Cultural Appropriateness in Health Communication: A Review and A Revised Framework

A revised framework for cultural appropriateness is offered on the basis of a systematic review of operationalizations in 44 cancer screening interventions for Asian Americans. Studies commonly conveyed the epidemiological bases of the intervention (97.7%) and used the language of the population (95.5%). Less commonly reported were strategies central to health communication: cultural features of the intervention messages (77.3%) and the cultural beliefs and values that the intervention focused on (43.2%). Few used cultural tailoring (4.5%) and none aimed to address acculturation or cultural identity. The theoretical framework most frequently used was the health belief model (27.3%) which does not explain the role of culture. More studies focused on cultural barriers (20.5%) than cultural strengths (9.1%). Our revised framework comprises six cultural appropriateness strategies of cultural identity, linguistic, perceptual features, content, constituent-involving, and socioeconomic context-adaptive. It prioritizes cultural identity to recognize the dynamics within racial ethnic groups and to inform adaptive efforts for cultural appropriateness. It emphasizes examining cultural strengths that can facilitate change, as well as reducing cultural barriers. Future research and action should address the disparities in extant health disparities research in which theory and methods are underdeveloped and underutilized for Asian Americans.

Pathways to Early Cancer Detection for Latinas: En Acción Contra el Cáncer

Latinas have less breast cancer, have more cervical cancer, and obtain fewer screening tests at recommended intervals. This article reviews the epidemiology and use of screening tests for these cancers and cultural factors that affect screening. En Acción Contra el Cáncer was designed to increase use of breast and cervical cancer screening services by distributing free cancer educational materials in Spanish, implementing a media campaign, conducting community outreach, training lay networkers, and assisting clinicians. A survey of 1,601 Latinas, 20 to 74 years old, ascertained screening behavior and knowledge and attitudes about cancer. Comparison of intervention and control cities showed significant differences in proportion insured, married, born in the United States, and less acculturated. There were no significant differences in mammography and Pap smear use, knowledge, and attitudes. Culturally appropriate prevention interventions that target ethnic-specific concerns arc needed.

Tailoring Lay Health Worker Interventions for Diverse Cultures: Lessons Learned from Vietnamese and Latina Communities

Indigenous lay health workers are presumed to be effective communicators in their communities due to their cultural competence. Lay health worker programs in Vietnamese and Latino communities show the influence of each community's culture and structure on the intervention designs and recruitment and training of lay health workers. To promote cancer screening. Vietnamese lay health workers conducted educational sessions in neighborhoods, while Latina lay health workers served as networkers and media role models. The studies demonstrated ways to build upon cultural strengths of the community and to tailor interventions to meet community expectations and needs. The authors conclude that ongoing responsiveness to both cultural norms and structural conditions in the community is the sine qua non of successful community programs.

Pathways to Early Cancer Detection for Vietnamese Women: Suc Khoe La Vang! (Health is Gold!)

To promote breast and cervical screening among Vietnamese women, a neighborhood-based intervention was developed that included small-group education, distribution of Vietnamese-language educational materials, and health fairs. The rationale for these modes of intervention is described. A pretest/posttest controlled trial is used to evaluate the intervention. San Francisco, California, is the experimental community; Sacramento, California, is the comparison community. The study hypothesizes that postintervention measurements of screening rates will reflect significantly greater increases among women in the experimental community than in the comparison community. This article reports results from the 1992 baseline household survey of 306 Vietnamese women in San Francisco and of 339 Vietnamese women in Sacramento. There were no significant differences in screening rates between the two communities. Only 50-54% of women had received routine checkups; 44-55%, mammograms; 40-45%, clinical breast examinations; 40-46%, Pap smear tests; and 58-65%, pelvic examinations.

Pathways to Early Detection of Cervical Cancer for a Multiethnic, Indigent, Emergency Department Population

When access to primary care is limited, low-income women of all races and ethnicities seek care in public hospital emergency departments (EDs) in which preventive services are often unavailable. This project implemented and evaluated a cervical screening program in an inner-city ED. Clinicians were asked to offer Pap smears to women undergoing diagnostic pelvic examinations. Women with abnormal results were randomized to follow-up in one of two settings. Women with normal results received an intervention promoting annual rescreening. In 12 months, 1,523 Pap smears were performed on 1,442 women; 58% were African American; 21%, Hispanic; and 7%, Asian. Among these women, more than 22 languages were spoken, and 26% did not recall having a prior Pap smear. Preliminary findings suggest that cervical cancer screening can be incorporated into routine ED care, creating an important alternative pathway to early detection for a high-risk population.

Problems and Progress in Translation of Health Survey Questions: The Pathways Experience

Pathways to Early Cancer Detection in Four Ethnic Groups is a program project funded by the National Cancer Institute aimed at increasing the use of breast and cervical cancer screening among underserved African American, Chinese, Hispanic, and Vietnamese women. The program project core is dedicated to cross-cultural studies including development of survey questions that are comparable in four languages. This article describes the Pathways surveys, summarizes the challenges encountered in question translation, and presents an adapted approach to translation. Concurrent, multilingual, decentered translation was the process through which an English version of each question was selected only when it could be directly and meaningfully translated into Mandarin, Cantonese, Spanish, and Vietnamese. Examples of challenges and how these were addressed in the Pathways surveys are presented, along with lessons learned throughout this process.

Similarities and Differences Across Cultures: Questions to Inform a Third Generation for Health Promotion Research

The increasing diversity of American communities raises an important question about the efficiency, appropriateness, and feasibility of tailoring messages and intervention strategies to target groups identified by race and ethnicity. To explore this issue, This article distinguishes race and ethnicity from culture and then discusses four questions: (1) What is the meaning of culture in health promotion? (2) What is the role of culture in understanding health behavior? (3) What is the role of culture in the design of interventions? and (4) What do the relationships of culture to behavior and to intervention mean for cultural tailoring? Based on this analysis, the authors suggest that effective health promotion will tailor interventions by culture as necessary but reach across cultures when possible and appropriate. A framework is presented to assess the need for cultural tailoring, and a new generation of health promotion research is proposed to facilitate cross-cultural comparisons.

Pathways to Early Breast and Cervical Detection for Chinese American Women

The authors used telephone interviews to investigate the knowledge, attitudes, beliefs, and practices regarding breast and cervical cancer screening among 775 Chinese American women in San Francisco. The rates of ever had a mammogram, ever had a clinical breast examination, and ever examined one's breasts among women aged 40 and older were 70%, 75% and 70%, respectively. The rates of ever had a Pap smear and ever had a pelvic examination were 67% and 85%, respectively. However, the rates of having had these cancer screening tests at regular intervals were much lower (25% for mammograms, 37% for Pap smears). Ability to speak English and insurance status were significantly associated with breast and cervical cancer screening knowledge and practices. Further analysis of the data, together with the data collected from a survey on physicians serving this population, will provide a basis for future interventions.

Cultural Affiliation and Mammography Screening of Chinese Women in an Urban County of Michigan

The aim of this study is to explore the relationship of culturally based attitudes on breast cancer screening behavior of Chinese women currently residing in the United States. This cross-sectional study used a survey instrument that was administered to a consecutive nonprobability sample of 202 Chinese women residing in an urban Michigan county. Mood’s strength of cultural affiliation scale (SCAS) was modified for cultural appropriateness prior to being translated into Chinese, back-translated, and pretested prior to use for this study. Data were analyzed using descriptive, correlational, and multivariate analysis techniques. Statistical analyses revealed that cultural diversity within the Chinese sample was associated with differing health behaviors and that the SCAS had indirect effects, through access to health care, on women’s mammography screening use (R2 = 28.3%). These study’s findings reveal that cultural affiliation and beliefs are related to the breast cancer screening behavior of immigrant Chinese women.

Effectiveness of Lay Health Worker Outreach in Reducing Disparities in Colorectal Cancer Screening in Vietnamese Americans

OBJECTIVES

We conducted a cluster randomized controlled study of a lay health worker (LHW) intervention to increase colorectal cancer (CRC) screening rates among Vietnamese Americans, who typically have lower rates than do non-Hispanic Whites.

METHODS

We randomized 64 LHWs to 2 arms. Each LHW recruited 10 male or female participants who had never had CRC screening (fecal occult blood test, sigmoidoscopy, or colonoscopy). Intervention LHWs led 2 educational sessions on CRC screening. Control LHWs led 2 sessions on healthy eating and physical activity. The main outcome was self-reported receipt of any CRC screening at 6 months after the intervention. We conducted the study from 2008 to 2013 in Santa Clara County, California.

RESULTS

A greater proportion of intervention participants (56%) than control participants (19%) reported receiving CRC screening (P < .001). When controlling for demographic characteristics, the intervention odds ratio was 5.45 (95% confidence interval = 3.02, 9.82). There was no difference in intervention effect by participant gender.

CONCLUSIONS

LHW outreach was effective in increasing CRC screening in Vietnamese Americans. Randomized controlled trials are needed to test the effectiveness of LHW outreach for other populations and other health outcomes.

Differences in knowledge, attitudes, beliefs, and perceived risks regarding colorectal cancer screening among Chinese, Korean, and Vietnamese sub-groups

Asian ethnic subgroups are often treated as a single demographic group in studies looking at cancer screening and health disparities. To evaluate knowledge and health beliefs associated with colorectal cancer (CRC) and CRC screening among Chinese, Korean, and Vietnamese subgroups, a survey assessed participants' demographic characteristics, healthcare utilization, knowledge, beliefs, attitudes associated with CRC and CRC screening. Exploratory factor analysis identified six factors accounting >60 % of the total variance in beliefs and attitudes. Cronbach's alpha coefficients assessed internal consistency. Differences among Asian subgroups were assessed using a Chi square, Fisher's exact, or Kruskal-Wallis test. Pearson's correlation coefficient assessed an association among factors. 654 participants enrolled: 238 Chinese, 217 Korean, and 199 Vietnamese. Statistically significant differences existed in demographic and health care provider characteristics, knowledge, and attitude/belief variables regarding CRC. These included knowledge of CRC screening modalities, reluctance to discuss cancer, belief that cancer is preventable by diet and lifestyle, and intention to undergo CRC screening. Chinese subjects were more likely to use Eastern medicine (52 % Chinese, 25 % Korean, 27 % Vietnamese; p < 0.001); Korean subjects were less likely to see herbs as a form of cancer prevention (34 % Chinese, 20 % Korean, 35 % Vietnamese; p < 0.001). Vietnamese subjects were less likely to consider CRC screening (95 % Chinese, 95 % Korean, 80 % Vietnamese; p < 0.0001). Important differences exist in knowledge, attitudes, and health beliefs among Asian subgroups. Understanding these differences will enable clinicians to deliver tailored, effective health messages to improve CRC screening and other health behaviors.

An outline of the need for psychology knowledge in health professionals: implications for community development and breast cancer prevention

Knowledge of health and community psychology in health professionals influences psychosocial and community determinants of health and promoting participation in disease prevention at the community level. This paper appraises the potential of knowledge on psychology in health care professionals and its contribution to community empowerment through individual behavior change and health practice. The authors proposed a schematic model for the use of psychological knowledge in health professionals to promote participation in health interventions/disease prevention programs in developing countries. By implication, the paper provides a vision on policies towards supporting breast cancer secondary prevention efforts for community health development in Asian countries.

Broadening the examination of sociocultural constructs relevant to African-American colorectal cancer screening

The importance of sociocultural constructs as influences on cancer attitudes and screening has been established in the literature. This paper reports on the efforts to explore alternatives to sociocultural constructs previously associated with African-American cancer screening, but with low acceptance among community members or incomplete measurement (empowerment and collectivism) and develop a measure for a recently identified construct of interest (privacy). We report preliminary psychometric data on these sociocultural scales and their associations with cancer attitudes. African-Americans (N = 1021), 50-75 years of age participated in this study. Participants were identified via a listed sample and completed a telephone survey administered via call center. Sociocultural attitudes were assessed using items identified through computerized database searches, reviewed by advisory panels, edited and tested using cognitive response strategies. Cancer screening pros and cons, cancer worry, perceived cancer risk, colorectal cancer (CRC) screening subjective norms, and perceived self-efficacy for colorectal cancer screening (CRCS) were also assessed. Confirmatory factor analyses and multivariate analyses were conducted to provide support for the validity of the constructs and to understand the associations among the selected sociocultural constructs (empowerment, collectivism, and privacy) and cancer beliefs and attitudes (CRC perceived benefits and barriers, perceived risks, subjective norms, and perceived behavioral control/self-efficacy). Consistent with the literature, the factor analytic model (RMSEA for the model was .062; 90% CI: .060-.065) provided support for the empowerment, collectivism, and privacy constructs. The modified collectivism and privacy scales had acceptable reliability. The privacy scale demonstrated the strongest associations with measures of cancer beliefs and attitudes. The implication of the findings and need for further scale development activities is discussed.

Health beliefs associated with cervical cancer screening among Vietnamese Americans

BACKGROUND

Vietnamese American women represent one of the ethnic subgroups at great risk for cervical cancer in the United States. The underutilization of cervical cancer screening and the vulnerability of Vietnamese American women to cervical cancer may be compounded by their health beliefs.

OBJECTIVE

The objective of this study was to explore the associations between factors of the Health Belief Model (HBM) and cervical cancer screening among Vietnamese American women.

METHODS

Vietnamese American women (n=1,450) were enrolled into the randomized controlled trial (RCT) study who were recruited from 30 Vietnamese community-based organizations located in Pennsylvania and New Jersey. Participants completed baseline assessments of demographic and acculturation variables, health care access factors, and constructs of the HBM, as well as health behaviors in either English or Vietnamese.

RESULTS

The rate of those who had ever undergone cervical cancer screening was 53% (769/1450) among the participants. After adjusting for sociodemographic variables, the significant associated factors from HBM included: believing themselves at risk and more likely than average women to get cervical cancer; believing that cervical cancer changes life; believing a Pap test is important for staying healthy, not understanding what is done during a Pap test, being scared to know having cervical cancer; taking a Pap test is embarrassing; not being available by doctors at convenient times; having too much time for a test; believing no need for a Pap test when feeling well; and being confident in getting a test.

CONCLUSION

Understanding how health beliefs may be associated with cervical cancer screening among underserved Vietnamese American women is essential for identifying the subgroup of women who are most at risk for cervical cancer and would benefit from intervention programs to increase screening rates.

Findings from focus groups indicating what Chinese American immigrant women think about breast cancer and breast cancer screening

OBJECTIVES

To explore beliefs of Chinese American, immigrant women related to breast cancer and mammography.

DESIGN

Qualitative description with semistructured focus groups.

SETTING

Metropolitan Portland, Oregon.

PARTICIPANTS

Thirty eight foreign-born Chinese women, age 40 and older, in five focus groups.

METHODS

Focus group discussions in Chinese were audiotaped, transcribed, and translated into English. Using a process of directed content analysis, group transcripts were coded for themes based on the discussion guide.

RESULTS

Three main themes emerged from the analysis: knowledge and beliefs; support, communication, and educational needs; and access to care. Subthemes included beliefs such as barriers and facilitators to screening and perceptions about personal breast cancer risk. Several women were profoundly affected by the negative breast cancer-related experiences of relatives and friends. Some common myths remain about causes and treatment of breast cancer.

CONCLUSIONS

Although Chinese American immigrant women share beliefs with other minority women in the United States, some culturally related barriers such as alienation due to cultural reasons for not sharing diagnosis with anyone and beliefs about the efficacy of Eastern versus Western medicine may affect adherence to screening and treatment. Facilitators included being told to get the test and getting screened for the sake of the family, whereas erroneous information about the cause of breast cancer such as diet and stress remained. Primary care providers such as advanced practice nurses should take into account culturally driven motivations and barriers to mammography adherence among Chinese American immigrant women. Provider/client interactions should involve more discussion about women's breast cancer risks and screening harms and benefits. Such awareness could open a dialogue around breast cancer that is culturally sensitive and nonthreatening to the patient. Information may need to be tailored to women individually or targeted to subethnic groups rather than using generic messages for all Asian immigrant women.

Effectiveness of a controlled trial to promote colorectal cancer screening in Vietnamese Americans

OBJECTIVES

We conducted a controlled trial of a public education and provider intervention to increase colorectal cancer (CRC) screening rates among Vietnamese Americans, who typically have lower rates than non-Hispanic Whites.

METHODS

The public education intervention included a Vietnamese-language CRC screening media campaign, distribution of health educational material, and a hotline. The provider intervention consisted of continuing medical education seminars, newsletters, and DVDs. Vietnamese in Alameda and Santa Clara Counties, California, received the intervention from 2004 to 2006; Vietnamese in Harris County, Texas, were controls and received no intervention. A quasi-experimental study design with pre- and postintervention surveys of the same 533 participants was used to evaluate the combined intervention.

RESULTS

The postintervention-to-preintervention odds ratio for having ever had a sigmoidoscopy or colonoscopy was 1.4 times greater in the intervention community than in the control community. Knowledge and attitudes mediated the effect of the intervention on CRC screening behavior. Media exposure mediated the effect of the intervention on knowledge.

CONCLUSIONS

Improving CRC knowledge through the media contributed to the effectiveness of the intervention.

Intention, subjective norms, and cancer screening in the context of relational culture

Research targeting disparities in breast cancer detection has mainly utilized theories that do not account for social context and culture. Most mammography promotion studies have used a conceptual framework centered in the cognitive constructs of intention (commonly regarded as the most important determinant of screening behavior), self-efficacy, perceived benefit, perceived susceptibility, and/or subjective norms. The meaning and applicability of these constructs in diverse communities are unknown. The purpose of this study is to inductively explore the social context of Filipina and Latina women (the sociocultural forces that shape people's day-to-day experiences and that directly and indirectly affect health and behavior) to better understand mammography screening behavior. One powerful aspect of social context that emerged from the findings was relational culture, the processes of interdependence and interconnectedness among individuals and groups and the prioritization of these connections above virtually all else. The authors examine the appropriateness of subjective norms and intentions in the context of relational culture and identify inconsistencies that suggest varied meanings from those intended by behavioral theorists.

Behavioral theory in a diverse society: like a compass on Mars

The behavioral theory constructs most often used to study mammography utilization-perceived benefit, perceived susceptibility, self-efficacy, intention, and subjective norms-have neither been developed nor sufficiently tested among diverse racial/ethnic subgroups. The authors explored these constructs and their underlying assumptions relating to the social context of Filipina and Latina women. The mixed-methods study included testing construct measures in the multilingual surveys of a concurrent intervention study of 1,463 women from five ethnic groups. An intensive inductive investigation then targeted Latina and Filipina women to elucidate connections between social context and individual screening behavior. In-depth interviews were conducted with 11 key informant scholars, 13 community gatekeepers, and 29 lay women, and a supplemental study videotaped and interviewed 9 mother-daughter dyads. Three social context domains emerged: relational culture, social capital, and transculturation and transmigration. The meaning and appropriateness of the five behavioral constructs were analyzed in relation to these domains. In contradistinction to tenets of behavioral theory, the authors found that social context can influence behavior directly, circumventing or attenuating the influence of individual beliefs; contextual influences, synthesized from multiple perspectives, can operate at an unconscious level not accessible to the individual; and contextual influences are dynamic, contingent on distal and proximal forces coming together in a given moment and are thus not consistent with an exclusive focus at the individual level. This article describes the study methods, summarizes main findings, and preview the detailed results presented in the other articles in this issue.

Perceived susceptibility to illness and perceived benefits of preventive care: an exploration of behavioral theory constructs in a transcultural context

This article describes how the social context of transculturation (cultural change processes) and transmigration (migration in which relationships are sustained across national boundaries) can directly influence use of mammography screening. The authors conducted semistructured interviews with Latino and Filipino academics and social service providers and with U.S.-born and immigrant Latinas and Filipinas to explore direct and indirect influences of social context on health behavior (Behavioral Constructs and Culture in Cancer Screening study). Iterative analyses identified themes of the transcultural domain: colonialism, immigration, discrimination, and therapeutic engagement. In this domain, the authors examine two key behavioral theory constructs, perceptions of susceptibility to illness and perceptions of benefits of preventive medical care. The findings raise concerns about interventions to promote mammography screening primarily based on provision of scientific information. The authors conclude that social context affects behavior directly rather than exclusively through beliefs as behavioral theory implies and that understanding contextual influences, such as transculturation, points to different forms of intervention.

Social and cultural meanings of self-efficacy

This article describes the influences of social context on women's health behavior through illustration of the powerful influences of social capital (the benefits and challenges that accrue from participation in social networks and groups) on experiences and perceptions of self-efficacy. The authors conducted inductive interviews with Latino and Filipino academics and social service providers and with U.S.-born and immigrant Latinas and Filipinas to explore direct and indirect influences of social context on health behaviors such as mammography screening. Iterative thematic analysis identified themes (meanings of efficacy, spheres of efficacy, constraints on efficacy, sources of social capital, and differential access to and quality of social capital) that link the domain of social capital with the behavioral construct perceived self-efficacy. The authors conclude that social capital addresses aspects of social context absent in the current self-efficacy construct and that these aspects have important implications for scholars' and practitioners' understandings of health behavior and intervention development.

HIV testing among sexually experienced Asian and Pacific Islander young women association with routine gynecologic care

PURPOSE

To describe the proportion of HIV testing in the past 12 months among sexually experienced Asian and Pacific Islander (API) women and to investigate to what extent routine gynecologic care (RGC) increases HIV testing among API women.

METHODS

Data were derived from Wave III of the National Longitudinal Study of Adolescent Health (Add Health). Analyses were limited to 7,576 sexually experienced women (White, n = 4,482 [68.5%]; Black, n = 1,693 [25.6%]; Hispanic, n = 923 [13.9%]; API, n = 478 [7.2%]) aged 18-27 years. Multiple logistic regression analyses were used to estimate the association between RGC and HIV testing after controlling for predisposing, need, and enabling factors.

FINDINGS

On average, 22.8% (n = 1,504) of sexually experienced women reported HIV testing in the past year. API women had the lowest proportion of testing (17.2%), and Black women had the highest (26.2%). Overall, 60.2% of API women reported receiving RGC; however, only 15.5% of API who received RGC reported HIV testing. After controlling for covariates, significantly positive associations were found for White, Black, and Hispanic women between RGC and HIV testing; however, there was no evidence that RGC was associated with HIV testing among API women.

CONCLUSION

Our data suggest that RGC does not [corrected] increase HIV testing among API women. To eliminate disparities in HIV testing service utilization among API women, appropriate efforts should be directed to better understand the barriers and facilitators of HIV testing among this population.

The use of sociocultural constructs in cancer screening research among African Americans

BACKGROUND

Studies are increasingly examining the role of sociocultural values, beliefs, and attitudes in cancer prevention. However, these studies vary widely in how sociocultural constructs are defined and measured, how they are conceived as affecting cancer beliefs, behaviors, and screening, and how they are applied in interventions.

METHODS

To characterize the current state of this research literature, we conducted a critical review of studies published between 1990 and 2006 to describe the current use of sociocultural constructs in cancer screening research among African Americans. We included quantitative and qualitative studies with cancer as a primary focus that included African American participants, assessed screening behaviors, reported race-specific analyses, and considered one or more sociocultural factors. Studies were evaluated for type of cancer and screening analyzed, study population, methodology, sociocultural constructs considered, definitions of constructs, provision of psychometric data for measures, and journal characteristics.

RESULTS

Of 94 studies identified for review, 35 met the inclusion criteria and were evaluated. Most focused on breast cancer screening, and thus African American women. Sociocultural constructs were seldom clearly defined, and the sources and psychometric properties of sociocultural measures were rarely reported.

CONCLUSIONS

A multidisciplinary approach to developing a common language and a standardized set of measures for sociocultural constructs will advance research in this area. Specific recommendations are made for future research.

Predictors of breast examination practices of Chinese immigrants

Breast cancer is a significant threat to Chinese women living in the United States. The purposes of this study are, first, to examine the relationships among breast cancer risk knowledge, general cancer beliefs, and breast examination practices and, second, to determine the predictors of breast examination practices among Chinese women in New York. The study offers a descriptive approach that makes use of a correlation cross-sectional survey (N = 135). Five significant predictors are related to breast examination practices as a result of the study findings: age, acculturation, private insurance status, legal status, and length of stay in New York. Findings show that women who have regular breast examinations most likely belong to older generations, as compared with their younger peers. Study findings suggest that healthcare providers must become more culturally sensitive to the practices and needs of Chinese immigrants. Evidently, providing information regarding cancer prevention targeted for female Chinese immigrants can help increase use of cancer screening tests.

Lower adherence to screening mammography guidelines among ethnic minority women in America: a meta-analytic review

OBJECTIVE

This study investigates the association between ethnic minority status and receiving a screening mammogram within the past 2 years among American women over 50.

METHOD

The findings from 33 studies identified from interdisciplinary research databases (1980 to 2006) were synthesized. Separate pooled analyses compared white non-Hispanics to African Americans (28 outcomes), Hispanics (18 outcomes), and Asian/Pacific Islanders (10 outcomes).

RESULTS

Using the random effects model, results showed that African Americans were screened less than white non-Hispanics at a marginal level (OR 0.87, 95% CI 0.75, 1.00). Larger and significant discrepancies were observed for Hispanics (OR 0.65, 95% CI 0.50, 0.85) and Asian/Pacific Islanders (OR 0.63, 95% CI 0.39, 0.99) compared to white non-Hispanics. However, among studies controlling for socioeconomic status, ethnic differences in mammography screening were no longer significant for African Americans (OR 1.05, 95% CI 0.71, 1.76), Hispanics (OR 1.08, 95% CI 0.64, 1.93), or Asian/Pacific Islanders (OR 1.08, 95% CI 0.64, 1.93). Subgroup analyses further showed that geographical region, sampling method, and data collection strategy significantly impacted results.

CONCLUSIONS

This study found evidence that ethnic minority-screening mammography differences exist but were impacted by socioeconomic status. Implications for interpreting existing knowledge and future research needs are discussed.

Performance of the U.S. Office of Management and Budget's Revised Race and Ethnicity Categories in Asian Populations*

OBJECTIVES: The U.S. Office of Management and Budget (OMB) guidelines for collecting and reporting race and ethnicity information recently divided the "Asian or Pacific Islander" category into "Asian" and "Native Hawaiian or Other Pacific Islander". The OMB's decision to disaggregate the "Asian or Pacific Islander" category was the first step toward providing these communities with information to better serve their needs. However, whether individuals who formerly made up the combined group categorize themselves as the new guidelines intend is a question analyzed in this report. METHODS: A subset of adults participating in the Hemochromatosis and Iron Overload Screening Study completed both the OMB-minimum and the expanded race and ethnicity measure used in the National Health Interview Survey. We compared responses on the expanded measure contained within the OMB "Asian" definition (Filipino, Korean, Vietnamese, Japanese, Asian Indian, Chinese, and/or Other Asian) to "Asian" responses on the OMB-minimum measure. RESULTS: Mixed heritage Asians less often marked "Asian". Among mixed heritage Japanese, Chinese, and Filipinos, 27%, 49%, and 52% did not mark "Asian" on the OMB measure, respectively. Eleven percent of single-heritage Filipinos did not mark "Asian." CONCLUSIONS: Many individuals formerly making up the combined "Asian or Pacific Islander" group do not categorize themselves as the revised OMB guidelines intend. This is particularly evident among Filipinos and among Asians of mixed heritage. This research illuminates the reliability and utility of the broad "Asian" category and points to possible consequences of collapsing groups into a single category, i.e., missed information and/or erroneous generalization.

Breast Cancer Beliefs and Mammography Screening Practices Among Chinese American Immigrants

OBJECTIVE

To explore knowledge and beliefs (perceived risk factors, susceptibility, benefits, common barriers, and cultural barriers) in relation to mammography screening practices among Chinese American women.

DESIGN

A descriptive study guided by the Health Belief Model.

SETTING

Metropolitan area in the northwestern United States.

PARTICIPANTS

One hundred Chinese immigrant women, 40 years or older.

MAIN OUTCOME MEASURES

The percentage of Chinese American women ages 40 and older who ever received a mammogram and who received a mammogram within the past year.

RESULTS

Although 86% of the respondents reported that they had once had a mammogram, only 48.5% had a mammogram within the past year. The strongest factor associated with having a mammogram within the past year was having an immediate family member diagnosed with breast cancer, followed by having insurance that covered a mammogram and lower perceived barriers to obtaining a mammogram. Respondents had low knowledge of breast cancer and mammography screening guidelines. They also perceived low susceptibility to breast cancer.

CONCLUSIONS

Nurses may influence the mammogram rates among Chinese American women by providing health education to family members of patients with breast cancer, reducing perceived barriers to mammogram, and seeking alternative payment mechanisms for patients who do not have insurance coverage for mammogram.

Knowledge about cervical cancer risk factors, traditional health beliefs, and Pap testing among Vietnamese American women

INTRODUCTION

The objective of this paper was to examine knowledge about cervical cancer risk factors and traditional health beliefs in relation to Papanicolaou (Pap) testing among Vietnamese women.

METHODS

A population-based survey was conducted in Seattle (n<352, response rate=82%) during 2002.

RESULTS

The proportions of women who knew that older age, not getting regular Pap tests, and Vietnamese ethnicity are associated with an elevated cervical cancer risk were only 53%, 62%, and 23%, respectively. The majority (87%) incorrectly believed poor women's hygiene is a risk factor for cervical cancer. Approximately two-thirds (68%) of the women had received a Pap test during the preceding three years. Knowing that lack of Pap testing increases the risk of cervical cancer was strongly associated (p<0.001) with recent Pap smear receipt.

CONCLUSION

Our results confirm that Vietnamese women have lower levels of cervical cancer screening than non-Latina white women. Intervention programs addressing Pap testing in Vietnamese communities should recognize women's traditional beliefs while encouraging them to adopt biomedical preventive measures into their daily lives.

Provider knowledge and practice regarding hepatitis B screening in Chinese-speaking patients

BACKGROUND

The extent to which academic general medicine providers screen Chinese-speaking patients for hepatitis B virus (HBV) is not known.

METHODS

Retrospective cohort study of Chinese-speaking patients' HBV screening status and survey of providers' HBV knowledge/screening.

RESULTS

Most patients (65%) received HBV screening. Being screened was independently associated with marital status and years in the clinic. Providers with Asian language abilities and greater knowledge of HBV risk factors/guidelines were more likely to screen.

CONCLUSIONS

Chinese-speaking patients in this setting were underscreened for HBV. Providers underestimated the risks associated with Chinese ethnicity. Education is needed to improve risk assessment and guideline awareness.

Breast cancer early detection among Chinese women in the Philadelphia area

BACKGROUND

Breast cancer is the most frequently diagnosed cancer and the second leading cause of cancer death among Chinese American women. Previous studies identified disparities in breast cancer screening between Asian and Caucasian women. This study describes breast cancer awareness, attitudes, and knowledge, as well as barriers and facilitators of early detection among Chinese women in Philadelphia.

METHODS

A cross-sectional, translated survey was conducted among a convenience sample of 111 Chinese women from the greater Philadelphia area. Data were analyzed using descriptive statistics to describe participant experiences and attitudes, and Pearson correlation coefficients, chi-square tests, and multiple regressions were used to identify significant predictors of breast cancer screenings.

RESULTS

Of respondents, 53.2% had ever performed breast self-examination (BSE). Among women aged >or=40, 53.6% had ever had clinical breast examination (CBE), and 71.1% had ever had mammogram. Knowledge (p < 0.001) and self-efficacy (p = 0.001) predicted BSE ever performance. Having a doctor as information source of CBE (p = 0.001) and belief in family history as a risk factor of breast cancer (p = 0.002) were significant predictors of having ever had a CBE. Having a doctor as information source of mammogram (p = 0.002) was the only significant predictor of having ever had mammogram screening.

CONCLUSIONS

This study laid a foundation for developing culturally sensitive breast cancer education and screening programs for Chinese women in the Philadelphia area. Recommendations include a call for physician education to improve breast cancer screening rates in this population.

Papanicolaou testing among Vietnamese Americans: results of a multifaceted intervention

BACKGROUND

Vietnamese-American women have the highest incidence of cervical cancer of any ethnic group, and they underutilize Papanicolaou (Pap) tests.

DESIGN

Development and implementation of a multifaceted intervention using community-based participatory research (CBPR) methodology and evaluated with a quasi-experimental controlled design with cross-sectional pre-intervention (2000) and post-intervention (2004) telephone surveys. Data were analyzed in 2005.

SETTING

Santa Clara County, California (intervention community) and Harris County, Texas (comparison community).

PARTICIPANTS

Vietnamese-American women aged 18 and older (n =1566 at pre-intervention and 2009 at post-intervention).

INTERVENTION

A community-academic coalition developed and implemented six components: Vietnamese-language media campaign, lay health worker outreach, Vietnamese Pap clinic, patient registry/reminder system, restoration of a government-funded low-cost screening program, and continuing medical education for Vietnamese physicians.

OUTCOME MEASURE

Pap test receipt.

RESULTS

Overall response rate was 56%. Pap test receipt increased in the intervention (77.5% to 84.2%, p <0.001), but not in the comparison community (73.9% to 70.6%, p >0.05). In multivariate analyses, the intervention was associated with increased Pap test receipt (odds ratio [OR]=2.02, 95% confidence interval [CI]=1.37-2.99). Other factors associated with increased Pap testing included longer U.S. residence, having health insurance, having a regular site of care, having a respectful physician, having a non-Vietnamese or a female Vietnamese physician, and recalling exposure to Vietnamese-language media about Pap testing. Factors associated with reduced likelihood of Pap test receipt were age 65 years and older, never married, less than high school education, and income below poverty level.

CONCLUSIONS

A multifaceted CBPR intervention was associated with increased Pap test receipt among Vietnamese-American women in one community.

Cervical cancer among Vietnamese women: Efforts to define the problem among Houston's population

INTRODUCTION

Asian American/Pacific Islanders (AAPIs) in the United States (US) continue to bear a disproportionate burden of cancer. This report focuses on the interviews with local health-care delivery providers, directors, administrators, and community outreach liaisons in the Vietnamese community in Houston, Texas.

METHODS

The Center for Minority Health (CMRH) at the University of Texas M.D. Cancer Center interviewed 17 leaders, as defined above, to identify factors that have a negative impact on screening practices among Vietnamese women.

RESULTS

The results show that some of the barriers to cervical cancer screening include: lack of knowledge, lack of female physicians, language barriers, lack of insurance, and embarrassment. Interviews established that "prevention" is a Western concept that the Vietnamese community has not yet adopted. Vietnamese women used their churches, community physicians (licensed or not), circle of friends, and families for their health information. Many patients used herbs as alternative or complementary therapies.

CONCLUSION

Cultural factors play a vital role in limiting Vietnamese women in the use of cervical screening. Further research needs to focus on identifying specific barriers and how they can be overcome.

The effectiveness of a community outreach intervention to improve follow-up among underserved women at highest risk for cervical cancer

BACKGROUND

A disproportionate number of women diagnosed with cervical cancer are from low-income and/or ethnically diverse groups. This study was designed to evaluate the effectiveness of an outreach and counseling intervention at improving the rate of follow-up of abnormal Pap smears among women at Alameda County Medical Center, Oakland, CA.

METHODS

Between September 1, 1999 and August 31, 2001, 348 women with abnormal Pap test results were randomly assigned to intervention or usual care. The main outcome was rate of follow-up.

RESULTS

The intervention produced a significant increase in the rate of follow-up visits within 6 months. Women in the intervention group were much more likely to obtain timely follow-up at Highland Hospital than were those in the control group (61% vs. 32%, P = 0.001). The intervention was equally effective when delivered to women in the control group who had no follow-up by 6 months. Overall, we were able to contact 90% of women in the intervention group.

CONCLUSIONS

An outreach intervention is highly effective at increasing follow-up of abnormal Pap smears in a public hospital setting. Institutions offering cervical cancer screening to low-income, high-risk women should consider the use of outreach workers to reduce loss to follow-up.

Cancer preventive screening: a cross-border comparison of United States and Canadian Chinese women

OBJECTIVE

To compare screening mammography and Pap testing among Chinese women in Seattle, Washington to Vancouver, and British Columbia.

METHODS

Using community-based sampling methods, trilingual female interviewers surveyed Chinese women in Seattle and Vancouver. Multiple preventive health behaviors and health care access variables were assessed. Mammography analysis included 409 women aged 50-74 years. Pap testing analysis included 973 women aged 20-69 years. Main outcome measures were ever use and use in the last 2 years of screening mammography and Pap testing.

RESULTS

Chinese women in Vancouver were younger, more educated and fluent in English. Unadjusted rates of mammography and Pap testing were similar between the two cities. Provider type was consistently associated with screening in both cities; female providers had the highest rates and Chinese male providers the lowest. Adjusted logistic regression analysis demonstrated similar mammography use in the two cities. However, for Pap testing, women in Seattle had higher odds of screening compared to Vancouver.

CONCLUSION

Despite universal health care coverage and baseline characteristics typically associated with greater utilization of preventive screening services, Chinese women in Vancouver did not have higher rates of screening mammography and Pap testing compared to Chinese women in Seattle.

Are risk factors for breast cancer associated with follow-up procedures in diverse women with abnormal mammography?

OBJECTIVE

We evaluated the association of risk factors for breast cancer with reported follow-up procedures after abnormal mammography among diverse women.

METHODS

Women ages 40--80 years were recruited from four clinical sites after receiving a screening mammography result that was classified as abnormal but probably benign, suspicious or highly suspicious, or indeterminate using standard criteria. A telephone-administered survey asked about breast cancer risk factors (family history, estrogen use, physical inactivity, age of menarche, age at birth of first child, parity, alcohol use), and self-reported use of diagnostic tests (follow-up mammogram, breast ultrasound, or biopsy).

RESULTS

Nine hundred and seventy women completed the interview, mean age was 56, 42% were White, 19% Latina, 25% African American, and 15% Asian. White women were more likely to have a positive family history (20%), use estrogen (32%), be nulliparous (17%) and drink alcohol (62%). Latinas were more likely to be physically inactive (93%), African Americans to have early onset of menarche (53%) and Asians first child after age 30 (21%). White women were more likely to have suspicious mammograms (40%) and to undergo biopsy (45%). In multivariate models, Latinas were more likely to report breast ultrasound, physical inactive women reported fewer follow-up mammograms, and care outside the academic health center was associated with fewer biopsies. Indeterminate and suspicious mammography interpretations were significantly associated with more biopsy procedures (OR=8.4; 95% CI=3.8-18.5 and OR=59; 95% CI=35-100, respectively).

CONCLUSIONS

Demographic profile and breast cancer risk factors have little effect on self-reported use of diagnostic procedures following an abnormal mammography examination. Level of mammography abnormality determines diagnostic evaluation but variance by site of care was observed.

Pap testing among Vietnamese women: health care system and physician factors

Cervical cancer occurs more frequently among Vietnamese Americans than women of any other race/ethnicity. In addition, previous studies in California have documented low Papanicolaou (Pap) testing rates in Vietnamese communities. This study focused on health care system factors and physician characteristics associated with recent cervical cancer screening among Vietnamese women. A population-based survey was conducted in Seattle during 2002. In-person interviews were conducted by bilingual, bicultural female survey workers. The survey response rate was 82% and 518 women were included in the analysis. Seventy-four percent of the respondents reported having been screened for cervical cancer on at least one occasion, and 64% reported a Pap smear within the previous 2 years. Women with a regular doctor were more likely to have been recently screened than those without a regular doctor (OR = 2.33, 95% CI = 1.45-3.74). Among those with a regular doctor, having a male physician, receiving care at a private doctor's office (rather than a community, hospital, or multi-specialty clinic), and concern about the cost of health care were independently associated with lower screening rates. Physician ethnicity was not associated with recent Pap smear receipt. The findings support targeted interventions for Vietnamese women without a regular physician and private doctors' offices that serve Vietnamese Americans. The availability of low cost screening services should be publicized in Vietnamese communities.

Lessons learned from community-based cancer screening intervention research

Behaviors associated with cancer screening have been the focus of intensive research over the past 2 decades, primarily in the form of intervention trials to improve screening based in both clinical and community settings. Meta-analyses and literature reviews have synthesized and organized the resulting literature. From the accumulated work, this review distilled lessons learned from cancer screening intervention research in community settings. The authors posed the question, "What do we know about the development of effective community-based interventions (the level of good over harm achieved in real-world conditions)?" Framed around the concept of focal points (the simultaneous combination of target population, behavioral objective, and setting for an intervention), 13 lessons were derived. One lesson was cross-cutting, and the other lessons addressed the three focal-point components and the major intervention categories (access-enhancing strategies, mass media, small media, one-on-one and small-group education, and combinations of these categories). To build more systematically on existing research, recommendations are made for new directions in basic behavioral and intervention research.

Breast and cervical cancer screening among Latinas and non-Latina whites

OBJECTIVES

We examined whether Latinas differ from non-Latinas in having undergone recent mammography, clinical breast examination, or Papanicolaou testing, as well as the contribution of sociodemographic and health care variables to screening.

METHODS

We used data from the 1991 National Health Interview Survey Health Promotion and Disease Prevention supplement.

RESULTS

Latinas were less likely than non-Latina Whites to have undergone mammography (odds ratio [OR] = 0.71; 95% confidence interval [CI] = 0.57, 0.88), but this difference was attenuated when we controlled for socioeconomic factors (OR = 0.90; 95% CI = 0.70, 1.15). Latinas did not differ from Whites on Papanicolaou tests or clinical breast examinations. Quality of and access to health care predicted screening.

CONCLUSIONS

Latina ethnicity does not predict breast and cervical cancer screening behavior independent of sociodemographic and structural factors.

Socio-cultural influences on Chinese women's attendance for cervical screening

BACKGROUND

Compared with other countries, Hong Kong has a relatively high rate of cervical cancer. Much of this morbidity should be avoidable with cervical screening, but uptake rates for screening in Hong Kong are low. In programmes to promote cervical screening attendance, it is essential that aspects of the socio-cultural system be taken into account to provide appropriate preventive health strategies.

AIM

This paper outlines an investigation of the cultural and social factors contributing to Chinese women's attendance for cervical screening.

METHOD

A mixed methods design was employed, combining and comparing two data sets. The initial data set was drawn from 10 focus groups involving both screened and unscreened Chinese women (n = 54). The second data set was drawn from a total population of Hong Kong doctors, and involved face-to-face semi-structured interviews (n = 28).

RESULTS

Thematic analysis of the data from women indicated that the social factors of cost, educational base, knowledge of risk, the social value of early detection and cultural issues such as modesty and embarrassment contributed to screening attendance. The doctors perceived a cultural tendency towards fatalism, as well as seeing the gender, interpersonal and interprofessional skills of the practitioner to be important in influencing levels of Chinese women's shyness and discomfort, and hence affecting attendance. The lay and practitioner data sets varied in the perceptions of women's pain, embarrassment and risk factors.

CONCLUSION

Programmes providing services for Chinese women need to ensure that the philosophy of the staff and the approach and materials used are culturally relevant. Recommendations are that nurses equipped with relevant social and cultural knowledge of population groups should have a central role in health promotion and screening services.

Pap Testing Adherence among Vietnamese American Women

Objectives: Vietnamese American women are five times more likely to be diagnosed with cervical cancer than their White counterparts. Previous research has demonstrated low levels of Papanicolaou (Pap) testing among Vietnamese. Our study objective was to examine factors associated with interval Pap testing adherence. Methods: A population-based, in-person survey of Vietnamese women aged 18–64 years was conducted. Questionnaire content was guided by the Health Behavior Framework (HBF). The study sample was randomly selected from 1639 south Seattle households. Statistical methods included χ2 tests and logistic regression. Results: The response rate among eligible households was 82%, and the study included 352 women. Sixty-eight percent of the participants had been screened during the preceding 3 years. The following HBF factors were associated (P &lt; 0.05) with interval Pap testing in bivariate comparisons: believing Pap tests decrease the risk of cervical cancer and believing cervical cancer is curable if detected early (perceived effectiveness); knowing testing is necessary for women who are asymptomatic, sexually inactive, or postmenopausal (knowledge); reporting concern about pain/discomfort as a barrier to screening (barriers); family member(s) and friend(s) had suggested testing (social support); doctor(s) had recommended testing; and had asked doctor(s) for testing (communication with provider). In a multivariate analysis, being married, knowing Pap testing is necessary for asymptomatic women, doctor(s) had recommended testing, and had asked doctor(s) for testing were independently associated (P &lt; 0.05) with screening participation. Conclusion: Our results confirm low levels of Pap testing among Vietnamese women and demonstrate the importance of physician-patient communication in increasing screening adherence. Health education efforts should target unmarried women and reinforce the importance of Pap testing for all Vietnamese women.

Disparities in screening mammography. Current status, interventions and implications

OBJECTIVE

This paper describes trends in screening mammography utilization over the past decade and assesses the remaining disparities in mammography use among medically underserved women. We also describe the barriers to mammography and report effective interventions to enhance utilization.

DESIGN

We reviewed medline and other databases as well as relevant bibliographies.

MAIN RESULTS

The United States has dramatically improved its use of screening mammography over the past decade, with increased rates observed in every demographic group. Disparities in screening mammography are decreasing among medically underserved populations but still persist among racial/ethnic minorities and low-income women. Additionally, uninsured women and those with no usual care have the lowest rates of reported mammogram use. However, despite apparent increases in mammogram utilization, there is growing evidence that limitations in the national survey databases lead to overestimations of mammogram use, particularly among low-income racial and ethnic minorities.

CONCLUSIONS

The United States may be farther from its national goals of screening mammography, particularly among underserved women, than current data suggests. We should continue to support those interventions that increase mammography use among the medically underserved by addressing the barriers such as cost, language and acculturation limitations, deficits in knowledge and cultural beliefs, literacy and health system barriers such as insurance and having a source regular of medical care. Addressing disparities in the diagnostic and cancer treatment process should also be a priority in order to affect significant change in health outcomes among the underserved.

"Good health for new years": development of a cervical cancer control outreach program for Vietnamese immigrants

BACKGROUND

Cervical cancer incidence rates are higher among Vietnamese American women than among any other race/ethnic group in the United States. High rates of cervical cancer are associated with low rates of Papanicolao (Pap) testing adherence.

METHODS

Twenty-five qualitative interviews and 5 focus groups were conducted with Vietnamese women.

RESULTS

Interviews and focus groups revealed unanticipated information about sociocultural influences on women's beliefs about risk factors for cervical cancer. These data were utilized to develop culturally appropriate outreach materials.

CONCLUSIONS

Engaging with the target community enabled the development of culturally appropriate materials addressing cervical cancer risk factors and encouraging Pap testing adherence.

Interventions for patients, providers, and health care organizations

Clinicians and the organizations within which they practice play a major role in enabling patient participation in cancer screening and ensuring quality services. Guided by an ecologic framework, the authors summarize previous literature reviews and exemplary studies of breast, cervical, and colorectal cancer screening intervention studies conducted in health care settings. Lessons learned regarding interventions to maximize the potential of cancer screening are distilled. Four broad lessons learned emphasize that multiple levels of factors-public policy, organizational systems and practice settings, clinicians, and patients-influence cancer screening; that a diverse set of intervention strategies targeted at each of these levels can improve cancer screening rates; that the synergistic effects of multiple strategies often are most effective; and that targeting all components of the screening continuum is important. Recommendations are made for future research and practice, including priorities for intervention research specific to health care settings, the need to take research phases into consideration, the need for studies of health services delivery trends, and methods and measurement issues.

Hepatitis B knowledge and practices among Chinese Canadian women in Vancouver, British Columbia

INTRODUCTION

Liver cancer rates are higher in North American Chinese than non-Asian ethnic/racial groups, largely due to chronic hepatitis B virus (HBV) infection.

METHODS

A community-based survey of Chinese women (n = 147) was completed during 1999 to examine HBV knowledge and practices in Vancouver, British Columbia.

RESULTS

Most women had heard of HBV (85%) but smaller proportions knew about some routes of transmission (e.g., sexual intercourse) and sequelae of infection. Knowledge about HBV was significantly associated with education level (p = 0.005), English fluency (p < 0.001) and household income (p = 0.007). Previous serologic testing for HBV infection was significantly associated with education level (p = 0.04), English fluency (p = 0.01), and level of knowledge about HBV (p < 0.001).

CONCLUSIONS

Efforts to increase knowledge about HBV infection in this community should consider targeting less educated and less acculturated individuals.

Screening mammography among Chinese Canadian women

BACKGROUND

Though breast cancer is the most common malignancy among Chinese women, screening mammography is underutilized. This study examined barriers and facilitators of screening mammography among Chinese Canadian women.

METHODS

Using community-based sampling, Chinese women in British Columbia were interviewed in 1999 about multiple preventive health behaviours. We included 213 women in the mammography analysis; main outcome measures were ever having a mammogram and routine mammography.

RESULTS

Seventy-five percent of women 50 to 79 years old reported ever having had a mammogram, and 53% had two or more mammograms within the last five years. Receiving a recommendation for a mammogram from medical personnel or from a family member, and believing that cancer cannot be prevented by faith were independently associated with both screening outcomes.

CONCLUSIONS

A multifaceted approach to screening mammography promotion in Chinese Canadian women is suggested. Interventions that include education of and by medical providers and family members should be considered.