Cultural Awareness and Health Literacy Level Assignment

For this Discussion, you will analyze a health-related scenario to determine how differences in health literacy levels may affect the success of a public health outreach program. In addition, you will consider the appropriateness of the outreach material from a cultural awareness standpoint, and how you might apply the lessons learned from the scenario to improve additional outreach efforts.

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With these thoughts in mind:

Consider the following scenario:

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• You are a public health or healthcare administration professional charged with implementing a new outreach program for colorectal cancer in an urban population. You are handed materials and protocols used in a previous outreach program targeting college-educated white adults. Be sure to take into account health literacy levels in your Discussion. Cultural Awareness and Health Literacy Level Assignment

Submit a 3- to 4-paragraph post that includes the following:

• Explain how differences in health literacy levels may affect the success of your outreach program.
• Next, using the concept of culturally competent care covered in this week’s Learning Resources, identify two ways in which the outreach material or protocols may not be appropriate for your population. Cultural Awareness and Health Literacy Level Assignment
• What lessons can you take from this experience with colorectal outreach efforts, and how might you apply these lessons to improving breast cancer screening?
  • Refer to the Hasnain, Menon, Ferrans, and Szalacha (2014) article found in this week’s Learning Resources. Cultural Awareness and Health Literacy Level Assignment

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JOURNAL OF WOMEN’S HEALTH Volume 23, Number 7, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2013.4569 Breast Cancer Screening Practices Among First-Generation Immigrant Muslim Women Memoona Hasnain, MD, MHPE, PhD,1 Usha Menon, PhD, RN, FAAN,2 Carol Estwing Ferrans, PhD, RN, FAAN,3 and Laura Szalacha, EdD 4 Abstract Background: The purpose of this study was to identify beliefs about breast cancer, screening practices, and factors associated with mammography use among first-generation immigrant Muslim women in Chicago, IL. Methods: A convenience sample of 207 first-generation immigrant Muslim women (Middle Eastern 51%; South Asian 49%) completed a culturally adapted questionnaire developed from established instruments. The questionnaire was administered in Urdu, Hindi, Arabic, or English, based on participant preference. Internalconsistency reliability was demonstrated for all scales (alpha coefficients ranged from 0.64 to 0.91). Associations between enabling, predisposing, and need variables and the primary outcome of mammography use were explored by fitting logistic regression models. Results: Although 70% of the women reported having had a mammogram at least once, only 52% had had one within the past 2 years. Four factors were significant predictors of ever having had a mammogram: years in the United States, self-efficacy, perceived importance of mammography, and intent to be screened. Five factors were significant predictors of adherence (having had a mammogram in the past 2 years): years in the United States, having a primary care provider, perceived importance of mammography, barriers, and intent to be screened. Conclusions: This article sheds light on current screening practices and identifies theory-based constructs that facilitate and hinder Muslim women’s participation in mammography screening. Our findings provide insights for reaching out particularly to new immigrants, developing patient education programs grounded in culturally appropriate approaches to address perceived barriers and building women’s self-efficacy, as well as systemslevel considerations for ensuring access to primary care providers. Introduction B reast cancer is a leading cause of death and disability globally and is the most commonly diagnosed cancer in women, regardless of race or ethnicity, in the United States.1 Early detection of breast cancer is a key to reducing morbidity and mortality. Substantial increases in mammography use in the 1990s resulted in up to 30% reduction in mortality attributed to breast cancer.2–8 Despite these advances, segments of our population have not benefited from cancer prevention and control efforts, and disparities in breast cancer screening and health outcomes persist for minority groups.1,9–15 Low mammography use has been associated with a variety of factors, including not having a medical home, not having health insurance, being a recent immigrant, and having low levels of knowledge and awareness about breast cancer.16–18 Migration to Western countries and increased length of stay are associated with increased risk of breast cancer,19 which in turn is attributed to a number of factors and is compounded by barriers to timely screening.20 Ethnicminority women residing in Western countries are more likely to be diagnosed with advanced-stage disease and hence have higher mortality rates.21 This often results from lower utilization of timely breast cancer screening services.22–26 Personalizing or tailoring education about mammography to 1 Department of Family Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois. College of Nursing, The Ohio State University, Columbus, Ohio. 3 College of Nursing, University of Illinois at Chicago, Chicago, Illinois. 4 Center for Research and Transdisciplinary Scholarship, College of Nursing, The Ohio State University, Columbus, Ohio. This research was presented at Women’s Health 2012: The 20th Annual Congress in Washington, DC, and received the First Place Award in Community & Public Health Research from the Office of Research on Women’s Health, National Institutes of Health. 2 602 BREAST CANCER SCREENING FOR MUSLIM WOMEN patients’ culture and beliefs has the potential to increase breast cancer prevention awareness and screening utilization.27–33 The purpose of this study was to identify beliefs about breast cancer, screening practices, and factors associated with mammography use among first-generation immigrant Muslim women (born outside the United States) in Chicago, IL. In the United States, immigrant Muslim women represent a fastgrowing and understudied population whose healthcare behaviors and utilization of health services, including cancer screening, are influenced by religious and cultural beliefs.34–38 There is a paucity of rigorous theory-based, descriptive, and intervention research on this population, and few studies have evaluated breast cancer incidence, stage, treatment, and mortality rates for Muslim women. Preliminary evidence suggests that Muslim women underutilize mammography.34,39–40 More importantly, lack of cultural accommodation hinders Muslim women’s utilization of mammography services. When breast cancer screening programs are not structured in a manner consistent with their beliefs and customs, Muslim women choose not to participate.34,39–40 The number of Muslims in the United States is estimated to be 2–6 million (47% women) and growing.41–43 African American Muslims indigenous to the United States comprise the largest number of American Muslims. Apart from these, immigrant Muslims are extremely varied ethnically, coming from virtually every country where Muslims live. The largest group of Muslim immigrants in the United States is from South Asian (SA) countries (33%), followed by the Middle Eastern (ME) countries (25%).44 Hence, these two immigrant groups were the focus of our research. The limited literature on ME women indicates that breast cancer is a leading cause of cancer-related mortality in this group in their home countries, as well as when they immigrate to Western countries.45–51 Within the United States, breast cancer is the most frequently diagnosed cancer among SA women in California.52 In the United Kingdom, the risk of breast cancer among SA women differs according to their specific ethnic subgroup; Muslim women from India and Pakistan are almost twice as likely to develop breast cancer as their counterparts.53 In Australia, immigrants from Pakistan, a country with a predominantly (95%) Muslim population,54 present with the highest age-standardized breast cancer mortality rate.55 Multiple factors, such as language barriers; lack of medical insurance; geographical barriers; and limited knowledge, education, and access to healthcare services, contribute to barriers faced by immigrant women in accessing and utilizing healthcare.56 In order to identify factors that influence Muslim women’s decision making to engage in breast cancer screening, our study had the following three primary objectives: 1. Develop a culturally relevant survey to assess screening practices and to identify factors associated with mammography use by Muslim women. 2. Confirm psychometric properties of survey subscales in differing languages. 3. Explore the associations between mammography use and predisposing, enabling, and need variables. Three theoretical models—the Andersen Behavioral Model of Health Services Utilization,57,58 the Health Belief 603 Model,59–61 and the Transtheoretical Model62–64—were used to guide the development of the study. Materials and Methods Study design and setting A cross-sectional study design was used to survey 215 first-generation immigrant Muslim women. The study was conducted in Chicago, IL, home to a large number of immigrant Muslims. According to estimates by the Council of Islamic Organizations of Greater Chicago, approximately 400,000 Muslims live in the Chicago area. Recruitment sites were several Chicago-based community agencies and faithbased institutions. Data collectors were bilingual or trilingual females and were trained research interviewers. Survey development and translation took place in 2008 and 2009; survey administration and data collection, in 2009 and 2010. The Institutional Review Board of the University of Illinois at Chicago approved this study. Measures and survey development A written survey was developed to collect information on two sets of core measures: 1. Breast cancer screening practices, with mammography the primary dependent variable. Participants were asked about their past mammography use and future intent to screen in order to assess stage of readiness. Mammography use was categorized as (a) never having had a mammogram (never-screened group), (b) having had at least one mammogram but none in the past 2 years (overdue group), and (c) having had a mammogram in the past 2 years (adherent group). For our study, the National Cancer Institute recommendations for breast cancer screening were used to define adherence: mammogram screening every 1–2 years, beginning at age 40.64 2. Predictors of mammography screening, organized into predisposing, enabling, and need categories (see Table 1). Three instruments—the Champion Breast Health Survey,65 Ferrans Cultural Beliefs Scale,66 and Suinn-Lew Asian SelfIdentity Acculturation Scale (SL-ASIA)67—were adapted, combined into one survey, and translated into the study languages (Urdu, Hindi, and Arabic). Focus groups were conducted to confirm that the survey items were understandable and culturally relevant to the target population (described later). Champion Breast Health Survey. The widely used subscales for breast cancer screening beliefs (perceived susceptibility, perceived benefits, perceived barriers, and perceived self-efficacy), with established reliability and validity,68 were included in our study. All subscales have good internal consistency reliability (Cronbach’s alphas greater than 0.70) and construct validity (demonstrated by confirmatory factor analysis; all subscales were unidimensional). Ferrans Cultural Beliefs Scale. This scale, which measures cultural beliefs about breast cancer, has previously been tested with African American, Hispanic, and Caucasian women. The instrument focuses on beliefs in three content 604 HASNAIN ET AL. Table 1. Predictors of Mammography Use Predisposing a Perceived risk (susceptibility) for developing breast cancer Perceived benefitsa— positive outcomes associated with screening for breast cancer Perceived barriersa—obstacles associated with breast cancer screening Self-efficacya—self-confidence in one’s ability to get a mammogram Knowledgea—cognitive information about breast cancer risk, screening recommendations, causes, treatment, and cure Emotional factors—fear and shame associated with breast cancer and mammography screening Cultural factorsb—cultural beliefs regarding breast cancer Global rating of importance of mammography—self-perceived overall importance of the need for getting a mammogram Enabling Need Education Income Insurance—third-party payer of healthcare costs Acculturationc—modification of the culture of a group or individual as a result of contact with a different culture Self-perceived health status Physician recommendation— patients’ perception of recommendation by their respective providers to screen a Source: Champion Breast Health Survey65 modified/refined via focus groups. Source: Ferrans Cultural Beliefs Scale.66 c Source: Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA).67 b areas: those that make women feel less vulnerable to breast cancer, those that discourage participation in breast cancer screening, and those about the lack of efficacy of breast cancer treatment. Higher scores on the Ferrans scale indicated that more cultural myths inhibiting screening were believed. The scale has demonstrated reliability (alpha = 0.73) and validity in the populations tested.69 Suinn-Lew Asian Self-Identity Acculturation Scale. The SL-ASIA67 was originally modeled after the Acculturation Rating Scale for Mexican Americans70 and has been developed for and extensively tested with East Asian groups. The measurement approach recognizes the multidimensionality of the acculturation process and takes into account the issue of bicultural development. The instrument assesses cognitive, behavioral, and attitudinal areas, and its 21 multiple-choice questions yield five factors and a single acculturation score that range from 1:00 (low acculturation) to 5:00 (high acculturation). The scale demonstrated internal consistency reliability (Cronbach’s alpha: 0.88–0.91 in two studies) and concurrent validity.67 The questions in the scale are generic; to make the scale more relevant to our study population, we changed country/region names to represent those of our study population. Global rating of importance of mammography screening. A 10-point Likert-type scale measuring global rating of the importance of regularly getting mammograms (ranging from ‘‘not at all important’’ to ‘‘very important’’) developed for this study was also included in the survey. Cultural adaptation and refinement of survey via focus groups. To account for regional and ethnic differences in beliefs and to add culturally relevant content, two focus groups were conducted (one each for SA and ME women), with 10–12 participants in each group. To be eligible to participate in the focus groups, participants had to be female, Muslim (defined as those who self-identify with the Islamic faith), aged 40 years or older, first-generation immigrants (18 years or older on arrival in the United States) from the Middle East or South Asia and able to read, write, and speak English and one of the study languages (Urdu, Hindi, Arabic). Two of the study authors (Memoona Hasnain and Usha Menon, who are fluent in Urdu and Hindi), moderated the focus groups. An Arabic-language translator participated in the Middle Eastern focus group. We used a semistructured format to refine survey items and to identify new items. The process was used to confirm that the survey items were understandable and culturally relevant to the target population. Based on participant input, the Champion scales were adapted; some of the items were reworded, some items were removed, and others were added. See Appendix 1 for the modified Champion scales. No changes were made to the Ferrans Cultural Beliefs Scale and SL-ASIA; both were determined to be understandable and culturally appropriate by the focus groups in their original form. Translation of survey. To address language barriers, the culturally adapted survey and other study documents (informational flyer and consent brochure) were translated into Urdu, Hindi, and Arabic. The committee-translation method71 was utilized, as it is a more rigorous process than using a single translator. A translation team consisting of three translators and a language expert (adjudicator) was established for each language to guide the translation. This systematic development of study survey and other documents BREAST CANCER SCREENING FOR MUSLIM WOMEN increased the likelihood of developing a culturally appropriate and psychometrically sound survey. Sample and data collection Sample size. A sample size of 230 participants (115 per ethnic group) was planned on the basis of recommendations by Nunnally72 for measurement reliability. To account for incomplete data, we planned to oversample by 9% for a total 250 participants. First-generation immigrant Muslim women (same eligibility criteria as for those who participated in the focus groups) were eligible for the study. Given the exploratory nature of this study, self-reported mammography-screening practices were not verified via medical records. Recruitment and data-collection procedures. Participants were selected from a purposive sample of Muslim women residing in Chicago, IL. Participant recruitment and datacollection procedures were standardized and kept similar for both SA and ME women. Study flyers, in English and translated languages, inviting participation were circulated electronically and posted in community agencies and mosques. Trained research assistants approached women at community sites and used snowball sampling to accrue the proposed sample size. After obtaining full written informed consent, the in-person survey was administered to eligible participants at data-collection sites. Participants received a small monetary incentive to participate in the study. Statistical analyses In addition to psychometric assessment (reliability and validity) of the various scales used in each of the three language groups, descriptive statistics, bivariate correlations, contingency-table analyses, analyses of variance (ANOVAs), and hierarchically nested logistic regression models were conducted. Owing to the significant differences in screening behavior based on ethnicity, we stratified by ethnicity for all bivariate analyses. For each outcome—(1) ever having had a mammogram versus not and (2) adhering to mammogram guidelines (mammogram within the past 2 years) versus not—modeling began with all sociodemographic characteristics. Model 2 contained only cultural and health-related predictors. Model 3 included all sociodemographic and cultural and health-related predictors significant in Models 1 and 2 at alpha = 0.10. We then tested for statistical interactions as was necessary. The sample size was insufficient to fit separate logistic models for ME and SA women. Therefore, we tested for ethnicity in the models. Finally, only one participant completed the survey in Hindi, precluding psychometric analysis for data collected in that language; hence, data from the Hindi survey were not included in the analysis. Data analysis was performed using SPSS v. 21 (IBM, New York). Psychometric analyses Each of the established scales, translated into Urdu and Arabic from English, was examined for reliability (internal consistency) and validity (correlations) within and across each language group. More than one-third of the participants 605 completed the survey in English (38.2%, n = 79), one-third in Arabic (35.3%, n = 73), and about one-fourth in Urdu (26.1%, n = 54). Every subscale was internally consistent, with alpha coefficients ranging from 0.72 to 0.92, and constructs expected to be related were significantly appropriately correlated (e.g., benefits and self-efficacy r = 0.53, p < 0.001, barriers and cultural beliefs r = 0.39, p < 0.001). There were no significant differences based on the language of the survey, so we analyzed the combined data. Results Sample characteristics The 207 participants had emigrated from 13 South Asian and Middle Eastern nations: The largest proportions were from Pakistan (30%, n = 65), Palestine (21%, n = 45), and India (17%, n = 37). Although 37% (n = 80) spoke primarily English, 35% (n = 75) spoke primarily Arabic, and 27% (n = 59) spoke primarily Urdu. The majority of participants were married (85%, n = 183), with a mean age of 52 years (standard deviation [SD] = 10.0). Almost one-third of the participants (31%, n = 66) were college graduates, and onethird (30%, n = 65) had a high school diploma. More than one-third (42%, n = 90) reported incomes less than $20,000, and one-third (34%, n = 70) reported having health insurance. In terms of mammography-screening practice (Table 2), 32% (n = 66) had never had a mammogram (never-screened group); 17% (n = 37) had had a mammogram but more than 2 years prior to the survey (overdue group); and 52% (n = 112) had had a mammogram within the past 2 years (adherent group). Only 20% (n = 44) reported a family history of breast cancer. Bivariate analyses There were significant differences in mammographyscreening practice based on sociodemo … Cultural Awareness and Health Literacy Level Assignment