Your Health Kiosk: A Pilot Study to Enhance Healthcare Access and Health Promotion among Spanish-Speaking Hispanics

doi:10.21203/rs.3.rs-3335834/v1

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Your Health Kiosk: A Pilot Study to Enhance Healthcare Access and Health Promotion among Spanish-Speaking Hispanics

https://doi.org/10.21203/rs.3.rs-3335834/v1

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Importance: Cancer screening remains a pivotal step in early detection and treatment, yet disparities persist in healthcare access, particularly among racial-ethnic minorities and low-income residents. Digital platforms offer innovative avenues to bridge these gaps.

Objectives: To evaluate the feasibility and effectiveness of a digital platform named Your Health Kiosk (YHK), which pairs a text-based intervention with patient navigators (PN), to promote cancer screening and assess social risk factors (SRF) among Spanish-speaking Hispanics.

Design, Setting, and Participants: This pilot study, conducted six months following the official launch, involved 220 participants recruited in Middlesex County, New Jersey. Demographic and SRF were gathered through surveys sent by YHK.

Results: Most participants were female (168, 76%), Hispanic (158, 72%), and Spanish speaking (142, 65%). The majority (183, 83%) were flagged for cancer screening. Out of 183 flagged, 26 (14%) were subsequently contacted by our PN, with a vast majority (25, 96%), accepting a referral for cancer screening. Additionally, four individuals not flagged for cancer screening opted in to receive a referral. In total, 29 participants were provided with a referral, and of these, nearly two-thirds (19, 66%), either scheduled or underwent cancer screening. Furthermore, five participants (17%) who expressed SRF were appropriately directed to relevant social services.

Conclusion: YHK has demonstrated promise in reaching underserved communities, successfully providing referrals to cancer screening, and addressing barriers to care.

The COVID-19 pandemic laid bare and intensified pre-existing disparities in access to healthcare, notably across racial-ethnic and socioeconomic lines.[1,2] These inequities were not limited to vaccination and outpatient treatment for COVID-19 but also other essential public health interventions like cancer screenings.[3] Certain financial, physical, and personal barriers to care known as social risk factors (SRF) are potentially responsible for decreased utilization of these critical services in underserved, often racial-ethnic minority and low income communities.[4,5] As community health centers operated under capacity constraints, access to preventive care services was further reduced, potentially contributing to otherwise avoidable downstream healthcare costs manifested as inpatient and emergency department admissions.[6,7]

Your Health Kiosk (YHK) is a digital platform designed for text-based interventions (TBI) that seeks to bridge the gap between marginalized populations and vital healthcare resources. New Jersey (NJ) is home to one of the largest Hispanic populations in the US. This state showcases marked disparities in language proficiency, socioeconomic status, and health outcomes when comparing Hispanics to non-Hispanic Whites (NHW).[8] Specifically, one in every five Hispanics in NJ is uninsured, and many face hurdles related to cost, transportation, and navigating healthcare, particularly if they are undocumented.[9] We strategically conducted this pilot study in Middlesex County, NJ because of its diverse demographic makeup, particularly its sizable Spanish-speaking Hispanic community.

Cancer stands as the foremost cause of death among US Hispanics.[10] Notably, when it comes to screening for breast and colorectal cancers, Hispanic individuals lag behind NHWs contributing to a higher proportion of late-stage cancer diagnoses.[11] Furthermore, Hispanic women are among those with the highest incidence rates of cervical cancer in the US when compared to other major racial-ethnic groups. While this gap is largely driven by SRF, even after controlling for socioeconomic status, Hispanics continue to face a heightened risk of treatment delays or a higher prevalence of these types of cancer.[12–14]

Lung cancer is the predominant cause of cancer-related deaths in Hispanic men and the second leading cause among women. Although lung cancer screening can reduce mortality by 20% in high-risk individuals, the actual rates remain low.[15] Major reasons for this include providers being unfamiliar with lung cancer screening requirements, a prevailing fatalistic attitude towards lung cancer, and, particularly among Hispanics, financial costs associated with the procedure serving as a significant disincentive.[16, 17] In NJ, only 4% of high-risk individuals are screened for lung cancer, lagging behind the national average of 6%.[18] Despite Hispanics generally smoking less than NHWs, they are frequently diagnosed at later stages. In fact, 23% of lung cancers are diagnosed at an early stage for Latinos in the state, which is below the 28% rate seen in NHW.

During the six months of the pilot, YHK prioritized the promotion of cancer screening. Participants were required to fill out an intake survey to determine their risk for specific cancers based on United States Preventive Services Task Force (USPSTF) criteria, providing basic demographic information and details regarding their smoking history. YHK utilized a TBI to enhance cancer screening health literacy through the delivery of educational text messages. YHK also incorporated a patient navigator (PN) who actively referred participants to ScreenNJ, a statewide comprehensive cancer screening initiative, and assessed them for SRF.[19] This publication seeks to assess the feasibility and efficacy of the pilot intervention, specifically whether YHK was able to reach its target population, encourage cancer screening, and address barriers to care in a historically marginalized group.

This pilot study seeks to determine the feasibility and efficacy of YHK through three aims: 1) identifying the population reached by YHK, 2) ascertaining the need for cancer screening within this demographic, and 3) determining whether participants who engage with a PN are effectively connected to health and social services. The Institutional Review Board reference for this study is Pro2022000244.

Community partners were actively recruited to engage in regular weekly stakeholder meetings focused on building trust with key figures who represent or interface with racial-ethnic minorities and low-income residents. Additionally, these community partners helped identify potential local events for recruitment. A medical communications vendor was enlisted to develop YHK and implement the tools and messaging created by project leadership.

The pilot of YHK began in February 2023 and ran for 6 months. Prior to February, the YHK team attended local events and recruited individuals using paper sign-ups and making manual referrals but this pilot study specifically examined YHK’s capability to flag participants for cancer screening and the PN’s efficiency in making referrals after the launch. Consequently, data collected prior to the launch, along with records lacking valid dates and any duplicate entries, were excluded. The consort diagram (Fig. 1) shows the overall process for YHK.

Recruitment took place at various venues including churches, hospital fairs, food pantries, wellness and fitness centers, and vaccine clinics. Participants registered their contact information and were sent survey links to their mobile device with questions regarding demographics and health risks (Table 1). Participants who met the criteria for breast, cervical, or colon cancer screening, based on USPSTF criteria, were flagged by YHK for possible referral to cancer screening.(Table 2).[20, 21] At registration, a number of participants specifically requested to be contacted for a referral to cancer screening; these participants ‘opted-in’ to the referral but were not flagged per se.

We did not strictly adhere to the USPSTF criteria for lung cancer screening; based on our interactions with participants, we consciously decided to not inquire about detailed smoking histories to avoid stigmatizing those who smoked.[22] Consequently, without precise pack-year information, everyone within the appropriate age range with a history of smoking was flagged as qualifying for a lung cancer screening referral.

Flagged participants received automated messaging about cancer screening based on their demographic information and risk factors (Table 3). Our PN subsequently called flagged participants and those who opted-in for cancer screening to provide a referral to Screen NJ. Following the initial referral, the PN followed up to ensure the completion of the referral, defined as either scheduled or already completed cancer screening. If, during conversations with the PN, participants expressed challenges related to SRF, an SRF assessment was conducted (Table 4).[23] Based on the results of this assessment, the navigator provided information on relevant social services.

All communication materials were made available in both English and Spanish, and the PN was required to be fluent in both languages for effective interaction. This approach ensured a comprehensive and culturally sensitive engagement with participants but created a delay in hiring; the PN completed training in May 2023 and functioned on a part-time basis only throughout the pilot.

Data were summarized as frequencies (percentages) for categorical variables and means (standard deviation) for continuous variables. Demographics of Middlesex County, NJ, were extracted from the Census Bureau’s Quick Facts for Middlesex County and included for context.[24] Similarly, county estimates for the percentage of adults currently smoking was also shown.[25] One sample proportion tests were performed to assess differences between demographics of the pilot sample and that of Middlesex County. All analyses were performed using R Studio (4.0.3).

Table 1

Intake Form
Category	Data
Contact Information	• First Name • Last Name • Mobile Number • Birth Date • Email • Cellphone Number
Demographics	• Race/Ethnicity • Biological Sex • Gender Identity • Preferred Language • Zip Code
Risk Factors	• Smoking History

Caption: This table outlines the various categories and associated data fields captured in the registration and intake form.

Table 2

Flagging Criteria for Cancer Screening
Type of Cancer	Criteria
Breast	• For women aged 50 to 74 years, recommend biennial screening mammography.
Cervical	• For women aged 21 to 29 years, recommend cervical cytology alone screening for cervical cancer every 3 years. • For women aged 30 to 65 years, recommend cervical cytology alone every 3 years, hrHPV testing alone every 5 years, or hrHPV testing in combination with cytology every 5 years.
Colon	• For adults aged 50 to 75 years, recommend colonoscopy.
Lung	• For adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years, recommend LDCT should be completed until a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

Caption: hrHPV: high-risk human papillomavirus; LDCT: low-dose computed tomography. This table provides a breakdown of the United States Preventive Services Task Force (USPSTF) criteria for cancer screenings by type of cancer.

Table 3

SMS Reminder Schedule for Cancer Screenings
Day #	Logic	SMS Message
3	General	1 in 3 people will be diagnosed with cancer. Getting screened early when treatment is likely to work best.
6	Lung cancer	Surviving lung cancer starts with a scan. If found early, lung cancer is more likely to be successfully treated.
9	Breast cancer	Early detection through screening tests help detect breast cancer early when the chances of survival are highest.
12	Colon cancer	With regular screenings, you have the power to prevent colon cancer. Schedule a screening with your doc or text a navigator for help.
18	General	Cancer doesn’t wait – neither should you. Screening means checking your body for cancer before you have symptoms.
21	Breast cancer	Many women with breast cancer have no symptoms. This is why regular breast cancer screening is so important.
24	Lung cancer	Lung cancer causes more deaths than colon, breast and prostate cancers combined Take charge and ask your doctor or text a navigator.
27	Colon cancer	There are simple, affordable options to screen for colon cancer including at-home tests. Talk to your doctor about which option is right for you.
30	General	Finding cancer early can make a difference in the success of treatment and improves your chances of living longer.

Caption: This table shows the timed SMS reminders Your Health Kiosk sends over 30 days as part of the text-based intervention, emphasizing the importance of early cancer detection across various types. Not shown are links to cancer screening resources included in each text.

Table 4

Screening Tool for Social Risk Factors
Social Risk Factor	Screening Question
Food Insecurity	In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?
Utility Debt	In the last 12 months did you have trouble paying your utility bills?
Housing Instability	Are you worried that you may lose your housing or be evicted on the next 2 months?
Cost-Related Nonadherence	In the last 12 months, have you had difficulty purchasing or taking medications as prescribed by a doctor?
Transportation Limitation	In the last 12 months have you missed a doctor or medical appointment because of a transportation related issue?
Inadequate Caregiver Support	Do you have childcare or caregiver issues/concerns that make it difficult for you to work or study?
Inability to Afford Healthcare	In the last 12 months have you missed a doctor or medical appointment because of cost?

Caption: This table outlines specific screening questions used to assess various social risk factors for participants who endorsed barriers to cancer screening.

This pilot study of YHK includes data collected from the first participant registration on YHK in February 2023 to August 2023. Of the 220 participants surveyed, the majority were females (76%), identified as Hispanic/Latino (72%), and primarily spoke Spanish (65%) (Table 5). Compared to Middlesex County, the pilot sample had a greater proportion of females, Hispanics, and Spanish speakers (p < 0.001). The average age of our cohort was 43 years old (± 14). Of our predominantly Hispanic cohort, 94% had never smoked, aligning with the observation that Hispanic individuals in the U.S. generally smoke at lower rates than most other racial-ethnic groups; still, 5% were current smokers and 1.4% had smoked in the past.

Based on the USPSTF criteria, 183 (83%) participants were flagged for cancer screening (Table 7). Of those flagged, the most common screening qualification was for cervical cancer (84%), followed by colon (32%), breast (21%), and lung (4.4%) cancer. All these flagged participants received relevant messaging. Of the 183 flagged participants, 26 (14%) were successfully reached by phone about cancer screening (Table 8). Of those contacted, 25 (96%) accepted the referral to ScreenNJ for cancer screening.

Of the 29 participants who were referred, 19 (66%) either scheduled or underwent cancer screening. Furthermore, five participants (17%) discussed care barriers when contacted by the PN, leading to SRF screenings and subsequent referrals to the relevant social services. Of these participants, three (60%) reported food insecurity, one (20%) had accumulated utility debt, one (20%) experienced housing instability, one (20%) demonstrated cost-related nonadherence, one (20%) encountered transportation challenges, and three (60%) expressed an inability to afford healthcare.

Table 5

Demographic Characteristics of Study Participants
Characteristic	N = 220¹	Middlesex County, NJ	P-value
Age	43 ± 14
Sex			< 0.001
Female	168/220 (76%)	50.2%
Male	52/220 (24%)	49.8%
Race/Ethnicity
Asian	3/220 (1.4%)	26.1%	< 0.001
Black/African American	18/220 (8.2%)	12.9%	0.0375
Caucasian/White	26/220 (12%)	38.9%	< 0.001
Hispanic/Latino	158/220 (72%)	23.2%	< 0.001
Choose not to answer	11/220 (5.0%)
Preferred Language			< 0.001
English	77/220 (35%)	54.4%
Spanish	142/220 (65%)	45.6%
Smoking Status
I currently smoke	11/220 (5.0%)	11.4%	0.0028
I have never smoked	206/220 (94%)
I previously smoked	3/220 (1.4%)
¹Mean ± SD; n/N (%)

Caption: The table outlines the demographics of study participants, including age, sex, race/ethnicity, and language preferences. Comparative percentages from the USCensus data for Middlesex County, New Jersey, are provided. Note: In the Census data, "White alone, not Hispanic or Latino" corresponds to "Caucasian/White," and the "Language other than English spoken at home" corresponds to preferred language of “Spanish.” Groups with less than 1% representation in Race/Ethnicity and Preferred Language are excluded.

Table 7

Cancer Screening Recommendations for Study Participants
Characteristic	n (%)
Flagged for Cancer Screening	183/220 (83%)
Breast	38/183 (21%)
Cervical	153/183 (84%)
Colon	58/183 (32%)
Lung	8/183 (4.4%)
Successfully contacted by PN	26/183 (14%)
Accepted Referral	25/26 (96%)
Opted-In for Referral to Cancer Screening	4/220 (1.8%)
Neither	33/220 (15%)

Caption: This table outlines the number and percentage of participants flagged for specific cancer screenings, the types of cancers they were screened for, and the follow-up actions taken after the recommendations. Data also includes the number of participants contacted regarding cancer screening and their responses to the referral offers.

Table 8

Cancer Screening Follow-up and Social Risk Factors
Characteristic	n/N (%)
Scheduled or Completed Cancer Screening	19/29 (66%)
Screened for Social Risk Factors	5/29 (17%)
Food Insecurity	3/5 (60%)
Utility Debt	1/5 (20%)
Housing Instability	1/5 (20%)
Cost-Related Nonadherence	1/5 (20%)
Transportation Limitation	1/5 (20%)
Inability to Afford Healthcare	3/5 (60%)

Caption: This table presents the proportion of participants who scheduled or completed cancer screenings, as well as the percentage who underwent a social risk factor (SRF) screening. Additionally, the specific SRF issues faced by the participants are detailed.

In this pilot study, we aimed to evaluate YHK's potential in accessing underserved communities, its proficiency in pinpointing participants requiring cancer screenings, and the effectiveness of its PN-centric referral approach. Remarkably, YHK managed to engage a significant portion of Spanish-speaking Hispanics, a demographic that faces disproportionately adverse cancer outcomes both in NJ and nationwide. While the NJ State Health Assessment Data reports parity in screening rates across racial-ethnic groups, such data might overlook nuances brought by socioeconomic status and SRF. [26] A striking 83% of our participants were flagged for screening. Moreover, several participants not flagged actively approached us for cancer screening, driven by personal concerns. This highlights that for many participants, YHK offered a unique or convenient gateway to cancer screening that wasn't readily available through their current healthcare system. Out of these, nearly two-thirds of those referred to ScreenNJ by the PN committed to the screening process. Some participants also received guidance on applying for beneficial programs like NJ’s Supplemental Nutrition Assistance Program or charity care options.

Community partnerships were invaluable to YHK’s credibility and success. During our pursuit of sustained community engagement, we prioritized regular stakeholder meetings and valued their insights.[27] One critical recommendation from our community partners was to develop a digital platform that carefully broached the topic of collecting personal information, as immigration policies and their enforcement in the US may cause Hispanic immigrants and their families to be deterred from seeking medical care.[28] This was evidenced by the sizable number of entries with accurate contact information but falsified ages, excluded from the analysis, which may have been meant to protect the participant but prevented us from potentially flagging them for cancer screening. Thus, the study team opted to have the PN introduce the SRF screen only when discussing barriers to care, recognizing the delicacy of the subject and potential discomfort participants might experience.

Building trust is a lengthy process, particularly within communities that have been historically neglected or mistreated by the medical complex and/or have seen many such interventions come and go. By consciously distancing ourselves from prominent brands and major local hospital systems, we cultivated an environment of trust, adaptability, and patient-centricity, ensuring individuals could access care without the constraints of mainstream healthcare influences. Furthermore, the YHK team regularly attended local events, building meaningful relationships with community gatekeepers. Reports from YHK staff who attended these events suggest that this consistent presence increased engagement over time. Our success in reaching a population more prone to late diagnoses for specific cancers underscores the critical role of sustained, community-focused outreach when addressing the needs of marginalized groups.[29, 30]

A TBI was included as a component of YHK to boost health literacy. TBIs have demonstrated efficacy in diverse contexts – from assisting homeless youth quit smoking to helping schizophrenic patients.[31–33] Additionally, our approach of sending tailored messages to those who meet cancer screening criteria mirrors a method used in another study that utilized kiosks to identify asthma in children.[34] Combining health education with PN might have allowed participants to apply what they learned, potentially leading to improved scheduling and completion rates for cancer screenings.

LESSONS LEARNED AND FUTURE DIRECTIONS

From our YHK pilot study, several key lessons emerged that can guide its expansion into other health needs and offer valuable instruction for subsequent community-based digital initiatives. Foremost, more time was required than allotted for transition periods. Our reliance on a PN proficient in both English and Spanish was necessary, but we miscalculated how long it would take for the PN to acclimate to the platform and the referral workflow. The delayed initiation by the PN, coupled with their part-time commitment, ultimately affected our reach to the flagged individuals. Additionally, we underestimated the time needed by our medical communications vendor to develop YHK, pushing back the digital platform's launch to February 2023. Despite the challenges, YHK successfully engaged Spanish-speaking Hispanics, and the impressive referral acceptance and screening completion rates demonstrates its feasibility and effectiveness in this population.

Reflecting on YHK's goals, the platform demonstrates potential in bridging healthcare disparities, specifically in cancer screening rates, by effectively engaging Spanish-speaking Hispanics in Middlesex County, NJ. Not only did YHK efficiently identify participants in need of cancer screenings, but it also linked them through a PN-centric referral system to both ScreenNJ and relevant social services. Despite some challenges faced during this pilot phase, primarily with contact rates, the initial six-month results signal a promising trajectory for YHK in promoting cancer screening among underserved communities.

ACKNOWLEDGEMENTS

This research received funding support from the FFY22 Preventive Health and Health Services Block Grant provided by the NJ Department of Health Division of Community Health Services. The authors acknowledge that the contents of this work are solely their responsibility and do not necessarily reflect the official viewpoints of the NJ Department of Health.

Sabiha Hussain is the founder and director of YHK. Derek Ge wrote this publication, and he and Tracy Andrews contributed to study conception, data analysis, and editing of the draft. Elif Akaf, Ganesh Sarilla, Elvia Fernandez-Rodriguez, and Carol Shu recruited participants from local events. Nabeeha Soherwardy and Hanzla Ahmad contributed to the literature review.

We also extend our gratitude to Stacey Abate, Saleena Maria, and Mariam Merced for their pivotal roles in launching the project. Furthermore, our sincere appreciation goes to our community partners who without this project would not have been possible.

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No competing interests reported.

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