J Canc Educ DOI 10.1007/s13187-015-0859-3

Evaluation of a Culturally Tailored Education to Promote Breast and Cervical Cancer Screening Among Chinese-Australian Women Cannas Kwok 1 & Danforn Lim 2

# American Association for Cancer Education 2015

Abstract This paper aims to evaluate the impact of the culturally sensitive and linguistically appropriate education program on the following: (i) awareness of screening practices (breast awareness, mammogram, and Pap smear test); (ii) screening intention within the next six months; and (iii) knowledge about breast and cervical cancer among ChineseAustralian women. Titled BHappy and Healthy Life in Sydney,^ this was a quasi-experimental study with both pre- and post-test design. A convenience sample of 288 Chinese women was recruited through Chinese organizations such as churches and community centers. Participants completed the questionnaires before and after the educational program. The results show that the program was effective in promoting awareness of breast and cervical cancer screening and resulted in increased participative intentions in both mammogram and Pap smear testing within the next 6 months. Results also indicate that knowledge and belief scores were significantly increased. Conclusion: Our study supports that educational programs which use culturally sensitive and linguistically appropriate strategies are effective in improving both knowledge of breast and cervical cancer and awareness of their early detection practices among Chinese-Australian women.

Keywords Breast cancer education . Chinese women . Screening promotion

* Cannas Kwok [email protected] 1

School of Nursing & Midwifery, University of Western Sydney, Sydney, Australia

2

University of Technology Sydney, Sydney, Australia

Introduction Despite Chinese women having a relatively lower incidence rate compared to the Caucasian population, breast cancer remains the most common cause of cancer morbidity among Chinese women in Australia [1]. There is increasing concern that Chinese-born women living in Australia [2] and the USA [3] have a respectively 40 and 60 % higher risk of developing breast cancer compared to their counterparts in China. Cervical cancer is the 12th most common cancer diagnosed among Australian women [4]. To date, no data exists indicating the incidence of cervical cancer for among the various ethnic groups in Australia. However, studies indicate that cervical cancer is more common in developing countries [5]. In 2012, there were 130,000 new cases of cervical cancer in China, accounting for 28 % of the world’s total [6]. Considering the rapid increase of Chinese population in Australia, it is reasonable to believe that cervical cancer is as an important health concern for Chinese-Australian women. Regular mammography and Pap smear testing have been shown to be effective in reducing breast and cervical cancer deaths [7, 8]. In Australia, a national screening program provides free mammographic screening for women aged between 50 and 69 while there is a similar Pap smear program for women aged between 18 and 70 [9]. However, the participation rates of women from Chinese background are consistently lower than those of Caucasian women [10, 11]. This could be because access to health care is limited in both China and Hong Kong while preventive medicine or early detection measures enjoy only low priority. [12]. As a result, many Chinese women undertake cancer screening only after migration to Australia. Additionally, studies indicate that Chinese women, who have immigrated to Western countries, face many barriers such as language and the difficulty of navigating complex health care systems [13, 14].

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International studies among Chinese women also reveal certain culturally based norms, beliefs, and values hamper the uptake of breast and cervical cancer screening [15–17]. For instance, since according to Chinese cultural beliefs, negative thinking creates negative outcomes, some Chinese women are of the opinion that undergoing mammography increases their chances of developing the disease [15]. Moreover, a previous study conducted by the lead author revealed a commonly held belief among Chinese-Australian women that breast cancer is a disease specific to Western women and that they are therefore immune to it, making it unnecessary for them to have mammograms [18]. Similar study has demonstrated that because some Chinese women believe that promiscuity is the cause of cervical cancer, having a Pap smear test implies that a woman has been unfaithful to her husband and is therefore to be avoided [17]. Furthermore, cultural beliefs about the inexorable nature of Bfate^ and Bdestiny^ which nothing can avert result in many Chinese women seeing mammography and Pap smear testing as being futile [17, 19]. All such evidence points to the conclusion that if cancer screening practices are to be promoted effectively in Chinese immigrant communities, it is essential that their cultural beliefs be taken into account. International studies on interventions, which have employed culturally and linguistically appropriate strategies targeting women from CALD backgrounds, have reported positive improvements not only in knowledge and beliefs about breast and cervical cancer but also in the uptake of mammography and Pap smear testing. Such studies include those of Kim and colleagues in the Korean-American community [20], of Ahmad et al. in the Asian community of Canada [21], of Hall et al. among Hispanic Americans [22], and of Tanjasiri et al. among Hmong-Americans [23]. Despite Australia being very culturally diverse, only limited information is available on the effectiveness of interventions which focus on promoting breast and cervical cancer screening practices among Chinese-Australian women, who form part of the largest ethnic community from the non-English speaking background in Australia. In 2013, our research team developed and evaluated a community-based, culturally sensitive, and linguistically appropriate breast and cervical cancer awareness education program. This paper aims to evaluate the impact of the program on the following: (i) awareness of screening practices (breast awareness, mammogram, and Pap smear test); (ii) screening intention within the next six months; and (iii) knowledge about breast and cervical cancer among Chinese-Australian women. To our knowledge, this is the first education program of its kind to be piloted and evaluated in Australia.

Methods and Materials Quasi-experimental study design using pre and post-test was used in this study.

Educational Sessions and Take-Home Information Kit An educational session titled “Happy and healthy life in Sydney” program was designed to be a culturally sensitive and linguistically appropriate breast and cervical cancer education program. The specific focus was on the promotion of breast and cervical cancer knowledge and awareness of their early detection among Chinese-Australian women living in Sydney. The contents of the educational program were based on literature [15, 16] and previous studies conducted by the first author [17, 18]. These were reviewed by the Cancer Institute NSW, a major national cancer organization, and health leaders from several Chinese organizations involved in cancer care and Chinese women’s health. In addition to basic biomedical messages, the contents addressed cultural misconceptions and myths about breast and cervical cancer such as those described above and also the idea that there is no need for anyone who is asymptomatic to undergo cancer screening and that Chinese women are immune to breast cancer. The message “early detection saves lives” was promoted as being as important as any Chinese traditional beliefs. Information about where and how to attend a mammography and Pap smear testing was also included. The educational program, presented in Cantonese by the lead author, was delivered as a 35- to 40-min long PowerPoint presentation in venues provided by Chinese organizations. The use of PowerPoint enabled us to present information in graphic format which made the concepts easier to comprehend. There was a Q&A section at the end of the presentation in which the participants were encouraged to ask questions. At the end of the program, the participants were given a take-home information kit; there was an information booklet using simple language and pictures to summarize the contents of the educational session, a calendar containing reminders about the dates of mammography and Pap smear testing, contact details for appointment booking, a fridge magnet, and a coffee mug with the program logo. All materials were presented in Chinese. The participants were encouraged to spread the message to family members, relatives, and peers. Efforts have been made to enhance the cultural sensitivity and competency of the program. Firstly, the presentations were delivered in Chinese organizational venues because their environments were familiar and easily accessible to participants. Secondly, recognizing the belief that talking about disease and death before and during the festival seasons will lead to bad luck during the entire year, we chose to deliver the program in June, a few months after Chinese new year celebrations. Thirdly, we designed all printed program materials and the bag for the information kit with a pink color theme because pink indicates femininity and harmony in Chinese culture. Images of Chinese women and culturally relevant graphics were used in all materials to convey a feeling of enjoyment and a happy and healthy life.

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Participants A convenience sample of women was recruited through a number of Chinese organizations in Sydney. These included churches and community centers which have as their mission serving Chinese-Australian families with a range of social services such as health education. Participants’ eligibility criteria included being a ChineseAustralian woman aged 18 years or older with no personal history of breast and cervical cancer, being able to speak Cantonese, and having an ability to read and write Chinese. With the assistance of the Chinese organizations, eligible participants were identified and invited to join the program. Advertising flyers were posted at community organizations and meeting venues and published in the local Chinese newspaper. On the day of educational session, the first author gave the women a brief description of the program, explained the project, and answered their questions. The participants were required to sign consent forms prior to commencing the program. The study was approved by the Human Ethics committee of the University of Western Sydney.

(strongly disagree (5) to strongly agree (1)) were used; higher scores indicated more positive knowledge, beliefs, and attitudes. Certain items (1, 6) were reverse scored. The original English-version questionnaire was translated into Chinese by the lead author who is fluent in English and Chinese. Back translation was conducted by another independent bilingual translator to ensure lexical equivalence and reconciled [25]. The Chinese-version questionnaire was piloted with 10 Chinese-Australian women. The women were asked to comment on the clarity, understandability, and readability of the Chinese-language version questionnaire. No problematic sentences or wording were identified. Data Analysis Using SPSS version 18, descriptive statistics and frequencies were employed to describe the demographic background information of the participants and program evaluation. Differences in knowledge, beliefs, and attitudes towards breast and cervical cancer and its early detection practices of the pre- and post- intervention were measured using the t test.

Data Collection

Results A total of seven educational sessions were conducted during June and July in 2013. Attendance ranged 10 to 88 participants in each session. Questionnaires were administered immediately before and after the educational program to assess the impact of the program on the following: (i) awareness of screening practices (breast awareness, mammogram, and Pap smear testing); (ii) screening intentions within the next six months; and (iii) knowledge about breast and cervical cancer screening and early detection practices. Demographic data, including age, country of birth, education level, and selfassessed English proficiency were collected at the baseline. The questionnaires in paper format were administered by project staff. The participants could either complete the questionnaires by themselves or with assistance from the project staff. Measurement Awareness of screening practices and screening intentions was assessed by means of multiple choices questions and also by “yes,”, “no,”, and “don’t know” answers. For example: “Have you ever heard of breast awareness? Yes/No/Don’t know;” “Do you have any intention of having a Pap smear test in the next six months? Yes/No/Don’t know.” Questions about knowledge, beliefs, and attitudes about breast cancer were adapted from the “Chinese Breast Cancer Screening Beliefs” questionnaire which has been validated as a reliable tool [24]. The cervical cancer and Pap smear test items were developed from the literature and a previous study conducted by the lead author [17]. Five point agreement scales

Sociodemographic A convenience sample of 302 Chinese-Australian women selected according to the criteria set out above were enrolled in the program. Fourteen participants (5 %) were excluded from the data analysis because they left the program early and did not complete the post-questionnaire. The sociodemographic data of the remaining 288 women are presented in Table 1. The age range was from 30 to 78, the mean age being 46.5 years (SD=8.685). Almost all were born in China or Hong Kong (96 %). Nearly half (46.2 %) had completed either primary or secondary school, while 11.5 % had never attended school. Despite the fact that nearly half (46.2 %) had been in Australia for more than 10 years, almost two-thirds (65.3 %) rated their English proficiency as poor to non-existent. Awareness of Screening Practices and Intention Table 2 compares the women’s responses, both pre- and postprogram, regarding their awareness of screening practices and testing intentions. The program appeared to be effective in promoting awareness of breast and cervical cancer screening while the participants also reported that they had become more aware of breast health (81.9 vs 41.7 %) and of mammogram (97.2 vs 69.4 %) and Pap smear testing (100 vs 77 %). In terms of knowing the correct age at which mammogram and Pap smear testing should be undertaken, a significantly greater

J Canc Educ Table 1

Social demographic information of participants (N=288)

Knowledge, Belief, and Attitudes Towards Breast and Cervical Cancer

Age (years) (Mean, 46.5; SD, 8.685)

No.

%

0

0

30–39

48

16.4

40–49

79

27.2

50–59

100

35.7

60–69

56

19.3

5

1.4

70 Country of birth

Discussion

China

153

53

Hong Kong

125

43

10

4

Other (Taiwan, Macau, Vietnam, Singapore) Length of stay in Australia (year) (Mean, 16.8; SD, 9.365) 1–5

56

19.5

6–10

98

34.3

11–15

67

23.2

16–20

43

14.9

>20

24

8.3

Marital status Single

25

8.7

190

66.0

Divorced/separated

45

15.6

Widowed

28

9.7

Married

Missing Education level Not at all

33

11.5

Primary School

45

15.6

Secondary School

88

3.6

TAFE/college

81

28.0

Tertiary or above

36

12.5

5

1.7

Missing Employment status Full time worker

25

8.7

Part time worker

98

34.0

Retired

96

33.3

Unemployed

69

24.0

0

0

Missing English proficiency Very good

13

4.5

Good

35

12.1

52

18.0

Average Little Not at all

A comparison of mean scores of each question regarding breast and cervical cancer was conducted for the 288 women who completed the pre- and post-questionnaire. A significance level of 0.05 was set and 7 of the 10 questions were found to be significant. Table 3 presents the details.

102

35.4

86

29.9

Missing

number of women responded correctly after participating in the program (82.6 vs 41.7, 86 vs 23.6 % respectively). Similarly, more women expressed an intention of attending cancer screening within the next 6 months (76.4 vs 47.9 % for Pap smear test and 35.4 vs 23.6 % for mammograms).

This study demonstrated that culturally sensitive and linguistically appropriate education programs delivered in community settings are effective improving knowledge of breast and cervical cancer and awareness of their early detection practices. A particularly noteworthy point about our findings was that they revealed that only small proportion of participants had heard of the concept of “breast awareness” at the baseline. This may be because “breast awareness” is a new term devised comparatively recently to replace that of “breast self-examination” in Australia [9]. However, paying special attention to breast health is not a cultural norm among Chinese women [18], and they do not find the concept appealing. That is the cause for alarm since the peak incidence of breast cancer is among younger Chinese women [26]. Our findings point to an urgent need for additional efforts to be made to promote breast awareness in a culturally sensitive manner among those women younger than 50 who are not eligible for mammograms. Our study has provided a positive starting point in this regard. With respect to intentions to undertake mammogram and Pap smear testing within the next 6 months, the findings at baseline suggest that while a significant number knew of screening practices, only a relatively low proportion intended to use them. Our study demonstrates positive results similar to those of Wang et al. [27] who used a culturally sensitive video intervention to increase Chinese-American women’s intentions to participate in mammography. The increased screening intention rate among our participants may have been enhanced by changes in their knowledge and health beliefs as a result of the program, which may also have changed fatalistic views about cancer. This is supported by studies indicating that knowledge about breast and cervical cancer is positively correlated to screening intentions [21, 23, 27]. However, this pilot study is too small to constitute an adequate examination of such association. Investigating that association will form an important focus of our future work. Furthermore, our findings indicate that a quarter to one third of participants had no intention (the answer Bnot sure^ was treated as having no intention) of participating in Pap smear and mammogram after the program. Substantial evidence indicates that language barriers form a key disincentive dissuading this minority of women from attending screening

J Canc Educ Table 2 Result of pre- and post questionnaires regarding awareness of screening practices and intention (N=288). Blank response were treated as missing data and are not presented above, so percentages may not sum to 100

Awareness of screening practices Heard of breast awareness

Heard of a mammogram

Heard of Pap smear test

Correct answer to target age group for mammogram Correct answer to target age group for Pap smear test Intention of attending screening in near future Intention to have a Pap smear test in near future

Intention to have a mammogram in near future (those aged between 50 and 69, N=156)

Pre-program frequency (%)

Post-program frequency (%)

Yes No Don’t know

120 (41.7 %) 98 (34.0 %) 70 (24.3 %)

236 (81.9 %) 8 (2.8 %) 21 (7.3 %)

Yes No Don’t know Yes No Don’t know

200 (69.4 %) 80 (27.8 %) 8 (2.8 %) 222 (77.0 %) 38 (13.2 %) 21 (7.3 %) 120 (41.7 %) 68 (23.6 %)

280 (97.2 %) 0 0 288 (100 %) 0 0 237 (82.6 %) 248 (86.0 %)

Yes No Not sure Yes No Not sure

138 (47.9 %) 98 (34.0 %) 47 (16.3 %) 68 (43.6 %) 39 (25 %) 49 (31.4 %)

220 (76.4 %) 34 (11.8 %) 34 (11.8 %) 102 (65.3 %) 17 (1.9 %) 37 (23.7 %)

practices [17, 28]. That nearly two-third of participants reported they had poor or no English proficiency may shed light on the reasons for their lack of intention to participate in screening services. Thus, further research into these women’s particular reasons for resistance to screening seems to be called for. Our findings demonstrated that the participants significantly improved their knowledge and beliefs about breast and cervical cancer. One important finding was a significant decrease in the fatalistic view of cancer which is common among Chinese women [15, 19]. This may be attributed to the fact that traditional views can be counteracted by advancing the Table 3

concept of early detection. Thus, in our presentations, we acknowledged traditional Chinese preventive health beliefs before emphasizing the importance of early detection. In contrast, there was no significant change in attitudes towards preventive health actions, encapsulated in the feeling that Bif a woman feels well, she doesn’t need to worry about getting breast cancer^ and that Bif a woman feels well, she doesn’t need to worry about getting cervical cancer.^ This may be due to the fact that the majority of the participants were over 40 and that preventive health orientation is not deeply rooted in the traditional Chinese health paradigm, which focuses on

Breast and cervical cancer knowledge and belief scores before and after the program (N=288)

1. Breast cancer is the leading cause of cancer among females in Australia 2. Breast cancer is like a death sentence; if you get it, you will surely die from it 3. If a woman feels well, she doesn’t need to worry about getting breast cancer 4. If a woman has no physical S/S, there is little chance that she will have breast cancer 5. If a woman has small breasts, there is little chance of having breast cancer 6. Cervical cancer can be cured if detected early 7. Thinking of cervical cancer will cause it to happen 8. If a woman feels well, she doesn’t need to worry about getting cervical cancer 9. Only women who have more than one sexual partners will get cervical cancer 10. Women who have been through menopause will not get cervical cancer

Pre-program

Post-program

Mean

SD

Mean

SD

t

P value

3.56 2.23 2.08 2.61 2.55 1.83 2.74 3.21 2.98 2.55

1.31 1.37 1.56 1.22 1.12 1.33 1.55 1.31 1.66 1.23

4.57 3.35 3.68 3.09 3.55 3.78 3.88 3.79 3.79 3.97

0.99 0.99 0.76 0.58 0.87 0.88 0.97 0.79 0.77 0.76

9.807 11.590 1.125 9.981 13.040 12.045 9.501 12.022 9.011 1.123

Evaluation of a Culturally Tailored Education to Promote Breast and Cervical Cancer Screening Among Chinese-Australian Women.

This paper aims to evaluate the impact of the culturally sensitive and linguistically appropriate education program on the following: (i) awareness of...
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