J Immigrant Minority Health DOI 10.1007/s10903-015-0228-7
ORIGINAL PAPER
Assessing Oral Cancer Awareness Among Rural Latino Migrant Workers Virginia J. Dodd1
•
David P. Schenck2 • Elizabeth H. Chaney3 • Tapan Padhya2
Ó Springer Science+Business Media New York 2015
Abstract Latino migrant farm workers suffer significant health disparities, including poor oral health. The purpose of this research was to assess Latino migrant farm workers’ OC awareness, including knowledge and care-seeking behaviors. A 42-item survey was developed. Trained, bilingual researchers verbally administered the survey to migrant farm workers in Hillsborough County, Florida. Frequencies and descriptive statistics were generated to report baseline data. The sample consisted of 53.7 % female respondents. The mean age for males and females respectively was 38.7 and 39.2. Most respondents had attended grade school; 6.7 % never attended school. Perceptions of cancer susceptibility were present; knowledge of OC risk factors, signs and symptoms was low. Participants were unlikely to seek preventive care. The results contribute to the limited studies regarding Latino migrant farm workers and oral cancer risk factor awareness and knowledge. Findings highlight factors influencing motivation and care-seeking behaviors, as well as provide guidance for development of educational materials.
& Virginia J. Dodd [email protected] 1
Department of Community Dentistry and Behavioral Science, University of Florida, 1329 SW 13th Street, Suite 5187, Gainesville, FL 32608, USA
2
Department of Otolaryngology-Head and Neck Surgery, Moffitt Cancer Center and Research Institute, College of Medicine, University of South Florida, Tampa, FL, USA
3
Department of Health Education and Promotion, East Carolina University, Greenville, NC, USA
Keywords Latino migrant farm worker Oral health Oral cancer risk factors Oral health care access Delivery of oral health care
Introduction Oropharyngeal cancer (OPC) is a disease characterized by the presence of malignant cells in the tissues of the oropharynx, specifically the back one-third of the tongue, soft palate, side and back walls of the throat, and the tonsils [1, 2]. Oral cancer (OC) is cancer that originates in the mouth or oral cavity and affects the tongue, floor of the mouth, lining of the cheeks, gums, lips, or palate [1, 3]. It is important to note that both terms, OPC and OC, have been used interchangeably within the literature [3]. Cancer beginning in the mouth (OC) can often spread and involve tissues in the oropharynx (OPC) causing definitions to become cloudy and complicated. Screening procedures differ in that the OC exam is performed visually and the OPC exam involves use of various scopes to view the deeper structures of the throat [2]. Early detection of either cancer reduces an individual’s risk of death and disfigurement. In 2015, approximately 39,500 people are expected to be diagnosed with OPC and 7500 will die [2]. OPC is more than twice as common in men than women [2]. Currently, the 5-year relative survival rate for localized disease is nearly 83 %; for regional disease (spread to regional lymph nodes) the rate is 59.2 %; and the distant (metastatic) disease rate is 36 % [4]. Approximately one-third of OC cases are diagnosed early, while the cancer is localized, and treatment more likely to be successful [1]. Since OC is preceded by visible changes in the oral mucosa, goals for early detection and treatment are not unreasonable [5].
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However, most cases are detected at late stage, when treatment is complex, more costly (both monetarily and psychosocially), less effective, and significantly lowers one’s overall quality of life [5–10]. Contributing to diagnostic delays and the resulting negative outcomes are lack of OC awareness in the public, specifically of the signs, symptoms, and risk factors for oral cancer, coupled with an absence of early detection by health-care providers [1, 5]. According to the Health Resources and Services Administration (HRSA), approximately 4.2 million seasonal and migrant farm workers, primarily of Latino origin, reside in the United States. Migrant farm workers come from Central American countries such as Mexico, Guatemala, Honduras, and the Dominican Republic [11]. Each year the farm workers, sometimes with their families, come to the US to plant, cultivate, harvest, and package crops. Migrant farm workers in the United States receive marginal healthcare services, primarily due to access issues associated with their cultural isolation, geographic mobility, healthcare provider contact, most often limited to acute injury care or lingering illness, and sometimes murky immigration status [12–16]. Also present are barriers related to time constraints, financial issues, lack of transportation, and low literacy levels [12, 17–21]. For this population of workers the numerous and often insurmountable barriers make consistent, preventive health care unlikely. As a result, incidence rates for many cancers are underestimated and/or unknown. For most Latino migrant workers oral health care is virtually nonexistent [22]. Often, workers lack information regarding available oral health services and screening exams [23]. Health care barriers such as lack of knowledge and poor access to services are compounded by related time and financial constraints, cultural isolation, immigration status, and sometimes disease stigma, create overwhelming obstacles to maintaining even minimal oral health among immigrants [12, 31]. Most low income populations, including migrant farm workers, access health care through Medicaid. Nationally, 80 % of local health departments lack dental programs, 38 % of rural counties do not have a dentist, and 62 % of the rural counties lack dental hygienists [24]. A 2002 study of migrant worker oral health issues (n = 119) found that 42 % of participants received dental care only when they experienced pain, and 51 % reported no oral health care during the previous year [25]. Other studies confirm these findings [16, 26]; poor oral health outcomes are consistently linked with an overall lack of knowledge about dental care [21] and to lack of access to preventive care and restorative services [12, 22]. According to the Florida Department of Health each year 150,000 to 200,000 migrant and seasonal farm
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workers, sometimes with their families, travel and work in the state [9]. For these workers access to health care, especially oral health care is difficult. Chronic underfunding of Florida dental Medicaid programs has severely limited service availability and contributed to very low dental provider participation rates [9, 10]; statewide Medicaid dental providers number 790. The US Census Bureau uses the terms ‘‘Hispanic’’ and ‘‘Latino/a’’ in reference to persons of Hispanic origin [32]. The word ‘‘Hispanic’’ is a US federal designation used in national and state reporting systems, separate from the concept of race. The terms Latino/a are considered as selfdesignated terms of ethnicity. As a result, the majority of federal and state reports use the terms Hispanic/Latino/a interchangeably. The synonymous use of these terms should be assumed in the studies cited below [32]. Studies of cancer in Florida Hispanics have focused on issues such as screening for cervical cancer among female migrant workers [27], melanoma [28], and disparities suffered by Hispanic women in treatment for breast cancer [29]. Only a few studies have focused on OC in Hispanics [30, 31, 33]. However, the prevalence and incidence of OC in migrant farm workers, a group at higher risk to some forms of OC, is a neglected area of study. Risk factors for this group include high levels of prolonged and unprotected sun exposure, tobacco and alcohol use, poor oral health in general, and behavioral factors associated with a migratory lifestyle such as poor nutrition and exposure to the Human Papilloma Virus [34]. Significance of Research To our knowledge oral cancer incidence and prevalence, specifically that of Latino migrant farm workers, is unknown. The Florida Cancer Data System offers incidence and prevalence data for Hispanics; however, identifying cases by occupation is not possible. Expanding our understanding of migrant farm workers’ knowledge and attitudes regarding oral cancer is needed to develop tailored, culturally relevant and appropriate programs and materials designed to improve access to primary and secondary oral health care. Culturally and linguistically appropriate assessment tools are critical for gathering accurate information [35]. As such, the purpose of this study was to assess Latino migrant farm workers’ OC awareness, including knowledge and care-seeking behaviors.
Methods Prior to data collection this study received approval from the University of Florida and University of South Florida Institutional Review Boards.
J Immigrant Minority Health
Measures Survey Development The Health Belief Model (HBM) [36] frames this study. Constructs from the HBM were used to refine survey questions previously developed by authors TP and DS, and to develop additional items for assessing OC-related knowledge, awareness, and behavior. Findings from focus groups (N = 8 groups: 4 male and 4 female) with Latino migrant farm workers also informed item development, both content and cultural appropriateness. It should be noted that the original survey contained items assessing HPV-knowledge and risk factors. However, female focus group participants felt the items were inappropriate and discouraged inclusion of HPV-related questions on the survey. In respect for their advice, items relating to sexual behaviors and HPV transmission were omitted from the survey. Demographic questions included respondents’ age, gender, highest level of education, and country of origin. Once the survey revisions were complete, questions were formatted for consistency and clarity. The completed survey was then translated into Spanish and back-translated into English. Survey Validation Individual interviews (N = 10) were conducted with native Spanish speakers (similar to target audience members); feedback resulted in further survey revisions. The newly revised survey was reviewed by two different native Spanish speakers (one reviewer was a public school Spanish teacher); problematic phrases and grammatical errors were corrected. Finally, the survey was administered to five native Mexican restaurant workers (individually, on separate occasions) who were asked to suggest ways to improve survey readability and acceptability. No changes were suggested. The final 42-item questionnaire was then back-translated from Spanish to English to confirm accuracy.
workers during the workday was given by a large commercial grower; data collectors were invited by a local mission pastor to collect data during mission activities; and on two consecutive Saturday’s data was collected from community residents at the local market in Wimauma, Florida, a large migrant community near Tampa. Data collectors approached potential respondents and (in Spanish) offered the following information: (1) the purpose of the survey, emphasizing no connection of the research to any government agency; (2) participation in the study did not require them to give their names or any other identifying information; (3) they could refuse to answer any question; (4) they could withdraw at any time without penalty; (5) for participating they would receive a $10.00 gift card to Wal-Mart; and (6) the survey would take approximately 20 min to complete. Once the above information was provided and participant understanding confirmed, individuals were asked to provide verbal consent. Following verbal consent, participants’ were asked to confirm their age and migrant worker status. Following verbal consent to participate, bilingual data collectors verbally administered the 42-item survey to each individual participant. Participants were asked their preference for survey administration in either English or Spanish; the majority of participants responded in Spanish. Refusals to participate were not tracked; 134 usable surveys were completed. Data Analysis Statistical analyses were completed using IBM SPSS version 19 [37]. Frequencies and descriptive statistics were generated to report baseline data on perceived susceptibility and severity of OC, and to determine perceived health status, knowledge of OC risk factors, signs and symptoms, and OC risk/preventive behaviors. The Cronbach’s alpha (a = 0.78) indicated good internal consistency for the instrument.
Survey Administration, Participants/Data Collection
Results
Prior to data collection all survey administrators attended a 4 h workshop on data collection procedures. Workshop attendees received explicit procedural information, viewed a demonstration video of a mock survey administration, and rehearsed the approach script and survey administration procedures. During March and April (2010) data were collected at several time points and locations in Hillsborough County, Florida. The convenience sample was obtained through cooperative relationships with pastors, growers, and farm workers. Permission for data collectors to approach
The sample consisted of 53.7 % female respondents. Approximately 66 % of respondents self-identified as Mexican-born, while others were native to Colombia (0.7 %), Puerto Rico (5.2 %), Cuba (0.7 %), Guatemala (8.2 %), and other Central American countries (18.7 %). The mean age for respondents was 38.7 years for males (SD 14.0 years) and 39.2 years for females (SD 11.5 years). Eighty-three percent of participants had attended some school (grades 1 through 12); 45.5 % of the sample reporting attending grades 1 through 6; 6.7 % reported never attending school. See Table 1 for additional information.
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J Immigrant Minority Health Table 1 Summary statistics for demographic variables
Table 2 Summary of care-seeking behavior
Characteristic
Item
Frequency
Valid percent
Male
62
46.3
Excellent
10
7.5
Female
72
53.7
Very good
14
10.4
Gender
Age
Frequency
Valid percent
Perceived health status
(SD)
(Mean)
Good
33
24.6
Male
14.061
38.77
Normal
65
48.5
Female
11.54
39.26
Poor
9
6.7
Total
12.722
39.04
Don’t know
3
2.2
134
100.0
Never attended school
9
6.7
Grades 1–6
61
45.5
More than 12 times
Grades 7–9 Grades 10–12
29 21
21.6 15.7
7–9 times 3–6 times
Education level
Total Doctor visit without being sick
3
2.2
1 19
0.7 14.2
Some tech. or voc. school
0
0.0
1–2 times
37
27.6
Graduated tech. or voc.
2
1.5
Never
74
55.2
Some university classes
5
3.7
Total
134
100.0
Graduated from university
6
4.5
Other
1
0.7
More than 12 times
4
0.3
Total
134
100.0
10–12 times
2
1.5
7–9 times
5
3.7 15.7
Country of origin
Doctor visit while being sick
Colombia
1
0.7
3–6 times
21
Puerto Rico
7
5.2
1–2 times
51
38.1
Cuba
1
0.7
Never
51
38.1
Guatemala
11
8.2
Total
134
100.0
Mexico
88
65.7
Other
25
18.7
No
37
27.6
Total
134
100.0
Yes
97
72.4
Care-Seeking Behavior As supported by the literature, members of this population sought healthcare for acute conditions, but not preventive services. During the past year, approximately 38 % of respondents reported not going to the doctor, even when sick. Seventy-five percent of respondents reported knowing where to go for an oral cancer examination. However, this knowledge was not verified. When asked whether they would seek care for a sore in their mouth from a doctor or a dentist, 59.7 % of respondents indicated they would seek care from a doctor. See Table 2 for additional information. Barriers to Oral Cancer Screening Few respondents (2.1 %) cited barriers to oral cancer screening such as fear of pain, lack of trust, and/or lack of money. Interestingly, 94.8 % of respondents did not acknowledge barriers to oral cancer screening. Some respondents stated they would be willing to pay for oral cancer screenings if options to make ‘‘small payments here and there’’ or ‘‘monthly payments’’ were available. Many
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Do you know where to go for oral cancer treatment?
Total 134 100.0 Who would you visit if you had a sore in your mouth Doctor
80
59.7
Dentist
44
32.8
No one
6
4.5
Doctor and/or dentist
3
2.2
(–)
1
0.7
134
100.0
Total
respondents emphasized the need for oral cancer screenings in the evening, after work, since most felt sure the farmers would not allow unpaid time for preventive care. For this population, the barriers of time and money are strong and intertwined. Many respondents stressed that time away from the fields meant no money to pay for anything, including healthcare. The prevailing theme among this sample is the need to work every day for as many hours as possible. Issues of Trust/Mistrust Ninety-three percent of respondents indicated they would be willing to have an OC exam if a doctor told them it was
J Immigrant Minority Health Table 3 Attitudes of trust toward healthcare workers Healthcare worker
Frequency
Valid percent
Doctors Completely
60
44.8
Somewhat
56
41.8
Neutral
11
8.2
A little
4
3.0
Nothing
3
2.2
134
100.0
Completely
51
38.1
Somewhat
59
44.0
Neutral A little
11 10
8.2 7.5
Total Nurses
Nothing Total
3
2.2
134
100.0
Clerks Completely
49
36.6
Somewhat
55
41.0
Neutral
13
9.7
A little
10
7.5
Nothing
6
4.5
(–)
1
0.7
133
100.0
Total
necessary. However, willingness in a hypothetical example often differs from actual behavior in the face of multiple access barriers. Interestingly, respondents reported high levels of general trust in doctors (44 %), nurses (38.1 %), and clerks (36.6 %). Although specific reasons for mistrust were not included in the survey, respondents repeatedly mentioned fear of being discovered without legal documentation alongside issues of trust/mistrust. See Table 3 for additional information. Oral Cancer and Risk Factor Knowledge Overall, respondents lacked knowledge of OC and associated risk factors. Approximately 8 % of the sample believed that smoking does not increase one’s chances of developing OC; 9 % did not know if smoking was a risk factor for developing OC. Twenty-seven percent said alcohol does not increase one’s risk of cancer, while 21 % did not know. Approximately 32 % of respondents said drinking hot liquids increased one’s chances of developing OC. Twelve percent did not know that chewing tobacco was a risk factor for oral cancer, while 4.5 % responded that chewing tobacco did not increase OC risk. Approximately 64 % of respondents were aware that prolonged and unprotected sun exposure could increase the possibility of cancer; nearly 40 % of respondents either did
not know or were uncertain when asked if sun exposure was an OC risk factor (15.7 vs. 2 % respectively). Many respondents (53 %) knew that cancer risk was increased if family members had experienced cancer, and 54 % were aware of increasing cancer risk with age. See Table 4 for additional information. Despite a general lack of oral cancer knowledge, perceptions of cancer susceptibility and severity were present among participants. Nearly 40 % of participants believed they could someday get cancer; interestingly, 78.4 % of participants reported believing that they could someday develop oral cancer. Thirty-two percent of participants reported they would react badly to an oral cancer diagnosis. See Table 5 for additional information. Oral Cancer Screening Knowledge During the treatment-related questions, many participants gave highly affirmative responses for all questions mentioning a cure for cancer. For example, several items assessed participants’ beliefs about whether a special diet or prescription could cure cancer; more than 75 % provided a positive response. While most participants agreed that early detection of oral cancer is beneficial for individuals and their families, participants possessed limited knowledge of OC signs and symptoms. For this reason, findings indicating all but low levels of OC knowledge must be questioned. See Table 6 for additional information. Alcohol and Tobacco Use The majority of the respondents reported not using tobacco products. Nine percent of the sample admitted to smoking tobacco and 2.2 % reported some use of chewing tobacco/ snuff. Although more respondents admitted to drinking alcoholic beverages, 56 % of respondents reported abstaining from all alcoholic beverages. Twenty-three percent of respondents who drank alcohol reported doing so ‘‘only on special occasions.’’ The definition of ‘‘special occasion’’ was not explored. See Table 7 for additional information.
Discussion This study provides a brief description of the informational and health service needs required by the study population. Findings provide an opportunity to address oral health needs through development of culturally appropriate materials, including information to increase Latino migrant farm workers’ understanding of relevant oral health issues, available services and resources, and ways to access services within the constraints of their everyday lives. While
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J Immigrant Minority Health Table 4 Oral cancer risk factor knowledge Valid
Frequency
Table 4 continued Valid percent
Smoking Doesn’t increase Yes, increases
Valid
Frequency
Valid percent
Using drugs 10
7.5
111
82.8
Doesn’t increase
14
10.5
95 23
71.4 17.3
12
9.0
Yes, increases Don’t know
1
0.7
(–)
134
100.0
Doesn’t increase
36
26.9
Doesn’t increase
45
33.6
Yes, increases
68
50.7
Yes, increases
71
53.0
Don’t know
29
21.6
Don’t know
15
11.2
1 134
0.7 100.0
Doesn’t increase
65
48.5
Doesn’t increase
34
25.4
Yes, increases
29
21.6
Yes, increases
73
54.5
Don’t know
38
28.4
Don’t know
25
18.7
2
1.5
134
100.0
Don’t know (–) Total Drinking alcohol
(–) Total
Total
1
0.8
133
100.0
Having a family member with cancer
Eating spicy foods
(–)
Total
(–) Total
3
2.2
134
100.0
Being older than 40
Drinking hot liquid
(–)
2
1.5
Total 134 Kissing someone with oral cancer
100.0
Doesn’t increase
58
43.6
Doesn’t increase
62
46.3
Yes, increases
43
32.3
Yes, increases
39
29.1
Don’t know
31
23.3
Don’t know
30
22.4
1
0.8
133
100.0
6
4.6
107 16
82.3 12.3
1
0.8
130
100.0
Not a symptom
40
29.9
Doesn’t increase
23
17.4
Yes, sign or symptom
68
50.7
Yes, increases
87
82.3
Don’t know
21
12.3
Don’t know Total
26 134
19.4 100.0
1
0.8
132
100.0
Doesn’t increase
83
62.4
Yes, increases
13
9.8
Don’t know
34
25.6
3
2.3
133
100.0
(–) Total Chewing tobacco Doesn’t increase Yes, increases Don’t know (–) Total
Total Chewing gum
(–) Total Not brushing your teeth Doesn’t increase
23
17.3
Yes, increases
82
61.7
Don’t know
26
19.5
(–) Total
123
Total
3
2.2
134
100.0
Swelling or bump on the chin, throat or tongue
Tanning too much
(–)
(–)
2
1.5
133
100.0
Not a symptom
23
17.2
Yes, sign or symptom
85
63.4
Don’t know Total
26
19.4
134
100.0
Having difficulty chewing or swallowing
the farm workers in our sample reported sparse use of health care services, the provision of funds for community health centers and nurse managed health clinics, via the Patient Protection and Affordable Care Act may aid in increasing access to health care programs and services for undocumented immigrants such as migrant farm workers [38, 39]. The reliance of this population on medical provider’s direction is highlighted by 93 % of respondents who reported willingness to have an oral cancer screening if told to do so by a doctor. However, numerous barriers to oral health care access point to advantages inherent in routine physicianprovided screening for OC and unmet dental needs.
J Immigrant Minority Health Table 5 Perceived susceptibility and severity of oral cancer
Item
Frequency
Valid percent
Do you worry that one day you will get cancer in the mouth? No
29
Yes
105
21.6 78.4
Total
134
100.0
If someone told you that you have oral cancer, how would you take it? Calmly
36
Don’t know
26
19.4
Would worry/badly
29
21.6
Would worry a lot/very bad Total
Also of importance for this population is trust for their healthcare providers. While a majority of respondents said they trusted doctors, this was expressed as a general trust, not the specific trust of one provider. Migrant workers are unlikely to access care unless they can be certain their immigrant status will not be divulged. Despite a general lack of oral cancer knowledge, 40 % of participants believed they could develop cancer, including 78 % who reported perceptions of oral cancer susceptibility. Since knowledge of OC risk behaviors was low, their perceptions of OC susceptibility may result from their desire to provide socially desirable responses. When asked whether a special diet or prescription could cure cancer more than 75 % responded affirmatively. While this response may be attributed to lack of knowledge, it may also result from Latin American healers or Curandismos use of prayer, herbal medicines, healing rituals, diet, and massage to reduce pain and improve symptoms, including cancer-related symptoms. Interpretation of these findings must consider and respect the wide spread use of healers in the Latin American culture [40]. Culturally appropriate health education programs, recognizing existing barriers to oral health care, coupled with providers who are both culturally aware and sensitive, will contribute to program success. Currently, it is estimated that only 1 in 10 migrant farm workers is able to read and write in English, while 85 % of migrant farm workers report having trouble reading and writing in any language [20]. As such, program materials and outreach must be tailored to those with low or no literacy skills through the use of delivery mechanisms such as outreach workers, radio and video/DVD. Trained, culturally sensitive oral and medical healthcare providers, along with trained community health educators, are needed if oral health disparities are to be addressed [20]. Using the promotora model, community health educators can introduce preventive oral health care information to the Latino farm worker community, and dispel misperceptions surrounding oral health and oral health
26.9
43
32.1
134
100.0
care, including sensitive topics such as the HPV/OC association. Educational efforts aimed at increasing both awareness of oral cancer risk factors and the importance of oral cancer screenings are a first step in eliminating oral health disparities and associated quality of life issues resulting from oral disease.
New Contribution to the Literature In the US poor oral health affects large segments of the population resulting in suffering and quality of life issues. For many, oral health care access, even in the presence of severe pain, is not possible. The literature lacks studies focusing expressly on oral cancer incidence and prevalence in the growing Latino migrant farm worker population, likely due to the absence of culturally and linguistically appropriate assessment tools. The present study provides an initial OC assessment tool, developed with input from the target audience, to aid in gathering information on the oral health knowledge, attitudes, and behaviors of Latino migrant farm workers. Use of this instrument has produced base line data to guide future studies and aid program development. The current study points to a general lack of oral health knowledge among migrant farm workers, including misperceptions that impede access to care. Interactions with study participants revealed an eagerness for more information concerning preventive behaviors and OC risk factors, signs and symptoms. Along with increased service provision, health care providers cognizant of the barriers and non-monetary costs faced by migrant workers when accessing services are required. For example, offering oral cancer exams at no charge during the work week does not mean the exam is truly cost-free to those who access them. For the worker, a ‘‘free’’ exam requires time away from the field and lost wages, a cost that also affects the worker’s family. As a result, when free screenings are not widely attended, sparse attendance is attributed to the population’s ‘‘apathy’’ or
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J Immigrant Minority Health Table 6 Oral cancer sign and symptom knowledge Valid
Frequency
Table 7 Use of alcohol and tobacco products Valid percent
A sore in the mouth
Valid
Frequency
Valid percent
Smoking tobacco use
Not a symptom
32
23.9
Yes
12
9.0
Yes, sign or symptom
70
52.2
No
122
91.0
Total
143
100.0
Don’t know Total
32
23.9
134
100.0
47
35.1
A sore outside the mouth Not a symptom
Chewing tobacco use Yes No
Yes, sign or symptom
52
38.8
(–)
Don’t know
35
26.1
Total
134
100.0
Total
White or red stain on the lip that does not go way Not a symptom 22
1
0.7
131
97.8
2
1.5
132
100.0
1 11
0.7 8.2
Alcohol use
16.4
Everyday Many times a months
Yes, sign or symptom
83
61.9
A couple times a months
12
9.0
Don’t know
29
21.6
Only on special occasions
32
23.9
134
100.0
Never
75
56.0
3
2.2
Total
White or red stain on the mouth that does not go away Not a symptom
16
(–) 12.0
Yes, sign or symptom
87
65.4
Don’t know
29
21.8
(–) Total
1
0.8
133
100.0
Pain in mouth (not including teeth) Not a symptom
34
25.6
Yes, sign or symptom
71
53.4
Don’t know
28
21.1
133
100.0
Total
Sore in the mouth that bleeds easily and does not heal Not a symptom 15 11.2 Yes, sign or symptom
97
72.4
Don’t know
22
16.4
134
100.0
Total
medical providers to perform oral cancer screenings is necessary. Current findings contribute to the limited data describing oral health knowledge and access behaviors of Latino migrant farm workers. However, study limitations include the use of a small convenience sample recruited from one county. Findings cannot be generalized to the migrant community at large. Even so, this study provides relevant and critical information necessary for improved planning, implementation, and evaluation of oral cancer screening programs for this underserved and often invisible population.
Swelling or bump on the chin, throat or tongue Not a symptom
23
17.2
Yes, sign or symptom
85
63.4
Don’t know
26
19.4
134
100.0
Total
Having difficulty chewing or swallowing Not a symptom
40
29.9
Yes, sign or symptom
68
50.7
Don’t know Total
26
19.4
134
100.0
‘‘lack of interest.’’ Rarely are low participant numbers attributed to the planners’ lack of cultural sensitivity and poor understanding of the people they wish to help. Findings underscore the need for medical providers to routinely screen for oral conditions which may be contributing to systemic health issues, and oral cancer. For this, training
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Need for Future Studies Studies focusing on the oral health of migrant farm workers, especially relating to chronic disease, are absent from the literature. As such, the need for future studies is critical. Confirming the present findings in other geographic locales is a first step. Research in oral health program development, implementation, and efficacy is also needed. Out of respect for female focus group participant’s feelings, survey questions relating to HPV and high-risk sexual behaviors were omitted from our survey. However, the continued increase in HPV-related oral cancer in men indicates a critical need for future work in this area [41]. While identifying population-specific health care needs is important, the need for studies aimed at addressing the identified health care needs through improved and expanded access cannot be overemphasized.
J Immigrant Minority Health Acknowledgments Funding for this descriptive pilot project was provided by a Joint Cancer Center Funding Opportunity, an Advancing the Partnership (AP) Award designed to support collaborative research between institutions of higher education in the state of Florida.
References 1. Thomson P. Introduction. In: Thomson P, editor. Oral precancer: diagnosis and management of potentially malignant disorders. Newcastle: Wiley-Blackwell; 2012. p. 2–12. 2. ACS. Oral Cavity and Oropharyngeal Cancer. American Cancer Society; 2015: http://www.cancer.org/cancer/oralcavityandor opharyngealcancer/. 3. Dodd VJ, et al. Developing an oral pharyngeal cancer knowledge and attitude scale. AJHB. 2012;36(5):589–601. 4. NCI: Surveillance, Epidemiology, and End Results Program 1975–2010. National Cancer Institute 2014. http://seer.cancer. gov/csr/1975_2010/browse_csr.php. 5. Rethman M, et al. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. JADA. 2010;141(5):509–20. 6. ACS: Cancer Facts and Figures 2013. American Cancer Society 2013: http://www.cancer.org/research/cancerfactsfigures/cancer facts/figures/cancer-facts-figures-2013. 7. Silverman S Jr. Demographics and occurrence of oral and pharyngeal cancers: The outcomes, the trends, and the challenge. JADA. 2001;132(S1):7S–11S. 8. Howlander N, et al. SEER Cancer Statistics Review, 1975–2009. National Cancer Institute; 2013: http://seer.cancer.gov/csr/1975_ 2009_pops09/. 9. Riley JL III, et al. Psychosocial factors associated with mouth and throat cancer examinations in rural Florida. Am J Public Health. 2012;102(2):7–14. 10. Hernandez M, et al. Cancer in Florida Hispanics 1989–2006. Florida Cancer Data System 2010: http://fcds.med.miami.edu/ downloads/HispanicMonograph2010Hispanic%20Monograph_ 2010.pdf. 11. Gonzalez E, Jr. Migrant farm workers: our Nation’s Invisible Population. 2012: http://www.extension.org/pages/9960/migrantfarm-workers:-our-nations-invisible-population. 12. Carrion I, et al. Barriers impeding access to primary oral health care among farmworker families in Central Florida. Soc Work Health Care. 2011;50:828–44. 13. Bail K, et al. The impact of invisibility on the health of migrant farmworkers in the Southeastern United States: a case study from Georgia. Nurs Res Pract. 2012; 8. 14. Hernandez M, et al. Cancer in Florida Hispanics 1989–2006. 2010. http://fcds.med.miami.edu/downloads/HispanicMonograph 2010/Hispanic%20Monograph_2010.pdf. 15. Quandt S, et al. Oral health and quality of life of migrant and seasonal farmworkers in North Carolina. JASH. 2007;13(1): 45–55. 16. Poss J, Pierce R. Characteristics of selected migrant farmworkers in west Texas and southern New Mexico. Calif J Health Promot. 2003;1(2):9. 17. Cruz G, Salazar C, Morse C. Oral and pharyngeal cancer incidence and mortality among Hispanics, 1996–2002: the need for ethnoregional studies in cancer research. AJPH. 2006;96(12):9. 18. Jemal A, et al. Annual report to the nation on the status of cancer, 1975–2001, with a special feature regarding survival. Cancer. 2004;101:3–27.
19. Acury T, Quandt S. Delivery of health services to migrant and seasonal farmworkers. Annu Rev Public Health. 2007;28:345–63. 20. Clark P, Surry L, Contino K. Health care access for migrant farmworkers: a paradigm for better health. Internet J Health. 2008;8(2). https://ispub.com/IJH/8/2/6311. 21. Hansen E, Donohoe M. Health issues of migrant and seasonal farmworkers. J Health Care Poor Underserved. 2003;14(2): 153–64. 22. Gavaldon IR, Bagramian R, Inglehart M. Objective and subjective oral health and quality of life of migrant farm workers in the USA. Oral Health Dent Manag. 2010;9(2):79–87. 23. Kerr R, et al. An academic dental center grapples with oral cancer disparities: current collaboration and future opportunities. J Dent Educ. 2004;68(5):531–41. 24. Lombardi GR. Dental/oral health services. Migrant Health Issues, Monograph Series; 2002: 1–8. 25. Luke S, Simon B. Dental services for migrant and seasonal farmworkers in U.S. community/migrant health centers. J Dental Hygiene. 2002;76:134–40. 26. Villarejo D. The health of U.S. hired farmworkers. Annu Rev Public Health. 2003;24:175–93. 27. Luque J, et al. Increasing cervical cancer screening in a Hispanic migrant farmworker community through faith-based clinical outreach. J Low Genit Tract Dis. 2011;15(3):200–4. 28. Rouhani P, et al. Increasing rates of melanoma among nonwhites in Florida compared with the United States. Arch Dermatol. 2010;146(7):741–6. 29. Voti L, et al. The effect of race/ethnicity and insurance in the administration of standard therapy for local breast cancer in Florida. Breast Cancer Res Treat. 2006;95(1):89–95. 30. Tomar SL, Logan HL. Florida adults’ oral cancer knowledge and examination experiences. J Public Health Dent. 2005;65(4): 221–30. 31. Molina MA, et al. African American and poor patients have a dramatically worse prognosis for head and neck cancer an examination of 20,915 patients. Cancer. 2008;113(10):2797–806. 32. Hispanic Origin. United States Census Bureau; 2015: http:// quickfacts.census.gov/qfd/meta/long_RHI825213.htm. 33. Trapido EJ, et al. Cancer in south Florida Hispanic women. A 9-year assessment. Arch Intern Med. 1994;154(10):1083–8. 34. ACS: What are the risk factors for oral cavity and oropharyngeal cancers? American Cancer Society; 2014: http://www.cancer.org/ cancer/oralcavityandoropharyngealcancer/detailedguide/oral-cav ity-and-oropharyngeal-cancer-risk-factors. 35. Culturally Appropriate Measures. San Diego Prevention Research Center, nd: http://www.sdprc.net/evaluation/culturally-appropriatemeasures/. 36. Rosenstock I, Strecher V, Becker M. Social Learning Theory and the Health Belief Model. Health Educ Q. 1988;15(2):175–83. 37. IBM Corporation: Statistical Package for Social Sciences (SPSS) v. 19; 2011. 38. KFF: Focus on Health Care: Summary of the Affordable Care Act. Kaiser Family Foundation, Editor; 2013: http://kaiserfami lyfoundation.files.wordpress.com/2011/04/8061-021.pdf. 39. Bustamante A, et al. Variations in healthcare access and utilization among Mexican immigrants: the role of documentation status. J Immigr Minor Health. 2012;14:146–55. 40. ACS: Curanderismo. American Cancer Society; 2013: http:// www.cancer.org/treatment/treatmentsandsideeffects/complementar yandalternativemedicine/mindbodyandspirit/curanderismo. 41. HPV and Cancer. National Cancer Institute; 2015: http://www. cancer.gov/cancertopics/factsheet/risk/HPV.
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ORIGINAL PAPER
Assessing Oral Cancer Awareness Among Rural Latino Migrant Workers Virginia J. Dodd1
•
David P. Schenck2 • Elizabeth H. Chaney3 • Tapan Padhya2
Ó Springer Science+Business Media New York 2015
Abstract Latino migrant farm workers suffer significant health disparities, including poor oral health. The purpose of this research was to assess Latino migrant farm workers’ OC awareness, including knowledge and care-seeking behaviors. A 42-item survey was developed. Trained, bilingual researchers verbally administered the survey to migrant farm workers in Hillsborough County, Florida. Frequencies and descriptive statistics were generated to report baseline data. The sample consisted of 53.7 % female respondents. The mean age for males and females respectively was 38.7 and 39.2. Most respondents had attended grade school; 6.7 % never attended school. Perceptions of cancer susceptibility were present; knowledge of OC risk factors, signs and symptoms was low. Participants were unlikely to seek preventive care. The results contribute to the limited studies regarding Latino migrant farm workers and oral cancer risk factor awareness and knowledge. Findings highlight factors influencing motivation and care-seeking behaviors, as well as provide guidance for development of educational materials.
& Virginia J. Dodd [email protected] 1
Department of Community Dentistry and Behavioral Science, University of Florida, 1329 SW 13th Street, Suite 5187, Gainesville, FL 32608, USA
2
Department of Otolaryngology-Head and Neck Surgery, Moffitt Cancer Center and Research Institute, College of Medicine, University of South Florida, Tampa, FL, USA
3
Department of Health Education and Promotion, East Carolina University, Greenville, NC, USA
Keywords Latino migrant farm worker Oral health Oral cancer risk factors Oral health care access Delivery of oral health care
Introduction Oropharyngeal cancer (OPC) is a disease characterized by the presence of malignant cells in the tissues of the oropharynx, specifically the back one-third of the tongue, soft palate, side and back walls of the throat, and the tonsils [1, 2]. Oral cancer (OC) is cancer that originates in the mouth or oral cavity and affects the tongue, floor of the mouth, lining of the cheeks, gums, lips, or palate [1, 3]. It is important to note that both terms, OPC and OC, have been used interchangeably within the literature [3]. Cancer beginning in the mouth (OC) can often spread and involve tissues in the oropharynx (OPC) causing definitions to become cloudy and complicated. Screening procedures differ in that the OC exam is performed visually and the OPC exam involves use of various scopes to view the deeper structures of the throat [2]. Early detection of either cancer reduces an individual’s risk of death and disfigurement. In 2015, approximately 39,500 people are expected to be diagnosed with OPC and 7500 will die [2]. OPC is more than twice as common in men than women [2]. Currently, the 5-year relative survival rate for localized disease is nearly 83 %; for regional disease (spread to regional lymph nodes) the rate is 59.2 %; and the distant (metastatic) disease rate is 36 % [4]. Approximately one-third of OC cases are diagnosed early, while the cancer is localized, and treatment more likely to be successful [1]. Since OC is preceded by visible changes in the oral mucosa, goals for early detection and treatment are not unreasonable [5].
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However, most cases are detected at late stage, when treatment is complex, more costly (both monetarily and psychosocially), less effective, and significantly lowers one’s overall quality of life [5–10]. Contributing to diagnostic delays and the resulting negative outcomes are lack of OC awareness in the public, specifically of the signs, symptoms, and risk factors for oral cancer, coupled with an absence of early detection by health-care providers [1, 5]. According to the Health Resources and Services Administration (HRSA), approximately 4.2 million seasonal and migrant farm workers, primarily of Latino origin, reside in the United States. Migrant farm workers come from Central American countries such as Mexico, Guatemala, Honduras, and the Dominican Republic [11]. Each year the farm workers, sometimes with their families, come to the US to plant, cultivate, harvest, and package crops. Migrant farm workers in the United States receive marginal healthcare services, primarily due to access issues associated with their cultural isolation, geographic mobility, healthcare provider contact, most often limited to acute injury care or lingering illness, and sometimes murky immigration status [12–16]. Also present are barriers related to time constraints, financial issues, lack of transportation, and low literacy levels [12, 17–21]. For this population of workers the numerous and often insurmountable barriers make consistent, preventive health care unlikely. As a result, incidence rates for many cancers are underestimated and/or unknown. For most Latino migrant workers oral health care is virtually nonexistent [22]. Often, workers lack information regarding available oral health services and screening exams [23]. Health care barriers such as lack of knowledge and poor access to services are compounded by related time and financial constraints, cultural isolation, immigration status, and sometimes disease stigma, create overwhelming obstacles to maintaining even minimal oral health among immigrants [12, 31]. Most low income populations, including migrant farm workers, access health care through Medicaid. Nationally, 80 % of local health departments lack dental programs, 38 % of rural counties do not have a dentist, and 62 % of the rural counties lack dental hygienists [24]. A 2002 study of migrant worker oral health issues (n = 119) found that 42 % of participants received dental care only when they experienced pain, and 51 % reported no oral health care during the previous year [25]. Other studies confirm these findings [16, 26]; poor oral health outcomes are consistently linked with an overall lack of knowledge about dental care [21] and to lack of access to preventive care and restorative services [12, 22]. According to the Florida Department of Health each year 150,000 to 200,000 migrant and seasonal farm
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workers, sometimes with their families, travel and work in the state [9]. For these workers access to health care, especially oral health care is difficult. Chronic underfunding of Florida dental Medicaid programs has severely limited service availability and contributed to very low dental provider participation rates [9, 10]; statewide Medicaid dental providers number 790. The US Census Bureau uses the terms ‘‘Hispanic’’ and ‘‘Latino/a’’ in reference to persons of Hispanic origin [32]. The word ‘‘Hispanic’’ is a US federal designation used in national and state reporting systems, separate from the concept of race. The terms Latino/a are considered as selfdesignated terms of ethnicity. As a result, the majority of federal and state reports use the terms Hispanic/Latino/a interchangeably. The synonymous use of these terms should be assumed in the studies cited below [32]. Studies of cancer in Florida Hispanics have focused on issues such as screening for cervical cancer among female migrant workers [27], melanoma [28], and disparities suffered by Hispanic women in treatment for breast cancer [29]. Only a few studies have focused on OC in Hispanics [30, 31, 33]. However, the prevalence and incidence of OC in migrant farm workers, a group at higher risk to some forms of OC, is a neglected area of study. Risk factors for this group include high levels of prolonged and unprotected sun exposure, tobacco and alcohol use, poor oral health in general, and behavioral factors associated with a migratory lifestyle such as poor nutrition and exposure to the Human Papilloma Virus [34]. Significance of Research To our knowledge oral cancer incidence and prevalence, specifically that of Latino migrant farm workers, is unknown. The Florida Cancer Data System offers incidence and prevalence data for Hispanics; however, identifying cases by occupation is not possible. Expanding our understanding of migrant farm workers’ knowledge and attitudes regarding oral cancer is needed to develop tailored, culturally relevant and appropriate programs and materials designed to improve access to primary and secondary oral health care. Culturally and linguistically appropriate assessment tools are critical for gathering accurate information [35]. As such, the purpose of this study was to assess Latino migrant farm workers’ OC awareness, including knowledge and care-seeking behaviors.
Methods Prior to data collection this study received approval from the University of Florida and University of South Florida Institutional Review Boards.
J Immigrant Minority Health
Measures Survey Development The Health Belief Model (HBM) [36] frames this study. Constructs from the HBM were used to refine survey questions previously developed by authors TP and DS, and to develop additional items for assessing OC-related knowledge, awareness, and behavior. Findings from focus groups (N = 8 groups: 4 male and 4 female) with Latino migrant farm workers also informed item development, both content and cultural appropriateness. It should be noted that the original survey contained items assessing HPV-knowledge and risk factors. However, female focus group participants felt the items were inappropriate and discouraged inclusion of HPV-related questions on the survey. In respect for their advice, items relating to sexual behaviors and HPV transmission were omitted from the survey. Demographic questions included respondents’ age, gender, highest level of education, and country of origin. Once the survey revisions were complete, questions were formatted for consistency and clarity. The completed survey was then translated into Spanish and back-translated into English. Survey Validation Individual interviews (N = 10) were conducted with native Spanish speakers (similar to target audience members); feedback resulted in further survey revisions. The newly revised survey was reviewed by two different native Spanish speakers (one reviewer was a public school Spanish teacher); problematic phrases and grammatical errors were corrected. Finally, the survey was administered to five native Mexican restaurant workers (individually, on separate occasions) who were asked to suggest ways to improve survey readability and acceptability. No changes were suggested. The final 42-item questionnaire was then back-translated from Spanish to English to confirm accuracy.
workers during the workday was given by a large commercial grower; data collectors were invited by a local mission pastor to collect data during mission activities; and on two consecutive Saturday’s data was collected from community residents at the local market in Wimauma, Florida, a large migrant community near Tampa. Data collectors approached potential respondents and (in Spanish) offered the following information: (1) the purpose of the survey, emphasizing no connection of the research to any government agency; (2) participation in the study did not require them to give their names or any other identifying information; (3) they could refuse to answer any question; (4) they could withdraw at any time without penalty; (5) for participating they would receive a $10.00 gift card to Wal-Mart; and (6) the survey would take approximately 20 min to complete. Once the above information was provided and participant understanding confirmed, individuals were asked to provide verbal consent. Following verbal consent, participants’ were asked to confirm their age and migrant worker status. Following verbal consent to participate, bilingual data collectors verbally administered the 42-item survey to each individual participant. Participants were asked their preference for survey administration in either English or Spanish; the majority of participants responded in Spanish. Refusals to participate were not tracked; 134 usable surveys were completed. Data Analysis Statistical analyses were completed using IBM SPSS version 19 [37]. Frequencies and descriptive statistics were generated to report baseline data on perceived susceptibility and severity of OC, and to determine perceived health status, knowledge of OC risk factors, signs and symptoms, and OC risk/preventive behaviors. The Cronbach’s alpha (a = 0.78) indicated good internal consistency for the instrument.
Survey Administration, Participants/Data Collection
Results
Prior to data collection all survey administrators attended a 4 h workshop on data collection procedures. Workshop attendees received explicit procedural information, viewed a demonstration video of a mock survey administration, and rehearsed the approach script and survey administration procedures. During March and April (2010) data were collected at several time points and locations in Hillsborough County, Florida. The convenience sample was obtained through cooperative relationships with pastors, growers, and farm workers. Permission for data collectors to approach
The sample consisted of 53.7 % female respondents. Approximately 66 % of respondents self-identified as Mexican-born, while others were native to Colombia (0.7 %), Puerto Rico (5.2 %), Cuba (0.7 %), Guatemala (8.2 %), and other Central American countries (18.7 %). The mean age for respondents was 38.7 years for males (SD 14.0 years) and 39.2 years for females (SD 11.5 years). Eighty-three percent of participants had attended some school (grades 1 through 12); 45.5 % of the sample reporting attending grades 1 through 6; 6.7 % reported never attending school. See Table 1 for additional information.
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J Immigrant Minority Health Table 1 Summary statistics for demographic variables
Table 2 Summary of care-seeking behavior
Characteristic
Item
Frequency
Valid percent
Male
62
46.3
Excellent
10
7.5
Female
72
53.7
Very good
14
10.4
Gender
Age
Frequency
Valid percent
Perceived health status
(SD)
(Mean)
Good
33
24.6
Male
14.061
38.77
Normal
65
48.5
Female
11.54
39.26
Poor
9
6.7
Total
12.722
39.04
Don’t know
3
2.2
134
100.0
Never attended school
9
6.7
Grades 1–6
61
45.5
More than 12 times
Grades 7–9 Grades 10–12
29 21
21.6 15.7
7–9 times 3–6 times
Education level
Total Doctor visit without being sick
3
2.2
1 19
0.7 14.2
Some tech. or voc. school
0
0.0
1–2 times
37
27.6
Graduated tech. or voc.
2
1.5
Never
74
55.2
Some university classes
5
3.7
Total
134
100.0
Graduated from university
6
4.5
Other
1
0.7
More than 12 times
4
0.3
Total
134
100.0
10–12 times
2
1.5
7–9 times
5
3.7 15.7
Country of origin
Doctor visit while being sick
Colombia
1
0.7
3–6 times
21
Puerto Rico
7
5.2
1–2 times
51
38.1
Cuba
1
0.7
Never
51
38.1
Guatemala
11
8.2
Total
134
100.0
Mexico
88
65.7
Other
25
18.7
No
37
27.6
Total
134
100.0
Yes
97
72.4
Care-Seeking Behavior As supported by the literature, members of this population sought healthcare for acute conditions, but not preventive services. During the past year, approximately 38 % of respondents reported not going to the doctor, even when sick. Seventy-five percent of respondents reported knowing where to go for an oral cancer examination. However, this knowledge was not verified. When asked whether they would seek care for a sore in their mouth from a doctor or a dentist, 59.7 % of respondents indicated they would seek care from a doctor. See Table 2 for additional information. Barriers to Oral Cancer Screening Few respondents (2.1 %) cited barriers to oral cancer screening such as fear of pain, lack of trust, and/or lack of money. Interestingly, 94.8 % of respondents did not acknowledge barriers to oral cancer screening. Some respondents stated they would be willing to pay for oral cancer screenings if options to make ‘‘small payments here and there’’ or ‘‘monthly payments’’ were available. Many
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Do you know where to go for oral cancer treatment?
Total 134 100.0 Who would you visit if you had a sore in your mouth Doctor
80
59.7
Dentist
44
32.8
No one
6
4.5
Doctor and/or dentist
3
2.2
(–)
1
0.7
134
100.0
Total
respondents emphasized the need for oral cancer screenings in the evening, after work, since most felt sure the farmers would not allow unpaid time for preventive care. For this population, the barriers of time and money are strong and intertwined. Many respondents stressed that time away from the fields meant no money to pay for anything, including healthcare. The prevailing theme among this sample is the need to work every day for as many hours as possible. Issues of Trust/Mistrust Ninety-three percent of respondents indicated they would be willing to have an OC exam if a doctor told them it was
J Immigrant Minority Health Table 3 Attitudes of trust toward healthcare workers Healthcare worker
Frequency
Valid percent
Doctors Completely
60
44.8
Somewhat
56
41.8
Neutral
11
8.2
A little
4
3.0
Nothing
3
2.2
134
100.0
Completely
51
38.1
Somewhat
59
44.0
Neutral A little
11 10
8.2 7.5
Total Nurses
Nothing Total
3
2.2
134
100.0
Clerks Completely
49
36.6
Somewhat
55
41.0
Neutral
13
9.7
A little
10
7.5
Nothing
6
4.5
(–)
1
0.7
133
100.0
Total
necessary. However, willingness in a hypothetical example often differs from actual behavior in the face of multiple access barriers. Interestingly, respondents reported high levels of general trust in doctors (44 %), nurses (38.1 %), and clerks (36.6 %). Although specific reasons for mistrust were not included in the survey, respondents repeatedly mentioned fear of being discovered without legal documentation alongside issues of trust/mistrust. See Table 3 for additional information. Oral Cancer and Risk Factor Knowledge Overall, respondents lacked knowledge of OC and associated risk factors. Approximately 8 % of the sample believed that smoking does not increase one’s chances of developing OC; 9 % did not know if smoking was a risk factor for developing OC. Twenty-seven percent said alcohol does not increase one’s risk of cancer, while 21 % did not know. Approximately 32 % of respondents said drinking hot liquids increased one’s chances of developing OC. Twelve percent did not know that chewing tobacco was a risk factor for oral cancer, while 4.5 % responded that chewing tobacco did not increase OC risk. Approximately 64 % of respondents were aware that prolonged and unprotected sun exposure could increase the possibility of cancer; nearly 40 % of respondents either did
not know or were uncertain when asked if sun exposure was an OC risk factor (15.7 vs. 2 % respectively). Many respondents (53 %) knew that cancer risk was increased if family members had experienced cancer, and 54 % were aware of increasing cancer risk with age. See Table 4 for additional information. Despite a general lack of oral cancer knowledge, perceptions of cancer susceptibility and severity were present among participants. Nearly 40 % of participants believed they could someday get cancer; interestingly, 78.4 % of participants reported believing that they could someday develop oral cancer. Thirty-two percent of participants reported they would react badly to an oral cancer diagnosis. See Table 5 for additional information. Oral Cancer Screening Knowledge During the treatment-related questions, many participants gave highly affirmative responses for all questions mentioning a cure for cancer. For example, several items assessed participants’ beliefs about whether a special diet or prescription could cure cancer; more than 75 % provided a positive response. While most participants agreed that early detection of oral cancer is beneficial for individuals and their families, participants possessed limited knowledge of OC signs and symptoms. For this reason, findings indicating all but low levels of OC knowledge must be questioned. See Table 6 for additional information. Alcohol and Tobacco Use The majority of the respondents reported not using tobacco products. Nine percent of the sample admitted to smoking tobacco and 2.2 % reported some use of chewing tobacco/ snuff. Although more respondents admitted to drinking alcoholic beverages, 56 % of respondents reported abstaining from all alcoholic beverages. Twenty-three percent of respondents who drank alcohol reported doing so ‘‘only on special occasions.’’ The definition of ‘‘special occasion’’ was not explored. See Table 7 for additional information.
Discussion This study provides a brief description of the informational and health service needs required by the study population. Findings provide an opportunity to address oral health needs through development of culturally appropriate materials, including information to increase Latino migrant farm workers’ understanding of relevant oral health issues, available services and resources, and ways to access services within the constraints of their everyday lives. While
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J Immigrant Minority Health Table 4 Oral cancer risk factor knowledge Valid
Frequency
Table 4 continued Valid percent
Smoking Doesn’t increase Yes, increases
Valid
Frequency
Valid percent
Using drugs 10
7.5
111
82.8
Doesn’t increase
14
10.5
95 23
71.4 17.3
12
9.0
Yes, increases Don’t know
1
0.7
(–)
134
100.0
Doesn’t increase
36
26.9
Doesn’t increase
45
33.6
Yes, increases
68
50.7
Yes, increases
71
53.0
Don’t know
29
21.6
Don’t know
15
11.2
1 134
0.7 100.0
Doesn’t increase
65
48.5
Doesn’t increase
34
25.4
Yes, increases
29
21.6
Yes, increases
73
54.5
Don’t know
38
28.4
Don’t know
25
18.7
2
1.5
134
100.0
Don’t know (–) Total Drinking alcohol
(–) Total
Total
1
0.8
133
100.0
Having a family member with cancer
Eating spicy foods
(–)
Total
(–) Total
3
2.2
134
100.0
Being older than 40
Drinking hot liquid
(–)
2
1.5
Total 134 Kissing someone with oral cancer
100.0
Doesn’t increase
58
43.6
Doesn’t increase
62
46.3
Yes, increases
43
32.3
Yes, increases
39
29.1
Don’t know
31
23.3
Don’t know
30
22.4
1
0.8
133
100.0
6
4.6
107 16
82.3 12.3
1
0.8
130
100.0
Not a symptom
40
29.9
Doesn’t increase
23
17.4
Yes, sign or symptom
68
50.7
Yes, increases
87
82.3
Don’t know
21
12.3
Don’t know Total
26 134
19.4 100.0
1
0.8
132
100.0
Doesn’t increase
83
62.4
Yes, increases
13
9.8
Don’t know
34
25.6
3
2.3
133
100.0
(–) Total Chewing tobacco Doesn’t increase Yes, increases Don’t know (–) Total
Total Chewing gum
(–) Total Not brushing your teeth Doesn’t increase
23
17.3
Yes, increases
82
61.7
Don’t know
26
19.5
(–) Total
123
Total
3
2.2
134
100.0
Swelling or bump on the chin, throat or tongue
Tanning too much
(–)
(–)
2
1.5
133
100.0
Not a symptom
23
17.2
Yes, sign or symptom
85
63.4
Don’t know Total
26
19.4
134
100.0
Having difficulty chewing or swallowing
the farm workers in our sample reported sparse use of health care services, the provision of funds for community health centers and nurse managed health clinics, via the Patient Protection and Affordable Care Act may aid in increasing access to health care programs and services for undocumented immigrants such as migrant farm workers [38, 39]. The reliance of this population on medical provider’s direction is highlighted by 93 % of respondents who reported willingness to have an oral cancer screening if told to do so by a doctor. However, numerous barriers to oral health care access point to advantages inherent in routine physicianprovided screening for OC and unmet dental needs.
J Immigrant Minority Health Table 5 Perceived susceptibility and severity of oral cancer
Item
Frequency
Valid percent
Do you worry that one day you will get cancer in the mouth? No
29
Yes
105
21.6 78.4
Total
134
100.0
If someone told you that you have oral cancer, how would you take it? Calmly
36
Don’t know
26
19.4
Would worry/badly
29
21.6
Would worry a lot/very bad Total
Also of importance for this population is trust for their healthcare providers. While a majority of respondents said they trusted doctors, this was expressed as a general trust, not the specific trust of one provider. Migrant workers are unlikely to access care unless they can be certain their immigrant status will not be divulged. Despite a general lack of oral cancer knowledge, 40 % of participants believed they could develop cancer, including 78 % who reported perceptions of oral cancer susceptibility. Since knowledge of OC risk behaviors was low, their perceptions of OC susceptibility may result from their desire to provide socially desirable responses. When asked whether a special diet or prescription could cure cancer more than 75 % responded affirmatively. While this response may be attributed to lack of knowledge, it may also result from Latin American healers or Curandismos use of prayer, herbal medicines, healing rituals, diet, and massage to reduce pain and improve symptoms, including cancer-related symptoms. Interpretation of these findings must consider and respect the wide spread use of healers in the Latin American culture [40]. Culturally appropriate health education programs, recognizing existing barriers to oral health care, coupled with providers who are both culturally aware and sensitive, will contribute to program success. Currently, it is estimated that only 1 in 10 migrant farm workers is able to read and write in English, while 85 % of migrant farm workers report having trouble reading and writing in any language [20]. As such, program materials and outreach must be tailored to those with low or no literacy skills through the use of delivery mechanisms such as outreach workers, radio and video/DVD. Trained, culturally sensitive oral and medical healthcare providers, along with trained community health educators, are needed if oral health disparities are to be addressed [20]. Using the promotora model, community health educators can introduce preventive oral health care information to the Latino farm worker community, and dispel misperceptions surrounding oral health and oral health
26.9
43
32.1
134
100.0
care, including sensitive topics such as the HPV/OC association. Educational efforts aimed at increasing both awareness of oral cancer risk factors and the importance of oral cancer screenings are a first step in eliminating oral health disparities and associated quality of life issues resulting from oral disease.
New Contribution to the Literature In the US poor oral health affects large segments of the population resulting in suffering and quality of life issues. For many, oral health care access, even in the presence of severe pain, is not possible. The literature lacks studies focusing expressly on oral cancer incidence and prevalence in the growing Latino migrant farm worker population, likely due to the absence of culturally and linguistically appropriate assessment tools. The present study provides an initial OC assessment tool, developed with input from the target audience, to aid in gathering information on the oral health knowledge, attitudes, and behaviors of Latino migrant farm workers. Use of this instrument has produced base line data to guide future studies and aid program development. The current study points to a general lack of oral health knowledge among migrant farm workers, including misperceptions that impede access to care. Interactions with study participants revealed an eagerness for more information concerning preventive behaviors and OC risk factors, signs and symptoms. Along with increased service provision, health care providers cognizant of the barriers and non-monetary costs faced by migrant workers when accessing services are required. For example, offering oral cancer exams at no charge during the work week does not mean the exam is truly cost-free to those who access them. For the worker, a ‘‘free’’ exam requires time away from the field and lost wages, a cost that also affects the worker’s family. As a result, when free screenings are not widely attended, sparse attendance is attributed to the population’s ‘‘apathy’’ or
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J Immigrant Minority Health Table 6 Oral cancer sign and symptom knowledge Valid
Frequency
Table 7 Use of alcohol and tobacco products Valid percent
A sore in the mouth
Valid
Frequency
Valid percent
Smoking tobacco use
Not a symptom
32
23.9
Yes
12
9.0
Yes, sign or symptom
70
52.2
No
122
91.0
Total
143
100.0
Don’t know Total
32
23.9
134
100.0
47
35.1
A sore outside the mouth Not a symptom
Chewing tobacco use Yes No
Yes, sign or symptom
52
38.8
(–)
Don’t know
35
26.1
Total
134
100.0
Total
White or red stain on the lip that does not go way Not a symptom 22
1
0.7
131
97.8
2
1.5
132
100.0
1 11
0.7 8.2
Alcohol use
16.4
Everyday Many times a months
Yes, sign or symptom
83
61.9
A couple times a months
12
9.0
Don’t know
29
21.6
Only on special occasions
32
23.9
134
100.0
Never
75
56.0
3
2.2
Total
White or red stain on the mouth that does not go away Not a symptom
16
(–) 12.0
Yes, sign or symptom
87
65.4
Don’t know
29
21.8
(–) Total
1
0.8
133
100.0
Pain in mouth (not including teeth) Not a symptom
34
25.6
Yes, sign or symptom
71
53.4
Don’t know
28
21.1
133
100.0
Total
Sore in the mouth that bleeds easily and does not heal Not a symptom 15 11.2 Yes, sign or symptom
97
72.4
Don’t know
22
16.4
134
100.0
Total
medical providers to perform oral cancer screenings is necessary. Current findings contribute to the limited data describing oral health knowledge and access behaviors of Latino migrant farm workers. However, study limitations include the use of a small convenience sample recruited from one county. Findings cannot be generalized to the migrant community at large. Even so, this study provides relevant and critical information necessary for improved planning, implementation, and evaluation of oral cancer screening programs for this underserved and often invisible population.
Swelling or bump on the chin, throat or tongue Not a symptom
23
17.2
Yes, sign or symptom
85
63.4
Don’t know
26
19.4
134
100.0
Total
Having difficulty chewing or swallowing Not a symptom
40
29.9
Yes, sign or symptom
68
50.7
Don’t know Total
26
19.4
134
100.0
‘‘lack of interest.’’ Rarely are low participant numbers attributed to the planners’ lack of cultural sensitivity and poor understanding of the people they wish to help. Findings underscore the need for medical providers to routinely screen for oral conditions which may be contributing to systemic health issues, and oral cancer. For this, training
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Need for Future Studies Studies focusing on the oral health of migrant farm workers, especially relating to chronic disease, are absent from the literature. As such, the need for future studies is critical. Confirming the present findings in other geographic locales is a first step. Research in oral health program development, implementation, and efficacy is also needed. Out of respect for female focus group participant’s feelings, survey questions relating to HPV and high-risk sexual behaviors were omitted from our survey. However, the continued increase in HPV-related oral cancer in men indicates a critical need for future work in this area [41]. While identifying population-specific health care needs is important, the need for studies aimed at addressing the identified health care needs through improved and expanded access cannot be overemphasized.
J Immigrant Minority Health Acknowledgments Funding for this descriptive pilot project was provided by a Joint Cancer Center Funding Opportunity, an Advancing the Partnership (AP) Award designed to support collaborative research between institutions of higher education in the state of Florida.
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