Final Report - Cover Page v1.pptx

Breast Cancer & Eleuthera:
Improving Island Health Based
on Community Needs
Final Report Meg O’Connor, MTSc, MPHc Candler School of Theology, Rollins School of Public Health, Emory University Sara Tomaso, BSNc Nell Hodgson Woodruff School of Nursing, Emory University Alannah Kittle, MPHc Rollins School of Public Health, Emory University Maisie Pinder, Community Outreach Coordinator Cancer Society of Eleuthera/One Eleuthera Foundation Breast Cancer & Eleuthera:
Improving Island Health Based on
Community Needs
Executive Summary Breast Cancer in Eleuthera Partners 300-­‐500 new cases of breast cancer are diagnosed each year in the Bahamas, where the average age of diagnosis is just 42. Despite the young age of diagnosis, many Bahamian women only catch the disease when it is in later, harder to treat stages. Past research suggests Bahamian women are at an increased risk for breast cancer because of a genetic predisposition as well as the increasing Westernization – or more accurately, Americanization – of the Bahamian lifestyle. In Eleuthera speciJically, women face the added burden of having to travel to Nassau to get mammograms. On a low-­‐income, rural island, the additional cost and effort required to get yearly mammograms, plus a number of cultural barriers, creates an environment where women are not taking care of their breast health as actively as they should be. Project Overview This project was carried out over the course of six weeks. Graduate students from Emory University in Atlanta, Georgia, with the Community Outreach Coordinator (COC) from the Cancer Society of Eleuthera (CSE) conducted surveys with a total of 180 women representing each settlement on Eleuthera, Spanish Wells, and Harbour Island. Surveys were used to identify any gaps in or barriers to breast cancer k n o w l e d g e . A f t e r s u r v e y s w e r e administered, the team gave a short presentation, informing the women about breast cancer, breast health, and the services available to them via the Cancer Society of Eleuthera. The ultimate goal of the project was to provide data that can i n f o r m r e c o m m e n d a t i o n s f o r t h e Community Outreach Coordinator’s work. Findings Recommendations The island is not homogenous. Depending on where women live their education, along with their needs, concerns, and access to resources will vary. Trusted messengers are an essential means of spreading information on the island. This includes doctors and nurses for health information and friends and family for events and activities on the island. For education and community engagement programs, divide the island into three regions, the North, Central, and South and create tailored programming. Create and empower trusted messengers by investing in the ongoing health education of the COC, and developing a network of women to represent the CSE in their own settlements. Women want to be a part of the CSE and learn from it, but need to be met where they are, especially in areas where resources are scarce. Establish quarterly meetings or events in each region that bring education to the women. Quarterly meetings allow more planning time for all and would keep the COC’s workload manageable. Foster a sense of community and bonding whenever possible when creating and running educational events. FIMS participants reported positive experiences in being a part of the program. They felt it was a supportive environment that encouraged bonding. In general, there is a lack of awareness and not much of a sense of urgency about breast health. There are also misconceptions about the risk factors for breast cancer. 69% of the women surveyed said they could pay up to $100 for a mammogram. Fear and misconception are powerful forces keeping women from actively getting mammograms.. Nurses have good knowledge of breast cancer and the CSE. Use the quarterly meetings to improve women’s awareness of breast health issues. Learn from existing programs doing breast health education in low-­‐ and middle-­‐resource areas. Explore having women contribute to the cost of their mammograms/travel and possibly increase the number of women who can participate in the FIMS program. Create programs that encourage women to support each other and debunk any myths about breast cancer and the screening process. . Continue to foster positive relationships and open communication with nurses and clinic workers to keep them up to date on research and CSE services. Acknowledgements We would like to thank the following individuals for their guidance and assistance throughout the duration of this project: Shaun Ingraham, One Eleuthera Foundation Caroline Coburn, MS, ANP, DNP, Nell Hodgson Woodruff School of Nursing, Emory University Juanita Pinder, Cancer Society of Eleuthera Sandra Ingraham, One Eleuthera Foundation/Island Journeys Gacintha Gordon, One Eleuthera Foundation Robin Curry, Island Journeys Stephen Holowesko, Ride for Hope Bahamas Mandaleen Thompson, Cancer Society of Eleuthera Rotary International, Eleuthera Branch The Women of Eleuthera, Harbour Island, and Spanish Wells Lilly Webster, DPTc, MPHc, Emory University Table of Contents Program Description .............................................................................................................. 3 One Eleuthera and the Health and Wellness Initiative ........................................................ 3 Cancer Society of Eleuthera and the Community Outreach Coordinator ....................... 3 Emory Global Health Institute ...................................................................................................... 4 Eleuthera & Breast Cancer ............................................................................................................. 4 Project Description ................................................................................................................. 6 Need ....................................................................................................................................................... 6 Research Questions .......................................................................................................................... 7 Stakeholders & Intended Uses ...................................................................................................... 8 Methods ................................................................................................................................................ 8 Sampling ............................................................................................................................................... 9 Project Activities ............................................................................................................................... 9 Instrument Development ............................................................................................................... 9 Tools & Measurement ................................................................................................................... 10 Data Analysis ................................................................................................................................... 10 Results ...................................................................................................................................... 10 Total Population ............................................................................................................................. 10 By Region .......................................................................................................................................... 11 Cancer Society of Eleuthera ........................................................................................................ 11 Nurses ................................................................................................................................................ 11 Limitations ....................................................................................................................................... 12 Findings & Recommendations ......................................................................................... 13 1 ............................................................................................................................................................ 13 2 ............................................................................................................................................................ 14 3 ............................................................................................................................................................ 15 4 ............................................................................................................................................................ 15 5 ............................................................................................................................................................ 16 6 ............................................................................................................................................................ 17 7 ............................................................................................................................................................ 18 8 ............................................................................................................................................................ 18 Conclusion ............................................................................................................................... 18 Figures & Tables Figure 1. Research Questions ....................................................................................................... 6 Table 1. Stakeholders and Intended Uses ................................................................................ 7 Figure 2. Suggested Regions for Focused Education & Outreach .................................. 12 Appendices Appendix 1. Post-­‐Survey Education Presentation .............................................................. 20 Appendix 2. General Survey ....................................................................................................... 27 Appendix 3. Nurses Survey ......................................................................................................... 33 Appendix 4. Data: General Survey ........................................................................................... 37 Appendix 5. Data: General Survey by Region ....................................................................... 41 Appendix 6. Data: Nurses Survey ............................................................................................. 47 2 Program Description One Eleuthera and the Health and Wellness Initiative The One Eleuthera Foundation is an organization built on “bringing together people, resources, and expertise to develop opportunities for all Eleutherans to prosper” and moving Eleuthera, along with Harbour Island and Spanish Wells, towards being a better, healthier, and more sustainable island.1 One Eleuthera currently has three full-­‐time employees but through a number of partnerships both national and international, they are able to expand their organizational and human resources, creating a vast network of support for their projects. Partnerships are in fact key to the organization’s work: “One Eleuthera believes deeply in working collaboratively and expects to advance its goals through partnerships with local and central government officials and organizations such as Chambers of Commerce, Rotary and service clubs, local businesses, international development organizations and other established nonprofits on the island.”1 The organization engages in projects that enhance their five major initiatives on the island: 1) cultural and heritage development, 2) economic development, 3) educational enhancement, 4) environmental sustainability, and 5) health and wellness. This project, which focuses on Eleutheran women’s knowledge of breast health and breast cancer and how that knowledge can inform better health and wellness programs on the island, falls under the umbrella of the One Eleuthera Health and Wellness initiative, which is described by the organization as “a comprehensive approach” that includes the “coordination of research, policy development, strategic planning, and development of a wellness centre.”1 At this time, the Health and Wellness initiative includes this project and a yearly health and wellness symposium. Much of this initiative is still in the developmental phase. Cancer Society of Eleuthera and the Community Outreach Coordinator The Cancer Society of Eleuthera (CSE) is a chapter of the Cancer Society of the Bahamas (CSOB) which specifically serves Eleuthera, Harbour Island, and Spanish Wells. One full-­‐time employee and a number of volunteers currently support the organization, which describes its primary mission as “to shorten the time from initial idea to new treatment — conducting innovative basic research, providing excellent care and significantly strengthening our infrastructure.”2 The CSE works to provide and enhance the offerings for cancer patients on the island of Eleuthera; services include financial support for testing and treatment, counseling for families and patients affected by cancer, and health education outreach around self-­‐examination and monitoring of cancer. Current programs include the Rush for the Cure, an island-­‐wide event bringing cancer education and solutions to the people; the 40-­‐Day Health Challenge, a health and wellness initiative in collaboration with the Eleutheran medical community; twice-­‐yearly, free medical clinics that provide breast examinations, pap smears, and prostate exams; and the Family Island Mammogram Screening program (FIMS) which flies up to 45 uninsured women from Eleuthera to Nassau for mammograms each year. Each month, the CSE holds a public meeting, primarily 1 One Eleuthera website. (Retrieved 3/3/2013). www.oneeleuthera.org Cancer Society Eleuthera website. (Retrieved 3/3/2013). http://www.cancersocietyeleuthera.org/ 2
3 attended by women from the central region of the island, to discuss cancer, the CSE’s programs, and to encourage fellowship. While making sure that all people on the island are aware of the risk factors and treatment options related to cancer is important to the CSE, the organization’s current calendar does not include regular education in a way that is accessible for most people living on Eleuthera. Emory Global Health Institute The Emory Global Health Institute (EGHI) is an academic organization at Emory University in Atlanta, Georgia that acts both independently of and in conjunction with the various schools at Emory University to further global health. Each summer, EGHI supports several Field Scholars Award groups, which are multidisciplinary student teams granted funds to do work advancing health in low-­‐resource settings around the world. By engaging students with backgrounds in at least three different disciplines per team, EGHI encourages students to approach issues from a number of perspectives and to gain experience working within a diverse team. This project was conducted by graduate students representing the Candler School of Theology, the Nell Hodgson Woodruff School of Nursing, and the Rollins School of Public Health. Eleuthera & Breast Cancer As of 2010, neoplasms (or malignant tissue growths) were the second leading cause of mortality in the Bahamas, making up 19.5 percent of deaths in females on the islands.3 Of those cancer-­‐related deaths, 14.6 percent were caused by breast cancer.3 There are roughly 300-­‐500 new cases of breast cancer diagnosed in the Bahamas each year, with the average age of diagnosis at 42, significantly lower than the average age of diagnosis in the United States (61).4,5 In fact, a retrospective study conducted by Hurley et al. found that in the Bahamas, 48 percent of the patients with breast cancer are less than 50 years old.6 In addition to the young age of diagnosis, 48 percent of the patients also present with Stage III breast cancer at the time of diagnosis.6 Furthermore, Dr. Hurley’s data suggests that the high prevalence and young age of diagnosis of breast cancer in the Bahamas is in part due to the presence of the BRCA1 and BRCA2 (breast cancer susceptibility) gene mutations, and as a result, genetics plays an important role in Bahamian breast cancer. Breast cancers caused by BRCA gene mutations are more likely to be triple negative, meaning estrogen receptor-­‐
negative, progesterone receptor-­‐negative, and HER2/neu-­‐negative.8 These triple negative cancers are found more often in younger women and are usually more aggressive than PAHO. (Retrieved 3/3/2013). http://ais.paho.org/phip/viz/mort_chapters_en.asp Akbari M.R., Donenberg, T., Lunn, J., Curling, D., Turnquest, T., Krill-­‐Jackson, E., Zhang, S., Narod, S.A., and Hurley, J. (2013). The spectrum of BRCA1 and BRCA2 mutations in breast cancer patients in the Bahamas. Clinical Genetics. Vol. 10.111 5
SEER Fact Sheet. (Retrieved 6/20/2013). http://seer.cancer.gov/statfacts/html/breast.html 6
Hurley, J., Lunn, J., Turnquest, T., Reis, I., Doliny, P., Donenberg, T., De Zarraga, F., and Mirhashemi, R. (2003). Breast cancer in the Bahamas: Preliminary evidence for a high incidence of genetic risk. American Society of Clinical Oncology. Volume 22. 3
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4 estrogen receptor-­‐positive types.8 Thus, mutations on the BRCA1 and BRCA2 genes confer a 10-­‐30 times greater risk for developing breast cancer compared to the general population.7 The prevalence of these gene mutations is higher in the Bahamas than in any other country; some data even suggest that Bahamian women are twice as likely to have a BRCA1 gene mutation compared to the general population.4,8 24-­‐27 Percent of breast cancer cases in women in the Bahamas can be attributed to mutations in the BRCA1 or BRCA2 genes, which is the highest percentage in any population worldwide of breast cancer cases caused by these genetic mutations.4 Although women in the Bahamas have a unique genetic predisposition to the BRCA gene mutation, other factors have been identified that contribute to the decreasing age of diagnosis in low-­‐ and middle-­‐resource countries. Factors include shorter time breastfeeding, fewer children, and a decrease in physical activity.9 These factors are common among women in populations that are becoming increasingly westernized, including the Bahamas.9 With an increased likelihood for being diagnosed with breast cancer, Bahamian women should be actively monitoring their breast health. Nevertheless, there are numerous individual-­‐ and system-­‐level barriers preventing breast cancer screening on Eleuthera, most of which are related to a lack of breast health knowledge and the isolated nature of an island population. Studies conducted with low-­‐resource populations have recognized common barriers that typically underlie low screening rates, including inadequate knowledge related to screening, fear of a positive cancer diagnosis, “lack of motivation, inadequate transportation, lack of health insurance, lack of physician screening recommendation, and poor availability of screening facilities.”10 Unfortunately, there is an absence of information on breast cancer in the Bahamas specifically, which highlights the need for more research focused solely on how the disease affects Bahamian women. Because of the lack of literature on breast cancer in the Bahamas, it is difficult to establish any baseline understanding about how the women of Eleuthera are affected by and feel about breast cancer. However, a significant amount of research has been conducted focusing on the disease in both African and African American women. Given the similarities among these three groups, African and African American women can serve as proxies for Bahamian women. Firstly, these populations have disproportionately high mortality rates associated with breast cancer.11 Such high mortality rates in these groups of women can be attributed in many cases to factors such as “lower socioeconomic status, diagnostic and treatment delays, and advanced stage of disease at diagnosis.”11 On Eleuthera, for example, because all screening and treatment must be conducted off-­‐island, every woman must be flown into Nassau for the Christinat, A. & Pagani, O. (2013). Practical aspects of genetic counseling in breast cancer: Lights and shadows. The Breast. http://dx.doi.org/10/1016/j.breast.2013.04.006 8 Susan G. Komen, Research Fast Facts: BRCA. (Retrieved 6/20/2013). http://ww5.komen.org/uploadedFiles/Content/AboutUs/MediaCenter-­‐2/BRCA%2010-­‐01-­‐
12%20Final.pdf 9 Yip, C-­‐H., Smith, R., Anderson, B., Miller, A., Thomas, D., Ang, E-­‐S., Cafarella, R., Corbex, M., Kreps, G., and McTiernan, A. (2008). Guideline Implementation for Breast Healthcare in Low-­‐ and Middle-­‐Income Countries: Early Detection Resource Allocation. American Cancer Society, Wiley Interscience. (interscience.wiley.com). 10 Davis, T., Arnold, C., Rademaker, A., Bailey, S., Platt, D., Reynolds, C., Esparza, J., Liu, D., and Wolf, M. (2012). Differences in Barriers to Mammography Between Rural and Urban Women. Journal of Women’s Health. Volume 21, No. 7. 11 Gregg, G. (2009). Psychosocial Issues Facing African and African American Women Diagnosed with Breast Cancer. Social Work in Public Health. Issue 24. 7
5 day to receive her mammogram and any patient with a cancer diagnosis must make multiple trips to undergo any treatments for their condition. The second way in which African, African American, and Bahamian women experience breast cancer similarly is their tendency to present in later stages at diagnosis, as well as with larger and more aggressive tumors.11 Finally, cultural barriers among these populations are alike and include misconceptions related to the causes of breast cancer and perceptions of fatalism related to the diagnosis. Many studies have found that African American women believe the diagnosis of breast cancer is out of their control and that God will lead them to the desired outcome.11 In a country such as the Bahamas, where faith is an integral aspect of daily life for many, these beliefs are present and indicate a need for health care providers and religious leaders to work together in approaching cancer education from both a medical and cultural standpoint. In addition, in family-­‐centered cultures, such as African American, African, and Bahamian populations, cost of screening and treatment are weighed against the need to provide for the children in the household.11 It is essential for women to be educated in a way that emphasizes the need to take care of themselves first so they are able to live a longer life and take care of their children. Finally, it is important to understand the health care infrastructure of Eleuthera. Healthcare services on the island are driven by the Ministry of Health (MoH) which operates four primary health clinics on the island. Each primary clinic is supported by a number of smaller, satellite clinics. The primary clinics are located in Governor’s Harbor, Rock Sound, Hatchet Bay, and Harbour Island. Services offered at the primary clinics include pharmacies, family medicine, family planning, pediatrics, immunizations, home health, school health, disease surveillance, ambulatory and emergency care, and general clinic service.12 There are currently no hospitals on Eleuthera and as such, the clinics are essential to the care of the islanders. Additionally, none of the clinics are equipped to provide breast cancer-­‐specific treatment. The closest mammogram facility is located on Nassau and Eleutheran women who receive a positive diagnosis of breast cancer ultimately seek treatment in either Nassau or the United States. Without screening and treatment facilities on-­‐island, for women on Eleuthera diagnosing and treating breast cancer carries additional expenses of travel and housing. Project Description Need Given the high incidence of breast cancer diagnoses on the island and the relatively low resources on the island, cancer is an important issue for Eleuthera to address. Recently, One Eleuthera, in partnership with CSE, secured funding through a grant from the Susan G. Komen for the Cure organization for the creation of a new position in order to take on the task of bringing together individuals and organizations on the island in order to better facilitate cancer screening, prevention, and treatment. The position of Community Outreach Coordinator will promote the CSE’s current services, lead cancer-­‐ and wellness-­‐related education efforts among the general population, connect Eleutherans in need of cancer treatment with the right people and organizations, build relationships with various Ministry of Health website. (Retrieved 3/3/2013). http://www.bahamas.gov.bs/wps/portal/public/About%20Us/About%20MOH 12
6 community members on the island, and act as a liaison between the CSE and its partner organizations. The intent of this project is to provide the Community Outreach Coordinator with information that will allow her to better focus her efforts and tailor any education to the unique needs of the Eleutheran women. This report can help those efforts by identifying the current gaps in as well as the barriers to breast cancer-­‐related knowledge and service. The report also provides One Eleuthera and the CSE with recommendations for how to improve breast cancer knowledge and outcomes on the island as efficiently and effectively as possible. Research Questions Prior to beginning the survey and education process, the team collaborated with both One Eleuthera and the CSE to determine what each partner in the project hoped to achieve through this research. Subsequently, a four-­‐part research question was developed to help guide all project activities and outputs. (See Figure 1.) Figure 1. Research Questions Given the high incidence of breast cancer on Eleuthera and the toll the disease takes on women here: What is the level of breast cancer knowledge among women on Eleuthera? Are women actively getting screened, and if not, what are the barriers holding them back? Are women here aware of their unique genetic predisposition to the BRCA gene mutation? Are women familiar with the Cancer Society of Eleuthera and are they taking advantage of its services? The goal of each part of the research question is to determine how each of the stakeholders can best approach the women on the island to a) improve education regarding breast health and break down any barriers to screening, b) educate women about the genetic predisposition in the Bahamas, and c) shape programs and services as well as the communication about those programs/services to best reach and engage women. 7 Stakeholders & Intended Uses Stakeholders are individuals and organizations who have a vested interest in a program or project’s functionality and/or success. The stakeholders for this project include the CSE, One Eleuthera, Ride for Hope, and EGHI. Below are the ways in which each of the identified stakeholders is likely to utilize this report. (See Table 1.) Table 1. Stakeholders and Intended Uses Stakeholder Cancer Society Eleuthera One Eleuthera Foundation Ride for Hope Emory Global Health Institute Intended Use To inform programming and the allocation of outreach and education efforts as well as funds To make a compelling case to donors for the need for a mammogram machine on the island To use as a reference tool when exploring ways to improve the number of breast cancer screenings available to each woman on the island To make a compelling case to donors for the need for a mammogram machine on the island To make a compelling case to researchers involved in genetic testing to study the island’s women and provide them with free or low-­‐cost genetic testing To contribute to the base of health and wellness information about the island and provide a foundation of knowledge for future health and wellness projects To support on-­‐going efforts to raise funds that sustain the FIMS program To establish baseline knowledge that can be built upon by future EGHI studies on Eleuthera Methods This project utilized written surveys that were administered to women ages 30 and older in each settlement on the island. The aim of the survey was to establish baseline knowledge and understanding among women on Eleuthera in regard to both breast cancer and the CSE; essentially functioning as a community needs assessment tool. The surveys were also designed to discover any disconnects between the way the CSE currently functions and communicates with women on the island, according to those women, and the way CSE as an organization feels it is functioning and communicating. The surveys included questions aimed at gathering both quantitative and qualitative data. The research for this project was conducted over a six-­‐week period and lead by the EGHI team in conjunction with the Community Outreach Coordinator. 8 Sampling In order to ensure representation from women all over the island, we endeavored to collect completed surveys from women in every settlement. The island was divided into three regions: South (Tarpum Bay and below), Central (Palmetto Point to Gregory Town), and North (all settlements north of the Glass Window Bridge, including Spanish Wells and Harbour Island). We visited settlements in a systematic manner, first focusing on the South, then working with the North, and finally the Central area. The project utilized convenience sampling methods; leveraging the existing relationships between the Cancer Society and One Eleuthera staff, we were able to reach out to key contacts in each settlement and through them coordinate gatherings of women in each settlement. Where possible, we tried to engage existing women’s groups (church groups, for example) in order to maximize the number of women we could reach at each settlement as those meetings would already be scheduled and part of the women’s regular calendars. Recruitment occurred through word of mouth, as well as flyers posted in churches and community centers where possible. Project Activities The research sessions consisted of two parts: the survey and a short educational presentation. To begin the meeting, we introduced ourselves and explained that we would be conducting a survey about breast cancer, followed by a short presentation on breast cancer and the CSE. We explained that only women 30 years old and older would be able to participate; the age eligibility requirement was determined by the particularly young age of diagnosis (42 years) in the Bahamas and by the Cancer Society of the Bahamas’ recommendation that Bahamian women begin screening for breast cancer at the age of 30. Next, for those who had agreed to participate, consent forms were distributed and explained and the women initialed them to indicate their consent. The survey was distributed and the women were encouraged to work alone but to ask the researchers for clarification whenever needed. Additionally, participants were also provided assistance upon request; for those women who were either struggling with low literacy or unable to see the writing clearly, the survey was read to them and when necessary, answers were recorded for them. Upon completion of all the surveys, the women were thanked for their participation and a short presentation was given to the women which focused on three areas: breast cancer and the Bahamas, the CSE and its programs, and the project’s purpose. (See Appendix 1 for the Post-­‐Survey Education Presentation.) Instrument Development The survey was developed using several sources of input. The first questions developed were designed to assess basic demographic information about the women being surveyed, including (but not limited to) age, Bahamian nationality, settlement of residence, history of mammogram, and breast cancer status. Next, data from a 2010 Emory Global Health Institute Field Scholars project’s preliminary findings presentation, which focused on breast cancer and genetics, was used to guide in the development of questions such as “what do you believe are the causes of breast cancer,” and “have you been tested for the BRCA gene mutation?” Once the basic questions were compiled, an input meeting with representatives from One Eleuthera and the CSE was held to assess what each of those two stakeholders hoped to gain from the project. Using this information, additional questions were developed that would help to ascertain women’s income levels, whether or not they are the head of their household, and if there are any skills or crafts they might like to learn in the event that they are unemployed, among many others. The questions were then 9 reviewed and rephrased to simplify the language as much as possible, to improve readability for participants with lower literacy levels. The survey was then reviewed by two female employees of the CSE for cultural appropriateness and readability before being finalized. (See Appendix 2 for the General Survey and Appendix 3 for the Nurses Survey.) Tools & Measurement The survey was divided into three general sections. The first section focused on identifying the women’s basic knowledge of and experiences with breast cancer and screening. The second section served to determine if the women had any knowledge of the CSE’s breast cancer-­‐related programming, and to ascertain the women’s perceptions of the CSE. The third and final section was primarily demographic; it identified the women’s settlement of residence and employment and economic status. Questions were created to elicit a mixture of answer types. Several demographic questions required yes/no answers or multiple choices where all relevant answers could be checked. Questions geared towards gaining opinions about breast cancer and the CSE were on five-­‐point Likert-­‐scales (“strongly disagree” to “strongly agree”). Questions geared towards ascertaining familiarity with CSE programs were measured on a Likert-­‐like scale with three points that included “I have not heard of this,” “I have heard of this,” and “I have participated in this.” Additionally, many of the yes/no questions were accompanied by follow-­‐up questions that asked why the respondent answered either yes or no. The goal of these questions was to elicit more in-­‐
depth answers regarding the respondent’s motivations for any actions or inactions (for example: “if you responded that you did NOT have a mammogram, please tell us why you did not do it” or “if you do feel that you are at risk for breast cancer, please tell us why”). Data Analysis The data gathered was analyzed via IBM SPSS statistical software. Statistical tests were used to identify, where appropriate, the means, medians, standard deviations, frequencies, and percentages for each variable. Bivariate tests were run on several pairs of variables, which will be further discussed in the Results section. (See Appendices 4 and 5 for the General Survey data and Appendix 6 for the Nurses Survey data.) Results Total Population A total of 180 women from Eleuthera (including Spanish Wells and Harbour Island) participated in the survey, with Harbour Island (11%, n=19), Wemyss Bight (10%, n=18), and Governor’s Harbour (8%, n=14) having the most participants. The average age of respondents was 51 years (sd=11.43), and almost all (97%, n=175) identified themselves as Bahamian. Island-­‐wide, half of respondents (50%, n=90) had a secondary school education, while 23 percent (n=41) had attended college. Around 64 percent (n=108) of women indicated that they were employed. While 42 percent (n=73) made less than $15,000 a year, and 54 percent (n=93) do not have private insurance, 69 percent (n=114) of respondents indicated that they would be able to pay up to $100 for breast cancer screening or treatment services. 10 Most women (69%, n=122) answered yes to the question “have you ever gotten a mammogram?” However, more than half of women surveyed (58%, n=97) do not think that they are at risk for breast cancer, with 8 percent (n=14) of women indicating that they do not know whether they are at risk. A majority of respondents (73%, n=129) had never heard about the BRCA gene; however, 84 percent (n=135) said that they would get genetic testing to determine if they were at an increased risk for getting breast cancer if it were available at a free or reduced cost. By Region The variables were also considered by region. For this analysis, the North includes both Spanish Wells and Harbour Island. Secondary school (up to 12th grade) was the highest average level of education in each region (South=43%, Central=54%, North=58%). However, for those whose highest level of education was primary school there were large regional differences; the South had the highest percentage (23%) of women who had only completed primary school, while the Central and North regions had 12 percent and 4 percent of women, respectively, who had only completed primary school. A statistically significant relationship (x2=6.21, df=2, p=.045) was found between what region a respondent lived in and whether or not the respondent had heard of the BRCA gene, with 20 percent in the South answering that they had heard of it, followed by 25 percent in the Central region, and 41 percent in the North. Statistically significant relationships by region were also found for the belief that only a doctor or a nurse can do a breast exam (x2=7.50, df=2, p=.023); 20 percent of women surveyed in the South either agree or strongly agree with the statement “only a doctor or a nurse can do a breast exam,” while only 5 percent of women in the Central and 9 percent of women in the North agree. No significant relationships were found between the following pairs of variables: region and whether or not the participant had gotten a mammogram, region and education level, and region and whether or not the participant has insurance. Also when considered by region, insurance status was also found to have no significant relationship with whether or not a participant had gotten a mammogram. Cancer Society of Eleuthera An assessment of participants’ knowledge of the Cancer Society of Eleuthera indicates that a majority are aware of or have used the resources provided by the Cancer Society: 74 percent have either heard of or participated in FIMS, and 73 percent have either heard of or participated in the twice-­‐yearly free medical clinics. While not statistically significant at 95 percent confidence, (x2=5.70, df=2, p=.058), those close and therefore still worth noting is the relationship between the belief that the Cancer Society of Eleuthera does good work and the region where the respondents live; 18 percent of northern and 12 percent of southern respondents disagree with this statement while 97 percent of those in the central region agree, believing that the CSE does good work to help Eleutherans. Nurses Twelve nurses from various clinics across the island were also surveyed; the mean age was 40 years (sd=11.44). Over half (58%, n=7) of the nurses surveyed had had a mammogram. All (100%, n=12) believe family history to be a cause of breast cancer, while half incorrectly believe injury to the breast to also be a cause of breast cancer. A majority of 11 nurses (83%, n=10) had heard about the BRCA gene, and almost all (92%, n=11) answered that they would encourage their patients to get genetic testing if it were available. All nurses indicated that they taught their patients how to do a breast self-­‐exam. With regards to CSE programs: 8 percent (n=1) had never heard of the FIMS program, 25 percent (n=3) had no knowledge of cancer awareness training seminars, and 17 percent (n=2) had never heard of the CSE’s free medical clinics. A quarter of nurses (25%, n=3) did not know where FIMS forms were in their clinics. Limitations Throughout the project there were a number of factors that limited the way the project was carried out. The first and most important limitation was the fact that a majority of our team members were outsiders; we had restricted knowledge of the culture and the people. We found that, culturally, the Bahamian attitude is typically laid back and coupled with initial skepticism about researchers from the United States, it often proved difficult to get large numbers of women to attend meetings and for those who did attend, it was difficult to get them to engage in the material presented. Having the Community Outreach Coordinator, who is Bahamian, as part of our team however helped significantly, providing us with the ability to identify and contact different members of each community in order to organize meetings. Furthermore, her presence and support of our work gave us more legitimacy at meetings as well as provided us with a resource we could tap into whenever we had questions about Bahamian culture. Next, low literacy was an important limitation we encountered, especially in the South where 23 percent of respondents had attended only primary school. The low rates of literacy first came to our attention during the early stages of our project when we noticed that many surveys would return half-­‐completed, despite the fact that respondents spent over 30 minutes with the questionnaire. Unfortunately, in order to reach as many women as possible in as timely a manner as possible, we were unable to read the surveys to each participant one-­‐on-­‐one. In order to correct for the low literacy and still remain as efficient as possible, we offered to read surveys to any respondents who wanted assistance or “may have forgotten their reading glasses.” We also emphasized that we were available to answer any questions that they may have and that there were no wrong answers. By attempting to correct for limited literacy in this way, however, we came up against a concern that we could possibly be influencing their responses or make them uncomfortable answering specific questions (such as how much money they made). A third limitation was the lack of transportation on the island which made it difficult to get women to meetings; this was compounded by the fact that the weather tended to play a large role in whether or not people attended our meetings. Rain or the threat of rain served as a significant deterrent to attendance, and with several weeks of rain during our surveying, attendance in several settlements was lower than we would have liked. The project’s short time frame of six weeks was an important fourth limitation. The time frame restricted our ability to pilot test the survey with more than one or two women and as such, we were unable to correct for any confusing questions or adjust the survey if necessary. For example, many of the women surveyed appeared to have been unfamiliar with Likert scales but without proper piloting, we were unaware of this and thus unable to adjust the survey appropriately. Reading the surveys to some women, however, did help us to correct for any confusion with particular questions. The final limitation of this study includes the sampling method used. Convenience sampling resulted in the participation of primarily older women in the many of the settlements, despite the fact that ideally we would have had a greater representation of 12 younger women because Bahamian women are prone to diagnosis at a younger age. We attempted to correct for this early on by switching to evening meetings in order to capture employed and younger women. In addition, convenience sampling led to each settlement having varying numbers of participants, resulting in some settlements being more overly represented than others. Despite the drawbacks of convenience sampling, the method did allow the Community Outreach Coordinator to get some time, face to face, with women in each settlement. Findings & Recommendations 1 Despite a stable population and fairly limited geographic coverage, Eleuthera is far from homogenous. By holding groups in each settlement, we noticed quite clearly that there are three distinct regions on Eleuthera -­‐ the North, the Central, and the South -­‐ each of which has its own needs, concerns, and capacities. This segmentation is particularly noticeable in terms of education; in the South, 23 percent of women surveyed have no more than a primary school education, while in the North, just 4 percent of women surveyed had only a primary school education. Because education is an indication of literacy levels, contrasts such as this highlight how, despite being a relatively small island, Eleuthera has a great deal of diversity within it that must be taken into consideration when planning and executing any type of effective programming. Recommendation We recommend dividing the island into four distinct regions when planning programming. We suggest using the previously-­‐established Administrative Regions for Eleuthera specifically coupled with a fourth region that consists of Harbour Island. The regions would appear as follows (see Figure 1): Figure 2. Suggested Regions for Focused Education & Outreach Lower Bogue, Upper Bogue, Bluff, Current, Current Island, Spanish Wells, Harbour Island Gregory Town, Hatchet Bay, James Cistern, Governor’s Harbour, Palmetto Point, Savannah Sound Tarpum Bay, Rock Sound, Green Castle, Deep Creek, Waterford, Wemyss Bight, John Millars, Bannerman Town By dividing the island thusly, the Community Outreach Coordinator can create tailored programming that provides education that is relevant to the women given their specific literacy levels, existing breast health awareness, and general concerns. For example, in the South, basic scientific concepts such as cells would have to be discussed prior to any talk of genetics and the role they play in cancer. In the North, on the other hand, education may 13 begin at a slightly more advanced point. In essence, we recommend that a one-­‐size-­‐fits-­‐all approach be avoided given that our data reveals a significantly varied population. 2 Trusted messengers are key means of spreading and gaining information on the island. According to the results of our research, women on the island get health information from the clinics, doctors, and nurses and all other information is gained primarily through word of mouth among friends and relatives. These results suggest that trusted messengers, who are defined ”natural leaders that can positively influence the thoughts and behavior of a community,” are essential to the spread of information on Eleuthera.13 Recommendation We recommend investing in the cultivation of trusted messengers in the following ways: First, as a native Eleutheran as well as a representative of a health organization, the Community Outreach Coordinator is in the unique position to represent the two most important types of trusted messengers identified by our results: the friend/family and the health professional. In order to ensure that the Community Outreach Coordinator remains a viable source of information for the island’s women, there must be a significant investment made in her own cancer and health education. Budgeting time and funds to ensure that she is well-­‐versed in all things cancer is essential; to be considered an authority, her constant education, which can be achieved via webinars, seminars, and connections and relationships with experts, must be a priority. In addition to education for the Community Outreach Coordinator, constant efforts to strengthen partnerships with the Cancer Society of the Bahamas and the Breast Cancer Initiative to streamline education efforts, services, and communication will enhance the knowledge base and authority of the Community Outreach Coordinator. Second, recognizing the importance of friends and family in spreading information on the island, establishing a formal network of women -­‐ ideally 1-­‐2 from each settlement -­‐ who can be educated by the Community Outreach Coordinator and act as the local spokeswomen for the CSE can have several benefits. First, these women can extend the reach of the Community Outreach Coordinator by helping her to organize meetings and identify gaps in education/awareness in their respective communities. Second, they can capitalize on their own positions within their local networks that give them influence among their peers. Finally by investing these women with knowledge and authority, they will be empowered, taking their own health and that of the women in their networks into their own hands. Both of these recommendations-­‐ investing in the continuing education of the Community Outreach Coordinator and the establishment of a network of women who can act as local CSE advocates -­‐ have the added benefit of extending the reach of the island’s overburdened and limited number of health professionals. 13 Missouri Foundation for Health. (Retrieved 6/20/2013). http://www.mffh.org/mm/files/healthpromotionforyouth.pdf 14 3 Women want to be met where they are, both physically and in terms of education level and concerns. On a whole the women surveyed indicated that they were eager to hear from the CSE and to learn what they could do to be actively involved in bettering their own health and reducing their risk of suffering from breast cancer. Unfortunately, transportation is not always readily available, especially in the lower-­‐resource South, and meetings held at the CSE headquarters in Palmetto Point simply are not accessible to all. Furthermore, as noted in the first finding, depending on where a woman lives her needs and level of education will vary. The difficulty described by the women in terms of transportation in particular suggests that holding events and programs in the Central region results in many women who would like to participate opting out. Recommendation The recommendations listed for Findings 1 and 2 will also address this finding. Furthermore it is recommended that the CSE establish quarterly meetings in each region. In speaking with women at the preliminary findings meetings (which were regional), we found that asking women to meet each month might be a challenge. Additionally it would be a lot to ask of the Community Outreach Coordinator to not only develop new educational programs and materials each month but also to coordinate and execute those meetings in the various regions each month. In addition to keeping the Community Outreach Coordinator’s educational outreach workload from becoming unmanageable, quarterly meetings would allow for adequate time to promote meetings and in doing so, would ideally increase attendance. The more women are able to plan for and attend each meeting, the greater the reach the CSE’s messages will have. 4 There were a number of women who were surveyed that reported having participated in the FIMS program. During the post-­‐survey education and discussion, many of the FIMS participants spoke positively about the program and in particular mentioned how helpful it was to go through the experience as a part of a group. The women reported feeling supported, which was especially meaningful given that many of them were apprehensive about having the test done. Recommendation Given the positive feedback reported by the FIMS participants regarding the bonding aspect of the program, it would be beneficial to the CSE to try to replicate that sense of community and mutual support in other programs. Support can be crucial during a process that can often be tinged with fear, so keeping this in mind while developing programs can result in more sensitive, relevant, and helpful programming. Davis et al., for example, surveyed women in rural Louisiana and found that 89 percent of participants said if there was someone in their life, especially a child, mother, or sister, who told them to get a mammogram they would do it.10 Given the similarities between African American women in rural Louisiana and Bahamian women in other aspects of breast health, this is a number worth mentioning. When motivated by those whom they consider important to them, women are more likely to take steps to improve their own health. On Eleuthera and in terms of breast health, this could involve the development of smaller support groups or even teams for events such as the Fun Run Walk and Rush for the Cure. Another interesting approach is being taken by some hospitals in the United States, which are hosting 15 “mammogram parties,” where women come together to receive spa treatments, socialize, and receive their annual mammogram. Feedback among participants emphasizes a decrease in stress and fear associated with breast cancer screening, as well as an enjoyable experience overall. A program modeled like this, where women come together to bond and participate in fun activities on the day of their mammogram may increase overall reception to screening among Bahamian women. 5 There is a need for more education and awareness regarding breast cancer as well as clarification about its risk factors. In addition to low levels of literacy and general education, too many women do not know enough about breast health, breast cancer, or the options available to them for detection and treatment. The numbers reveal gaps in awareness: 31 percent of the women we surveyed had still not had a mammogram despite having surpassed the age of 30 (the age at which the CSOB recommends beginning yearly mammograms) and 69 percent of the women surveyed do not believe that they are at risk for breast cancer; 10 percent of the women surveyed in the South felt that only a nurse or doctor could do a manual breast examination; and 37 percent of the women surveyed (n=66) falsely believe that breast cancer is caused by injury to the breast, a belief that research has found to be common among many African American women as well.11 Between the lack of concern for or understanding of their own health and misconceptions about the disease’s likely causes there is a significant need for time and energy to be directed towards improving the women’s knowledge and awareness of breast cancer. Recommendation We recommend the creation of regular learning opportunities for women on the island. The quarterly education meetings suggested by Recommendation #3 would be the ideal setting to share accurate and relevant information about breast health. In terms of the content of these learning opportunities, the existing literature on breast health education in low-­‐ and middle-­‐resource countries can provide a helpful guide. Literature focused on improving breast health in low-­‐ and middle-­‐ resource countries places an emphasis on educating women on the signs and symptoms associated with breast cancer, as well as the importance of regular breast self-­‐examinations (BSEs) and clinical breast examinations (CBEs).9,14 Such education empowers women to feel in control of their own health, which will ideally help women to detect breast cancer at an early stage, leading to decreased mortality rates.9 One of the most important pieces of information to emphasize in breast health is the awareness that breast cancer is treatable, and that if it is caught early there are much better outcomes, including treatment options that do not require a mastectomy.14 Any time women are gathered for CSE-­‐related programs and events should be seen as an opportunity to improve their breast health knowledge; in fact the work of Knaul et al. suggests the importance of capitalizing on every opportunity possible to educate women on breast cancer.15 Providing education related to risk factors, signs and symptoms, BSEs, and CBEs during reproductive and maternal health visits can maximize the number of women 14 Anderson, B., Cazap, E., Saghir, N., Yip, C-­‐H., Khaled, H., Otero, I., Adebamowo, C., Badwe, R., and Harford, J. (2011). Lancet Oncology. Volume 12. 15 Knaul, F., Bustreo, F., Ha, E., and Langer, A. (2009). Breast cancer: Why link early detection to reproductive health interventions in developing countries? Salud Publica de Mexico. Volume 51, Supplement 2. 16 receiving breast health information, as well as target the younger population.15 Messages regarding breast health should be presented in vivid presentations that are culturally appropriate, including narratives of breast cancer survivors and visual illustrations of BSEs and healthy habits to help engage women in a greater way.9 Breast health awareness needs to be the most basic level of any program implementation to lower mortality rates.9 On Eleuthera, each FIMS trip could support an educational component ensuring that participants would ultimately learn more about breast health than simply the results of their mammograms. Finally, the CLEAN (Culture, Literacy, Education, Assessment, and Networking) model developed by Meade et al. for creating relevant community outreach work is a helpful framework to use when trying to develop culturally-­‐relevant breast health programming.16 The model can help those in a planning position to understand barriers and beliefs in the community and in turn implement the most appropriate educational methods in each community. Given our finding that the island is not homogenous and each region has its own needs, the CLEAN model can be used to help identify the different needs and concerns in each region in a systematic way. Along these lines, we suggest identifying common beliefs about the causes of breast cancer (for example, that injury to the breast can cause the disease) and drawing up well-­‐researched explanations that either support or debunk these beliefs. 6 69 Percent of the women surveyed reported that they could contribute up to $100 for a mammogram. On a low-­‐resource island like Eleuthera, a program like FIMS, which fully covers the cost of a woman’s mammogram (flight to Nassau included), is a game-­‐changer for many women who simply cannot afford to travel to Nassau and have their breasts checked. Because, however, FIMS does cover the entire cost per woman, it seriously limits the number of women which it can include each year. Our survey found that 69 percent of the women we spoke with could pay up to $100 for a mammogram. This information has important implications for the FIMS program: if women participating in FIMS were to contribute to the cost of their test and travel, perhaps their funds could stretch the Ride For Hope-­‐sponsored funds and in doing so, allow for more women to be tested. By ultimately subsidizing the cost of another woman’s test and travel expenses, the women of Eleuthera would have another way of taking their own health and that of their female friends and family into their own hands. Recommendation We recommend exploring the viability of increasing the number of women who are able to participate in the FIMS program each year by having those women who can contribute to the cost of the flight/mammogram subsidize the cost of those who cannot contribute. This would require the admittedly complicated development of a pay scale. Health centers that work on a pay-­‐what-­‐you-­‐can model exist all over the world, in both urban and rural settings and we suggest looking to organizations like the Good Samaritan Health Center in Georgia and the Aravind Eye Clinics in India for guidance on how to implement a successful pay-­‐what-­‐you-­‐can model in low-­‐resource, rural areas. Such a model could have the potential to significantly increase the number of women on the island who can receive mammograms. 16 Meade, C. Menard, J., Martinez, D., and Calvo, A. (2007). Volume 14, No. 1. 17 7 Many women are put off from getting a mammogram because of fear or other misconceptions. Five percent of the women we surveyed reported not getting a mammogram because they were afraid or simply did not want to know their breast cancer status. During the post-­‐education discussions, many women expressed fear of the mammogram itself, citing that they had heard it was painful. We did our best to reject that notion, and encouraged those women who had had mammograms to explain to those who had not that it was merely uncomfortable but that the discomfort of a few moments was far preferable to the pain and hardship inevitable if one were to wait until the disease had progressed to a late state before detecting and treating it. Recommendation We recommend two primary methods of dealing with the barriers of fear and misconception. First, we suggest encouraging women to talk openly with one another and dispel myths about mammograms. The creation of programs that support bonding will help to create the kind of environment needed to foster such frank conversations. Second, the development of truthful rebuttals to the myths associated with mammograms and treatment, as noted in Recommendation 5, can help to break down the barriers caused by fear and misconception. Such rebuttals must be grounded in research but also presented in a way that does not scare the women. 8 Nurses are well educated on breast health but could benefit from regular contact with and updates from the CSE. Overall the nurses surveyed reported good knowledge of breast health, breast cancer, and the detection and treatment options available to women on Eleuthera. They were familiar with the FIMS program and recommended it to their patients. While there were some CSE-­‐sponsored programs that the nurses were unaware of, it should be noted that the sample size was fairly small and that while they may have not be familiar with the programs prior to taking the surveys, upon completion of our post-­‐survey education, they were all up to date on the programs and resources offered by the CSE. Recommendation Given that the results of the nurses’ surveys showed no real gaps in breast health and breast cancer knowledge, our only recommendation is to continue to foster positive relationships and regular communication with the nurses and clinic workers so that the island’s health professionals are always aware of the latest cancer-­‐related information as well as the programs and resources available to the island’s women via the CSE. Conclusion Eleuthera, though highly susceptible to breast cancer because of both genetics and, likely, lifestyle, is populated with women who are eager to learn more about how they can take control of their own health and improve not only their own lives but those of the women around them. While low education levels and a lack of financial resources are barriers that at present hold women back from actively getting screened for breast cancer, these are 18 barriers that can be addressed by investing in education and outreach that is truly tailored the needs of the women on the island. The establishment of the Community Outreach Coordinator position is the first step in breaking down those barriers and by organizing her time and energy in ways that are have been identified by this project, the CSE can begin to develop networks, programs, and relationships that can effectively and efficiently improve the health of women in every settlement. 19 Appendix 1. Post-­‐Survey Education Presentation Breast Cancer & The Bahamas
Maisie Pinder
Cancer Society Eleuthera
Meg O’Connor
Alannah Kittle
Sara Tomaso
Emory University
20 In the Bahamas…
300-500 new cases of breast cancer
are diagnosed each year
The average age of diagnosis is 42
The BRCA (‘bracka”) gene mutation is more
common than in any other country
24-27% of breast cancer is caused by
the BRCA gene mutation
21 Get Screened!
ª  Women
who get early
screening and treatment
have a 98% chance of
survival
ª  Don’t
just do it for you – do it for your
family too!
ª  Mammograms are free through
Cancer Society Eleuthera
22 Cancer Society Eleuthera
Family Island Mammogram Screening
ª 
Mammogram: a test
that can detect
tumors or masses
that might be cancer
ª 
You can participate if:
•  You are female, age 30
or older
•  You have never
participated in FIMS
•  You do not have
insurance
ª 
Registration forms
are available at clinics
and the Cancer
Society’s
headquarters in
Palmetto Point
23 Cancer Society Eleuthera
Services
Financial assistance to help with
treatment costs
Patient and family counseling
Thrift Shop
Open Monday – Friday
CSE Headquarters, Palmetto Point
Help with all types of cancer, for
women AND men
24 We’re Working Together
To Make Eleuthera Better
25 Queen’s Highway, Palmetto Point, Eleuthera
(242) 332-1804
Queen’s Highway, Tarpum Bay, Eleuthera
(242) 334-4630
26 Appendix 2. General Survey This survey is to help the Cancer Society of Eleuthera and the One Eleuthera Foundation to provide better education and services to the people of Eleuthera. The information you share with us will not be used for any other reasons. Your name will not be on this survey and the information you provide will not be connected to you. What is your age? Are you Bahamian? Yes No What is the highest level of school you have finished? Primary Junior Secondary College We would like to know about you and breast cancer. Please check the box that describes you. I have NOT had a mammogram for breast cancer. I have had a mammogram for breast cancer and I do not have breast cancer. I have had a mammogram for breast cancer and I DO have breast cancer. If you do have breast cancer, please tell us which stage you have: 1 2 3 4 If you said that you have had a mammogram, please tell us why you did it. If you said that you have NOT had a mammogram, please tell us why you did NOT do it. General 27 Has anyone in your family been diagnosed with breast cancer? Yes No What do you believe are the causes of breast cancer? You can check more than one answer. Family History Diet Injury to the breast Not breastfeeding Other (please write) Have you heard about the BRCA-­‐1 or BRCA-­‐2 genes? Yes No Have you had genetic testing done to see if you have the BRCA-­‐1 or BRCA-­‐2 gene mutations? Yes No The BRCA-­‐1 and BRCA-­‐2 gene mutations can increase your risk for getting breast cancer. If genetic testing for the breast cancer gene mutations were available for free or a low cost, would you do it? Yes No If you said yes, please tell us why. If you said no, please tell us why not. Do you think you are at risk for breast cancer? Yes No If you said yes, please tell us why you think you are at risk. If you said no, please tell us why you do NOT think you are at risk. General 28 Do you think that breast cancer is a problem on Eleuthera? Yes No Where do you usually get information about health? We would like to know how you feel about breast cancer and treatment. Please circle the answer that is most like how you feel. If I were to find out that I had breast cancer, there are Strongly Strongly Disagree No Opinion Agree resources that can help me Disagree Agree pay for treatment. I think that if you catch breast cancer early, you Strongly Strongly Disagree No Opinion Agree Disagree Agree have a better chance of treating it. I know how to do a breast Strongly Strongly Disagree No Opinion Agree Disagree Agree self-­‐exam. I think that only a nurse or Strongly Strongly Disagree No Opinion Agree Disagree Agree doctor can do a breast exam. If you needed to get a mammogram to test for breast cancer, how much could you pay? Up to $50 Up to $100 Up to $150 Up to $200 Up to $250 General 29 If you agreed or strongly agreed that there are resources that can help you pay for treatment if you need it, can you please tell us what those resources are? (You can pick more than one.) Family Friends Church Government Cancer Society of Eleuthera Other The Cancer Society of Eleuthera has several programs. We want to know how much you know about them. Please circle the answer that describes you. Family Island Mammogram Service Cancer Awareness Training Seminars Free medical clinics in February and October I have never heard of this I have heard of this I have participated in this I have never heard of this I have heard of this I have participated in this I have never heard of this I have heard of this I have participated in this If you have heard of the Family Island Mammogram Service, can you please describe it? Do you know anyone who has participated in the Family Island Mammograms Service? Yes No We would like to know how you feel about the services available to you through the Cancer Society of Eleuthera. Please circle the answer that is most like how you feel. If I needed to get a Strongly Strongly Disagree No Opinion Agree mammogram, I know that Disagree Agree the Cancer Society of General 30 Eleuthera could help me. I have learned helpful information about breast Strongly Strongly Disagree No Opinion Agree Disagree
Agree cancer from the Cancer Society of Eleuthera. I think the Cancer Society of Eleuthera does good work Strongly Strongly Disagree No Opinion Agree helping Eleutherans with Disagree Agree cancer education and treatment. The Cancer Society of Eleuthera wants to help everyone on the island to be healthier, but we need your help. What services would you like to see the Cancer Society offer? We would like to know more about you. We will not share your information with anyone. Which settlement do you live in? Who lives in your house? (For example: 2 sons, 1 daughter, husband, 1 cousin) Are you the head of your household? Yes No General 31 How much money do you make in a year? Please check one. $15,000 or less $15,000 -­‐ $24,999 $25,000 -­‐ $34,999 $35,000 -­‐ $44,999 $45,000 or more Do you have health insurance? Yes Public Private No Do you have a job right now? Yes No If you do not have a job, would you like to learn any of these activities? Please check all that you are interested in. Quilting Cooking Gardening Straw work Construction Fishing Other How do you usually get information about activities or events on Eleuthera? Flyers Radio
Television
Email
Web site
Newspaper
From friend or relative
Other General 32 Appendix 3. Nurses Survey This survey is to help the Cancer Society of Eleuthera and the One Eleuthera Foundation to provide better education and services to the people of Eleuthera. The information you share with us will not be used for any other reasons. Your name will not be on this survey and the information you provide will not be connected to you.
What is your age? Are you Bahamian? Yes No We would like to know about you and breast cancer. Have you had a mammogram? Yes No If you said that you have had a mammogram, please tell us why you did it. If you said that you have NOT had a mammogram, please tell us why you did NOT do it. What do you believe are the causes of breast cancer? You can check more than one answer. Family History Diet Injury to the breast Not breastfeeding Other (please write) Have you heard about the BRCA-­‐1 or BRCA-­‐2 genes? Yes No The BRCA-­‐1 and BRCA-­‐2 gene mutations can increase your risk for getting breast cancer. If genetic testing for the breast cancer gene mutations were available for free or a low cost, would you encourage your patients to do it? Yes No Nurses 33 If you said yes, please tell us why. If you said no, please tell us why not. Do you think that breast cancer is a problem on Eleuthera? Yes No Where do you usually get information about breast cancer? We would like to know how you feel about breast cancer and treatment. Please circle the answer that is most like how you feel. If one of my patients were to be diagnosed with breast cancer, there are resources I Strongly Strongly Disagree No Opinion Agree Disagree Agree can recommend to them to help them get treatment. I think that if you catch breast cancer early, you Strongly Strongly Disagree No Opinion Agree Disagree
Agree have a better chance of treating it. I teach my patients how to Strongly Strongly Disagree No Opinion Agree Disagree Agree do a breast self-­‐exam. I believe that my patients Strongly Strongly Disagree No Opinion Agree think breast cancer is a Disagree Agree problem on Eleuthera. Nurses 34 If you agreed or strongly agreed that there are resources that you can recommend to your patients for treatment if they needed it, can you please tell us what those resources are? Family Friends Church Social Services (Government) Cancer Society of Eleuthera Other The Cancer Society of Eleuthera has several programs. We want to know how much you know about them. Please circle the answer that describes you. Family Island Mammogram Service Cancer Awareness Training Seminars Free medical clinics in February and October I have never heard of this I have heard of this I have participated in this I have never heard of this I have heard of this I have participated in this I have never heard of this I have heard of this I have participated in this If you have heard of the Family Island Mammogram Service, can you please describe it? If you have heard of the Family Island Mammogram Service, do you tell your patients about it? Yes No Do you know where in your clinic the Family Island Mammogram Services forms are kept? Yes No Nurses 35 Now we would like to know how you feel about the services available to you through the Cancer Society of Eleuthera. Please circle the answer that is most like how you feel. If my patient needed a mammogram, I know that Strongly Strongly Disagree No Opinion Agree the Cancer Society of Disagree Agree Eleuthera could help them. I have learned helpful information about breast Strongly Strongly Disagree No Opinion Agree Disagree Agree cancer from the Cancer Society of Eleuthera. I think the Cancer Society of Eleuthera does good work Strongly Strongly Disagree No Opinion Agree helping Eleutherans with Disagree Agree cancer education and treatment. The Cancer Society of Eleuthera wants to help everyone on the island to be healthier, but we need your help. What services would you like to see the Cancer Society offer? We would like to know more about you. We will not share your information with anyone. Which settlement do you live in? How do you usually get information about activities or events on Eleuthera? Flyers Radio
Television
Email
Web site
Newspaper
From friend or relative
Other Nurses 36 Appendix 4. Data: General Survey Age Total # of participants Minimum age 180 30 years Settlement of Residence Total # (%) Tarpum Bay 11 (6.1%) Rock Sound 10 (5.6%) John Millers 2 (1.1%) Bannerman Town 6 (3.3%) Wemyss Bight 18 (10.0%) Palmetto Point 13 (7.2%) Governor’s Harbour 14 (7.8%) Green Castle 5 (2.8%) Waterford 10 (5.6%) Deep Creek 13 (7.2%) Savannah Sound 6 (3.3%) Gregory Town 7 (3.9%) Harbour Island 19 (10.6%) Spanish Wells 2 (1.1%) Current 10 (5.6%) Bluff 3 (1.7%) Lower Bogue 9 (5.0%) Upper Bogue 2 (1.1%) James Cistern 11 (6.1%) Hatchet Bay 9 (5.0%) Level of schooling completed Total # (%) Primary 26 (14.4%) Junior 22 (12.2%) Secondary 90 (50.0%) College 41 (22.8%) How much can you pay for treatment Total # (%) Up to $50 51 (30.9%) Up to $100 52 (31.5%) Up to $150 24 (14.5%) Up to $200 12 (7.3%) Up to $250 26 (15.8%) Maximum age 79 years Average age 51.32 years 37 Annual Income Total # (%) <$15,000 73 (41.7%) $15,000-­‐24,999 25 (14.3%) $25,000-­‐34,999 6 (3.4%) $35,000-­‐44,999 7 (4.0%) >$45,000 5 (2.9%) Did not answer 59 (33.7%) Why did you get a mammogram? At required age Family history of breast cancer To make sure (Dr) advised to Annual medical visit Lumps/pain in breast Required age and family history It was free Why didn’t you get a mammogram? Total # (%) 3 (1.8%) 9 (5.3%) 44 (25.9%) 15 (8.8%) 20 (11.8%) 16 (9.4%) 2 (1.2%) 11 (6.5%) Total # (%) Scared/don’t want to know 8 (4.7%) Can’t afford it 2 (1.2%) Didn’t know about it 7 (4.1%) Waiting until 40 6 (3.5%) Never got around/no reason 25 (14.7%) Going to soon 2 (1.2%) Why do you think you are at risk? Total # (%) Positive family history 29 (19.5%) All women are at risk 21 (14.1%) Lumps in breast 2 (1.3%) Unsure if unhealthy lifestyle contributes 7 (4.7%) Why don’t you think you are at risk? Total # (%) Faith in God 42 (28.2%) Denial/just don’t think so 22 (14.8%) Get regular check ups 10 (6.7%) Healthy lifestyle/feel healthy 7 (4.7%) No family history & get regular exams 6 (4.0%) Already have it 3 (2.0%) 38 Yes/No Questions Are you Bahamian Have you had a mammogram Anyone in family had breast cancer Believe family history causes breast cancer Believe diet causes breast cancer Believe injury to breast causes breast cancer Believe not breastfeeding causes breast cancer Believe in other causes of breast cancer Heard about BRCA gene Have you had genetic testing for BRCA gene Would you get genetic testing if available Yes/no questions continued Do you think that you are at risk for breast cancer Do you think that breast cancer is a problem Family is a resource to help pay for treatment Friends are a resource to help pay for treatment Church is a resource to help pay for treatment Government is a resource to help pay for treatment CSE is a resource to help pay for treatment Do you know anyone who has participated in FIMS Are you head of house Do you have insurance Do you have a job Would you like to learn quilting (if unemployed) Would you like to learn cooking (if unemployed) Yes No Maybe 175 (97.2%) 122 (69.3%) 86 (48.9%) 5 (2.8%) 54 (30.7%) 89 (50.6%) 0 (0%) 0 (0%) 1 (0.6%) 159 (89.3%) 19 (10.7%) 0 (0%) 81 (45.5%) 97 (54.5%) 0 (0%) 66 (37.1%) 112 (62.9%) 0 (0%) 25 (14.0%) 153 (86.0%) 0 (0%) 11 (6.2%) 167 (93.8%) 0 (0%) 47 (26.7%) 7 (4.0%) 129 (73.3%) 0 (0%) 167 (96.0%) 0 (0%) 135 (84.4%) 22 (13.8%) 3 (1.9%) Yes No Maybe 55 (33.1%) 150 (87.7%) 11 (6.4) 10 (5.8%) 102 (67.5%) 49 (32.5%) 38 (25.2%) 113 (74.8%) 0 (0%) 58 (38.4%) 93 (61.6%) 21 (13.9%) 130 (86.1%) 0 (0%) 110 (72.8%) 41 (27.2%) 0 (0%) 115 (68.9%) 52 (31.1%) 0 (0%) 71 (39.4%) 78 (45.6%) 108 (63.5%) 26 (42.6%) 109 (60.6%) 93 (54.4%) 62 (36.5%) 35 (57.4%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 30 (49.2%) 31 (50.8%) 0 (0%) 97 (58.4%) 14 (8.4%) 0 (0%) 0 (0%) 39 Would you like to learn 19 (31.1%) 42 (68.9%) 0 (0%) gardening (if unemployed) Would you like to learn 27 (44.3%) 34 (55.7%) 0 (0%) straw work (if unemployed) Would you like to learn 4 (6.6%) 57 (93.4%) 0 (0%) construction (if unemployed) Would you like to learn 4 (6.6%) 57 (93.4%) 0 (0%) fishing (if unemployed) How you do usually get information on island activities? Yes No Flyers 106 (61.3%) 67 (38.7%) Radio 103 (59.5%) 70 (40.5%) Television 98 (56.6%) 75 (43.4%) Email 45 (26.0%) 128 (74.0%) Web 15 (8.7%) 158 (91.3%) Newspaper 80 (46.2%) 93 (53.8%) Friend or relative 129 (74.6%) 44 (25.4%) Other 13 (7.2%) 167 (92.8%) Likert scale questions Strongly disagree/ Strongly agree/ disagree/no opinion agree There are resources 59 (33.3%) 118 (66.7%) to help pay for treatment There is a better 7 (3.9%) 171 (96.1%) chance for treatment if you catch cancer early I know how to do a 42 (23.6%) 136 (76.4%) breast self-­‐exam Only a doctor or a nurse can 156 (87.6%) 22 (12.4%) do a breast self-­‐exam I know the CSE can help 26 (14.9%) 149 (85.1%) me pay for treatment I have learned good 72 (40.4%) 106 (59.6%) information from the CSE The CSE does good work 19 (10.6%) 160 (89.4%) helping Eleutherans Knowledge of CSE programs Never Have Have heard heard participated FIMS 42 (25.5%) 73 (44.2%) 50 (30.3%) Cancer awareness 45 (28.0%) 90 (55.9%) 26 (16.1%) training seminars Free medical clinics 44 (27.0%) 74 (45.4%) 45 (27.6%) 40 Appendix 5. Data: General Survey by Region Sample size Total # (%) South 75 (41.9%) Central 59 (33.0%) North 45 (25.1%) How much can you pay for treatment? South Central North up to $50 28 (40.0%) 11 (21.6%) 12 (27.3%) up to $100 23 (32.9%) 16 (31.4%) 13 (29.5%) up to $150 6 (8.6%) 12 (23.5%) 6 (13.6%) up to $200 7 (10.0%) 3 (5.9%) 2 (4.5%) up to $250 6 (8.6%) 9 (17.6%) 11 (25.0%) How much money do you make in a year? South Central North <$15,000 29 (38.7%) 23 (41.8%) 21 (47.7%) $15,000-­‐24,999 8 (10.7%) 7 (12.7%) 10 (22.7%) $25,000-­‐34,999 1 (1.3%) 4 (7.3%) 1 (2.3%) $35,000-­‐44,999 2 (2.7%) 3 (5.5%) 1 (2.3%) >$45,000 2 (2.7%) 3 (5.5%) 0 (0.0%) missing 33 (44.0%) 15 (27.3%) 11 (25.0%) Level of schooling South Central North Primary 17 (22.7%) 7 (11.9%) 2 (4.4%) Junior 11 (14.7%) 4 (6.8%) 7 (15.6%) Secondary 32 (42.7%) 32 (54.2%) 26 (57.8%) College 14 (18.7%) 16 (27.1%) 10 (22.2%) Why did you get a mammogram? South Central North At required age 1 (1.5%) 1 (1.7%) 1 (2.3%) Positive family history 5 (7.5%) 1 (1.7%) 3 (6.8%) To make sure 15 (22.4%) 18 (31.0%) 11 (25.0%) (Dr) advised to 6 (9.0%) 5 (8.6%) 4 (9.1%) Annual medical visit 7 (10.4%) 10 (17.2%) 3 (6.8%) Lumps/pain in breast 7 (10.4%) 3 (5.2%) 6 (13.6%) Req. age & family history 1 (1.5%) 0 (0.0%) 1 (2.3%) It was free 5 (7.5%) 4 (6.9%) 2 (4.5%) 41 Why didn’t you get a mammogram? South Central North Never got around/ 9 (13.4%) 8 (13.8%) 7 (15.9%) no reason Going to soon 1 (1.5%) 1 (1.7%) 0 (0.0%) Scared/don’t 4 (6.0%) 3 (5.2%) 1 (2.3%) want to know Can’t afford 2 (3.0%) 0 (0.0%) 0 (0.0%) Didn’t know 4 (6.0%) 2 (3.4%) 1 (2.3%) (about it) Waiting until 40 0 (0.0%) 2 (3.4%) 4 (9.1%) Why do you think you are at risk for breast cancer? South Central North Positive Family history 11 (18.3%) 6 (12.2%) 12 (30.8%) All women are at risk 6 (10.0%) 6 (12.2%) 9 (23.1%) Lumps in breast 2 (3.3%) 0 (0.0%) 0 (0.0%) Unsure if unhealthy 3 (5.0%) 2 (4.1%) 2 (5.1%) lifestyle contributes Why don’t you think you are at risk for breast cancer? South Central North Faith in God 21 (35%) 14 (28.6%) 7 (18.0%) Denial/just don’t 9 (15.0%) 8 (16.3%) 4 (10.3%) think so Get regular 6 (10.0%) 2 (4.1%) 2 (5.1%) check-­‐ups Healthy lifestyle/ 1 (1.7%) 5 (10.2%) 1 (2.6%) feel healthy No family history & 1 (1.7%) 4 (8.2%) 1 (2.6%) get regular exams Already have it 0 (0.0%) 2 (4.1%) 1 (2.6%) Has anyone in family been diagnosed with breast cancer? South Central North Yes 33 (46.5%) 25 (42.4%) 27 (60.0%) No 37 (52.1%) 34 (57.6%) 18 (40.0%) Don’t know 1 (1.4%) 0 (0%) 0 (0%) Have you had a mammogram? South Central North Yes 48 (66.7%) 43 (72.9%) 31 (70.5%) No 24 (33.3%) 16 (27.1%) 13 (29.5%) 42 Believe family history causes breast cancer South Central Yes 66 (90.4%) 50 (84.7%) No 7 (9.6%) 9 (15.3%) Believe diet causes breast cancer South Central Yes 27 (37.0%) 31 (52.5%) No 46 (63.0%) 28 (47.5%) Believe injury to breast causes breast cancer South Central Yes 28 (38.4%) 25 (42.4%) No 45 (61.6%) 34 (57.6%) Believe not breastfeeding causes breast cancer South Central Yes 12 (16.4%) 8 (13.6%) No 61 (83.6%) 51 (86.4%) Heard about the BRCA gene South Central Yes 15 (20.3%) 14 (24.6%) No 59 (79.7%) 43 (75.4%) Had genetic testing for BRCA gene South Central Yes 2 (2.8%) 1 (1.8%) No 70 (97.2%) 56 (98.2%) Would you get genetic testing if available South Central Yes 55 (83.3%) 42 (84.0%) No 11 (16.7%) 5 (10.0%) Maybe 0 (0%) 3 (6.0%) Think you are at risk for breast cancer South Central Yes 22 (32.8%) 14 (24.6%) No 39 (58.2%) 39 (68.4%) Don’t know 6 (9.0%) 4 (7.0%) North 42 (93.3%) 3 (6.7%) North 22 (48.9%) 23 (51.1%) 13 (28.9%) 32 (71.1%) North 5 (11.1%) 40 (88.9%) 18 (40.9%) 26 (59.1%) 4 (9.1%) 40 (90.0%) 37 (86.0%) 6 (14.0%) 0 (0%) 19 (46.3%) 18 (43.9%) 4 (9.8%) North North North North North 43 Think that breast cancer is a problem on Eleuthera South Central Yes 59 (81.9%) 50 (90.9%) No 6 (8.3%) 4 (7.3%) Don’t know 7 (9.7%) 1 (1.8%) Family is a resource to help pay for treatment South Central Yes 42 (65.6%) 34 (72.3%) No 22 (34.4%) 13 (27.7%) Friends are a resource to help pay for treatment South Central Yes 10 (15.6%) 17 (36.2%) No 54 (84.4%) 30 (63.8%) Church is a resource to help pay for treatment South Central Yes 20 (31.2%) 23 (48.9%) No 44 (68.8%) 24 (51.1%) Government is a resource to help pay for treatment South Central Yes 9 (14.1%) 7 (14.9%) No 55 (85.9%) 40 (85.1%) CSE is a resource to help pay for treatment South Central Yes 48 (75.0%) 34 (72.3%) No 16 (25.0%) 13 (27.7%) Do you know anyone who has participated in FIMS South Central Yes 43 (63.2%) 41 (75.9%) No 25 (36.8%) 13 (24.1%) Are you head of household South Central Yes 35 (46.7%) 22 (37.3%) No 40 (53.3%) 37 (62.7%) 40 (93.0%) 1 (2.3%) 2 (4.7%) North 26 (66.7%) 13 (33.3%) North 11 (28.2%) 28 (71.8%) North 15 (38.5%) 24 (61.5%) North 5 (12.8%) 34 (87.2%) North 27 (69.2%) 12 (30.8%) North 31 (70.5%) 13 (29.5%) North 13 (28.9%) 32 (71.1%) North 44 Do you have a job South Central North Yes 41 (57.7%) 35 (63.6%) 31 (72.1%) No 30 (42.3%) 20 (36.4%) 12 (27.9%) Do you have insurance South Central North Yes 30 (41.7%) 28 (51.9%) 20 (45.5%) No 42 (58.3%) 26 (48.1%) 24 (54.5%) There are resources to help pay for treatment South Central Strongly disagree/ 27 (36.5%) 19 (32.8%) disagree/no opinion Strongly agree/ 47 (63.5%) 39 (67.2%) agree If you catch breast cancer early you have a better chance of treatment South Central Strongly disagree/ 4 (5.4%) 2 (3.4%) disagree/no opinion Strongly agree/ 70 (94.6%) 56 (96.6%) agree I know how to do a breast self-­‐exam South Central Strongly disagree/ 22 (29.7%) 11 (19.0%) disagree/no opinion Strongly agree/ 52 (70.3%) 47 (81.0%) agree Only a Dr or a nurse can perform a breast exam South Central Strongly disagree/ 59 (79.7%) 55 (94.8%) disagree/no opinion Strongly agree/ 15 (20.3%) 3 (5.2%) agree I know the CSE could help me pay for treatment South Central Strongly disagree/ 12 (16.7%) 6 (10.5%) disagree/no opinion Strongly agree/agree 60 (83.3%) 51 (89.5%) North 13 (29.5%) 31 (70.5%) North 1 (2.2%) 44 (97.8%) North 9 (20.0%) 36 (80.0%) North 41 (91.1%) 4 (8.9%) North 8 (17.8%) 37 (82.2%) 45 I have learned good information from the CSE South Central Strongly disagree/ 37 (50.0%) 18 (31.0%) disagree/no opinion Strongly agree/ 37 (50.0%) 40 (69.0%) agree I think the CSE does good work South Central Strongly disagree/ 9 (12%) 2 (3.4%) disagree/no op Strongly agree/ 66 (88.0%) 56 (96.6%) agree Knowledge of CSE programs: FIMS South Central Never heard 21 (30.9%) 9 (16.7%) Have heard 28 (41.2%) 27 (50.0%) Have participated 19 (27.9%) 18 (33.3%) Knowledge of CSE programs: Cancer awareness training seminars South Central Never heard 25 (37.3%) 12 (22.6%) Have heard 35 (52.2%) 29 (54.7%) Have participated 7 (10.4%) 12 (22.6%) Knowledge of CSE programs: Twice-­‐yearly free medical clinics South Central Never heard 23 (34.8%) 12 (22.6%) Have heard 29 (43.9%) 24 (45.3%) Have participated 14 (21.2%) 17 (32.1%) North 17 (37.8%) 28 (62.2%) North 8 (17.8%) 37 (82.2%) North 11 (26.2%) 18 (42.9%) 13 (31.0%) North 7 (17.5%) 26 (65.0%) 7 (17.5%) North 9 (20.9%) 20 (46.5%) 14 (32.6%) 46 Appendix 6. Data: Nurses’ Survey Age Total # of participants Minimum age 10 27 years Settlement of residence Total # Deep Creek 1 (8.3%) Hatchet Bay 1 (8.3%) Gregory Town 1 (8.3%) James Cistern 1 (8.3%) Governor’s 2 (16.7%) Harbour Palmetto Point 2 (16.7%) Spanish Wells 1 (8.3%) Harbour Island 3 (25%) Why would you encourage genetic testing for patients Total # Early detection/ 12 (100%) prevention Why haven’t you gotten a mammogram Total # Too young 2 (16.7%) Uncomfortable 2 (16.7%) Low risk factor 1 (8.3%) Why have you gotten a mammogram Total # Annual physical 2 (16.7%) Cancer survivor 1 (8.3%) Pain in breast 1 (8.3%) Family history 1 (8.3%) Annual physical 2 (16.7%) & family history Yes/No Questions Yes Are you Bahamian 11 (91.7%) Have you had a 7 (58.3%) mammogram Maximum age 53 years Average age 40 years No 1 (8.3%) 5 (41.7%) 47 Believe that family history 12 (100%) 0 (0%) causes breast cancer Believe that diet causes 7 (58.3%) 5 (41.7%) breast cancer Believe that injury to the 6 (50%) 6 (50%) breast causes breast cancer Believe not breastfeeding 1 (8.3%) 11 (91.7%) causes breast cancer Believe in other causes 2 (16.7%) 10 (83.3%) of breast cancer Heard about BRCA gene 10 (83.3%) 2 (16.7%) Would you encourage genetic 11 (91.7%) 1 (8.3%) testing for patients if available Do you think that breast 11 (100%) 0 (0%) cancer is a problem There are resources to help 6 (50%) 6 (50%) patients pay for treatment Friends are a resource to help 5 (41.7%) 7 (58.3%) patients pay for treatment Church is a resource to help 4 (33.3%) 8 (66.7%) patients pay for treatment Government is a resource 5 (41.7%) 7 (58.3%) to help patients pay for treatment CSE is a resource to help 12 (100%) 0 (0%) patients pay for treatment Do you tell patients 11 (100%) 0 (0%) about FIMS Do you know where FIMS 9 (75%) 3 (25%) forms are in clinic How you do usually get information on island activities Yes No Flyers 10 (83.3%) 2 (16.7%) Radio 6 (50%) 6 (50%) Television 3 (25%) 9 (75%) Email 6 (50%) 6 (50%) Web 1 (8.3%) 11 (91.7%) Newspaper 7 (58.3%) 5 (41.7%) Friend or relative 10 (83.3%) 2 (16.7%) Other 3 (25%) 9 (75%) Likert scale questions Strongly disagree/ Strongly agree/ disagree/no opinion agree There are resources 1 (8.3%) 11 (91.7%) to help patients pay for treatment There is a better 1 (8.3%) 11 (91.7%) chance for treatment if you catch cancer early I teach patients how to 0 (0%) 12 (100%) 48 do a breast self-­‐exam My patients think breast cancer is a problem I know the CSE can help patients pay for treatment I have learned good information from the CSE The CSE does good work helping Eleutherans Knowledge of CSE programs FIMS Cancer awareness training seminars Free medical clinics 4 (33.3%) 8 (66.7%) 2 (16.7%) 10 (83.3%) 2 (16.7%) 10 (83.3%) 2 (16.7%) 10 (83.3%) Never heard Have heard Have participated 1 (8.3%) 3 (25%) 8 (66.7%) 6 (50%) 3 (25%) 3 (25%) 2 (18.2%) 4 (36.4%) 5 (45.5%)
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