Abstract
A focus group study was conducted with five medical and nursing education programs in the Southeastern United States. Twenty five third and fourth year students were queried about their experiences, beliefs, and attitudes regarding Latino patients and cancer care. A general inductive process using open coding and content comparison to identify emerging themes was used to analyze the qualitative data. Investigators used a process of constant comparison to identify emerging themes. Themes included: 1) importance of cultural specificity and relevance in cancer training; 2) timing and placement of cancer education in the curriculum, including classes and/or clinical rotations; 3) anatomical system specificity of cancer training-studying cancer in the context of a specific body system; and 4) the prevention-focused nature of cancer training. Results of the focus groups have been used to inform a web-based survey of medical and nursing students to identify gaps in cancer education specific to Latino populations.
Background
As the Latino population grows, health care organizations and providers are interacting with a greater number of Latino clients [1]. The barriers to health care faced by Latinos include lack of insurance; financial, language and immigration status concerns; barriers related to health care provider practices and behaviors; and barriers related to acculturation and culture [1]. The Intercultural Cancer Council reports that “lack of cultural competency is a serious problem that results in greater suffering and higher death rates from cancer for multicultural patients compared to the white population as a whole. All patients deserve the same access to quality cancer care and this starts with a recognition that culture counts” [2].
According to a recent Institute of Medicine (IOM) report [3], barriers related to provider practice can be reduced by increasing provider awareness of the disparities in health care and through cross-cultural education. Studies that assess providers’ cultural competence or confidence in caring for Hispanic patients report that increased exposure to treating Hispanic patients contribute to increased cultural competence [4,5]. Providers who are confident in cultural skills are also confident in knowledge of Hispanic culture and had higher education levels [6,7]. Most health care research assessing students’ perceptions of potential client bias has taken a broad focus on providers’ perceptions of minority patients. Studies solely focused on cancer care for Latino patients have not been reported.
Attitudes toward cancer may create barriers to communication between patients and health care professionals and may influence decision-making about referral to specialist services and the selection of appropriate treatments [8, 9]. In a focus group study, Buki, Borrayo, Feigal, and Carrillo [10] examined whether perceived barriers to breast cancer screening were the same among Latinos with different origins. It was found that ‘distrust in health care providers’ was one of the major themes; participants did not perceive doctors as trusty gatekeepers of information. In another survey of minority breast and cervical cancer survivors, Latin American women were more likely than their African American counterparts to report a delay in accessing a diagnosis [11].
Cancer incidence and mortality display distinct risk patterns that result from the interplay of economic, social and cultural factors [12]. Among Latino adults, cancer is the second leading cause of death [13]. Even though the incidence rates of the common cancer types are lower in the Latino population, the average annual drop in the rate of mortality is smaller than that of white non-Latinos. Also, disparities in survival rates among all cancer sites may reflect less access to timely, high quality treatment for this population group [13]. Research has shown that as acculturation occurs, a shift in cancer incidence and mortality rates approaches the rate of non-Latinos [14,15]. Through, Days, and Know surveyed Hispanic workers with significantly low cancer survival rates and found that many of them were not knowledgeable of cancer causes, preventive measures, and treatments; respondents also feared the cost and physical examination of a doctor’s visit [16].
Raghavan recommends a structured medical curriculum to allow/require medical schools to provide majority populations with educational interventions that will attend to the unique needs of minority populations [17]. As the Latino population greatly increases in the Southeastern United States and cancer disparities grow, health care providers must be trained to interact with and provide care for a greater number and diversity of Latino clients. Examining medical and nursing students’ experience with and education regarding cancer care of Latinos will inform the development of medical and nursing education programs training future health service providers. The focus of this study was to assess characteristics of medical and nursing students’ cancer education and training in the context of care for Latino patients.
Methods
Data collection occurred at five medical education and nursing education programs in the Southeastern United States. The programs have similar institutional structure, curricula and student populations. Twenty seven total participants, fifteen nursing and twelve medical students (five to six participants at each site) were queried about their experiences, beliefs, and attitudes regarding Latino patients and cancer care and given a preliminary survey for discussion. All focus group participants were in their third or fourth year of study at the time of participation. Students were recruited through letters describing the study sent by open e-mail invitations from the medical/nursing associate dean of education offices at each program to all third and fourth year students.
The focus groups were led by two experienced moderators, co-investigators with over ten years experience in qualitative research (including facilitating focus groups), one each for nursing and medical school site. Moderators posed a series of open-ended questions regarding experiences, beliefs, and attitudes regarding Latino patients and cancer care, with a specific focus on students’ training and curricula. The focus group guide is found as Table 1. Focus groups lasted between 60 to 90 minutes, and participants were provided a $25 financial incentive. Upon participant consent, verbal (audio) data from the focus group were recorded by the assistant moderator, who also served as notetaker.
Table 1.
Focus Group Guide
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These data, including both verbal and non-verbal communication were transcribed verbatim within two weeks. The moderator team also participated in coding. Two notetakers, the primary coders, read all transcripts and generated an initial list of codes. Next, two members of the research team each independently coded two transcripts using the initial list and also to look for possible other interview subthemes. The team then met to discuss overarching themes and subthemes which were identified through initial and axial coding process. Three members of the research team independently coded a different focus group transcript and submitted their coded interviews to one researcher. A general inductive process using open coding and built on a variation of constant comparison was used to analyze the qualitative data [18, 19]. Researchers then independently analyzed the transcripts and organized codes into QSR-NVIVO software [20]. After coding the data, the research team met to discuss interpretations of the qualitative results.
Results
Sixteen participants were female, and eleven participants were male. A majority of participants from medical programs were male, while most participants from nursing programs were female. The mean age of nursing students was 23 years and 25 years for medical students. The majority of students were White, with two African American participants and one Hispanic.
Table 2 shows general characteristics of reported medical and nursing curricula divided into type, amount of cancer training, and placement in the curriculum. Nursing students and medical students reported much more cancer prevention and education training than treatment training. Nursing students reported that, if interested in oncology, they had opportunities to seek out additional clinical exposure. Medical students noted that they had significant clinical exposure and experience with cancer. Nursing students reported that they receive most of their cancer training during clinical rotations, while medical students reported consistent cancer pathology, prevention, and treatment training were spread throughout their curricula.
Table 2.
Content, Placement, Acquisition of Cancer Education Training for Medical and Nursing Students
| Cancer Education Curriculum | Nursing Students | Medical Students |
|---|---|---|
Type of Cancer Training
|
|
|
| Amount of Cancer Training |
|
|
| Placement of Cancer Training in Curriculum |
|
|
Focus Group Themes
Table 3 shows the four themes that emerged in all of the focus groups: (1) Importance of cultural specificity and relevance in cancer training; (2) Timing and placement of cancer training in the curriculum, especially in classes and/or clinical rotations; (3) Anatomical system specificity of cancer training, that is studying cancer in the context of a specific body system (i.e., lung cancer); and (4) Prevention-focused nature of cancer training.
Table 3.
Focus Group Themes and Corresponding Sample Comments
| Theme | Nursing Students | Medical Students |
|---|---|---|
| Cultural Specificity |
|
|
| Timing in Curriculum |
|
|
| Anatomical System Specificity |
|
|
| Prevention- focused |
|
|
Cultural Specificity
Medical and nursing students reported cancer training lacked specific emphasis on cancer rates in the Hispanic population. Cancer rates of minority populations were sometimes addressed in medical and nursing curricula, only if they represent significant disparities from white populations. However, those minority populations were limited to African Americans. Cancer treatment or prevention education was presented generally in curricula, without regard to specific cultural characteristics of patients. For example, one medical student noted, “I don’t remember any cancer training that was culture-specific” (Table 3).
Timing in Curriculum
Medical and nursing students reported having opportunities to seek out exposure to cancer care and treatment education, depending on student specialty interest. For example, students might pursue clinical experiences and elective classes that focused on cancer because they were interested in specializing in oncology. According to focus group participants, courses were not provided that specifically focused on cancer care, but oncology clinical rotations are available for both nursing and medical students. Some cancer training for all students was included in the context of courses such as pathology, and was dispersed throughout multiple sections and examinations. One medical student noted, “The third and fourth years, really, if you’re more interested in cancer, you’ll get more exposure” (Table 3).
Anatomical System Specificity
Medical and nursing students reported receiving training on types of cancer in the context of corresponding anatomical systems. Rather than approaching the topic of cancer within the context of the disease, cancer care is taught as it is relevant to pathology of certain anatomical systems. One nursing student stated, “We have had lectures on different types of cancer, the patho{physiology}, the pharmacology, the assessment skills for it, but that’s pretty much it”. Students believed that it was their responsibility to learn cancer care as it related to the body systems in which they intend to specialize (e.g., a neurologist should learn about brain cancer). For example, one medical student mentioned, “If you’re a specialist in a certain system…if it’s in your specific system, you should know” (Table 3).
Prevention-focused Training
Medical and nursing students reported that cancer prevention strategies and techniques are dispersed throughout curricula, but that it is not addressed comprehensively. Prevention was referenced via clinical tests, patient social history and interview, and patient education. Nursing students reported more training with patient counseling and education, and medical students stated that lifestyle counseling occurs only if the patient was participating in an activity that could lead to cancer (e.g., smoking). Nursing students reported more direct training with prevention methods, counseling, and patient education, while medical students reported more practice and testing regarding clinical exams such as skin examinations, clinical breast examinations, and pap testing. One nursing student reported, “We definitely are taught and are taught to teach others or teach our patients things that you can do that will reduce your risk of cancer”, while one medical student noted, “I don’t remember getting any general training on how to prevent cancer.,” Still another stated, “I think talking about cancer prevention is pretty much good lifestyle choices.” (Table 3).
Discussion
Analysis of medical and nursing student focus group transcripts revealed consistent regularities and some minor differences in themes regarding cancer training for Latino cancer care. Students reported that their curricula generally did not focus on cancer rates, treatment options, or special considerations for specific cultures. Both medical and nursing students in this study voiced a desire to have more about Latino health and culture in their curriculum. However, they clearly emphasized that their clinical experiences have the most impact on their perceptions and practices (more than anything taught in a classroom setting). Students reported a desire to have opportunities to seek out more detailed, extensive, and culturally relevant cancer training. Medical students pointed to the intended path of specialization, and stated that students should familiarize themselves with the types of cancer and corresponding treatment options that occur within their intended specialties for Latinos. Students, for instance, who had obstetrics, pediatric or emergency room clinical rotations were more likely to have encounter Latino patients. Students felt that more in-depth cancer training would be provided to students in an oncology rotation rather than other clinical experiences. Both medical and nursing students reported that cancer was taught within the context of separate anatomical systems, especially during pathology courses. Nursing and medical students were both instructed in cancer prevention methods such as screening, but nursing students reported having more experience and training counseling patients about health behaviors and cancer prevention. Medical students referred to clinical rotations as opportunities to witness and practice prevention techniques, supporting Wilkerson, Lee, and Hodgson’s findings [15] for medical students’ self-perception of cancer prevention skills. It could be surmised that medical students perceive their training as more disease-specific, while nursing students’ training represents a more patient-centered approach to cancer care. Surbone [21] stated that cultural competence is a significant construct of patient-centered care. Potter and Johnston stated, “The traditional illness- and anatomy-based approach to cancer education results in failure to address overarching themes that pertain to all cancer survivors” [22]. Since both groups reported regarding cancer in terms of its pathology, a patient’s cultural and ethnic characteristics may be such a theme.
Most participants had very limited contact with cancer care specific to Latino patients. Medical students reported interacting clinically with Latinos in mostly primary care settings or in urgent care settings. These settings do not usually feature high levels of cancer care; other socio-cultural factors combined with medical students’ limited experience could prevent Latinos with cancer and medical students from interacting with each other. Both medical and nursing students identified lifestyle factors as concerns for cancer in the Latino population, yet nursing students had more practice counseling and coaching patients with regard to these lifestyle factors.
Limitations of the study include recruitment of focus group participants, selection of academic institutions, and limitations inherent to qualitative research. Focus group participants were recruited via convenience sample by their institution, so it is unlikely the students selected are a true representative example of all medical and nursing students in the programs. It is possible that students selected were those with more interest, contact and experience with Latinos and cancer care. It was also requested that selected students be in their third or fourth year of study so that there would be no overlap with future sample groups, so these students may simply have more clinical experience than younger students.
As with all qualitative studies, results lack generalizability to other students or medical and nursing programs. However, scientific rigor was maintained through adhering to team established data collection and analysis protocols and a ‘checks and balance’ system across the team that included post focus group debriefing sessions, transcript reviews, and a rigorous coding processes for each transcript and follow-up review of all coding by the investigative team. Participating medical and nursing education programs were limited to South Carolina and Georgia. The data are reflective of schools in the region, however variance exists between programs. Although no such review exists for the southeastern United States, as Barton points out, “Medical undergraduate education about cancer leaves many practitioners ill-prepared” [23]. Hudelson, et al [24], suggests, “Methods are needed for assessing clinicians’ cultural knowledge frameworks [25]; that is, their knowledge of social and cultural factors that might affect care in a specific situation and their ability to apply this knowledge during patient assessment [26]. This study suggests that cancer education specific to Latino patients is needed.
It has been suggested that medical and nursing cancer education should be multidisciplinary, and include integration and coordination of education programs with special emphasis on prevention training [27, 28]. The focus group participants reported exposure to and practice with preventive techniques, with nursing students reporting more experience with counseling patients’ behaviors, while medical students report more experience with clinical screening tests.
Further support for integrated training is provided by Geller et al. [29], who suggest that students’ knowledge, skills, and confidence with cancer prevention increases when counseling and screening techniques are woven into preexisting curricula. This study has informed a larger web-based survey to examine a large sample of medical and nursing education programs’ regarding cancer education for Latino patient care. Culturally-appropriate cancer care education could be assessed in the classroom versus in a clinical rotation setting. Students’ autonomy in self-selecting exposure to cancer care and the Latino population should be examined, as a student’s desired specialty plays a large role in determining their education experience. Ultimately, more comprehensive and culturally relevant cancer education for Latinos could be implemented through intervention programs at the institutional level.
Acknowledgments
The project described was supported by Award Number R15CA135349 from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.
Contributor Information
Dr. Rachel Mayo, Email: rmayo@clemson.edu, 519 Edwards Hall, Clemson, SC 29634, Phone: 864-656-7435, Fax: 864-656-6227
Dr. Windsor W. Sherrill, 521 Edwards Hall, Department of Public Health Sciences, Clemson University, Clemson, SC 29634
Dr. Sarah F. Griffin, 507 Edwards Hall, Department of Public Health Sciences, Clemson University, Clemson, SC 29634
Dr. Veronica G. Parker, 404 Edwards Hall, School of Nursing, Clemson University, Clemson, SC 29634
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