Exploring Potential Use of Internet, E-mail, and Instant Text Messaging to Promote Breast Health and Mammogram Use among Immigrant Hispanic Women in Los Angeles County

Breast cancer is now the leading cause of death in Hispanic women (HW). Internet, e-mail, and instant text messaging may be cost-effective in educating HWabout breast health and in reducing breast cancer mortality. We surveyed 905 HW women attending a free health fair about their technology use, acculturation, insurance status, mammography use, and breast cancer knowledge. Data were analyzed by t test or x2 tests. Mean age was 51.9 ± 14.2 years (range, 18 to 88 years). Ninety-two per cent were foreign-born. Most had completed some high school (39%) or elementary (38%) education. Most (62%) were uninsured. The majority spoke (67%) and read (66%) only Spanish. Only 60 per cent of HW older than 40 years had a recent mammogram. HW older than 40 years who had not had a recent mammogram were younger (mean 54.9 ± 10.8 vs 58 ± 10.4 years) and less likely to have health insurance (25 vs 44%; P < 0.001). Most HW never use the Internet (58%) or e-mail (64%). However, 70 per cent have mobile phones (66% older than 40 years), and 65 per cent use text messaging daily (58% older than 40 years, P = 0.001). In fact, 45 per cent wish to receive a mammogram reminder by text. Text messaging may be an inexpensive way to promote breast health and screening mammography use among uninsured HW.

B REAST CANCER IS NOW the leading cause of death among Hispanic women (HW) with an estimated 17,100 HW diagnosed in 2012 alone.1 HW are more likely to be diagnosed with advanced-stage breast cancer than non-Hispanic white women (NHWW) and are 20 per cent more likely to die of it.2 A preventative program that results in earlier detection of breast cancer among HW is an important public health goal because Hispanic Americans are the fasting growing segment of the U.S. population.

Early cancer detection can be accomplished by a combination of screening and increased awareness of risk factors. Regular use of screening mammography, in fact, has been associated with lower odds of latestage breast cancer in all racial and ethnic groups.3 The American Cancer Society and the California Department of Health Services recommend that women 40 years and older undergo yearly clinical breast examination and screening mammography. HW are less likely to adhere to screening guidelines and more likely not to have had a mammogram within the 2 years before their cancer diagnosis (37.1% HW vs 29.7% NHWW vs 32.7%black women).4, 5 While affected by the degree of acculturation, age, household income, fluency in English, and insurance status, breast cancer knowledge among HW can be effectively increased with intensive community outreach using lay health educators, also known as promotoras.3, 5-9 Although effective, the use of promotoras is expensive and limited in scope. Lower cost means of communication such as the Internet, e-mail, and instant text messaging throughmobile phones may provide more cost-effective approaches. The Federal Communication Commission 2009 survey estimated that 78 per cent of adults in America are Internet users; 74 per cent (but only 49 per cent of Hispanics) have Internet access at home.10 Furthermore, in a national survey, 59 per cent of all adults have used the Internet for information about a specific health condition and 18 per cent have consulted online reviews of drugs or treatments.11 We hypothesized that current telecommunication technology can be used to reach out to the growing community of uninsured HW in Los Angeles County and be accepted as a means of receiving reminders to comply with breast cancer screening guidelines.

Methods

To test our hypothesis and perform a baseline assessment of an urban, uninsured Hispanic community, we conducted a 25-question survey that was administered by bilingual-trained volunteers to HW 18 years and older attending a free health fair held annually in Los Angeles County. The health fair is sponsored by a local Spanish language media network and our institution and provides thousands of free health screenings and information to the local community. The survey was designed to assess participants' English and Spanish fluency, literacy, technology use, degree of acculturation, insurance status, mammography use, and knowledge about breast health. Survey questions regarding acculturation were previously established by Marin et al.12 Groups were categorized by age older than 40 years and insurance status for comparison because both factors affect use of screening mammography. Data were analyzed by t test or x2 tests as appropriate. Statistical significance was set at P < 0.05.

Results

A total of 905 HW attending the community health fair were surveyed. The mean age of participants was 51.9 ± 14.2 years (range, 18 to 88 years). Eight hundred thirty-seven (92%) were born outside of the United States with Mexico (47%), El Salvador (19%), and Guatemala (14%) being the most common countries of origin. Among all participants, the mean duration of residence within the United States was 23.7 ± 12.5 years. Overall, 62 per cent did not have health insurance, which was also significantly associated with a shorter residency period (uninsured residency 20.6 ± 11.2 years vs insured residency 29.2 ± 13 years, P < 0.001). The distribution of highest level of educational attainment was: high school 39 per cent, elementary school 38 per cent, college degree 12 per cent, professional degree 6 per cent, and trade school 3 per cent. The great majority spoke only Spanish at home (67%) or with their peers (73%) with 66 per cent literate in Spanish only. Those without health insurance were younger (mean age 50.4 ± 12.6 vs 54.8 ± 16.5 years), more likely to speak Spanish only (73 vs 56%), and more likely to read Spanish only (73 vs 53%; P < 0.001).

Regarding knowledge about breast health, 51 per cent of those surveyed believed that women should have their first mammogram before the age of 40 years, whereas 46 per cent believed that screening should begin between the ages of 40 and 50 years. This did not differ by age, insurance status, acculturation, or technology use. Not surprisingly, only 60 per cent (n 4 412) of the 689 women aged 40 years and older reported having had a mammogram within the past year. Those who had not had a recent mammogram were younger (mean 54.9 ± 10.8 vs 58 ± 10.4 years, P < 0.001), had resided in the United States for less time (23.1 ± 12.7 vs 26.7 ± 12.4 years, P < 0.001), and were less likely to have health insurance (25 vs 44%, P < 0.001) than those who had had a mammogram. Barriers to mammography use among those who had not had a recent mammogram included: lack of health insurance (49%), belief that they are not necessary (15%), lack of time (14%), and expense (12%).

Fifty-eight per cent of respondents reported that they never use the Internet; 21 per cent use the Internet almost everyday, with home (84%), work (23%), and mobile phone (19%) being the most frequent Internet access points among Internet users. Similarly, 64 per cent do not have e-mail access, although 79 per cent of those with e-mail access use it at least several times per week. There was a statistically significant difference between patterns of Internet and e-mail use between women younger than 40 years and older women. Specifically, a greater proportion of women younger than 40 years use the Internet and e-mail regularly (P < 0.001). See Table 1 for details.

In contrast, 70 per cent of all respondents have mobile phones, and 74 per cent of those with mobile phones have instant text messaging plans. In fact, 65 per cent of respondents with mobile phones use instant text messaging almost everyday. Forty-six per cent of all respondents stated that they would like to receive reminders to get their screening mammograms via instant text messaging.

Discussion

Hispanic Americans are the fastest growing ethnic group and are anticipated to account for 30 per cent of the U.S. population by the year 2050. This population growth is most keenly reflected in Los Angeles County where already 48 per cent of residents are Hispanic.13 Because HW have disproportionately higher breast cancer mortality rates despite a lower incidence of breast cancer compared with NHWW, improving breast cancer knowledge and regular use of screening mammography among HWin Los Angeles County is critical. In California, a greater proportion of HW with breast cancer (37%) did not have a mammogram in the 2 years before their breast cancer diagnosis compared with NHWW (29.7%) and black women (32.7%).4 Furthermore, HW with breast cancer are less likely to have an early-stage cancer at diagnosis than NHWW, 64 versus 71 per cent.14 Comparing the cost of breast cancer treatment by stage (average of $22,343 for localized disease, $41,005 for regional lymph node involvement, and $117,033 for distant metastases), it is clear that early diagnosis will save millions of dollars.15

Although we must be cautious in applying our data to the population of HWas a whole, our data suggest a need for ongoing outreach efforts to increase knowledge about breast health and appropriate use of screening mammography in the growing population of mostly uninsured, foreign-born HW. Access to lowcost screening mammograms is mandated by the California legislature, but in this population, only 60 per cent had undergone a recent screening mammogram.16 Actual rates of mammography use may be even lower because our survey was conducted among HWattending a free community health fair who are likely to be more highly motivated in seeking out health care. Low-cost means of disseminating knowledge and reminders to obtain screening mammography are needed. Unfortunately, at this time the Internet and e-mail are not good options for the thousands of uninsured, foreign-born HW in Los Angeles County because the majority do not use the Internet or e-mail. Instant text messaging, however, is a potentially powerful educational resource from a public health standpoint and could potentially increase the number of women getting screening mammography. The overwhelming majority of study participants have mobile phones and use instant text messaging regularly. Furthermore, nearly half of participants indicated that they would like to receive screening mammogram text reminders.

Conclusion

Significantly more uninsured, foreign-born HW regularly use instant text messaging than the Internet or e-mail. Many would prefer educational information and mammogram reminders via text messaging. Instant text messaging may be an inexpensive community outreach tool to increase mammography use and decrease knowledge gaps among HW in Los Angeles County, thereby decreasing disparities in breast cancer outcomes.

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CATHERINE M. DANG, M.D., SYLVIA ESTRADA, R.N.P., CATHERINE BRESEE, M.S., EDWARD H. PHILLIPS, M.D.

From the Saul & Joyce Brandman Breast Center, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California

Presented at the 24th Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons, January 18-20, 2013, in Santa Barbara, California.

Address correspondence and reprint requests to Catherine M. Dang, M.D., 310 N. San Vicente Boulevard, Los Angeles, CA 90048. E-mail: [email protected]. This research was supported by a grant from the Wasserman Foundation.