Applied Research and Evaluation

A COMMUNITY-BASED INTERVENTION TO
PROMOTE BREAST CANCER AWARENESS AND
SCREENING AMONG ASIAN AMERICAN WOMEN*

TSU-YIN WU, PH.D., RN
CHIUMAN LIN, MSN, RN
Eastern Michigan University, Ypsilanti
SHU-LING CHEN, PH.D., RN
Hung Kuang University, Taichung, Taiwan
YOOLIM JUNG
University of Michigan, Ann Arbor

ABSTRACT

Cancer is the leading cause of death for Asian Americans, and breast cancer
is the leading cancer diagnosed among Asian American women. Despite
the alarming facts, Asian American women have low breast cancer screening
rates. This study examined the effects of a culturally appropriate communitybased breast intervention program on participants’ knowledge about breast
cancer and intention for screening among Southeast Asian and South Asian
women in Michigan. Data were collected from 166 women. At baseline,
participants had limited knowledge of breast cancer screening guidelines and
misconceptions about the risk factors of breast cancer. After the educational
*This research was supported by the Susan G. Komen for the Cure (Grant #: POP0503877).

Int’l. Quarterly of Community Health Education, Vol. 34(2) 171-185, 2013-2014
Ó 2014, Baywood Publishing Co., Inc.
doi: http://dx.doi.org/10.2190/IQ.34.2.e
http://baywood.com
171

participants reported significantly higher knowledge scores related to breast cancer and screening recommendations and intentions to obtain follow-up CBE and mammograms. Therefore. since these screening activities can detect breast cancer early and prevent thousands of breast cancer deaths each year by diagnosing the disease when it is easier to treat.2 years. there is an urgent need to promote breast cancer screening among Asian women. intervention. Asian American (AA) women were the youngest to die (M = 46.172 / WU ET AL. and End Results (SEER) data indicated that while the mortality rate from breast cancer for White and Hispanic women decreased during 1990-1995. in particular. the Surveillance.1) during the hospitalization. and almost 19 years younger compared to Latina women [11]. SD = 10. In addition. primarily because of late detection [7. The epidemiologic study showed that for Asian women who immigrate to the United States. Epidemiology. . This culturally appropriate intervention provides strategies to overcome personal instructional barriers to meet the needs of this group for early detection and cancer control. a recent secondary analysis using a national dataset collected by the Agency for Healthcare Research and Quality revealed that among American women with breast cancer. the latest statistics available still show breast cancer as the leading cancer diagnosed in Asian American women [2. A recent study in Britain also revealed the evidence that breast cancer risk for South Asian women in Britain has increased considerably over the last decade.000) women. In addition. South Asian women were 8% more likely to develop breast cancer compared to White women [5]. Alarmingly. 8]. The low breast cancer incidence rates of Asian Americans perpetuate the belief of Asians as a “healthy minority” is no longer true. a recent study found the portion of South Asian women diagnosed at a localized stage was significant lower than proportions in other racial/ethnic groups [9]. the incidence rate of breast cancer for Asian American women now has approached that of White American women [4]. 000) and African American (102 per 100.000) compared with White (141 per 100. the rates rose for Asian and Pacific Islander women [10]. the incidence rate for developing breast cancer is six times greater than that of women who remain in their native countries. During the period 2000-2004. Between 2005-2009. In fact. Cancer is the leading cause of death for female Asian Americans [1]. AA women were 17 years younger at death compared with Caucasian women. Although Asian American women have a lower reported incidence rate of breast cancer (97 per 100. South Asian women’s risk of developing breast cancer was 45% lower than it was for White women. The literature documented that Asian American women are more likely to receive a diagnosis in the advanced stages of the disease [6]. 12 years younger compared with African American women. 3].

g. screening practices will become part of their health consciousness and later transform into actual screening behavior. the project team developed and implemented a culturally sensitive breast interventional program tailored to the unique cultural needs of this target population in order to increase the knowledge toward breast cancer and screening utilization (i. In these countries. immigrants from Asian countries in the United States are classified as Asian Americans and considered as one homogeneous group. For example. and have a wide range of religions. The current project focused on immigrant women living in those counties in the state of Michigan who were originally from southeastern and South Asia. including infectious diseases and basic survival [15]. . who more recently immigrated to the United States. whereas Japanese Americans are more acculturated and have a higher SES. It is hypothesized that culturally sensitive strategies will educate immigrant SEA and SA women about the importance of early detection for breast cancer. Working with Southeast Asian (SEA) and South Asian (SA) women to promote their breast health poses additional challenges because these SEA and SA women often emigrated from countries in political turmoil or where public health efforts were less advanced and comprehensive. the model minority stereotype could lead to a lack of understanding of the specific health problems and healthcare needs among different ethnic groups within Asian Americans. A generalization that one often hears about the Asian population is that they are a “model minority” population that is successful with few problems or needs [14].. Therefore. Therefore. In this article. Nevertheless. it is critical to increase the awareness of healthcare providers on Asian women’s special needs and cultural barriers toward breast cancer screening. etc.BREAST CANCER AWARENESS AND SCREENING / 173 In various surveillance systems. speak different languages. and cultures [13]. Asian women may not receive adequate and culturally appropriate information on mammography and clinical breast examination during routine care [11].e. Southeast Asians.). the Asian American population is highly diverse with a wide range in socioeconomic status (SES). particularly from three larger countries—the Philippines. clinical breast examination (CBE). this classification results in generalizations about the population as a whole [12]. are less acculturated and have a lower SES. lifestyles. access to care. Individuals who are part of this group come from many different countries and geographic locations. and mammography) for SEA and SA women in Michigan. a lower priority may be set for disease prevention because there is a greater need to control more immediate threats. language. As consequences. Vietnam. health professionals may underestimate the developing threat of breast cancer in Asian women due to the lower breast cancer incidence rate (compared to their Caucasian and African American counterparts) and cultural barriers (e.. Furthermore. and India. breast self-exam (BSE).

making presentations and volunteering in local ethnic celebration events (e. restaurants. ethnic social groups. the Mid-Autumn Festival.and post-intervention survey. The Project Director verbally explained the purpose of the study and its procedures. collaboration with the local community. These factors need to be considered in designing strategies to ..). In particular. 4. and India were hired to facilitate community networking and participant recruitment. an understanding of minority women’s cultural beliefs and values as well as personal life experiences with respect to utilization of breast cancer screening is essential. Asian New Year Celebration. participants had opportunities to ask any questions they might have. According the CEM. in order to be well connected to each ethnic community. which provides a comprehensive understanding of the use of breast cancer screening among minority women. etc. perceptions about such screening procedures can be considered as increasing the chance of getting the disease. with the projected 20% attrition rate. The following strategies were used to recruit eligible women to participate in the current study: 1. providing small monetary incentives for women who refer their friends and relatives to the project. In addition.174 / WU ET AL. four bilingual coordinators from the Philippines. 160 participants were needed as targeted sample size. etc. The calculation from the power analysis indicated that the required sample size for this study was at least 128 participants. The study intervention was an hour-long interactive education session delivered in a group format and conducted at community centers. and religious associations to distribute information to their members. Study protocol was approved by the Institutional Review Board. posting flyers at local ethnic grocery stores.. and 5. 3. Vietnam. Study eligibility criteria included self identify as SEA and SA women (Philippines. and the issue of modesty is relevant among Asian populations. Informed consents were obtained at the beginning of educational sessions for completing the pre. Vietnam.g. churches. 2. Conceptual Framework The study was guided by the Cultural Exploratory Model (CEM). and India) aged 30 or older and no personal history of breast cancer. collaboration with ethnic student associations to help recruit their mothers and other relatives into the study. and temples where participants gathered. beauty salons. professional organizations. METHODS Study Design and Procedure This study used a one-group pre-survey and post-survey design to examine the impact of a culturally appropriate intervention.

Medicine. access. The study intervention was developed utilizing the results of cultural beliefs and barriers about breast cancer screening that are specific to each ethnic group and incorporated into the education sessions.e.. and each session was facilitated by bilingual project staff to assist those women who are not fluent in English. the project staff (with social work background) performed a needs assessment and identified structural barriers (i. CBE. and “Don’t know where to get a mammogram” was a common barrier for the Asian Indian women [18]. “Don’t need mammogram if I feel OK” and “Waiting time is too long” were mentioned frequently by the Chinese women. the CEM stresses that the needs of minority women within ethnic groups do not only depend on their cultural background since individuals are shaped by social relationships that take place within and outside their cultural groups. and barriers to breast cancer screening in SEA and SA women residing in the United States. This model has been applied in examining religious and sociocultural issues relevant to breast cancer screening practices among older immigrant Asian Islamic women and practices of breast self-examination (BSE) among Middle Eastern Asian Islamic immigrant women [16. The current study applied the CEM to evaluate the cultural beliefs. educational background.g. All written materials were translated into their native languages. • Reducing structural barriers: Before the education session started. etc. In addition. socioeconomic factors. as well as their current practices related to breast cancer screening activities (e. “Afraid that mammogram will find cancer” was important for Filipino women. Filipino. All sessions were conducted in a small group setting (limited to 15 or less) to facilitate interactions. 17]. Therefore. • Reducing language barriers: The sessions were conducted separately for different ethnic groups. for example. it is important to consider women’s sociodemographic factors. and immigration status. and Asian Indian women found that different barriers related to cultural beliefs were identified by specific ethnic groups. child-care issues. • Reducing cultural barriers: The results from a previous descriptive study that examined mammography screening practices and related beliefs in Chinese. The CEM acknowledges and respects the individual and cultural explanations in health-seeking behavior that health professionals can utilize to assess Asian women’s needs in cancer screening. transportation. including their socioeconomic status.BREAST CANCER AWARENESS AND SCREENING / 175 promote screening in the minority population. Intervention Development and Implementation The interdisciplinary project team that consisted of professionals from Nursing. A feasible plan to perform the three breast cancer screening .) to screening. and Social Work used findings from earlier qualitative and descriptive studies to develop linguistically appropriate culturally sensitive content to address barriers and cultural beliefs toward breast cancer and screening practices.. and mammography). BSE.

language. Hindu (for Asian Indian group). or 5 = extremely high risk). participants were encouraged to share their personal cancer and screening experiences and points that highlight the importance of early detection and the necessity of a woman staying healthy to care for her family were emphasized. and 5. 4. 2 = low. The educational program also included information on following topics: 1. income. self-efficacy. The group presentations were delivered by the principal investigator and facilitated by the bilingual project staff. Two items were used to assess participants’ risk perceptions on getting breast cancer on a 5-point Likert scale (1 = no risk. ethnicity. The presentation content incorporated the content that addresses cultural. CBE. clinical breast exam and mammogram). 3. The process of back translation can be found in a previously reported study [19]. The study measures were initially developed in English and translated into Tagalog (for Filipino group). skills for performing breast self-examination. modalities (including BSE. and Vietnamese using standard back translation. beliefs toward susceptibility/risk. 2. . and personal and family histories of breast cancer. The sociodemographic section includes age. knowledge of breast cancer risk factors and frequency for recommended screening tests. During the sessions. duration of residing in the United States. For those participants who do not have health insurance and cannot have their screening done via routine healthcare. effective strategies for reducing barriers and increasing self-efficacy for adherence. and structure barriers encountered by immigrant SEA and SA women. early detection of breast cancer and promotion of breast health. and mammography) was developed.. education. benefits and access to breast cancer screening (i. free state-funded breast and cancer control program (BCCCP) or low-cost programs were identified and provided to women participants as resources. and intentions for future screening. Data Collection and Analysis A self-administered instrument was used to collect demographic data. and another item asked participants to rate their risk compared to other women with responses ranging from 1 (much lower than average) to 5 (much higher than average). 4 = high. insurance coverage for mammography. marital status.e. 3 = moderate. The knowledge sections consisted of: a) knowledge about breast cancer risks (eight items related to the knowledge of the following conditions that increases a woman’s chance of getting breast cancer: (i) hitting. availability of clinical breast exams and information on MI-BCCCP. The program lasted approximately one hour and allowed questions and answers at the end.176 / WU ET AL.

A total of 166 women were enrolled to participate in the study and 141 women completed both pre. and (viii) mammogram helps to detect cancer. only 36% of the participants had had their last mammogram within past 2 years. BSE. perceived barriers. or fondling the breasts. 65% were married. (iii) had previously breastfed a child. RESULTS Social-Demographic Characteristics Participant characteristics are detailed in Table 1. In terms of CBE use.0. and 45% had insurance coverage for the mammogram. (vii) ovarian cancer. 51% reported their last visits were up-to-date. 37% had annual income less than $15. Descriptive statistics were performed to summarize sample characteristics and study variables. (iv) overweight. and results demonstrated excellent internal consistency and provided evidence of construct and predictive validity [19. (ii) does not have any breast symptoms. was used to analyze the data. and (vi) healthy lifestyles. The mean age was 50 years (SD = 12. A set of 18 items assessing the women’s perceptions about benefits and barriers of breast cancer screening with six items focusing on the benefits and 12 items assessing the barriers to regular mammography.4. The SPSS statistical package. perceived selfefficacy) measures were tested in a previous study.and post-surveys. each item used a 4-point Likert scale. (iv) older age. version 18. (iii) immigration to the United States. range 30-83). CBE. and 28% expressed that they had never received a CBE in the past. Thirty-seven percent of participants reported they performed monthly BSE while 31-33% reported they had never heard of BSE or had never self-examined.. perceived benefits. Paired t-tests were used to determine changes before and after the educational intervention in knowledge and self-efficacy. (v) air pollution. A p value of < . and Mammography Use at Baseline At the baseline. .05 was considered significant.e. and 27% had never heard about the mammogram. McNear Chi-square tests were used to detect changes in correct responses of individual knowledge questionnaire items. (ii) doing something morally bad. and b) knowledge of recommendations for frequency of mammography screening (five items related to knowledge of the recommended frequency of having a mammogram for women with the following conditions: (i) does not have any family history of breast cancer.BREAST CANCER AWARENESS AND SCREENING / 177 bumping.000. (vi) large breasts. 20]. The intention to obtain a mammogram and CBE were assessed using two items in a post-intervention survey asking participants whether they were planning on having a mammogram/CBE in the future (in 6 months). 75% had received college education (M = 12 years). Health beliefs (i.

5 Education High school or lower College/university or higher 21 63 25. Table 1.0 Length of residency in the United States (years) < = 10 > 10 60 72 45.6 12.4 Age (years) 40-49 50-65 > 65 30 62 14 28.2 Marital status Married Not married 91 50 64. p < 0.1 45. Ninety-four percent of participants incorrectly thought that “women who have large breasts have a higher chance of getting breast cancer than women with .5 13.5 36. the results showed that the participants had significantly higher scores in overall knowledge of the risk of developing breast cancer after educational intervention (t = –11.7 18.5 Insurance coverage of mammogram Yes No Don’t know 57 47 24 44.05). Participant Characteristics Characteristics na % Ethnicity India Philippines Vietnam 60 17 64 42. Using a paired t-test to determine the effectiveness of the education intervention. When individual risk items were examined. Knowledge of Risk on Developing Breast Cancer The effects of the study intervention were examined with participants’ knowledge of risk of developing breast cancer.0 75.5 35. Fewer than half of the study sample responded to the seven items correctly (Table 2).8 aNumbers do not sum to 141 due to missing values.3 58. the results demonstrated that participants did not have the correct knowledge on the risks for developing breast cancer.97.5 54.178 / WU ET AL.

the results from the paired . larger breasts.05 Ovarian cancer increases the risk 26 45 7.05 Large breasts increases the risk PrePostintervention intervention Mean Mean Overall (eight items) 2.01 < 0.05 Mammogram helps doctors or nurses find breast cancer before it can be felt 79 82 0.54 < 0.05 Air pollution increases the risk 24 58 24.25 ns t p –11.97 < 0.BREAST CANCER AWARENESS AND SCREENING / 179 Table 2.42 < 0. or fondling the breasts increases the risk 41 84 50.05 6 86 104.46 *N = 141.62 < 0.05 Obesity increases the risk 21 50 21.” Eighty-eight percent of participants did not know that the immigration increases the likelihood of developing breast cancer. participants’ correct responses for each item significantly increased after the intervention (Table 2). ns = not significant.57 5. hitting.05 Doing something morally bad increases the risk 48 89 497. Knowledge of Mammography Frequency Under Different Scenarios In examining the knowledge dimension on recommendations for frequency of mammography screening with different scenarios.05 Immigrating to the United States increases the risk 12 52 36.70 < 0. Educational Intervention Impact on Knowledge of Risk of Developing Breast Cancer Items in knowledge of risk of developing breast cancer PrePostintervention intervention % correct % correct c2 p Bumping. The Chi-square analyses indicated that except for the “mammogram” item.78 < 0.89 < 0.

The correct response rate increased from 33% to 66% (c2 = 23.01). 23% knew when to begin regular screening at baseline. Self-Efficacy.09 ns No symptom 66 70 0. The percentage of participants who correctly knew the recommended frequency of performing CBE also increased after the intervention (pre-intervention: 28%.5 70. the mean of participants’ self-efficacy for Table 3. and Intention for Future Screening Plans Participants were asked to rate their self-efficacy for performing BSE (100point scale). Nevertheless.57 3. t-test showed that the overall mean score at post-test was not statistically different from the pre-test score (t = 0.2 0.81.00 ns Items in knowledge of risk of developing breast cancer Overall (five items) *N = 141. p = ns). The results showed that participants’ knowledge of recommended frequency for performing BSE increased significantly during post-intervention. Preintervention Mean Postintervention Mean t p 3. Educational Intervention Impact on Knowledge of Mammography Frequency under Different Scenarios Preintervention % correct Postintervention % correct c2 p Have no family history 70 72 0. none of p values reached statistical significance (Table 3).05). For mammography. c2 = 7. participants’ correct response rate increased with every item during post-intervention.40 0. During pre-intervention.39 ns Breast-fed a child 65 69 0.85 ns .180 / WU ET AL.60. Risk Perception. p < 0. Knowledge of Recommended Frequency for Performing BSE and CBE Participants were also tested on their knowledge of recommended frequency for performing BSE and CBE before and after the education intervention. ns = not significant.85. however.64 ns Healthy lifestyles 69. postintervention: 52%.57 ns Gets older 71 77 1. p < 0.

p < .43. more than 90% of women reported that they were not aware of the state program to obtain free mammograms.BREAST CANCER AWARENESS AND SCREENING / 181 performing BSE was 46.00). In terms of getting breast cancer screening.61).9 27. and 91% indicated that they plan to obtain mammograms. after the study intervention.8 7. whereas the mean of self-efficacy for performing BSE upon post-intervention was 73.8 Low risk 35. 94% of participants indicated that they were planning to obtain CBEs in the future. Perceptions of Risk of Developing Breast Cancer Preintervention % Postintervention % No risk 37. this was the first study in the literature to focus on the impact of educational intervention on Southeast Asian (SEA) and South Asian (SA) women in Michigan. DISCUSSION To our knowledge.1 High risk 6.5 — (< 1%) Risk perception .to post-intervention is statistically significant (t = 2.14 (SD = 31.37 (SD = 26. more than 70% of the women reported either no risk or very low risk at baseline.0 Extremely high risk 1. Before the education session. 94% of the participants reported their plans for making visits to obtain CBE and mammograms in the future. The t-test analysis showed a significant difference between pre-intervention and postintervention self-efficacy scores (t = –8.1 Moderate risk 18. After the educational intervention. at the post-test. The women rating their risk as moderate increased from 19% (pre-intervention survey) to 27% (post-intervention survey) (Table 4).6 41. The results demonstrate that it is feasible and effective in this study in reaching traditionally under-screened SEA and SA women and providing culturally appropriate intervention that increases their knowledge on breast cancer Table 4.14. When participants were asked about their risk of getting breast cancer on a scale from no risk to very high risk.05). p = . 60% of them indicated that they now are aware of MI-BCCCP and know how to contact the program for eligibility and enrollment information. the percentage for reporting on these two categories decreased to 66%.1 24. The changes of risk perception from pre.92). Moreover.

While previous intervention research on Asian Americans focused on current or existing screening behaviors [21-23]. The education was effective in modifying perceived risk perceptions of breast cancer in this group of SEA and SA women. Health education about the benefits of early detection and recommended screening intervals and tests is needed on an ongoing basis so the critical breast health information can be infused to this community. mammogram and CBE). cultural. and structural barriers so SEA and SA women have skills and knowledge for the follow-up screening routines.182 / WU ET AL. which in turn increases self-efficacy for participants in this study. it is important to investigate participants’ intentions in order to better predict their future screening behaviors. Although the majority of participants heard about breast cancer screening tests (i. This study intervention bridges the gap and provides strategies to address language. whereas participants’ risk perceptions significantly changed from pre. SEA and SA women after the education session had significantly higher knowledge scores related to breast cancer and screening recommendations. less than one-third of women at baseline knew obesity and being immigrants can increase the risk. and more than 90% of participants mistakenly believed that large breasts can increase the risk for breast cancer. thus had misconceptions about the risk factors of breast cancer. The study is limited by using a convenience sample and did not have a control group. In this immigrant population. immigrant SEA and SA women presented as one of most vulnerable groups who had limited awareness on early detection for cancer control and difficulty in accessing health information and healthcare when they immigrate to the United States. Therefore. Consistent with other studies reporting low perceived risks for breast cancer among Asian American women [24. In addition. they had limited knowledge of ACS screening guidelines. At baseline.to post-test.. while the study participants had low levels of screening practices for CBEs and mammograms (51% and 36% of up-to-date screening rates respectively) at pre-test. with limited health literacy in combination with English language proficiency. and screening practices. In particular.e. The findings illustrate the need for clinicians and health educators to be aware of the way perceived risks operate within SEA and SA groups and incorporate into an intervention based on the evaluation of their patient’s perceived risk of cancer to better deliver the messages of the importance for screening. The strength of this study is to incorporate previous study findings into the study interventions that provide culturally and linguistically appropriate content in their native languages so that women know strategies and resources for decreasing or minimizing identified barriers. a large proportion of women (73%) indicated they have less or much less risk of developing breast cancer. more than 90% of them reported their intent to obtain follow-up CBE and mammograms at the post-test. the findings from the current study support the notion that discussing risks is complex and must consider cultural values and beliefs specific to this group. the true intervention effects cannot be estimated. 25]. The .

8-29. the changes of risk perception among participants compared with their actual risks cannot be verified. In conclusion. The findings from this study support the notion that SEA and SA women are no longer considered as “low-risk” groups for breast cancer screening since they are less likely to be aware of their risks for breast cancer. The study was conducted in SEA and SA communities in suburban areas in the Midwest of the United States. during earlier stage of manuscript development and the editorial assistance of Alethea Helbig who helped the authors to review and improve the manuscript. . 51. mammography) also need to be carefully assessed during the clinical encounter so health professionals can better provide culturally competent care. A longitudinal study with longer periods after the study intervention is needed to evaluate the sustaining effect of educational intervention on knowledge and screening behaviors. Samuels. cultural. 2. E. www. Murray.sp. et al. A. and linguistic barriers. R. the specific perceptions of SEA and SA women toward such “newer” screening practices (for example. A. The participants self select into participation in the study and were already interested and motivated to learn more about this topic. In order to motivate them to obtain the recommended breast cancer screening tests. Ward. Tiwari. 2002.. Ghafoor. Angela Shu and Shelly Xiejuan Wu. We appreciate the work of our team staff.BREAST CANCER AWARENESS AND SCREENING / 183 actual risks for developing breast cancer were not measured. The current study laid the foundation for communitybased culturally appropriate education intervention for promoting breast health and screening behavior among SEA and SA women. Cancer Journal for Clinicians.ohio-state. REFERENCES 1. 2004. Cancer Statistics. In addition.edu/aancart/ABOUT_AANCART. T. SEA and SA women need to increase breast health awareness and change their misconceptions about risk factors related to breast cancer and screening procedures. structural. barriers toward screening. knowledge of risk factors. The intervention to promote breast cancer screening can be effective if the program is appropriately tailored to meet the needs of the targeted community by providing the relevant health education content and strategies and skills overcome social. and confidence in obtaining screening tests. Jemal. A. pp. the women’s decisions for getting breast cancer screening is influenced by a combination of factors including perceptions of breast cancer risk. therefore. ACKNOWLEDGMENTS We thank the Southeast Asian and South Asian community for their support and those women who participated in our study.htm. the findings of this study may not be generalized to SEA and SA women in other areas of the United States.

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