Abstract

INTRODUCTION

While cancer incidence in Arkansas is only slightly above that of the entire United States (US) (467.8/100,000 vs. 448/100,000 age-adjusted cases per year), a much higher cancer-associated mortality rate is a major public health issue (185.2/100,000 vs. 161/100,000) [1]. While there are many reasons for such disparity, contributing factors include the underutilization of recommended cancer prevention and early detection measures and a relatively higher tobacco smoking rate in Arkansas. In comparison to the national rates for human papillomavirus (HPV) vaccination, mammography, Papanicolaou (Pap) testing, and colorectal cancer (CRC) screening (53.2%, 72.5%, 71.9%, 67.7% respectively), those for Arkansas were lower (38.3%, 68%, 62.2%, 65.4%, respectively). On the other hand, the smoking rate was higher in Arkansas (22.3% vs. 17.1%) [1].

The University of Arkansas for Medical Sciences (UAMS) houses the state’s only allopathic academic medical center, and it offers a variety of cancer prevention programs for tobacco cessation, CRC screening [2], and breast cancer screening. To identify barriers from people who are likely to be knowledgeable and able to articulate specific examples preventing Arkansans from fulfilling recommended cancer prevention measures, an online survey and focus groups were conducted (1) to solicit suggestions for promoting cancer prevention measures, (2) to assess their awareness and compliance, and (3) to obtain feedback for a volunteer-based program called the Health Ambassador program.

METHODS

RESULTS

Most respondents were native Arkansans, as 65.2% (n=1,018) graduated high school in Arkansas. Free text suggestions for improving uptake of cancer prevention measures were solicited as a part of the online survey and the focus group sessions. The participants were asked how cancer prevention and early detection measures could be promoted in the Arkansas Delta region and what kind of new technologies should be incorporated. The answers provided were grouped in 4 broad categories: (1) to increase knowledge and awareness of cancers and cancer risk reduction screening measures (n=655), (2) use social media platforms to promote screening measures (n=263), (3) improve access to screening measures (n=150), and (4) reduce the cost of screening measures (n=122) (Figure 1). For increasing knowledge and awareness, participants advised engaging local organizations like churches, community centers, and schools to provide education about cancers and cancer screening methods, especially during local sporting events, health fairs, and community events (Supplementary Material 3). They also suggested posting educational content on various social media platforms. Additional input on strategies to improve screening uptake included utilization of telemedicine or mobile screening services to improve access, and to provide subsidies for screening tests for people of low socioeconomic status (SES).

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Figure 1.

Summary of suggestions for increasing the uptake of cancer prevention measures in Arkansas received during focus group discussions and in the online survey free-text responses.

Of the 11,660 UAMS employees and 2,759 UAMS students, 1,318 and 243 participated in the online survey, respectively, for a total of 1,561 survey respondents. The response rate was significantly higher for employees (11.3%) compared to that of students (8.8%, p=0.0002). Comparisons of the demographic characteristics of the UAMS population and the survey respondents (Table 1) showed significantly higher proportions of females and lower proportions of males for both employees and students (p<0.01 for 4 comparisons). For employees, there was a significantly higher rate of response from white respondents and lower rate for black respondents (p<0.01 for both). The survey respondents were almost evenly distributed across the age categories (Supplementary Material 2). Approximately 84.6% (n=1,321) had attained a Bachelor’s degree or higher. While the annual individual income most frequently reported was $40,000 to $70,000 (44.6%, n=628), the most frequently reported annual household income was $70,000 to $100,000 (24.2%, n=357). Questions regarding behavioral risk factors revealed that 71% (n=1,076) were tobacco nonusers, and 32.7% (n=495) consumed alcoholic beverages on a regular basis. The majority of alcohol consumers (52.9%, n=262) consumed between 2 – 5 drinks per week.

The willingness to participate in promotion of cancer prevention and early detection measures was high, as 67.7% (n=1,056) were willing to play a role in the promotion of cancer prevention and early detection measures in Arkansas (Supplementary Material 3). Further, 38.3% (n=559) expressed interest in participating in the focus groups, and 30.3% (n=442) expressed interest in participating in the “Health Ambassador” volunteer program.

The demographic characteristics and the responses to the questions regarding the Health Ambassador program and Heath Resources Navigator from 11 focus group discussions are displayed in Supplementary Material 4. Sixty percent (21 of 35) and 42.9% (15 of 35) were willing to participate as a Health Ambassador and a Health Resources Navigator, respectively.

DISCUSSION

As the only allopathic medical center which houses a medical school in the state of Arkansas, UAMS is also committed to addressing health inequities including those in cancer. Promotion of cancer prevention measures is one of our focus areas, as statistics demonstrate that underutilization of cancer prevention measures may be contributing to high cancer incidence, and more importantly, mortality in the state [1]. Being female and white were significantly associated with higher participation in the online survey (Table 1). This finding was not surprising, since a previous study of health-related behaviors has shown that females are more likely to attend educational sessions [4]. Likewise, lower participation in health-related research by members of racial and ethnic minorities is a well-known phenomenon, and has been demonstrated in a population-based study examining perception and participation in health-related research [5]. The low overall participation rate was consistent with other similar efforts on the UAMS campus that did not provide incentives (personal communication).

The most commonly received suggestions for promoting cancer prevention measures were to “educate and increase awareness” (Figure 1). In a recently published systematic review of community-based cancer prevention programs, education was found to be an important feature in most programs [6]. Educational contents such as tailored brochures [7]–[9] and/or audio-visual materials have been utilized [7], [10]. Furthermore, the effectiveness of in-person education on CRC knowledge for increasing inquiries to healthcare providers about screening was demonstrated [11]. The second most common suggestion we received was to use social media for promotion of cancer prevention measures (Figure 1). However, the use of social media has not always been shown to lead to success. In a study which used an advertising banner on Facebook to enroll subjects in a survey study about HPV and cervical cancer knowledge, only 243 of 3,312 (7.3%) people who visited the study homepage completed the survey [12]. Another program using Facebook to promote HPV vaccination was able to reach over 100,000 adolescents in the Philadelphia, PA, US area, but translated to only 2 adolescents receiving vaccination [13]. The remaining commonly received suggestions were to “improve access” and to “reduce screening cost” (Figure 1). The only program mentioned in the systematic review [6] which was able to reduce CRC cancer incidence and mortality at the population level provided access by performing the screening within the program and providing it for free for those without insurance [14] attesting to the importance of access and reduced cost.

The online survey results indicated that knowledge of and compliance to cancer prevention recommendations were good. Assessment of knowledge and compliance with the cancer screening measures revealed that 55.4% (n=36) of those who were within the targeted age range reported receiving at least one dose of HPV prophylactic vaccine, and 60.6% (n=132) reported vaccinating their age-eligible child/children with the vaccine (Supplmentary Mateiral 3). The most common reason given for not vaccinating one’s children was concern regarding vaccine safety (n=23), and the most common reason for not receiving the vaccine for oneself was parent/guardian objection (n=9) (data not shown in the tables). Questions about adherence to specific cancer screening recommendations showed fairly high compliance of 82.6% (n=954) for Pap testing, 75.8% (n=541) for mammography, and 76.7% (n=453) for CRC screening. Colonoscopy was the most frequently utilized screening test among those adherent with CRC screening (93.6%, n=424). UAMS employees are well-insured, as 96% of them are eligible for employer-sponsored health insurance, and 88% sign up according to information from human resources. Common reasons for not electing UAMS-provided health coverage are having coverage through spouse, or being eligible for Medicaid. All students are required to purchase insurance. Therefore, it is not surprising that the compliance rates for cancer screening were higher as compared to the reported rates in Arkansas [1]. A limitation of our approach was that the assessment of participation in cancer prevention measures was self-reported, and was not independently verified using medical records due to a need to preserve anonymity.

There were no significant associations between stated willingness to participate in focus groups with having a history of cancer (unadjusted p=0.97 and adjusted p=0.19) or having a family member with history of cancer (unadjusted p=0.31 and adjusted p=0.12) (data not shown in the tables). Some unexpected associations were uncovered between adherence to cancer prevention screening and various demographic/behavioral variables (Table 2). Having a personal history of cancer was significantly associated with increased CRC screening rate [84.8% (78 of 92) vs. 75.2% (375 of 499), p=0.04]. However, the opposite was true with mammography [64.5% (60 of 93) vs. 77.5% (481 of 621), p=0.007]. It is peculiar that a personal history of cancer was positively associated with CRC screening compliance, but negatively associated with mammography uptake. This may be because barriers for different screening methods are distinct. A decline in mammography uptake in cancer survivors, from 55% in first year of survivorship to 48% in the 5^th year, has been reported previously [15]. Patients recently diagnosed with cancer visited oncology specialists more frequently than other physicians, which possibly leads to lower mammogram uptake in cancer survivors [16]. Why the opposite has been observed (i.e., higher uptake in cancer survivors) for CRC screening is not clear. Intriguingly, those who felt they had good knowledge of cancer prevention recommendations were more likely to be compliant with CRC screening (p=0.02), while no significant associations were found with other interventions. Having a salary of $40,000 or more and having a Bachelor’s degree or higher were significantly associated with higher compliance of Pap test only [84.2% (660 of 784) vs. 76.6% (180 of 235), p=0.007; 84.5% (762 of 902) vs. 75.9% (192 of 253), p=0.001], but not for mammography or CRC screening. Again, this may be because barriers are different.

Positive history of cancers in the family and of tobacco use were both negatively associated with Pap test uptake (p=0.04 and p=0.02, respectively). On the other hand, salary of $40,000 and greater and educational attainment of Bachelor’s and above were positively associated with Pap test uptake (p=0.007 and p=0.001, respectively). It is difficult to explain why family history of cancer is negatively associated, as the opposite has been reported by others [17], [18]. It is possible that in this population, time taken to care for sick family negatively impacts self-care. The negative association of tobacco use and Pap test uptake can be partially explained by findings that tobacco users may be less likely to adopt a healthier lifestyle [19]. Associations of Pap test uptake with income and education has been consistently documented in the past [20], and are easier to understand as compared to the negative association of Pap test uptake with tobacco use and with family history of cancer. It is well-established that lower SES is associated with lower cancer screening adoption rate [20]–[22]. Therefore, the reverse finding of increased uptake of Pap test among people with higher income and higher educational attainment was expected.

A majority of respondents expressed the desire to contribute to the cancer prevention initiative in the online survey, but only about a third expressed willingness to participate as a volunteer and only 35 respondents (6.3%) participated in the focus groups. Of the 35 focus group participants, almost 38% were either not sure or did not want to participate in the Health Ambassador program, and more than half were either not sure or not willing to contribute as a Health Resources Navigator. Because the Health Ambassador Program and Health Resources Navigator services would require a greater time commitment compared to focus group participation, it became clear that this approach is not likely to succeed.

CONCLUSION

Suggestions provided for designing an effective cancer prevention program included increasing awareness through education, improving access, and reducing screening costs; all of which have been previously shown to be important in successful cancer prevention programs. The use of social media was also suggested, but this appears to be more difficult to adapt in the context of promoting cancer prevention measures. The self-reported knowledge of and compliance with cancer prevention recommendations was good. In addition, we uncovered associations which suggested that barriers for obtaining screening for different cancer types may be quite distinct. As participation in the focus group was low despite initial stated willingness, the participants’ suitability as educators is questionable.

Supplementary Material

Acknowledgments:

Footnotes

REFERENCES