Disparities in Knowledge of Mouth or Throat Cancer Among Rural Floridians

In the United States, there will be 52,100 new cases of cancers of the mouth and throat (MTC) diagnosed in the next year, with approximately 11,460 deaths.1 Oral cancer is preceded by visible changes in the oral mucosa, allowing clinicians to detect and treat effectively early intraepithelial stages of oral carcinogenesis.2 Nevertheless, most oral cancers are currently detected at a late stage, when treatment is complex and costly, and poor outcomes are likely. The 5-year relative survival rate among cases localized at diagnosis show disparities between blacks and whites among both males (56% vs 66%) and females (64% vs 71%).3 Lack of awareness among the public of the signs, symptoms, and risk factors for oral cancer, as well as an absence of prevention and early detection by health care providers, are believed to be responsible for the diagnostic delay.4 National data from the 1990 National Health Interview Survey (NHIS) indicated that only 25% of adults could correctly identify one early sign of MTC, and correct identification of risk factors ranged from 13% for alcohol use to 67% for tobacco use.5 Since that time, data from statewide surveys have suggested that levels of knowledge of MTC are increasing.5-9 Generally, there have been 2 strategies used to assess MTC knowledge. The simplest is to directly ask respondents for their subjective rating of MTC awareness—either, “Have you heard of MTC? (often called oral cancer)” or, “How much do you know about MTC?” State-level data from Maryland, North Carolina, New York, and Florida suggest that 15%-20% of residents have never heard of MTC.6-9 The second method to test knowledge has been to ask more specific questions about MTC. Knowledge of risk factors has typically been asked in a format where respondents rate the likelihood of a stated behavior increasing a person’s risk for MTC, often along with several foils. Other studies ask more specific questions about MTC signs and symptoms—often by open-ended questions.6-8 These studies have generally found that respondents know little about MTC. Health literacy refers to the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.10 Low health literacy is common, with a recent review of this literature of studies in the US concluding that 26% of participants were classified as having low health literacy.10 Because low health literacy is so common, it is important to understand how low health literacy can affect one’s health, both directly and indirectly. Our previously published work demonstrates an association between low health literacy in males and lack of MTC exam awareness.11 Also present in the literature are studies exploring the effects of health conditions such as depression on secondary prevention behaviors. For example, data from population-based studies in the US,12,13 Canada,14 and England15,16 have found that higher depressive symptoms predict reduced use of mammography. However, associations between depression and cervical cancer screenings are less consistent.13,14,17 Currently lacking are studies examining the presence or absence of participants’ health literacy levels on screening behaviors, specifically in the presence of chronic conditions such as depression. Also lacking are studies directly assessing health literacy levels, MTC knowledge and/or concern, and depressive symptoms within the individuals’ environmental context; ie, rural versus urban residence. Rural communities face unique and formidable access to care barriers—barriers placing them at a greater risk for experiencing chronic disease and cancer.18-20 Out-migration (leaving rural communities to move to urban areas) of younger residents has resulted in rural communities typically composed of individuals who are older, less educated, more likely to report their health as poor, and have reduced access to primary health care providers.21 Also resulting from geographic isolation and rurality are increased concentrations of minority populations, poor whites, higher rates of unemployment and poverty, and lower rates of education,21 all of which are barriers to accessing health care. Other barriers attributed to geographic isolation include fewer services such as cell phone service, broadband or other high-speed Internet technology.22 Because most health care providers locate in densely populated metro areas, nearly 80% of non-metropolitan US counties are classified as either whole or partial primary health care professional shortage areas (HPSA); 60% of nonmetropolitan counties are in dental care HPSAs. The percentage of rural residents lacking health insurance ranges from 20% to 30%, with lack of dental insurance even more common. Rural residents access health care via small private medical/dental practices or rural health care clinics usually offering limited, episodic and primary care service.18 Assuming improved health literacy results from increased health care provider contact, residents of HPSA are expected to have lower levels of health literacy than those living in urban areas. As a result, lower levels of health literacy, compounded by an overall lack of resources, including medical/dental specialists, cause rural residents to access/receive fewer preventive cancer services than urban residents.23,24 Also adding to the burden of cancer for rural communities is the high prevalence of risk factors such as cigarette smoking, sun exposure, poor diet, physical inactivity, alcohol consumption, and human papillomavirus infection.25,26 Urban residents wishing to access medical/dental care, including examinations for secondary cancer prevention, face far fewer barriers than do their rural counterparts. The formidable barriers faced by rural residents when accessing health care cause them to be at increased risk of late-stage diagnosis for cancer in general.27-30 As a whole, rural residents experience fewer medical and dental visits, spend little to no time using technology, and can have limited access to television and radio. In addition, contact with others is limited by geography and transportation issues. Each of these factors interferes with rural residents’ exposure to knowledge and services, especially in relation to cancer. Limited time with health care practitioners, combined with limited or no access to the Internet and/or other types of technology lowers opportunities for patient education. Although commonly used pamphlets and posters offer cancer information and resources, low levels of literacy, both health and general, limit their educational effectiveness. The aims of this study are to document the level of MTC knowledge and concern among residents of rural North Florida and then to determine risk factors of lack of knowledge and concern. Specific hypotheses include that (1) males, older adults, and blacks living in rural North Florida possess reduced MTC knowledge and concern, and (2) that among this rural sample depression and lower levels of education and health literacy are associated with an individual’s increased risk for low levels of MTC knowledge and concern.