This is the first study to use mixed-methods to describe family physicians’ barriers to cancer screening in extremely obese women. This integration of qualitative and quantitative data is very useful for exploring new topics and gaining better understanding of results.(25
) Barriers fell into three main areas: (i) difficulty doing exams, (ii) inadequate equipment, and (iii) challenges overcoming patient barriers and refusal. Similar to findings by Amy et al.
) difficulty doing exams and lack of adequate equipment were commonly experienced. This may have caused some physicians to avoid performing cancer screening examinations on extremely obese women. This avoidance, as well as not persisting when patients refuse, may contribute to the lower rates of cancer screening in obese women, a high-risk group that often delays cancer screening exams. Our findings support those of Adams et al.
that some physicians are more reluctant to perform pelvic examinations in patients who are very obese and those who are very reluctant,(21
) and our study offers reasons for this reluctance.
Although more of the OB/GYN providers in Amy et al.
’s study had large-sized exam tables, a higher percentage of our family physician respondents had scales, gowns, armless chairs, and blood pressure cuffs for large patients (11
). Still, availability of these supplies was less than optimal. For instance, 43% of respondents did not have extra large gowns, which may compound the embarrassment obese patients experience and their avoidance in getting undressed. As extremely obese persons comprise an increasing segment of the US population (2
), more practices will need equipment and supplies to better accommodate them.
Survey respondents were generally perceptive regarding obese patients’ barriers to receiving physical examinations. Embarrassment, aversion to undressing, and avoidance of discussions related to their weight were highly rated by physicians, congruent with barriers elicited from studies with patients (11
). Additionally, 40% of survey respondents reported disrespectful treatment from health-care providers was a reason patients gave for not getting mammograms and Pap smears, similar to the 36% of women answering affirmative to this statement in Amy et al.
Similar to others, we found female family physicians were more likely than male physicians to perform Pap smears in the office (30
). This may be due to greater emphasis on prevention by female physicians (30
), their greater comfort and skill with performing Pap smears (31
), or patient preference for female physicians when obtaining Pap smears (32
). Male physicians reported less difficulty than females with palpating masses on pelvic exams. This may be due to the higher percentage of female physicians performing Pap smears on extremely obese women. As expected, male physicians were more likely than female physicians to refer obese patients who refuse cancer screenings to OB/GYN. More research is needed to examine the influence of physician gender on delivery of preventive services for extremely obese patients.
To increase cancer screening rates in extremely obese women, interventions targeting specific patient and physician barriers are needed. We elucidate physician barriers that are potential targets for future interventions. For example, many family physicians were interested in receiving education on specific examination techniques. This may decrease difficulties that physicians have and subsequent avoidance of examinations on extremely obese patients. Second, practices may obtain equipment and supplies to help them examine extremely obese patients. For physicians who cannot afford to purchase these supplies or do not have the comfort or skills to perform breast and pelvic examinations on extremely obese patients, referring these patients to physicians that can accommodate them should be encouraged, with follow-up to ensure patient compliance. Finally, resources to assist physicians in dealing with patient refusal and overcoming patient barriers are needed. Publications which give advice on improving the office environment and interactions with obese patients should be disseminated (33
Limitations of this study should be considered. For the interviews, we used purposive sampling to obtain maximum variation regarding age, gender, location, and patient population, but we may not have obtained all possible responses. We relied on physician recall of specific patient encounters, which may be an incomplete picture of barriers faced. For the surveys, although a 53% response rate is generally acceptable for this type of survey research, the results cannot be generalized to other specialties or physicians outside of New Jersey. Responders may have more interest in obesity and cancer screening, so barriers may have been understated. Finally, all data were self-reported and not objectively measured, so true barriers may be lower or higher than suggested.
Interventions focusing on physician barriers, such as educating them on specific examination techniques, obtaining adequate equipment and supplies, and providing resources to assist physicians in overcoming patient barriers and refusal, may be fruitful in increasing cancer screening rates in extremely obese patients. Future research studies testing the effectiveness of these strategies are needed to improve cancer outcomes in this high-risk population.