Women's Health Issues 24-3 (2014) e327–e333
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Original article
Knowledge and Perceptions of Breast Health Among Free Clinic Patients Akiko Kamimura, PhD, MSW, MA a,*, Nancy Christensen b, Wenjing Mo, MS a, Jeanie Ashby, MA b, Justine J. Reel, PhD, LPC, CC-AASP c a b c
Department of Sociology, University of Utah, Salt Lake City, Utah Maliheh Free Clinic, Salt Lake City, Utah Department of Health Promotion and Education, University of Utah, Salt Lake City, Utah
Article history: Received 11 August 2013; Received in revised form 4 February 2014; Accepted 5 February 2014
a b s t r a c t Background: Breast cancer is a significant women’s health problem in the United States. However, critical information on specific populations is still lacking. In particular, it is not well known how free clinic patients perceive breast health. The purpose of this study was to assess knowledge and perceptions of breast health among uninsured women utilizing a free clinic that serves as a safety net for the underserved. Methods: A self-administrated survey that included knowledge and perceptions of breast health was conducted for female free clinic patients aged 40 or older in fall 2012. There were 146 participants. The participants were classified into three groups for comparison; U.S. citizen English speakers, non-U.S. citizen English speakers, and Spanish speakers. Results: Spanish speakers had the highest average score on the knowledge of breast health, whereas the non-U.S. citizen English speakers had the lowest average score. Free clinic patients may consider breast health screening if recommended by health care providers. The non-U.S. citizen English speakers and Spanish speakers were more likely to have negative perceptions of breast health compared with the U.S. citizen English speakers. Conclusions: Promoting knowledge about breast health is important for free clinics. Recommendation by a health care provider is a key to increasing attendance at health education programs and breast health screening. Non-U.S. citizens and non-English speakers would need culturally competent interventions. Free clinics have limited human and financial resources. Such characteristics of free clinics should be considered for practice implementations. Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
Breast cancer is a significant women’s health problem in the United States. In 2001, breast cancer was the second leading cause of cancer deaths among women followed by lung cancer (American Cancer Society, 2011). Early diagnosis is important to increase 5-year relative survival rates from breast cancer (American Cancer Society, 2011). Although screening mammography is associated with lower death rates from breast cancer, many women do not obtain the recommended periodical screening (Zoorob, Anderson, Cafalu, & Sidani, 2001). The risk factors related to lower screening mammography include minority status, low income, low education level, and no insurance
Funding: This work was supported by the Utah Cancer Action Network and the College of Social & Behavioral Science, University of Utah. * Correspondence to: Akiko Kamimura, PhD, MSW, MA, Department of Sociology, University of Utah, Salt Lake City, 380 S 1530 E, Utah 84112, USA. Phone: þ1 801 581 7858; fax: þ1 801 585 3784. E-mail address: [email protected] (A. Kamimura).
(Aldridge, Daniels, & Jukie, 2006; Wells & Roetzheim, 2007). Cultural beliefs and knowledge about breast health also affect compliance with screening recommendations (Kiger, 2003; Schettino, Hernandez-Valero, Moguel, Hajek, & Jones, 2006; Fernandez, Palmer, & Leong-Wu, 2005). Although previous research has increased our understanding of perceptions and knowledge about breast health among women in general (Pavic et al., 2007; Wampler, Ryschon, Manson, & Buchwald, 2006), critical information on specific populations is still lacking. In particular, it is not well known how free clinic patients perceive breast health. Free clinics serve as safety nets for uninsured individuals who lack access to primary care services (Gertz, Frank, & Blixen, 2011; Nadkarni & Philbrick, 2005). Since the first free clinic was opened in 1967, the number of free clinics in the United States has increased to approximately 1,200 (Schiller, Thurston, Khan, & Fetters, 2013). Previous studies addressed health problems among free clinic patients. For example, free clinic patients
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reported lower physical and mental health functioning compared with the U.S. general population, being moderately depressed (Kamimura, Christensen, Tabler, Ashby, & Olson, 2013), and high prevalence of smoking and obesity (Notaro et al., 2012). There is still a paucity of research studies to determine the needs and unique characteristics of free clinics and their patients (Johnson, 2010). More than half of free clinic patients are women (Gertz et al., 2011; Darnell, 2010; Nadkarni & Philbrick, 2005; Notaro et al., 2012). Yet there are few studies that focused on women’s health at free clinics. Breast health knowledge and perception is one of the areas where information is lacking about free clinic patients. Free clinics usually rely on volunteer staff and have unstable financial resources (Nadkarni & Philbrick, 2003, 2005). It would be challenging for most free clinics to provide breast health screening and education to their patients. We were particularly interested in a free clinic that provides services to the uninsured only and to immigrants who often do not have access to primary health care. The purpose of this study was to assess the knowledge and perceptions related to breast health among uninsured women utilizing a free clinic. Knowledge and perceptions of breast health are important owing to the influence on an individual’s health behavior and health literacy (Hadi, Hassali, Shafie, & Awaisu, 2010; Pavic et al., 2007; Wampler et al., 2006). This study contributes to increasing the understanding of free clinic patients and their knowledge and perceptions of breast health. Methods Study Population Before data collection, the university’s institutional review board reviewed the protocol for this study, and determined that it was exempt from institutional review board oversight. This study was a community-based research project in collaboration with a free clinic in a state in the Intermountain West. The clinic staff members were involved in designing the study, developing the survey instrument, the study protocol, and recruitment strategies, interpreting the study results, and preparing for a manuscript. The clinic where this study was conducted provides free health care services, mostly routine health maintenance and preventative care, to patients who do not have health insurance and are not eligible for Medicare or Medicaid. In addition, patients must have a household income below the 150th percentile to be eligible to receive services at the clinic. Slightly more than half of the clinic patients are women. Approximately half of the clinic patients are Hispanic. Clinic patients are not required to provide information on residency status to receive care. The clinic is open 5 days a week and serves approximately 65 patients a day. Six full-time paid staff and about 250 active volunteers support the clinic, which is funded by grants and donations, but not by governmental sources. Some of the health care providers speak Spanish or another foreign language. The clinic provides interpreter services in a wide variety of languages. The clinic is interested in increasing awareness of breast health among its patients. This study was not tied with any specific local or national health promotion events. There was no recent or current intervention or program in the clinic with respect to breast health, breast cancer screening, or breast cancer around the time of the data collection. The providers did not
specifically provide breast health education. The clinic did not have any breast health programs, but handed a flyer about breast health to relevant patients. The flyer was available in English and Spanish and included the information about self-breast examinations, risks, and mammogram. Study samples were women who were 40 years or older, and spoke and read English or Spanish. All survey materials, including a consent cover letter, a flyer, and a survey instrument, were available in English and Spanish. Some of patients’ native language is not English or Spanish, but most of them speak English. Non-native English speakers who did not speak Spanish participated in the survey only if they spoke and read English. A native English speaker, who is Hispanic and fluent in Spanish, translated English materials that did not have existing Spanish translations from English into Spanish. A separate, bilingual individual conducted back-translation. The investigators then checked the reconciliation. Data were collected in the fall of 2012 at a free clinic. The study team members were at the clinic several times a week (two to three times a week) during the study period. The time blocks were not necessarily the same every week. Potential participants were informed about the study in the waiting room by a study team member. If a potential participant expressed interest, they received a consent cover letter and a self-administered paper survey in their preferred language, English or Spanish. Study team members and a Spanish interpreter were available to answer any questions while participants were taking the survey. A pilot study to test the procedure of a self-administrated survey was conducted at the clinic earlier in the same year (2012) using general health questions. Although the clinic staff were involved in the study from beginning to completion, they did not conduct actual data collection. The clinic staff oversaw the data collection team, and did not interact with participants directly for the survey. Potential participants were not asked to register for this study. The data collection team members were students or investigators of the university, and did not know or gather participants’ names. Measures of Knowledge and Perceptions About Breast Health To the best of our knowledge, there is no measure in any aspects that are validated for this particular population. Measures were selected based on the clinic’s concern and interest in understanding more about the knowledge and perceptions of breast health among its female patient population. Knowledge of breast health was measured using the Health Knowledge and Perception Questionnaire developed by Pavic and associates (2007). The questionnaire consists of seven multiple choice or true/false questions. The sample questions include: “Who has a greater chance of getting breast cancer? A women who is: a) 40 years old, b) 60 years old, c) 70 years old.” The range of total scores is from 0 to 7 (1 point for each correct answer). For the first three questions, a half point was given for neighboring answers to the correct ones. For perceptions and beliefs about breast health, there were 12 questions using a 5-point Likert scale (1 ¼ strongly disagree to 5 ¼ strongly agree) to ask their perceptions and beliefs about breast health. The first question asked whether a participant would get a mammogram 1) if a health care provider recommended it, and 2) if a female technician did it. The next five questions were from the set of questions on perceptions toward management and treatment outcomes of breast cancer developed by Hadi, Hassali, Shafie, & Awaisu (2010). The last five
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questions related to beliefs about breast cancer were developed by Wampler and colleagues (2006) from the National Behavioral Risk Factor Surveillance System.
Results
Measures of Demographic Characteristics
There were 146 participants in the study. Table 1 presents the sociodemographic characteristics of the participants. The 146 participants were divided into three groups for further analysis: U.S. citizen English speakers (n ¼ 78), non-U.S. citizen English speakers (n ¼ 32), and Spanish speakers (n ¼ 36, 5 U.S. citizens and 31 non-U.S. citizens). Among five U.S. citizen Spanish speakers, only one of them was originally from the United States. The average age of the participants was 51.85 (SD ¼ 8.9). The self-reported race/ethnicity included non-Hispanic White (39%), Hispanic (34.9%), Asian or Pacific Islander (16.4%), African or African American (6.8%), and Native American or Alaska Native (1.4%). About 65% of the U.S. citizen English speakers were non-Hispanic White. Most non-U.S. citizen English speakers were Hispanic (46.9%) or Asian or Pacific Islander (43.8%). Most Spanish speakers were Hispanic (86.1%). Approximately 43% of the participants had some college or higher education, whereas one quarter of them had less than a high school education. About 43% of the participants reported full- or part-time employment at the time of the survey. About 57% of the participants were married. Nearly half of the participants (45.9%) had received mammogram screenings within the past year. The percentage of the participants who had a mammogram in the past year was significantly different among the three groups. The U.S. citizen English speakers had the lowest percentage (34.6%) of mammograms within the last year compared with the non-U.S. citizen English speakers (56.3%) and Spanish speakers (61.1%). Approximately 80% of the participants reported having a mammogram in the past. About 32% of the participants reported they had a family history of breast cancer. There was no difference among
In addition to knowledge and perceptions about breast health, participants were asked about demographic information, whether they had a mammogram in the past year or ever, and breast cancer family history. Data Analysis Statistical analyses were performed using statistical software SPSS (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY). Descriptive statistics were used to describe the distribution of the outcome and independent variables. The participants were classified into three groups and compared on breast health knowledge and perceptions using analysis of variance (ANOVA): English survey–U.S. citizen (considered U.S. citizen English speakers); English survey– non-U.S. citizen (considered non-U.S. citizen English speakers); and Spanish survey (considered Spanish speakers). Participants were categorized into these three groups because of differences in demographic characteristics and physical and mental health status previously demonstrated among the free clinic patient population (Kamimura et al., 2013). Before ANOVA tests, equality of variance was tested. Four of the items of perceptions about breast health violated assumption of equal variance. The robust procedure was performed for the four items. The results of ANOVA tests were confirmed with the robust procedure: The results were the same for three of the items and similar for one of the items. (Note: The results of the tests are available from the authors upon request.)
Participant Characteristics
Table 1 Sociodemographic Characteristics
Mean age, y (SD) Race/ethnicity, n (%) White (non-Hispanic) Hispanic Asian or Pacific Islander African or African American Native American/Alaska Native Education, n (%) Less than high school High school Some college or more Currently employed Marital status, n (%) Married Single (never married) Divorced Widowed Significant other or partner Other Mammogram in the past year Ever had a mammogram, n (%) Yes, once Yes, 2–3 times Yes, >3 times No Breast cancer survivor Breast cancer family history
Total (n ¼ 146)
U.S. Citizen, English Speakers (n ¼ 78)
Non-U.S. Citizen, English Speakers (n ¼ 32)
Spanish Speakers (n ¼ 36)
51.85 (8.90)
52.32 (7.8)
48.22 (6.7)
54.08 (11.7)
57 51 24 10 2
(39) (34.9) (16.4) (6.8) (1.4)
51 5 10 9 2
(65.4) (6.4) (12.8) (11.5) (2.6)
1 15 14 1 0
(3.1) (46.9) (43.8) (3.1)
5 (13.9) 31 (86.1) 0 0 0
37 45 63 62
(25.3) (30.8) (43.1) (42.5)
10 24 44 34
(12.8) (30.8) (56.4) (43.6)
7 14 11 17
(21.9) (43.8) (34.4) (53.1)
20 7 8 11
(55.6) (19.4) (22.2) (30.6)
83 13 24 11 5 4 67
(56.8) (8.9) (16.4) (7.5) (3.4) (2.7) (45.9)
37 7 19 7 3 4 27
(47.4) (9.0) (24.4) (9.0) (3.8) (5.1) (34.6)
21 4 3 2 2 0 18
(65.6) (12.5) (9.4) (6.3) (6.3)
(69.4) (5.6) (5.6) (5.6)
(56.3)
25 2 2 2 0 0 22
(61.1)
41 36 38 31 17 46
(28.1) (24.7) (26.0) (26.0) (11.6) (31.5)
19 23 21 15 12 28
(24.4) (29.5) (26.9) (19.2) (15.4) (35.9)
11 5 7 9 3 10
(34.4) (15.6) (21.9) (28.1) (9.4) (31.3)
11 8 10 7 2 8
(30.6) (22.2) (27.8) (19.4) (5.6) (22.2)
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the three groups in having a family history of breast cancer or never receiving a mammogram. Knowledge of Breast Health The average score of the breast health knowledge test was 2.86 (SD ¼ 1.07; Table 2). There was a significant difference in the score among the three groups (p < .01). The Spanish speakers had the highest average score 3.10 (SD ¼ 1.14) while the non-U.S. citizen English speakers had the lowest average score 2.23 (SD ¼ 1.20). Perceptions of Breast Health Overall, participants agreed with the statements about mammograms, “Would get mammogram if health care provider recommended it” (mean ¼ 4.33; SD ¼ 0.78; 85% agreed or strongly agreed) and “Would get mammogram if female technician did it” (mean ¼ 3.91; SD ¼ 1.00; 66% agreed or strongly agreed). There was no difference among the three groups. Regarding perceptions toward management and treatment outcomes of breast cancer, participants generally agreed with the statement “After receiving treatment for breast cancer, a woman can enjoy a good quality of life” (mean ¼ 4.04; SD ¼ 0.89). At the same time, participants tended to have a negative view about the treatment for breast cancer, “The treatment for breast cancer is a long and painful process” (mean ¼ 3.65; SD ¼ 1.00). There was no difference in these two statements among the three groups. The other three statements had lower levels of agreement, but had significant difference among the three groups. The non-U.S. citizen English speakers were more likely to agree with “Treatments for breast cancer are more helpful to young people” (mean ¼ 3.48; SD ¼ 1.34; p < .01) and “Treatment of breast cancer results in loss of physical beauty” (mean ¼ 3.45; SD ¼ 1.26; p < .01) than the U.S. citizen English speakers (mean ¼ 2.76, SD ¼ 1.19; and mean ¼ 2.35, SD ¼ 1.18) and the Spanish speakers (mean ¼ 3.06, SD ¼ 1.24; mean ¼ 2.76, SD ¼ 1.17). Spanish speakers were more likely to agree with “Treatment for breast cancer is embarrassing” (mean ¼ 3.14; SD ¼ 1.33) than the English speakers (U.S. citizen
English speakers mean ¼ 2.32, SD ¼ 1.07; non-U.S. citizen English speakers mean ¼ 2.84, SD ¼ 1.39; p < .01). As for beliefs about breast cancer, the participants tended to agree with “Breast cancer treatment may not be as bad if cancer is found early” (mean ¼ 4.03; SD ¼ 1.03) and disagreed with “Compared with other health problems, breast cancer is not important” (mean ¼ 1.90; SD ¼ 1.25). The mean score for “If you get breast cancer, you will die from it” was lower than neutral (mean ¼ 2.74; SD ¼ 1.28). There was no difference in these three statements among the three groups. The non-U.S. citizen English speakers were more likely to agree with “Breast cancer treatment is worse than cancer itself” (mean ¼ 3.10; SD ¼ 1.27) and “If you have breast cancer, better not to know” (mean ¼ 2.52; SD ¼ 1.73) than the U.S. citizen English speakers (mean ¼ 2.31, SD ¼ 1.05; mean ¼ 1.55, SD ¼ 0.99) and the Spanish speakers (mean ¼ 2.56, SD ¼ 1.11; mean ¼ 1.82, SD ¼ 1.22) (p < .01). Discussion This study examined knowledge and perceptions of breast health among free clinic patients. Previous studies show the percentage of women aged 40 or older who had a mammogram in the past 2 years was 74% (Centers for Disease Control and Prevention, 2012). Latino women aged 40 or older who ever had a mammogram ranged from 89 to 94% (Rosales & Gonzalez, 2013). The percentage among our participants who ever had a mammogram (78.8%) and who had a mammogram in the past year (45.9%) appeared low compared with that of the previous studies. The results suggest that free clinic patients need increased opportunities for breast health screening. This study has three main findings. First, the non-U.S. citizen English speakers had the lowest average score on the knowledge of breast health. Second, free clinic patients may consider breast health screening if recommended by health care providers. Third, the non-U.S. citizen English speakers and Spanish speakers among free clinic patients are more likely to have negative perception of breast health compared with the U.S. citizen English speakers. The results of this study show that the non-U.S. citizen English speakers had the lowest average score on the
Table 2 Knowledge, Perception, and Beliefs of Breast Cancer Total (n ¼ 146)
Knowledge 2.86 Perception about mammogram Would get mammogram if health care provider recommended it. 4.33 Would get mammogram if female technician did it. 3.91 Perception toward management and treatment outcomes of breast cancer After receiving treatment for breast cancer, a woman can enjoy 4.04 a good quality of life. The treatment for breast cancer is a long and painful process. 3.65 Treatments for breast cancer are more helpful to young people 2.99 Treatment for breast cancer is embarrassing. 2.64 Treatment of breast cancer results in loss of physical beauty. 2.69 Beliefs of breast cancer Breast cancer treatment is worse than cancer itself. 2.54 If you have breast cancer, better not to know. 1.82 Breast cancer treatment may not be as bad if cancer is found early. 4.03 Compared with other health problems, breast cancer is not 1.90 important. If you get breast cancer, you will die from it. 2.74 Abbreviation: NS, not significant.
U.S. Citizen, English Speakers (n ¼ 78)
Non-U.S. Citizen, English Speakers (n ¼ 32)
Spanish Speakers (n ¼ 36)
p-Value
(1.07)
3.01 (0.88)
2.23 (1.20)
3.10 (1.07)
< .01
(0.78) (1.00)
4.28 (0.62) 3.85 (1.06)
4.42 (0.62) 3.90 (1.05)
4.37 (0.88) 4.06 (0.81)
NS NS
(0.89)
3.97 (0.84)
4.06 (1.00)
4.04 (0.89)
NS
(1.00) (1.26) (1.25) (1.27)
3.56 2.76 2.32 2.35
(0.88) (1.19) (1.07) (1.18)
3.61 3.48 2.84 3.45
(1.38) (1.34) (1.39) (1.26)
3.88 3.06 3.14 2.76
(0.81) (1.24) (1.33) (1.17)
NS < .05 < .01 < .01
(1.15) (1.29) (1.03) (1.25)
2.31 1.55 3.96 1.68
(1.05) (0.99) (0.93) (0.97)
3.10 2.52 4.00 2.19
(1.27) (1.73) (1.27) (1.54)
2.56 1.82 4.21 2.12
(1.11) (1.22) (1.04) (1.45)
< .01 < .01 NS NS
(1.28)
2.56 (1.09)
3.19 (1.54)
2.74 (1.36)
NS
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knowledge of breast health among free clinic patients. It is highly possible that the non-U.S. citizen English speakers answered the questions in a non-native language, unlike other participants, the U.S. citizen English speakers and Spanish speakers, who participated in the survey in a native language. Previous studies suggested that immigrant women often had language barriers in learning about breast health and breast cancer screening (Ahmad, Jandu, Albagli, Angus, & Ginsburg, 2013; Kawar, 2013; Mounga & Maughan, 2012). For non-U.S. citizen English speakers, providing educational programs in a native language may help to increase the knowledge of breast health. However, because free clinics tend to have limited financial and human resources (Johnson, 2010; Nadkarni & Philbrick, 2005) and immigrants’ native languages may be diverse, it may not be feasible to provide breast health educational programs in every language spoken by free clinic patients. For example, using pictograph-based breast health care instructions may be one of the solutions to accommodate needs of patients whose native language is not available on educational programs (Choi, 2012). Although the Spanish speakers scored higher on the knowledge of breast health than the U.S. citizen English speakers and non-U.S. citizen English speakers, the level of knowledge about breast health among all study participants (mean ¼ 2.86; SD ¼ 1.07) was lower than that of the Pavic study participants who had the mean score of 4.29 (SD ¼ 1.26; Pavic et al., 2007). Pavic’s participants were breast cancer screening patients, the majority of whom had high school or college education. Although we do not know the national average of the knowledge level of breast health, these results suggest that free clinic patients need to improve their knowledge level of breast health. Little is known about how to increase the knowledge of breast health among free clinic patients. However, a previous study suggested health fair–style colorectal cancer screening was feasible and efficient for free clinic patients (Elmunzer et al., 2011). Future research is needed to determine whether that approach would be applicable to increase the knowledge of breast health among free clinic patients. Positive survivor stories can also change perceptions of breast health, and increase interest in learning about breast health and screening (Mishra, DeForge, Barnet, Ntiri, & Grant, 2012). Free clinics may set up opportunities to share positive survivor stories to increase the level of the knowledge of breast health. In addition, the results of this study suggest that recommendation by a health care provider is essential to increase breast health screening among free clinic patients. Health care providers are very important in promoting breast health education (Simonian et al., 2004). Few studies have examined patient–provider interactions at free clinics. However, the study on patient–provider communication in breast and cervical related health care among low-income women suggested that medical jargons affected communication with English speaking patients, whereas use of a Spanish language was an important factor for communication with Spanish speaking patients (Simon et al., 2013). Further research is necessary to explore strategies to recommend breast health screening that fit free clinics and their patients. Furthermore, the non-U.S. citizen English speakers and Spanish speakers among free clinic patients tended to have negative perceptions of breast cancer and treatment, although they were more likely to have had a mammogram in the past year. Immigrants and minorities have specific barriers to breast health treatment such as lack of awareness of available
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resources, language barriers, culture, health beliefs, or knowledge about breast cancer (Kawar, 2013; Mounga & Maughan, 2012; Simonian et al., 2004). The negative perceptions of breast cancer and treatment can be one of the barriers to early detection and treatment. Culturally competent intervention programs would be necessary to change immigrants’ and minorities’ negative perceptions of breast health treatment. Study Limitations This study has some limitations. This study is cross-sectional from convenience sampling at one free clinic. We cannot determine causal relationships of the associations that we found. The results of this study cannot be generalized to all free clinics in the United States. In future research, measures should be cognitively pilot tested before data collection and be validated for this particular population. Furthermore, we do not have enough information to address cultural variations within non-U.S. citizen English speakers and Spanish speakers as nonU.S. citizen English speakers and Spanish speakers included Hispanics, and Asian and Pacific Islanders. Future research should investigate the differences among immigrant or minority populations. Implications for Policy and/or Practice Data from this study provide recent information about knowledge and perceptions of breast health among free clinic patients, which is currently lacking. In addition, the results of this project suggest important practice implications for developing breast health promotion programs to women who are utilizing a free clinic. Free clinics serve as important safety nets by providing health care services to the medically underserved, but are often unable to provide a wide variety of services to patients owing to limited human and financial resources (Johnson, 2010; Nadkarni & Philbrick, 2005). Owing to the limited resources, the implementation of clinical practice guidelines is often challenging for free clinics (Foley et al., 2012). Such characteristics of free clinics are important to be considered for practice implications. The results of this study suggest three main practice implications to promote breast health among free clinic patients. First, promoting knowledge about breast health is essential. Second, a health care provider’s recommendation for breast health screening is a strong influence. Third, non-U.S. citizen English speakers and Spanish speakers are especially vulnerable in breast health promotion and need culturally competent intervention programs. Although promoting knowledge about breast health is essential, it may be challenging for free clinics to implement health promotion programs owing to limited human resources. Collaboration with medical or allied health science schools may increase human resources to assist in promoting breast health knowledge and screening. Medical students found educational value in volunteering at a student-run free clinic (Smith, Johnson, Rodriguez, Moutier, & Beck, 2012). Although not all free clinics are student run, having student volunteers can be a valuable asset for any free clinics and for students. As mentioned, a health care provider’s recommendation for screening can lead to improved breast health. However, it is often difficult to maintain the same guidelines for all health care providers at a free clinic because most providers are
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volunteers (Darnell, 2010; Gertz et al., 2011) and may not always treat patients regularly at a free clinic. The number of volunteer physicians in free clinics has declined in the past decade (Isaacs & Jellinek, 2007). Asking all health care providers to make recommendations to relevant patients may not always work at a free clinic. It would be important to develop a clinic-wide system to improve breast health education. Future projects should aim at developing, implementing, and evaluating an operation system of clinic-wide breast health promotion. Culturally competent intervention programs need to be developed for non-U.S. citizen English speakers and Spanish speakers. A previous free clinic study suggested that non-U.S. born English speakers and Spanish speakers reported lower health literacy than U.S.-born English speakers (Kamimura et al., 2013). A partnership with other community organizations would be one of the solutions to reduce barriers to care for free clinic patients (Sanders, Solberg, & Gauger, 2013), for example, inviting health educators who are familiar with specific cultures and breast health provide great opportunities for free clinic patients and staff to learn about culturally competent breast health interventions. Finally, this study contributes to increasing the awareness of the importance of women’s health at free clinics and the literature on the knowledge and perceptions of breast health among free clinic patients that is currently not available elsewhere. Women seeking care at a free clinic have very limited access to regular health care services. Even under the health care reform, needs for the safety net including free clinics will remain (Katz, 2010). Research on women’s health at a free clinic should be further developed. Acknowledgments The authors thank the study participants and would like to acknowledge the contribution of the staff and volunteers of the Maliheh Free Clinic: Yen Cao, Jessica Eckhardt, Elizabeth Keith, Eida Khiel, Silvia Solis, Corey Stephenson, and Nga Tran. We also thank Sarah Munro for her insightful input. References Ahmad, F., Jandu, B., Albagli, A., Angus, J. E., & Ginsburg, O. (2013). Exploring ways to overcome barriers to mammography uptake and retention among South Asian immigrant women. Health & Social Care in the Community, 21(1), 88–97. Aldridge, M. L., Daniels, J. L., & Jukic, A. M. (2006). Mammograms and healthcare access among US Hispanic and non-Hispanic women 40 years and older. Family & Community Health, 29(2), 80–88. American Cancer Society. (2011). Breast cancer facts & figures 2011-2012. Atlanta: Author. Centers for Disease Control and Prevention. (2012). Behavioral Risk Factor Surveillance System Survey Data (BRFSS). Available: http://apps.nccd.cdc.gov/ brfss/index.asp. Choi, J. (2012). Development and pilot test of pictograph-enhanced breast health-care instructions for community-residing immigrant women. International Journal of Nursing Practice, 18(4), 373–378. Darnell, Julie S. (2010). Free clinics in the United States A nationwide survey. Archives of Internal Medicine, 170(11), 946–953. Elmunzer, B. J., O’Connell, M. T., Prendes, S., Saini, S. D., Sussman, D. A., Volk, M. L., et al. (2011). Improving access to colorectal cancer screening through medical philanthropy: Feasibility of a flexible sigmoidoscopy health fair for uninsured patients. American Journal of Gastroenterology, 106(10), 1741–1746. Fernandez, M. E., Palmer, R. C., & Leong-Wu, C. A. (2005). Repeat mammography screening among low-income and minority women: A qualitative study. Cancer Control, 12(Suppl. 2), 77–83.
Foley, K. L., Pockey, J. R., Helme, D. W., Song, E.-Y., Stewart, K., Jones, C., et al. (2012). Integrating evidence-based tobacco cessation interventions in free medical clinics: Opportunities and challenges. Health Promotion Practice, 13(5), 687–695. Gertz, A. M., Frank, S., & Blixen, C. E. (2011). A survey of patients and providers at free clinics across the United States. Journal of Community Health, 36(1), 83–93. Hadi, M. A., Hassali, M. A., Shafie, A. A., & Awaisu, A. (2010). Knowledge and perception of breast cancer among women of various ethnic groups in the state of Penang: A cross-sectional survey. Medical Principles and Practice, 19(1), 61–67. Isaacs, S. L., & Jellinek, P. (2007). Is there a (volunteer) doctor in the house? Free clinics and volunteer physician referral networks in the United States. Health Affairs, 26(3), 871–876. Johnson, J. (2010). Free medical clinics keeping healthcare afloat. Nurse Practitioner, 35(12), 43–45. Kamimura, A., Christensen, N., Tabler, J., Ashby, J., & Olson, L. (2013). Patients utilizing a free clinic: Physical and mental health, health literacy, and social support. Journal of Community Health, 38(4), 716–723. Katz, M. H. (2010). Future of the safety net under health reform. JAMA, 304(6), 679–680. Kawar, L. N. (2013). Barriers to breast cancer screening participation among Jordanian and Palestinian American women. European Journal of Oncology Nursing, 17(1), 88–94. Kiger, H. (2003). Outreach to multiethnic, multicultural, and multilingual women for breast cancer and cervical cancer education and screening: A model using professional and volunteer staffing. Family & Community Health, 26(4), 307–318. Mishra, S. I., DeForge, B., Barnet, B., Ntiri, S., & Grant, L. (2012). Social determinants of breast cancer screening in urban primary care practices: A community-engaged formative study. Women’s Health Issues, 22(5), e429–e438. Mounga, V., & Maughan, E. (2012). Breast cancer in Pacific Islander women: Overcoming barriers to screening and treatment. Nursing for Women’s Health, 16(1), 26–35. Nadkarni, M. M., & Philbrick, J. T. (2005). Free clinics: A national survey. American Journal of the Medical Sciences, 330(1), 25–31. Nadkarni, M. M., & Philbrick, J. T. (2003). Free clinics and the uninsured: The increasing demands of chronic illness. Journal of Health Care for the Poor and Underserved, 14(2), 165–174. Notaro, S. J., Khan, M., Bryan, N., Kim, C., Osunero, T., Senseng, M. G., et al. (2012). Analysis of the demographic characteristics and medical conditions of the uninsured utilizing a free clinic. Journal of Community Health, 37(2), 501–506. Pavic, D., Schell, M. J., Dancel, R. D., Sultana, S., Lin, L., Sejpal, S. V., & Pisano, E. D. (2007). Comparison of three methods to increase knowledge about breast cancer and breast cancer screening in screening mammography patients. Academic Radiology, 14(5), 553–560. Rosales, M., & Gonzalez, P. (2013). Mammography screening among Mexican, Central-American, and South-American women. Journal of Immigrant and Minority Health, 15(2), 225–233. Sanders, J., Solberg, B., & Gauger, M. (2013). Breaking barriers to care: A community of solution for chronic disease management. Journal of the American Board of Family Medicine, 26(3), 311–315. Schettino, M. R., Hernandez-Valero, M. A., Moguel, R., Hajek, R. A., & Jones, L. A. (2006). Assessing breast cancer knowledge, beliefs, and misconceptions among Latinas in Houston, Texas. Journal of Cancer Education, 21(1 Suppl.), S42–S46. Schiller, E. R., Thurston, M. A., Khan, Z., & Fetters, M. D. (2013). Free clinics stand as a pillar of the health care safety net: Findings from a narrative literature review. In V. M. Brennan (Ed.), Free clinics: Local responses to health care needs. Baltimore: Johns Hopkins University Press. Simon, M. A., Ragas, D. M., Nonzee, N. J., Phisuthikul, A. M., Luu, T. H., & Dong, X. (2013). Perceptions of patient-provider communication in breast and cervical cancer-related care: A qualitative study of low-income English- and Spanish-speaking women. Journal of Community Health, 38(4), 707–715. Simonian, K., Brown, S. E., Sanders, D. B., Kidd, C. Y., Murillo, V. E., Garcia, R., et al. (2004). Promoting breast cancer screening to women of color. Nurse Practitioner, 29(3), 45–46. Smith, S. D., Johnson, M. L., Rodriguez, N., Moutier, C., & Beck, E. (2012). Medical student perceptions of the educational value of a student-run free clinic. Family Medicine, 44(9), 646–649. Wampler, N. S., Ryschon, T., Manson, S. M., & Buchwald, D. (2006). Knowledge, attitudes, and beliefs regarding breast cancer among American Indian women from the Northern Plains. Journal of Applied Gerontology, 25(1), 44S–59S. Wells, K. J., & Roetzheim, R. G. (2007). Health disparities in receipt of screening mammography in Latinas: A critical review of recent literature. Cancer Control, 14(4), 369–379. Zoorob, R., Anderson, R., Cefalu, C., & Sidani, M. (2001). Cancer screening guidelines. American Family Physician, 63(6), 1101–1112.
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Author Descriptions Akiko Kamimura, PhD, MSW, MA, is an Assistant Professor in the Department of Sociology at the University of Utah. Her current research interests include minority and immigrant health, intimate partner violence, health disparities, and global health.
Nancy Christensen is formerly a resource development coordinator for the Maliheh Free Clinic.
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Wenjing Mo, MS, is a doctoral student in the Department of Sociology at the University of Utah.
Jeanie Ashby, MA, is Executive Director for the Maliheh Free Clinic.
Justine J. Reel, PhD, LPC, CC-AASP, is an Associate Professor in the Department of Health Promotion and Education at the University of Utah. Her research interests include eating disorder and obesity prevention, body image concerns, and physical activity promotion and exercise education.
www.whijournal.com
Original article
Knowledge and Perceptions of Breast Health Among Free Clinic Patients Akiko Kamimura, PhD, MSW, MA a,*, Nancy Christensen b, Wenjing Mo, MS a, Jeanie Ashby, MA b, Justine J. Reel, PhD, LPC, CC-AASP c a b c
Department of Sociology, University of Utah, Salt Lake City, Utah Maliheh Free Clinic, Salt Lake City, Utah Department of Health Promotion and Education, University of Utah, Salt Lake City, Utah
Article history: Received 11 August 2013; Received in revised form 4 February 2014; Accepted 5 February 2014
a b s t r a c t Background: Breast cancer is a significant women’s health problem in the United States. However, critical information on specific populations is still lacking. In particular, it is not well known how free clinic patients perceive breast health. The purpose of this study was to assess knowledge and perceptions of breast health among uninsured women utilizing a free clinic that serves as a safety net for the underserved. Methods: A self-administrated survey that included knowledge and perceptions of breast health was conducted for female free clinic patients aged 40 or older in fall 2012. There were 146 participants. The participants were classified into three groups for comparison; U.S. citizen English speakers, non-U.S. citizen English speakers, and Spanish speakers. Results: Spanish speakers had the highest average score on the knowledge of breast health, whereas the non-U.S. citizen English speakers had the lowest average score. Free clinic patients may consider breast health screening if recommended by health care providers. The non-U.S. citizen English speakers and Spanish speakers were more likely to have negative perceptions of breast health compared with the U.S. citizen English speakers. Conclusions: Promoting knowledge about breast health is important for free clinics. Recommendation by a health care provider is a key to increasing attendance at health education programs and breast health screening. Non-U.S. citizens and non-English speakers would need culturally competent interventions. Free clinics have limited human and financial resources. Such characteristics of free clinics should be considered for practice implementations. Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
Breast cancer is a significant women’s health problem in the United States. In 2001, breast cancer was the second leading cause of cancer deaths among women followed by lung cancer (American Cancer Society, 2011). Early diagnosis is important to increase 5-year relative survival rates from breast cancer (American Cancer Society, 2011). Although screening mammography is associated with lower death rates from breast cancer, many women do not obtain the recommended periodical screening (Zoorob, Anderson, Cafalu, & Sidani, 2001). The risk factors related to lower screening mammography include minority status, low income, low education level, and no insurance
Funding: This work was supported by the Utah Cancer Action Network and the College of Social & Behavioral Science, University of Utah. * Correspondence to: Akiko Kamimura, PhD, MSW, MA, Department of Sociology, University of Utah, Salt Lake City, 380 S 1530 E, Utah 84112, USA. Phone: þ1 801 581 7858; fax: þ1 801 585 3784. E-mail address: [email protected] (A. Kamimura).
(Aldridge, Daniels, & Jukie, 2006; Wells & Roetzheim, 2007). Cultural beliefs and knowledge about breast health also affect compliance with screening recommendations (Kiger, 2003; Schettino, Hernandez-Valero, Moguel, Hajek, & Jones, 2006; Fernandez, Palmer, & Leong-Wu, 2005). Although previous research has increased our understanding of perceptions and knowledge about breast health among women in general (Pavic et al., 2007; Wampler, Ryschon, Manson, & Buchwald, 2006), critical information on specific populations is still lacking. In particular, it is not well known how free clinic patients perceive breast health. Free clinics serve as safety nets for uninsured individuals who lack access to primary care services (Gertz, Frank, & Blixen, 2011; Nadkarni & Philbrick, 2005). Since the first free clinic was opened in 1967, the number of free clinics in the United States has increased to approximately 1,200 (Schiller, Thurston, Khan, & Fetters, 2013). Previous studies addressed health problems among free clinic patients. For example, free clinic patients
1049-3867/$ - see front matter Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2014.02.006
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reported lower physical and mental health functioning compared with the U.S. general population, being moderately depressed (Kamimura, Christensen, Tabler, Ashby, & Olson, 2013), and high prevalence of smoking and obesity (Notaro et al., 2012). There is still a paucity of research studies to determine the needs and unique characteristics of free clinics and their patients (Johnson, 2010). More than half of free clinic patients are women (Gertz et al., 2011; Darnell, 2010; Nadkarni & Philbrick, 2005; Notaro et al., 2012). Yet there are few studies that focused on women’s health at free clinics. Breast health knowledge and perception is one of the areas where information is lacking about free clinic patients. Free clinics usually rely on volunteer staff and have unstable financial resources (Nadkarni & Philbrick, 2003, 2005). It would be challenging for most free clinics to provide breast health screening and education to their patients. We were particularly interested in a free clinic that provides services to the uninsured only and to immigrants who often do not have access to primary health care. The purpose of this study was to assess the knowledge and perceptions related to breast health among uninsured women utilizing a free clinic. Knowledge and perceptions of breast health are important owing to the influence on an individual’s health behavior and health literacy (Hadi, Hassali, Shafie, & Awaisu, 2010; Pavic et al., 2007; Wampler et al., 2006). This study contributes to increasing the understanding of free clinic patients and their knowledge and perceptions of breast health. Methods Study Population Before data collection, the university’s institutional review board reviewed the protocol for this study, and determined that it was exempt from institutional review board oversight. This study was a community-based research project in collaboration with a free clinic in a state in the Intermountain West. The clinic staff members were involved in designing the study, developing the survey instrument, the study protocol, and recruitment strategies, interpreting the study results, and preparing for a manuscript. The clinic where this study was conducted provides free health care services, mostly routine health maintenance and preventative care, to patients who do not have health insurance and are not eligible for Medicare or Medicaid. In addition, patients must have a household income below the 150th percentile to be eligible to receive services at the clinic. Slightly more than half of the clinic patients are women. Approximately half of the clinic patients are Hispanic. Clinic patients are not required to provide information on residency status to receive care. The clinic is open 5 days a week and serves approximately 65 patients a day. Six full-time paid staff and about 250 active volunteers support the clinic, which is funded by grants and donations, but not by governmental sources. Some of the health care providers speak Spanish or another foreign language. The clinic provides interpreter services in a wide variety of languages. The clinic is interested in increasing awareness of breast health among its patients. This study was not tied with any specific local or national health promotion events. There was no recent or current intervention or program in the clinic with respect to breast health, breast cancer screening, or breast cancer around the time of the data collection. The providers did not
specifically provide breast health education. The clinic did not have any breast health programs, but handed a flyer about breast health to relevant patients. The flyer was available in English and Spanish and included the information about self-breast examinations, risks, and mammogram. Study samples were women who were 40 years or older, and spoke and read English or Spanish. All survey materials, including a consent cover letter, a flyer, and a survey instrument, were available in English and Spanish. Some of patients’ native language is not English or Spanish, but most of them speak English. Non-native English speakers who did not speak Spanish participated in the survey only if they spoke and read English. A native English speaker, who is Hispanic and fluent in Spanish, translated English materials that did not have existing Spanish translations from English into Spanish. A separate, bilingual individual conducted back-translation. The investigators then checked the reconciliation. Data were collected in the fall of 2012 at a free clinic. The study team members were at the clinic several times a week (two to three times a week) during the study period. The time blocks were not necessarily the same every week. Potential participants were informed about the study in the waiting room by a study team member. If a potential participant expressed interest, they received a consent cover letter and a self-administered paper survey in their preferred language, English or Spanish. Study team members and a Spanish interpreter were available to answer any questions while participants were taking the survey. A pilot study to test the procedure of a self-administrated survey was conducted at the clinic earlier in the same year (2012) using general health questions. Although the clinic staff were involved in the study from beginning to completion, they did not conduct actual data collection. The clinic staff oversaw the data collection team, and did not interact with participants directly for the survey. Potential participants were not asked to register for this study. The data collection team members were students or investigators of the university, and did not know or gather participants’ names. Measures of Knowledge and Perceptions About Breast Health To the best of our knowledge, there is no measure in any aspects that are validated for this particular population. Measures were selected based on the clinic’s concern and interest in understanding more about the knowledge and perceptions of breast health among its female patient population. Knowledge of breast health was measured using the Health Knowledge and Perception Questionnaire developed by Pavic and associates (2007). The questionnaire consists of seven multiple choice or true/false questions. The sample questions include: “Who has a greater chance of getting breast cancer? A women who is: a) 40 years old, b) 60 years old, c) 70 years old.” The range of total scores is from 0 to 7 (1 point for each correct answer). For the first three questions, a half point was given for neighboring answers to the correct ones. For perceptions and beliefs about breast health, there were 12 questions using a 5-point Likert scale (1 ¼ strongly disagree to 5 ¼ strongly agree) to ask their perceptions and beliefs about breast health. The first question asked whether a participant would get a mammogram 1) if a health care provider recommended it, and 2) if a female technician did it. The next five questions were from the set of questions on perceptions toward management and treatment outcomes of breast cancer developed by Hadi, Hassali, Shafie, & Awaisu (2010). The last five
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questions related to beliefs about breast cancer were developed by Wampler and colleagues (2006) from the National Behavioral Risk Factor Surveillance System.
Results
Measures of Demographic Characteristics
There were 146 participants in the study. Table 1 presents the sociodemographic characteristics of the participants. The 146 participants were divided into three groups for further analysis: U.S. citizen English speakers (n ¼ 78), non-U.S. citizen English speakers (n ¼ 32), and Spanish speakers (n ¼ 36, 5 U.S. citizens and 31 non-U.S. citizens). Among five U.S. citizen Spanish speakers, only one of them was originally from the United States. The average age of the participants was 51.85 (SD ¼ 8.9). The self-reported race/ethnicity included non-Hispanic White (39%), Hispanic (34.9%), Asian or Pacific Islander (16.4%), African or African American (6.8%), and Native American or Alaska Native (1.4%). About 65% of the U.S. citizen English speakers were non-Hispanic White. Most non-U.S. citizen English speakers were Hispanic (46.9%) or Asian or Pacific Islander (43.8%). Most Spanish speakers were Hispanic (86.1%). Approximately 43% of the participants had some college or higher education, whereas one quarter of them had less than a high school education. About 43% of the participants reported full- or part-time employment at the time of the survey. About 57% of the participants were married. Nearly half of the participants (45.9%) had received mammogram screenings within the past year. The percentage of the participants who had a mammogram in the past year was significantly different among the three groups. The U.S. citizen English speakers had the lowest percentage (34.6%) of mammograms within the last year compared with the non-U.S. citizen English speakers (56.3%) and Spanish speakers (61.1%). Approximately 80% of the participants reported having a mammogram in the past. About 32% of the participants reported they had a family history of breast cancer. There was no difference among
In addition to knowledge and perceptions about breast health, participants were asked about demographic information, whether they had a mammogram in the past year or ever, and breast cancer family history. Data Analysis Statistical analyses were performed using statistical software SPSS (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY). Descriptive statistics were used to describe the distribution of the outcome and independent variables. The participants were classified into three groups and compared on breast health knowledge and perceptions using analysis of variance (ANOVA): English survey–U.S. citizen (considered U.S. citizen English speakers); English survey– non-U.S. citizen (considered non-U.S. citizen English speakers); and Spanish survey (considered Spanish speakers). Participants were categorized into these three groups because of differences in demographic characteristics and physical and mental health status previously demonstrated among the free clinic patient population (Kamimura et al., 2013). Before ANOVA tests, equality of variance was tested. Four of the items of perceptions about breast health violated assumption of equal variance. The robust procedure was performed for the four items. The results of ANOVA tests were confirmed with the robust procedure: The results were the same for three of the items and similar for one of the items. (Note: The results of the tests are available from the authors upon request.)
Participant Characteristics
Table 1 Sociodemographic Characteristics
Mean age, y (SD) Race/ethnicity, n (%) White (non-Hispanic) Hispanic Asian or Pacific Islander African or African American Native American/Alaska Native Education, n (%) Less than high school High school Some college or more Currently employed Marital status, n (%) Married Single (never married) Divorced Widowed Significant other or partner Other Mammogram in the past year Ever had a mammogram, n (%) Yes, once Yes, 2–3 times Yes, >3 times No Breast cancer survivor Breast cancer family history
Total (n ¼ 146)
U.S. Citizen, English Speakers (n ¼ 78)
Non-U.S. Citizen, English Speakers (n ¼ 32)
Spanish Speakers (n ¼ 36)
51.85 (8.90)
52.32 (7.8)
48.22 (6.7)
54.08 (11.7)
57 51 24 10 2
(39) (34.9) (16.4) (6.8) (1.4)
51 5 10 9 2
(65.4) (6.4) (12.8) (11.5) (2.6)
1 15 14 1 0
(3.1) (46.9) (43.8) (3.1)
5 (13.9) 31 (86.1) 0 0 0
37 45 63 62
(25.3) (30.8) (43.1) (42.5)
10 24 44 34
(12.8) (30.8) (56.4) (43.6)
7 14 11 17
(21.9) (43.8) (34.4) (53.1)
20 7 8 11
(55.6) (19.4) (22.2) (30.6)
83 13 24 11 5 4 67
(56.8) (8.9) (16.4) (7.5) (3.4) (2.7) (45.9)
37 7 19 7 3 4 27
(47.4) (9.0) (24.4) (9.0) (3.8) (5.1) (34.6)
21 4 3 2 2 0 18
(65.6) (12.5) (9.4) (6.3) (6.3)
(69.4) (5.6) (5.6) (5.6)
(56.3)
25 2 2 2 0 0 22
(61.1)
41 36 38 31 17 46
(28.1) (24.7) (26.0) (26.0) (11.6) (31.5)
19 23 21 15 12 28
(24.4) (29.5) (26.9) (19.2) (15.4) (35.9)
11 5 7 9 3 10
(34.4) (15.6) (21.9) (28.1) (9.4) (31.3)
11 8 10 7 2 8
(30.6) (22.2) (27.8) (19.4) (5.6) (22.2)
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the three groups in having a family history of breast cancer or never receiving a mammogram. Knowledge of Breast Health The average score of the breast health knowledge test was 2.86 (SD ¼ 1.07; Table 2). There was a significant difference in the score among the three groups (p < .01). The Spanish speakers had the highest average score 3.10 (SD ¼ 1.14) while the non-U.S. citizen English speakers had the lowest average score 2.23 (SD ¼ 1.20). Perceptions of Breast Health Overall, participants agreed with the statements about mammograms, “Would get mammogram if health care provider recommended it” (mean ¼ 4.33; SD ¼ 0.78; 85% agreed or strongly agreed) and “Would get mammogram if female technician did it” (mean ¼ 3.91; SD ¼ 1.00; 66% agreed or strongly agreed). There was no difference among the three groups. Regarding perceptions toward management and treatment outcomes of breast cancer, participants generally agreed with the statement “After receiving treatment for breast cancer, a woman can enjoy a good quality of life” (mean ¼ 4.04; SD ¼ 0.89). At the same time, participants tended to have a negative view about the treatment for breast cancer, “The treatment for breast cancer is a long and painful process” (mean ¼ 3.65; SD ¼ 1.00). There was no difference in these two statements among the three groups. The other three statements had lower levels of agreement, but had significant difference among the three groups. The non-U.S. citizen English speakers were more likely to agree with “Treatments for breast cancer are more helpful to young people” (mean ¼ 3.48; SD ¼ 1.34; p < .01) and “Treatment of breast cancer results in loss of physical beauty” (mean ¼ 3.45; SD ¼ 1.26; p < .01) than the U.S. citizen English speakers (mean ¼ 2.76, SD ¼ 1.19; and mean ¼ 2.35, SD ¼ 1.18) and the Spanish speakers (mean ¼ 3.06, SD ¼ 1.24; mean ¼ 2.76, SD ¼ 1.17). Spanish speakers were more likely to agree with “Treatment for breast cancer is embarrassing” (mean ¼ 3.14; SD ¼ 1.33) than the English speakers (U.S. citizen
English speakers mean ¼ 2.32, SD ¼ 1.07; non-U.S. citizen English speakers mean ¼ 2.84, SD ¼ 1.39; p < .01). As for beliefs about breast cancer, the participants tended to agree with “Breast cancer treatment may not be as bad if cancer is found early” (mean ¼ 4.03; SD ¼ 1.03) and disagreed with “Compared with other health problems, breast cancer is not important” (mean ¼ 1.90; SD ¼ 1.25). The mean score for “If you get breast cancer, you will die from it” was lower than neutral (mean ¼ 2.74; SD ¼ 1.28). There was no difference in these three statements among the three groups. The non-U.S. citizen English speakers were more likely to agree with “Breast cancer treatment is worse than cancer itself” (mean ¼ 3.10; SD ¼ 1.27) and “If you have breast cancer, better not to know” (mean ¼ 2.52; SD ¼ 1.73) than the U.S. citizen English speakers (mean ¼ 2.31, SD ¼ 1.05; mean ¼ 1.55, SD ¼ 0.99) and the Spanish speakers (mean ¼ 2.56, SD ¼ 1.11; mean ¼ 1.82, SD ¼ 1.22) (p < .01). Discussion This study examined knowledge and perceptions of breast health among free clinic patients. Previous studies show the percentage of women aged 40 or older who had a mammogram in the past 2 years was 74% (Centers for Disease Control and Prevention, 2012). Latino women aged 40 or older who ever had a mammogram ranged from 89 to 94% (Rosales & Gonzalez, 2013). The percentage among our participants who ever had a mammogram (78.8%) and who had a mammogram in the past year (45.9%) appeared low compared with that of the previous studies. The results suggest that free clinic patients need increased opportunities for breast health screening. This study has three main findings. First, the non-U.S. citizen English speakers had the lowest average score on the knowledge of breast health. Second, free clinic patients may consider breast health screening if recommended by health care providers. Third, the non-U.S. citizen English speakers and Spanish speakers among free clinic patients are more likely to have negative perception of breast health compared with the U.S. citizen English speakers. The results of this study show that the non-U.S. citizen English speakers had the lowest average score on the
Table 2 Knowledge, Perception, and Beliefs of Breast Cancer Total (n ¼ 146)
Knowledge 2.86 Perception about mammogram Would get mammogram if health care provider recommended it. 4.33 Would get mammogram if female technician did it. 3.91 Perception toward management and treatment outcomes of breast cancer After receiving treatment for breast cancer, a woman can enjoy 4.04 a good quality of life. The treatment for breast cancer is a long and painful process. 3.65 Treatments for breast cancer are more helpful to young people 2.99 Treatment for breast cancer is embarrassing. 2.64 Treatment of breast cancer results in loss of physical beauty. 2.69 Beliefs of breast cancer Breast cancer treatment is worse than cancer itself. 2.54 If you have breast cancer, better not to know. 1.82 Breast cancer treatment may not be as bad if cancer is found early. 4.03 Compared with other health problems, breast cancer is not 1.90 important. If you get breast cancer, you will die from it. 2.74 Abbreviation: NS, not significant.
U.S. Citizen, English Speakers (n ¼ 78)
Non-U.S. Citizen, English Speakers (n ¼ 32)
Spanish Speakers (n ¼ 36)
p-Value
(1.07)
3.01 (0.88)
2.23 (1.20)
3.10 (1.07)
< .01
(0.78) (1.00)
4.28 (0.62) 3.85 (1.06)
4.42 (0.62) 3.90 (1.05)
4.37 (0.88) 4.06 (0.81)
NS NS
(0.89)
3.97 (0.84)
4.06 (1.00)
4.04 (0.89)
NS
(1.00) (1.26) (1.25) (1.27)
3.56 2.76 2.32 2.35
(0.88) (1.19) (1.07) (1.18)
3.61 3.48 2.84 3.45
(1.38) (1.34) (1.39) (1.26)
3.88 3.06 3.14 2.76
(0.81) (1.24) (1.33) (1.17)
NS < .05 < .01 < .01
(1.15) (1.29) (1.03) (1.25)
2.31 1.55 3.96 1.68
(1.05) (0.99) (0.93) (0.97)
3.10 2.52 4.00 2.19
(1.27) (1.73) (1.27) (1.54)
2.56 1.82 4.21 2.12
(1.11) (1.22) (1.04) (1.45)
< .01 < .01 NS NS
(1.28)
2.56 (1.09)
3.19 (1.54)
2.74 (1.36)
NS
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knowledge of breast health among free clinic patients. It is highly possible that the non-U.S. citizen English speakers answered the questions in a non-native language, unlike other participants, the U.S. citizen English speakers and Spanish speakers, who participated in the survey in a native language. Previous studies suggested that immigrant women often had language barriers in learning about breast health and breast cancer screening (Ahmad, Jandu, Albagli, Angus, & Ginsburg, 2013; Kawar, 2013; Mounga & Maughan, 2012). For non-U.S. citizen English speakers, providing educational programs in a native language may help to increase the knowledge of breast health. However, because free clinics tend to have limited financial and human resources (Johnson, 2010; Nadkarni & Philbrick, 2005) and immigrants’ native languages may be diverse, it may not be feasible to provide breast health educational programs in every language spoken by free clinic patients. For example, using pictograph-based breast health care instructions may be one of the solutions to accommodate needs of patients whose native language is not available on educational programs (Choi, 2012). Although the Spanish speakers scored higher on the knowledge of breast health than the U.S. citizen English speakers and non-U.S. citizen English speakers, the level of knowledge about breast health among all study participants (mean ¼ 2.86; SD ¼ 1.07) was lower than that of the Pavic study participants who had the mean score of 4.29 (SD ¼ 1.26; Pavic et al., 2007). Pavic’s participants were breast cancer screening patients, the majority of whom had high school or college education. Although we do not know the national average of the knowledge level of breast health, these results suggest that free clinic patients need to improve their knowledge level of breast health. Little is known about how to increase the knowledge of breast health among free clinic patients. However, a previous study suggested health fair–style colorectal cancer screening was feasible and efficient for free clinic patients (Elmunzer et al., 2011). Future research is needed to determine whether that approach would be applicable to increase the knowledge of breast health among free clinic patients. Positive survivor stories can also change perceptions of breast health, and increase interest in learning about breast health and screening (Mishra, DeForge, Barnet, Ntiri, & Grant, 2012). Free clinics may set up opportunities to share positive survivor stories to increase the level of the knowledge of breast health. In addition, the results of this study suggest that recommendation by a health care provider is essential to increase breast health screening among free clinic patients. Health care providers are very important in promoting breast health education (Simonian et al., 2004). Few studies have examined patient–provider interactions at free clinics. However, the study on patient–provider communication in breast and cervical related health care among low-income women suggested that medical jargons affected communication with English speaking patients, whereas use of a Spanish language was an important factor for communication with Spanish speaking patients (Simon et al., 2013). Further research is necessary to explore strategies to recommend breast health screening that fit free clinics and their patients. Furthermore, the non-U.S. citizen English speakers and Spanish speakers among free clinic patients tended to have negative perceptions of breast cancer and treatment, although they were more likely to have had a mammogram in the past year. Immigrants and minorities have specific barriers to breast health treatment such as lack of awareness of available
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resources, language barriers, culture, health beliefs, or knowledge about breast cancer (Kawar, 2013; Mounga & Maughan, 2012; Simonian et al., 2004). The negative perceptions of breast cancer and treatment can be one of the barriers to early detection and treatment. Culturally competent intervention programs would be necessary to change immigrants’ and minorities’ negative perceptions of breast health treatment. Study Limitations This study has some limitations. This study is cross-sectional from convenience sampling at one free clinic. We cannot determine causal relationships of the associations that we found. The results of this study cannot be generalized to all free clinics in the United States. In future research, measures should be cognitively pilot tested before data collection and be validated for this particular population. Furthermore, we do not have enough information to address cultural variations within non-U.S. citizen English speakers and Spanish speakers as nonU.S. citizen English speakers and Spanish speakers included Hispanics, and Asian and Pacific Islanders. Future research should investigate the differences among immigrant or minority populations. Implications for Policy and/or Practice Data from this study provide recent information about knowledge and perceptions of breast health among free clinic patients, which is currently lacking. In addition, the results of this project suggest important practice implications for developing breast health promotion programs to women who are utilizing a free clinic. Free clinics serve as important safety nets by providing health care services to the medically underserved, but are often unable to provide a wide variety of services to patients owing to limited human and financial resources (Johnson, 2010; Nadkarni & Philbrick, 2005). Owing to the limited resources, the implementation of clinical practice guidelines is often challenging for free clinics (Foley et al., 2012). Such characteristics of free clinics are important to be considered for practice implications. The results of this study suggest three main practice implications to promote breast health among free clinic patients. First, promoting knowledge about breast health is essential. Second, a health care provider’s recommendation for breast health screening is a strong influence. Third, non-U.S. citizen English speakers and Spanish speakers are especially vulnerable in breast health promotion and need culturally competent intervention programs. Although promoting knowledge about breast health is essential, it may be challenging for free clinics to implement health promotion programs owing to limited human resources. Collaboration with medical or allied health science schools may increase human resources to assist in promoting breast health knowledge and screening. Medical students found educational value in volunteering at a student-run free clinic (Smith, Johnson, Rodriguez, Moutier, & Beck, 2012). Although not all free clinics are student run, having student volunteers can be a valuable asset for any free clinics and for students. As mentioned, a health care provider’s recommendation for screening can lead to improved breast health. However, it is often difficult to maintain the same guidelines for all health care providers at a free clinic because most providers are
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volunteers (Darnell, 2010; Gertz et al., 2011) and may not always treat patients regularly at a free clinic. The number of volunteer physicians in free clinics has declined in the past decade (Isaacs & Jellinek, 2007). Asking all health care providers to make recommendations to relevant patients may not always work at a free clinic. It would be important to develop a clinic-wide system to improve breast health education. Future projects should aim at developing, implementing, and evaluating an operation system of clinic-wide breast health promotion. Culturally competent intervention programs need to be developed for non-U.S. citizen English speakers and Spanish speakers. A previous free clinic study suggested that non-U.S. born English speakers and Spanish speakers reported lower health literacy than U.S.-born English speakers (Kamimura et al., 2013). A partnership with other community organizations would be one of the solutions to reduce barriers to care for free clinic patients (Sanders, Solberg, & Gauger, 2013), for example, inviting health educators who are familiar with specific cultures and breast health provide great opportunities for free clinic patients and staff to learn about culturally competent breast health interventions. Finally, this study contributes to increasing the awareness of the importance of women’s health at free clinics and the literature on the knowledge and perceptions of breast health among free clinic patients that is currently not available elsewhere. Women seeking care at a free clinic have very limited access to regular health care services. Even under the health care reform, needs for the safety net including free clinics will remain (Katz, 2010). Research on women’s health at a free clinic should be further developed. Acknowledgments The authors thank the study participants and would like to acknowledge the contribution of the staff and volunteers of the Maliheh Free Clinic: Yen Cao, Jessica Eckhardt, Elizabeth Keith, Eida Khiel, Silvia Solis, Corey Stephenson, and Nga Tran. We also thank Sarah Munro for her insightful input. References Ahmad, F., Jandu, B., Albagli, A., Angus, J. E., & Ginsburg, O. (2013). Exploring ways to overcome barriers to mammography uptake and retention among South Asian immigrant women. Health & Social Care in the Community, 21(1), 88–97. Aldridge, M. L., Daniels, J. L., & Jukic, A. M. (2006). Mammograms and healthcare access among US Hispanic and non-Hispanic women 40 years and older. Family & Community Health, 29(2), 80–88. American Cancer Society. (2011). Breast cancer facts & figures 2011-2012. Atlanta: Author. Centers for Disease Control and Prevention. (2012). Behavioral Risk Factor Surveillance System Survey Data (BRFSS). Available: http://apps.nccd.cdc.gov/ brfss/index.asp. Choi, J. (2012). Development and pilot test of pictograph-enhanced breast health-care instructions for community-residing immigrant women. International Journal of Nursing Practice, 18(4), 373–378. Darnell, Julie S. (2010). Free clinics in the United States A nationwide survey. Archives of Internal Medicine, 170(11), 946–953. Elmunzer, B. J., O’Connell, M. T., Prendes, S., Saini, S. D., Sussman, D. A., Volk, M. L., et al. (2011). Improving access to colorectal cancer screening through medical philanthropy: Feasibility of a flexible sigmoidoscopy health fair for uninsured patients. American Journal of Gastroenterology, 106(10), 1741–1746. Fernandez, M. E., Palmer, R. C., & Leong-Wu, C. A. (2005). Repeat mammography screening among low-income and minority women: A qualitative study. Cancer Control, 12(Suppl. 2), 77–83.
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Author Descriptions Akiko Kamimura, PhD, MSW, MA, is an Assistant Professor in the Department of Sociology at the University of Utah. Her current research interests include minority and immigrant health, intimate partner violence, health disparities, and global health.
Nancy Christensen is formerly a resource development coordinator for the Maliheh Free Clinic.
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Wenjing Mo, MS, is a doctoral student in the Department of Sociology at the University of Utah.
Jeanie Ashby, MA, is Executive Director for the Maliheh Free Clinic.
Justine J. Reel, PhD, LPC, CC-AASP, is an Associate Professor in the Department of Health Promotion and Education at the University of Utah. Her research interests include eating disorder and obesity prevention, body image concerns, and physical activity promotion and exercise education.
