Desire for Preventative Screening is Strong Among People Experiencing Homelessness

People experiencing homelessness have a much higher rate of cancer mortality, often due to late diagnosis. Collaborating with community organizations and providing multiple modes of communication helps support the needs of this often difficult-to-reach population. According to a new Cleveland Clinic Cancer Institute study published in BMC Primary Care, findings imply that primary care providers can promote earlier diagnosis and intervention through deliberate screening strategies to engage these patients.

Background

Since 2005, the Cancer Institute’s outreach team has worked across Northeast Ohio to support people with the highest need, including those who are uninsured or who lack stable housing. “We partner with community organizations that serve people experiencing housing insecurity or homelessness, as these individuals’ everyday needs for shelter, food and finances may take priority over preventative healthcare,” says Heather McKee Hurwitz, PhD, Project Staff with Cleveland Clinic’s Department of Hematology & Medical Oncology. “This population often has transportation barriers and scheduling barriers that may limit their engagement with screening programs.”

In 2022, the Outreach team piloted an initiative termed “Homeless Women Receiving Onsite Mammography, Patient Navigation and Education (HOPE)” to offer 3D mammography screening as well as language translation services and support for addressing transportation and scheduling barriers for people experiencing homelessness or housing insecurity. Community members received screening either through mobile mammography or by receiving an Uber Health ride to a preventative screening event at one of Cleveland Clinic’s regional hospitals.

Study details

To gain insights about further supporting this population, the Outreach group conducted both quantitative and qualitative analysis of this initiative. They studied the views, attitudes and experiences of participants about the screening process and about cancer screening in general. In addition, the researchers analyzed notes from patient navigators who were supporting participants during screening and screening follow-up.

The analysis included 124 participants in the Cleveland area who completed mammograms and follow-up surveys about preventative screening between 2023-2024. Participants were 40+ years old or 35-39 years old with an immediate family history of breast cancer who had not completed a mammogram in the past year.

Of those 124 participants, 86.3% received normal screening results and 13.7% received abnormal results indicating a need for additional testing. The latter then received extensive support from patient navigators, who reached out between 3-19 times.

Study outcomes

The quantitative data results aligned with broader literature that this population has a positive attitude toward primary care and also values screening. “In addition, we wanted to learn how our patient navigators were successfully helping people from initial cancer screening through follow-up, and what elements could be adopted in a primary care setting,” explains Hurwitz. “From our analysis, we were able to glean three salient themes that were key to success: Relationship building, persistence and collaboration.”

• Relationship building. “Maintaining contact over time, navigators repeatedly trouble shoot with patients to continue through the scheduling, screening and diagnostic testing process,” says Hurwitz. “Caring for patients even over months of back and forth is key to building trust with these constituents.”
• Persistence. Patient navigators engage in extensive communication back and forth with patients and they used multiple modalities, including reminder calls, MyChart messages and mailed letters. For participants who had abnormal results, an average of seven calls was necessary to ensure completion of diagnostic testing appointments. The repeated communication was not due to a lack of interest by participants, but to the many obstacles they face. “The greater the severity of housing insecurity, the greater the need is for tenacious and creative follow-up,” says Hurwitz.
• Collaboration. “We found that patient navigators weren’t just developing a relationship with the patients but were collaborating with many other people in the patients’ lives, bringing in housing managers, case workers, friends and family members,” she says. Throughout the study, the team even expanded its partnerships beyond overnight shelters. “People experience homelessness in different ways,” says Hurwitz. “They may be staying in shelters, living in their car, staying with friends or family or living on the streets. Others may be a paycheck or two away from being housing insecure. To extend our reach, we connected with agencies throughout Northeast Ohio that offer programs for people facing housing instability, such as food banks and other health-related community organizations.”

Study conclusions

The Outreach team continues to find ways to remove hurdles to early detection of cancer among housing insecure populations. Although most medical practices may not have the resources to engage a community outreach team or even a patient navigator to ensure that housing insecure patients complete cancer screenings, the study authors suggest that healthcare professionals adapt some practices from HOPE to find ways to address barriers for housing insecure patients. Speaking to the study’s impact, Dr. Hurwitz commented: “I am continually inspired by how strong participants’ desire was to care for themselves. With strategies learned from patient navigators, we can continue to improve care for housing insecure individuals.”