Asian Americans are a heterogeneous group and come from over 50 different countries and speak more than 100 languages (Gomez et al., 2013). VA immigrant women may have different cultural health beliefs and practices than other racial ethnic groups that significantly influence cancer risks and outcomes (Solanki, Ko, Qato, & Calip 2016). Previous researchers’ findings support the need to study groups separately. During the last 15-20 years, while breast cancer rates are declining in non-Hispanic American women, unfortunately, the rates are increasing among Asian-American women (Gomez et al., 2013). Furthermore, the incidence rates are significantly increased among VA immigrant women at 1.2% (95% CI = 0.1 to 2.2) per year (Gomez et al., 2013); and mammography screening rates (64%) are well below the national Healthy People 2020 (n.d.) goal of 81.1% (Pourat, Kagawa-Singer, Breen, & Sripipatana, 2010). VA immigrants encounter language, cultural, and economic barriers to preventive health care (McCracken et al., 2007). For example, VA immigrant women believe that breast cancer is only a concern when symptoms arise (Nguyen, Barg, Armstrong, Holmes, & Hornik, 2007). In addition, VA immigrants believe that looking for problems will invite new troubles into their lives. These suggest that VA immigrants need a compelling reason to seek a health care provider. Nguyen and colleagues (2010) found that VA immigrants were less likely compared to White and African Americans to report engaging in cancer information seeking. Researchers found that multiple intervention strategies that were culturally tailored were more likely to be effective at increasing mammography screening rather than singular non-tailored interventions among VA immigrant women (Lu et al., 2012). However, intervention intensity was difficult to determine because exposure to each of the multiple strategies was not tracked consistently. Therefore, the long-term sustainability is questionable (Lu et al., 2012). We previously developed and tested Early Care for Health (formerly known as the Targeted Breast Health Educational Program) among Chinese American immigrant women (Lee-Lin, Menon, Leo, & Pedhiwala, 2013; Lee-Lin, Nguyen, Pedhiwala, Dieckmann, & Menon 2015). The multi-component culturally targeted approach, which included targeted cultural and health belief messages delivered in an interactive education group that used power point media followed by individual counseling, was effective at increasing mammography screening at 3 months in a pilot study and at 6 and 12 months in a randomized controlled trial (n= 300) (Lee-Lin et al., 2013; 2015).
Methods: In our one- group pre- and post-test design, we recruited 40 VA immigrant women, aged 50 years and older, who had no personal history of breast cancer, had not had a mammography screening within the past 12 months, could understand and read Vietnamese or English, and were associated with/recruited from one Asian community-based organization as well as from the VA community in the Portland, Oregon metropolitan area, United States of America. We followed the American Cancer Society (ACS) 2015 screening guidelines (Oeffinger et al., 2015) since the ACS is most commonly followed by health care providers (Kwon et al., 2013). The Asian community-based organization is a trusted place “…where health and other information is sought and given” (Lee-Lin et al., 2013, p 363) and this recruitment approach has been successfully used by others (Nguyen and colleagues, 2010). In keeping with the exploratory nature, we based our sample size on our previous similar exploratory pilot study with Chinese American immigrant women (80% power and alpha level of 0.1). We adapted and modified Early Care for Health, which consists of two parts: an interactive group teaching (discussion) that used power point media followed by individual counseling session after 10 days to help women to overcome barriers to mammography screening. Topics for the interactive group teaching included: breast cancer incidences and mortality rates, risks for breast cancer, the process required/used to obtain mammography screening, perceived benefits of obtaining a mammography screening, and how to overcome perceived common barriers, and perceived cultural barriers, to obtain mammography screening. The materials also contained culturally relevant graphics such as photos of older and younger VA women having a mother, daughter, and grandmother conversation and Asian landscapes, and a breast cancer survivor story. We translated health messages into Vietnamese using a translation team approach. This was similar to our previous translation team approach (Nguyen-Truong et al., 2014), which included VA bilingual and bicultural community members and an academic investigator who first translated independently, and then discussed translation decisions as a team to resolve ambiguities. The translation team approach successfully captured meanings within the context of the discussion versus a strictly literal translation. A baseline survey included questions on mammography screening and breast cancer knowledge and measures on the following independent variables: perceived susceptibility, perceived benefits, perceived common barriers, and perceived cultural barriers (crisis orientation, modesty, use of Eastern/Asian medicine, family support). This information was collected from participants prior to the interactive group teaching, and again 12-weeks post-intervention. At baseline, we also asked each participant to identify major barriers that prevented her from obtaining mammography screening within the past 12 months. At 12-weeks post-intervention, we asked participants about mammography screening completion and determined if they were at the pre-contemplation, contemplation, or action stage (outcomes variables). We used a paired t test to compare mean differences and performed logistic regression analysis to determine related independent variables with the outcome variables.
Results: Of the 69 VA women who were eligible for the study, 40 agreed to participate, for a response rate of 58%. The sample ranged from aged 50 to 80 years old (mean = 67 years old), mean age of 53 years old (SD = 11.7) when immigrated to the United States, and a mean of 14 years (SD = 9.2) having lived in the United States. Most participants are currently married (58%, n = 23); with some high school education (33%, n = 13); not employed (78%, n = 31); have a total household income less than $15,000 (72%, n = 28); have health insurance (75%, n = 30); and do not speak English (38%, n = 15). Most participants have a regular health care provider (78%, n = 31). Thirty-nine women attended the interactive group teaching intervention. Participants identified the following reasons as top barriers to mammography screening: no reason (n = 17) followed by had no insurance or because of cost (n = 7), perceived they did not need to have a mammogram because they were over age 60 (n = 5), and did not have symptoms or did not think they would develop breast cancer (n = 3). Post-intervention survey results were encouraging: 75% (n = 30) of participants reported having obtained a mammography screening (action stage), of which 20% (n = 8) were in the pre-contemplation stage and 55% (n = 22) were in the contemplation stage at baseline. Of the 25% (n = 10) of participants who did not complete a mammography screening, one participant improved one stage from pre-contemplation to contemplation, seven remained the same stage, and one moved backward one stage from contemplation to pre-contemplation. The attrition rate was low with only one woman (3% of sample) lost to follow-up for a 98% (n = 39) completion rate. Ninety percent of participants judged Early Care for Health to be acceptable (e.g., cultural appropriateness of the content). Mean scores for the following variables significantly increased at post-test: breast cancer knowledge (t = -14.72, p < .001), perceived susceptibility to developing breast cancer (t = -2.69, p < .05), perceived benefits to mammography screening (t = -4.39, p < .001), and perceived breast cancer and mammography benefits (t = -4.09, p < .001). We found that crisis orientation towards mammography screening in pre- to post-test score difference was significantly positively associated with mammography screening completion (OR = 12.59, 90% confidence interval [CI] = 1.38-115.16) and stage in improvement (OR = 11.03, 90% CI = 1.34-91.05), whereas, older age was significantly negatively associated with both outcome variables (OR = .71, 90% CI = .57-.90; OR = .76, 90% CI = .62-.94 respectively) as well as modesty (OR = .04, 90% CI = .00-.45; OR = .04, 90% CI = .00-.45 respectively).
Conclusions: We achieved good feasibility, a good response rate, and very low attrition (Bowen et al., 2009). We also achieved acceptability of the program (Wahab, Menon, & Szalacha, 2008). Our pilot study findings are relevant to the congress themes and objectives because it is on health promotion and cancer disease prevention; based on theory and evidence-based research; a multi-component, culturally targeted educational program, which used power point media technology to deliver an interactive group teaching followed by individual counseling to improve access and remove barriers; and a strong interprofessional research team. This promising intervention can also be adapted for other Asian groups.