions about what people are based on crude categories, but the reality is much more complex.”

When the survey instrument is completed, Canales will use the Vermont Breast Cancer Surveillance System, a statewide registry led by colleague and co-author Berta Geller, research associate professor of family practice, to distribute the completed survey. Eventually, and with some modification, the survey may go out nationwide to see if trends that emerge in the data have wide application. Urban American Indian women in Colorado, for example, have some things in common with the predominantly rural native population in Vermont.

The eventual goal is to provide a foundation to test initiatives to promote breast health in American Indian women.

“What has been done in the past with this kind of survey work is to develop and begin to evaluate targeted medical interventions,” Canales says. “Obviously, the message and approach need to be different for someone who has never had a mammogram versus someone who had one a few years ago and is considering another one.”

The depths of disparity
Even in a country that spends a higher percentage of its national wealth on health care than any other, inequalities in treatment exact a terrible toll, Canales says. The too-low rate of mammography among American Indian women, and the complex reasons behind it, is only one facet of a larger problem.

Canales frames disparity within the context of a country where 43 million people have lacked health insurance for an entire year, and 70 million went without it for some portion of the year, and the nation’s largest employer offers neither insurance nor a wage high enough to pay for it on the open market.

Such structural problems with the nation’s health care system, from lack of access to a focus on technology and acute care over prevention, as well as racism, make the problems hard to attack, but Canales believes that academic work can push change forward.

She’s currently working with a group of colleagues on an article about disparities in cancer diagnosis and treatment for the Annual Review of Nursing Research. “That article is going to Senator Bill Frist’s (R-Tenn.) office. He is a point person on these issues in the Senate,” she says. “We hope it may help shape policy.”