The reach and rationale for community health fairs

Abstract

Latinos living in the United States account for one-third of the uninsured population and face numerous cultural, linguistic, and financial barriers to accessing health care services. Community health fairs have developed to address the unmet need for no- and low-cost services that target prevention and education among underserved communities. The current research describes an ongoing effort in a community in southern California and examines the barriers to health care among participants registering to receive free breast health screenings, one of the major services offered at a 2010 health fair. A total of 186 adult Latina women completed a brief questionnaire assessing their health care utilization and self-reported barriers to engaging in preventive and screening services. Approximately two-thirds of participants reported never receiving or having more than 2 years passing since receiving a preventive health check-up. Participants identified cost (64.5%) and knowledge of locations for services (52.3%) as the primary barriers to engaging in routine health care services. Engaging with health professionals represents a leading way in which adults obtain health information and health fairs offering cancer health screenings represent a culturally appropriate venue for increased cancer health equity. Implications of the current research for future health fairs and their role in community cancer education are discussed.

Latinos living in the United States have the lowest rates of health insurance, with Latinos accounting for one-third of the uninsured population in 2008 [1]. Even with the expansion of health care coverage through the Affordable Care Act many individuals in the U.S., with certain groups at greater risk, will remain uninsured or underinsured. For example, in California the remaining uninsured when the programs are fully implemented will be largely Latino (66%), living in Southern California (62%), have limited English proficiency (60%), and have household incomes at or below 200 percent of the Federal Poverty Level (57%) [2]. Moreover, three-quarters of the remaining uninsured will be U.S. citizens or legal immigrants [2]. Therefore, millions of Latinos living in the U.S. legally will remain at risk for being uninsured even following health care reform. In addition to financial barriers and high rates of uninsured, Latinos experience significant non-financial barriers (e.g., cultural and linguistic) that also contribute to lower rates of access and utilization of health care services, including important preventive screening services [3 - 7]. Thus, Latinos experience disparities in the incidence, mortality and/or morbidity of serious chronic diseases such as cancer [8], heart disease [9], HIV/AIDS [10], and diabetes [11].

Over the past 20 years there have been a number of changes in health care systems and services, which attempted to increase coverage for poor and underserved communities, including the Latino community. Some data have shown increases in utilization of colorectal [12] and other cancer screening services [13] in Latino populations; however, overall rates continue to lag use of screening services by Caucasians. For example, being Latina remains a risk factor for not having mammograms at the recommended age [14], and in 2008, Latinas’ rates of pap smears (77.9% of women aged 18-44) continued to be lower than those of non-Latina Whites (83.8%) and non-Latina Blacks (83.5%) [15]. In addition, health literacy has been identified as a critical barrier to health for Latinos, and national bodies are advocating for creative innovations for ensuring communication of health information to all individuals, particularly those with limited health literacy [16]. Receiving information from health professionals is one of the most important sources for obtaining health information regardless of health literacy [16]; thus, highlighting the importance of face-to-face contact with health professionals.

In an effort to reduce disparities in screening rates and access to health information in spite of persistent socioeconomic and literacy barriers, academic institutions and community-based organizations have worked to develop and sustain culturally competent health education and outreach interventions. One strategy is the implementation of community health fairs to bring needed health screenings and health information to low-income and medically underserved communities through informal community settings offering a broad spectrum of health services [17 - 21].

In San Diego the local chapter of MANA, a National Latina Organization¹, initiated such an effort through annual health workshops more than 20 years ago. The early MANA de San Diego workshops were expanded to become health fairs implemented on an annual basis since 1999. In 2003, as communication between Día de La Mujer Latina (http://www.diadelamujerlatina.org/), a non-profit organization with national efforts to promote health fairs and health education for Latina women, and local health agencies and programs discussed the possibility of organizing the Día de la Mujer Latina in San Diego (SDDML), MANA de San Diego was identified was the lead agency for the effort. In collaboration with other community and academic health programs and agencies, MANA de San Diego built on the experience of the organization’s health events to expand the audience and the services offered. The most significant addition to the services offered under the newly expanded collaborative was the provision of clinical breast exams and mammography screenings.

This manuscript focuses on the 2010 SDDML as a case study and its primary purpose is to assess challenges that program participants face in accessing health care services in general and breast cancer early detection screening, in particular. The current analyses aim to identify the reach of the health fair and to identify ongoing barriers to receiving health information and preventive screening services in more traditional health care settings. We provide details on the planning and execution of the health fair as an exemplar.

Methods

Health Fair Program

The SDDML health fairs are held in large community centers or parks with available public parking and near to public transit lines. The events include primarily no-cost screening and vaccination services. Supervised free activities for children while their parents are receiving health care services are also available. In the current analyses, we consider only the May 2010 event, which provided over 2000 different health services which included screenings (e.g. blood pressure, cholesterol, blood glucose) and vaccines (H1N1, Influenza, first dose of HPV). Table 1 provides a listing of the screenings and services provided at the health fair. The May 2010 health fair represented the largest SDDML health fair conducted to date and required intensive volunteer hours to coordinate and to carryout the daylong event. Services were provided by 13 community health clinics and other health organizations/programs between 9 am and 5 pm. Approximately 15 volunteers on the planning committee coordinated the event over a 10-month period prior to the event. In addition to the health care providers and planning committee members, approximately 100 non-medical volunteers provided support on the day of the event.

Table 1.

Estimated numbers of health screening or other medical services provided at the 2010 San Diego Health Fair

Screening or Other Medical Service	Number
Children’s physical exams and vaccines*	8
HPV Vaccine**	12
Lead***	30
Vision***	400
Dental Exam***	42
H1N1 and regular flu shots***	160
Blood glucose	474
Cholesterol	398
Blood pressure	273
Bone density	200
HIV/AIDS	40
Clinical Breast Exam	135
Mammography	120

^*Services provided to children in the 2 month-18 years old age range.

^**The first dose of the vaccine was provided at the health fair to young women ages 19-26, with the clinic providing the follow-up appointments to complete the three-vaccination series with participants.

^***Services provided to children and adults.

All program attendees were encouraged to register on site on the day of the event prior to receiving any health services; registrations were only available on site on the day of the event. Registration was required only for participants interested in getting breast health exams and, for all other services, attendees could receive services without registering by waiting in line. All services were provided on a first-come, first-served basis. Registration was required for women seeking breast health services because the free screenings could only be offered to women 40 years old or older meeting specific health insurance and income criteria. The eligibility criteria were consistent with the Every Woman Counts program [22] (http://www.dhcs.ca.gov/services/Cancer/ewc/Pages/default.aspx)

Program Participants

The primary target through advertising and outreach for the health fair is low-income and uninsured Latino families. However, the health fair is open to the public at large. Advertisements for the event were placed on Spanish-language radio and flyers were posted in the communities surrounding the health fair site. In addition, community health workers on the planning committee disseminated information about the event through formal and informal networks of all the SDDML partners. Because it was an open event and registration was not required for all services, complete data providing participant demographic information is only available for all individuals registering for the breast health screenings.

A total of 186 women interested in breast health screenings completed the registration forms. The information from the completed registration forms provides an initial assessment as to whether the Cancer Detection Program Every Woman Counts [22] eligibility criteria for free screenings were met. The criteria include age (40 years old or older), health insurance status (uninsured or underinsured), time since last mammography screening (one year or more), and low income. The registration forms were coded with an anonymous identification number and names and personal identifiers were not collected on the questionnaire nor were the data linked to any medical records or actual screening results. All information collected was kept and processed as confidential and the research protocol was reviewed and approved by the University of California San Diego Institutional Review Board.

Measures

The breast health screening registration forms were available in both English and Spanish. The forms were translated into Spanish and back-translated according to translation standards [23] by bilingual community and academic staff with over 20 years of experience. The registration questionnaire took approximately 10 minutes to complete and bilingual health fair volunteers were available to assist with completion of the form upon request. The registration forms included questions about demographics, health care access, and breast and cervical cancer screening.

Demographics

Registration forms assessed participant demographic variables such as age, gender, educational attainment, household income and size, country of origin, and employment. The women’s zip codes also were obtained to determine the reach of the health fair recruitment. Women were asked to indicate which of the available screening services they were interested in receiving at the health fair.

Health care access and utilization

Additional items assessed health insurance status and health care utilization and preferences, such as whether or not they had a usual source of care for general health and women’s health, in what country (U.S. or Mexico) and the type of health care provider (e.g. community clinic, emergency room, clinic at school or work) where they typically received their health care services. Participants were provided a list of nine barriers with yes/no response options to indicate whether they had experienced any of the barriers (e.g. lack of transportation, services were too expensive, services not available when they were needed) when trying to access health care services in the community. Moreover, women were asked to indicate their most recent mammogram and pap smear (never, < 2 years ago, or > 2 years ago), and if not in compliance with mammography and pap smear recommendations, they were asked the reasons why they had not received the screening services (“I forget/I don’t think about it,” “I’m afraid to do it,” “It’s too expensive,” etc.).

Data Analysis

Data were analyzed using SPSS statistical package (version 18). Data were entered and cleaned to ensure no errant data points. Data analyses include descriptive statistics to examine participant demographics and other study variables of interest.

Results

Table 1 presents a list of overall health services completed during the 2010 health fair as reported by the participating health care providers. Approximately 2,300 free screenings or vaccines were offered to 500 children and adults.

Socio-demographic information for women registering for breast health screenings is provided in Table 2. Among the women completing the registration (n = 186), the majority reported being born in Mexico (84%), having high school or less formal education (67%), and 50% had less than $20,000 household income. The majority of the participants completing the registration was between 40 and 59 years old (69.9%; mean age = 49 years, SD = 9.1) and was not currently employed (57%). Almost all women reported living in the zip codes immediately surrounding the health fair event and all reported living within the county limits. The majority of women heard about the health fair through television advertisements (n = 82, 44%), radio advertisements (n = 43, 23%) or from family and friends (n = 25, 13%).

Table 2.

Frequency and percentages of socioeconomic and demographic variable among breast health registered participants at the health fair.

Variable	N/Mean	Percent/SD
Country of Origin
Mexico	156	83.9
US	14	7.5
Other	5	2.7
Formal Education	10.75	7.595
Less than high school	54	29
High school	70	37.6
Some or completed higher education	33	17.7
Household income
<$20,000	93	50
$20,000-$30,000	33	17.7
$30,001-$40,000	7	3.8
$40,001-$50,000	1	0.5
Employment
Employed-Full Time	21	11.3
Employed-Part Time	38	20.4
Unemployed	106	57
Age (in years)	49.16	9.147
<40 years	14	7.5
40-49	69	37.1
50-59	61	32.8
60+	22	11.8

A very low health insurance coverage rate (9%) indicates limited health care access among breast health screening registered participants. Approximately one-third (n = 67) reported they had no usual source of health care or went to the emergency room for services. Further, of the nine barriers to health care included in the questionnaire, the cost of the medical services was identified to be the most frequent (64.5%), followed by a lack of information on where to get medical services (52.3%). Additional barriers that were frequently indentified were the long wait to get medical appointments (34.4%), the long waiting time to obtain services at the clinic (26.3%), and the lack of medical services available (25.3%). Table 3 provides a complete listing of the nine barriers assessed.

Table 3.

Health care access and barriers among breast health registered participants

Barriers to Health Care Reported	N (%)
1. Too expensive to seek medical services	120 (64.5%)
2. Don’t know where to get medical services	97 (52.3%)
3. Waiting too long for medical appointments	64 (34.4%)
4. Waiting too long at the clinic	49 (26.3%)
5. Medical services were not available	47 (25.3%)
6. No transportation	32 (17.2%)
7. No one at the site of care spokes Spanish	19 (10.2%)
8. No Latino/Hispanic staff members at the site of care	15 (8.1%)
9. No childcare	7 (3.8%)

Over half of the women registering for breast health screenings reported wanting to receive health screenings for cholesterol, diabetes, blood pressure, osteoporosis and vision. These screenings corresponded in part with participants’ top self-reported health conditions, which were: high cholesterol, high blood pressure, obesity, depression, and diabetes. Almost two-thirds (n = 110) of the women reported either never receiving a preventive check-up or that more than 2 years had passed since their last preventive check-up. These findings point to the success of the health fair efforts to reach out to the local medically underserved Latino community, and to the importance of the event as a source of education and preventive health care services for the participants.

Discussion

The goal of the SDDML health fair is to provide free health screening services to medically underserved Latino community members in order to reduce health disparities and to improve overall health. While data on all attendees is not available, the data on breast health screening participants indicate that health fair attendees were largely uninsured, low-income, and not receiving regular health care services. Access to regular health care is essential for identifying cancer and other illnesses early in disease progression and to ensure greater quality of life and reduced morbidity and mortality. However, the out-of-pocket cost for the uninsured of receiving health services, such as a mammography, is considerable. Despite the expansion of health care services through the Affordable Care Act, there are an estimated 3.1 to 4 million Californians who will remain uninsured when all aspects of the health care reform legislation have been implemented, with the largest percentages living in Southern California [2].

In the current sample the number one reported barrier to receiving health services in the community was the cost. Not only did the majority of participants report low household annual incomes, but also 91% of the participants were uninsured. These findings indicate that the health fair was reaching the targeted audience: low-income, uninsured, and medically underserved individuals. The Latino community has among the lowest rates of health insurance coverage [1], which along with where people receive care (e.g. emergency room versus primary care provider) and other socioeconomic factors are leading contributors to low preventive screening rates [24]. Advocacy efforts to improve insurance coverage and low-cost health care services are essential for improving these disparities.

One of the health care barriers endorsed by over half of the participants was the lack of information on where to get medical services. This finding indicates that more needs to be done to ensure the dissemination of information to the Latino community on available low cost health care services. It also reinforces the value of the health fair approach as a means to reach out to the medically underserved. Most of the participants at the health fair reported they heard about the event through Spanish-language television and radio advertising strategies; a finding that supports other research that non-print medias are essential for reaching the Latino community and low literacy populations [16]. This was accomplished free of charge through media sponsors of the community organization that led the coordination of the health fair. This case study suggests that media efforts be made to advertise health care opportunities, such as existing free services through health care organizations and patient navigator systems, as well as for providing other health information to the Latino community. This is particularly important given regular changes in available health care services through state and federal health programs. The health fair specifically advertised free health screenings; therefore, there was no ambiguity, as might be experienced in attending a health clinic setting, regarding the cost of services.

The uninsured participants who attended the health fair also reported the waiting time for medical appointments or services at sites of care as a barrier to health care. Research has shown that uninsured Latinos receive fewer physician services and wait longer between and during visits [25]. Other barriers identified elsewhere such as transportation and language services [3] were also identified as concerns among the current participants. Despite of the fact that health fair participants reside along the U.S.-Mexico border and Spanish-language services are readily available in the region, 10.2% reported having encountered language barriers in the health care setting during the previous year.

In addition to their desire to receive breast health screenings at the health fair, participants identified a range of health concerns including high cholesterol and blood pressure, obesity, and depression. While screening services were available for a number of services, there were no screening tests for other self-identified concerns such as obesity and depression. Approximately 1 in 5 women reported depression as a self-reported health concern; therefore, future health fairs would benefit from incorporating mental health screening and referral services for participants. In addition, the provision of information that promotes healthy behaviors for these identified health concerns provides an important public health opportunity. Health fairs can provide culturally competent forums for reaching and educating the medically underserved.

Lastly, the importance of health fairs in providing information to ensure the successful transition to usual sources of care cannot be understated. While awareness of risk profiles for health conditions is important, health fairs must ensure that participants have the information and opportunity to receive follow-up care. The provision of health educational materials that are culturally and linguistically competent provide valuable information toward the prevention and reduction of symptoms related to a variety of chronic and infectious diseases. Moreover, the provision of one-off screenings allow for the detection of cancer and health concerns at that particular time; however, without ongoing access to regular medical care there are limitations on the health fairs ability to reduce health disparities. Therefore, health fair organizers must work collaboratively with local resources to ensure follow-up care and the extension of services that ensures access to ongoing and regular health care services. While significant reductions in the uninsured will occur with the implementation of the Affordable Care Act, millions of U.S. citizens and residents are expected to remain uninsured in the years to come [2].

Limitations

Our results refer to a single case study and only a subset of health fair participants completed the breast health screening registration forms. A total of 186 Latina women registered to receive mammography at this health fair and completed the forms. By definition the individuals targeted by the health fair have limited socioeconomic resources and access to health care. Our sample is small and is not representative of the Latino population. Instead, it is a self-selected sample of women who sought out free services at the health fair located near the U.S.-Mexico border. All the women in this evaluation self-referred to the health fair which indicates they either knew the importance of receiving a breast health screenings or potentially had identified something abnormal and attended the health fair with the intent of receiving free screening services. Therefore, it is difficult to determine how the need for health screening services among the health participants compares to the larger Latino community. However, given the results of this study, the participants represent the medically underserved as well as a region of the country with among the highest numbers of Latinos and the uninsured. Due to the nature of the health fair there was no long-term follow-up evaluation with the participants. While the partner health care providers agreed to provide follow-up for participants as clinically relevant, there is no follow-up data on whether the health fair served as an entry point for participants to begin receiving regular health care services in the community.

Future Directions

Health fairs have evolved to fill an unmet public health need, including the dissemination of health information and the provision of screening services. Our case study demonstrates that there are indeed community segments that can greatly benefit from such efforts. Incorporating the lessons learned from this long-standing community-academic partnership could support the establishment of additional health fair programs and promote sustainable efforts that effectively reach underserved communities. This research indicated there is a need for additional advocacy, mental health services, provision of information on where to obtain services, and greater collaboration with community health providers to ensure the continuation of care and targeted outreach by the clinics to reach their underserved Latino community members. Future health fairs would benefit from more systematic tracking of all attendees and evaluating the effects of providing free screenings on health education and on subsequent health care services utilization; to the extent this is possible in this informal community-based setting. If we are to eliminate health disparities, it must be through collaborative public-private partnerships that ensure all people have access to health information and high-quality, affordable, and consistent health care services.