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Impact of a print intervention to increase annual mammography screening among Korean American women enrolled in the National Breast and Cervical Cancer Early Detection Program
Cancer Detection and Prevention 32 (2008) 229–235 www.elsevier.com/locate/cdp
Impact of a print intervention to increase annual mammography screening among Korean American women enrolled in the National Breast and Cervical Cancer Early Detection Program Annette E. Maxwell DrPHa,*, Angela M. Jo MD, MSHSb, Soo-Young Chin PhDc, Kyeong-Soo Lee MD, PhDd, Roshan Bastani PhDa a
Division of Cancer Prevention & Control Research, School of Public Health/Jonsson Comprehensive Cancer Center, University of California, Los Angeles, United States b Department of Family Medicine, School of Medicine, University of California, Los Angeles, United States c Visiting Scholar, Asian American Studies Center, University of California, Los Angeles, United States d Department of Preventive Medicine & Public Health, College of Medicine, Yeungnam University, South Korea Accepted 20 April 2008
Abstract Background: Although Korean American women have one of the lowest rates of mammography screening, only few interventions have been developed for them. We developed a theory-based Korean-language print intervention to increase annual mammography screening with the goal to disseminate it through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Methods: Korean American staff and patients at a community clinic advised on the content and layout of the brochure. We pilot tested the intervention from July to September 2005 at a community clinic in Koreatown, Los Angeles County that provides free mammograms through the NBCCEDP. The proportion of Korean American women who received a repeat mammogram during the intervention period was compared to the preintervention period using a NBCCEDP database. Results: We found a non-significant 6 percentage point increase in repeat screening from 32% to 38%. A debriefing survey with a subsample of 59 women revealed that only 32% recalled receipt of the brochure and a subsequent investigation revealed that only about 60% had identical address information in the NBCCEDP records and in their charts. Conclusions: Although dissemination of print information through NBCCEDP is very feasible, the reach and effectiveness of the intervention was limited due to incorrect or outdated address information. # 2008 Elsevier Ltd. All rights reserved. Keywords: Korean American low-income women; Print intervention; Annual mammography screening; National Breast and Cervical Cancer Early Detection Program; Effectiveness; Reach; Focus group; Debriefing interview; Brochure development; Patient education
1. Introduction One of the goals of Healthy People 2010 is to increase the proportion of women aged 40 years and older who have received a mammogram within the preceding 2 years to 70% [1]. Although screening mammography rates have increased dramatically over the past decade in general, they remain far * Corresponding author at: 650 Charles Young Drive South, Room A2125, CHS, Los Angeles, CA 90095-6900, United States. Tel.: +1 310 794 9282; fax: +1 310 206 3566. E-mail address: [email protected] (A.E. Maxwell). 0361-090X/$ – see front matter # 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.cdp.2008.04.003
below this goal among Korean American women. Based on data from the 2001 California Health Interview Survey, only 53% of Korean American women over the age of 40 had a mammogram in the past 2 years [2], as compared to 80% of White, 79% of African-American, and 74% of Hispanic women [3]. These data demonstrate that a large screening disparity exists. Surveys among Korean American women have identified factors associated with low mammography screening rates, including being a more recent immigrant, low levels of education, lack of health insurance, lack of visits to a health care provider for regular check-ups, lack of a doctor’s
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recommendation to get a mammogram, lack of knowledge of mammography screening guidelines, being embarrassed about getting mammograms, and being uncomfortable talking to a doctor about mammograms [4–10]. While some of these factors are not modifiable, others are good targets for interventions to increase screening. We found only three published programs to increase screening specifically among Korean American women, who were predominantly recruited through churches [11–13]. One large community health education program launched in 1996 over a 4-year period included educational materials, relationship building with Korean churches, lay health counselors, educational workshops, mammography facility negotiations, medical provider information, and a media campaign. It did not result in significant improvements in screening utilization, which the authors contributed to inadequate reach of the intervention [11]. Kim and Sarna [12] implemented a peer-group educational program that also provided access to a free or low-cost mobile mammography service at one church, and a mobile mammography-only group at another church. In both groups, mammography utilization at 2-month follow-up was significantly improved (87% and 72%, no significant difference between the two intervention arms) as compared to the control group (47%) based on self-reports. The result of this small study (N = 141) suggests that access to low-cost mammograms may be sufficient to improve mammography utilization. The third study developed a Korean-language photonovel to promote breast cancer screening that was passed out in small group educational presentations which also included a Koreandubbed videotape on how to perform breast self-examination. At 6-month follow-up (N = 186), significantly more women in the intervention group had intentions to have mammograms than in the delayed intervention control group [13], but actual mammography screening was not assessed. In recent years, the importance of disseminating effective cancer screening interventions has been stressed as one strategy for bridging health disparities [14,15]. Therefore, we tried to develop an intervention to increase annual mammography screening among Korean American women that could be disseminated through an existing mechanism, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which is administered through the Centers for Disease Control and Prevention (CDCP). This program was established by Congress in 1990, and provides free mammograms every 12 months to low-income women 40 years and older who do not have health insurance. All 50 states, the District of Columbia, 13 Native American tribes and tribal organizations, and 4 territories have provided screening services with the support of the NBCCEDP. In 2005, NBCCEDP has screened almost 400,000 women for breast cancer [16]. In Los Angeles County, about 14% of all women enrolled are Asian American, and Korean American are the largest Asian group served. We partnered with two community clinics in Koreatown, Los Angeles County, that offer free mammograms under this program with the common goal to
increase annual rescreening among Korean American women. The clinics already use several strategies to encourage rescreening in their early detection programs and to help patients overcome barriers to screening they may have: screening is provided free of charge to eligible women every 12 months (free access); most personnel is bi-cultural and bi-lingual in Korean and English (no language barrier; staff is culturally competent); and Korean American women receive a reminder postcard 1–2 months prior to their due date in English and Korean language (reminder systems have increased compliance to various health behaviors in many settings). Despite these strategies, clinic records showed that only about 30% of Korean American women received mammograms annually when we applied for funding for the study. Patient education has been shown to consistently improve the use of mammography screening in two meta-analyses. In an analysis of 14 randomized trials, mailed educational materials resulted in significantly higher attendance of mammography screening (odds ratio 2.81, 95% confidence interval 1.96–4.02) [17]. The other analysis included 33 studies and also found a significant effect of educational materials, although at a more moderate level (odds ratio 1.31, confidence interval 1.12–1.52) [18]. Educational print material is also recommended as an evidence-based intervention strategy in the Guide to Community Preventive Services [19]. Their analysis of 19 studies with small media interventions (including print interventions or videos) showed a median increase in screening of 5.3 percentage points for untailored interventions (http://www.thecommunityguide.org/cancer/screening/default.htm, accessed 13 February 2008). The studies that were included in these reviews assessed receipt of a mammogram within a pre-specified time period, and delivered patient education in different settings (hospital versus community settings) and in combination with other intervention strategies (e.g., nurse involvement, transportation assistance, chart reminders, etc.). However, none of the studies cited above focused on immigrants. Given the evidence base, we conducted a pilot study to develop educational print materials for and with Korean American women, disseminated it through the NBCCEDP, and evaluated its impact. We gathered pilot data on the intervention’s acceptability, potential effectiveness, and the feasibility for a clinic to implement the intervention on an ongoing basis. To our knowledge, this is one of the first studies examining the impact of educational print information on repeat mammography screening in a low-income, predominantly immigrant Korean American sample.
2. Materials and methods 2.1. Intervention development in clinic 1 In 2004, we conducted one-on-one semi-structured indepth interviews with a convenience sample of 11 Korean American women who had received one or more mammo-
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grams through the NBCCEDP at a community clinic in Koreatown to gain an initial understanding of the barriers and supports of regular screening and preferences for intervention strategies. We then developed a print intervention with the help of six Korean American clinic staff members and six Korean American women who were patients at the clinic. This group met four times over a 6-month period to advise on the content and layout of the intervention. All activities were conducted in Korean language by one of the authors (AMJ), who is a female Korean American physician and a researcher interested in health disparities. Both the one-on-one interviews and the intervention development sessions were audiotaped, transcribed, and translated into English. All subjects who participated in the one-on-one interviews and the development of the intervention were immigrants. 2.2. Conceptual framework The print intervention addressed several constructs from the Health Behavior Framework [20,21], which draws from the Health Belief Model [22] and the Theory of Reasoned Action/Planned Behavior [23]. The specific theoretical constructs that were addressed in the intervention are shown in Table 2. 2.3. Intervention implementation Clinic 1 had to discontinue their free mammography program due to internal restructuring for several months during the study period. Therefore, the intervention was implemented at clinic 2 which was also located in Koreatown. Clinic staff identified all patients with Korean first or last names from the NBCCEDP database who had an index mammogram 12 months ago and were due to receive a reminder mailing. This was deemed to be the most feasible method for identifying Korean American women in a busy clinic setting and the only method for identifying women if the intervention was going to be institutionalized in the future. During the 3 months intervention period (July–September 2005), clinic staff mailed the print intervention together with the routine reminder postcard to 360 women who were due to return for their annual mammogram, using address information from the NBCCEDP database. All women were 40 years of age or older, had no health insurance, and a self-reported income of less than 200% poverty level. 2.4. Impact evaluation in clinic 2 Glasgow et al. [14] propose that the public health impact of health promotion programs should be evaluated by examining five dimensions of the RE-AIM model: reach, efficacy or effectiveness, adoption, implementation and maintenance [24,25]. We used the RE-AIM framework to comprehensively evaluate the impact of the print intervention on repeat screening rates because it emphasizes factors at both the individual level (reach and effectiveness) and the
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setting level (adoption, implementation, and maintenance) that are important for translating research into practice. 2.4.1. Evaluation of reach We conducted debriefing telephone surveys with 59 women who were mailed the print intervention 3 months after the mailings, between October and December 2005, to assess reach and acceptability of the print intervention. Interviews were limited to the first wave of women who were potentially exposed to the intervention in order to complete all interviews within the timeline of the study. 2.4.2. Evaluation of effectiveness In clinic 2, we matched electronic NBCCEDP records from the past 15 months by name, date of birth, and women’s unique ID number to determine if women received a repeat mammogram 12–15 months after the index mammogram. Women were classified as repeat screeners if at least one mammogram between 12 and 15 months following the index mammogram was recorded. We allowed a 3 months time period for women to obtain their repeat mammogram which was feasible because the clinic was able to schedule all women who called to make an appointment within a 2–4week period. All women who had obtained a mammogram during the index period were included in the analysis, although some could have moved or passed away. Given the pilot nature of the study, a quasi-experimental design was used. Repeat screening rates among women who were mailed the print intervention in 2005 were compared with the rates achieved with the reminder postcard only during the same 3 months in 2004 using a chi-square test. The effectiveness of the intervention was computed in an intent-to-treat analysis, which included all women who were mailed the intervention in the denominator, regardless of whether or not they received it or read it. Intent-to-treat analysis is widely regarded as the best way to measure the impact of an intervention under realistic, real world conditions [26]. We were only authorized to receive screening data on the group level, not on individual women. The study protocol and all study materials were approved by the Committee for the Protection of Human Subjects of the University of California, Los Angeles. 2.4.3. Adoption, implementation and maintenance Print intervention was assessed at the institutional level by questioning the manager of the NBCCEDP program at clinic 2 about the initial and ongoing implementation of the print intervention.
3. Results 3.1. Intervention development: one-on-one interviews and focus group sessions Barriers to repeat screening cited by participants included access and financial barriers, perceived low importance of
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breast cancer screening, embarrassment, fear of pain while getting a mammogram, fear of finding breast cancer, and lack of knowledge on program eligibility. Women suggested several intervention channels, including Korean media, reminder calls to schedule an appointment, and a brochure describing the importance of regular breast cancer screening. Findings from the first focus group session confirmed the results of the one-on-one interviews. Focus group members strongly favored developing an educational brochure that can be mailed together with the NBCCEDP routine reminder postcard. 3.2. Additional focus group sessions to develop the print intervention In a series of focus group sessions, women provided input for the content and layout of the print intervention, developed quotes and slogans, and reacted to drafts of graphs, pictures, and messages that we showed them. In the second focus group session, women developed a number of phrases to stress the importance of regular screening, such as: ‘‘A wife needs to be healthy in order for the family to be at its best’’ and ‘‘If you don’t have your health, you have nothing’’. In the final two focus group sessions we obtained women’s feedback on various drafts of a print intervention regarding the wording and the graphics used. Each focus group session lasted 1–2 h (see Table 1). Working with a Korean graphic artist, we produced a Korean language print intervention (Fig. 1). Table 2 illustrates how the content of the brochure corresponds to health beliefs and barriers to obtain annual mammograms that were identified in the early phase of the study.
Table 1 Brochure development through focus group input Session 1: Barriers to repeat screening and intervention strategies Confirming results of the one-on-one interviews, woman stated several barriers including access and financial barriers, perceived low importance of breast cancer screening, embarrassment, fear of pain while getting a mammogram, fear of finding breast cancer, and lack of knowledge on CDP eligibility Session 2: Phrases and slogans that stress the importance of regular screening Women discussed the importance of females for the well being of the family, the importance of health, and the importance of not only breast cancer screening but regular check-ups. They developed the following slogans: ‘‘A wife needs to be healthy in order for the family to be at its best.’’ ‘‘If you don’t have your health, you have nothing.’’ ‘‘If you get a regular check up you won’t have to worry that you are sick.’’ Session 3: Discussion of drafts of print intervention Women discussed the use of a cartoon of a Korean family versus photographs for the cover page. Some women stated that they liked a cartoon better because ‘‘you can look at them without any feelings or judgments’’. There was a suggestion to have the picture of the family in color and the woman with breast cancer in grey, but others stated that that would be unlucky, and that no family would pose for such a picture. After we explained that we would be able to obtain such a picture (not using a real family), focus group members agreed that a photograph would be very convincing. The facial expression of the family pictured was discussed but there was no agreement if the family should look happy or concerned
3.3. Pilot evaluation of the print intervention
Session 4: Finalizing of text and further discussion of picture for cover page Women approved the text overall and did not want to make any more changes. They looked at various family pictures for the cover page and discussed the approximate age of the woman who was at risk for getting breast cancer. They felt that the woman at risk should be around 40 years old because ‘‘at 40 you still have one child in high school, middle school and maybe elementary school’’. Another woman stated ‘‘you need younger children in order to make them look helpless.’’ Another woman confirmed that and stated ‘‘I’m 70 right now and it’s an age where you wouldn’t feel cheated if you caught something and died.’’
3.3.1. Reach and acceptability Debriefing telephone interviews were conducted with 59 women out of the first 128 women who were mailed the intervention for a response rate of 46%. Of the 69 women who did not complete the debriefing interview, 34 had numbers that were disconnected or they had moved, 26 never answered the telephone, 4 were not reached but an informant confirmed their residence and 5 refused to be interviewed. The 59 women who were interviewed were, on average, 53 years old (range 41–65 years) and had resided in the U.S., on average, 17 years (range 4–35 years). Only 19 women (32%) recalled that they had received a small brochure from the clinic about mammography screening. Of these women, 60% read the entire brochure, another 30% most of the brochure, and 10% little or nothing. All women who had read the entire or most of the brochure understood everything (67%) or mostly everything (33%). Almost all women (90%) were encouraged to have regular mammograms and appreciated the information. About one third of the women discussed the brochure with somebody and 78% stated that they would
recommend it to a friend. During the debriefing interview, several of the women described in detail the messages and the pictures of the print intervention. In order to investigate why only one-third of the respondents remembered receipt of the brochure, we compared the addresses in the NBCCEDP database that were used for the reminder mailing with address information in patients’ charts. The NBCCEDP database is used for online reporting of screening and follow-up activities for billing purposes to the NBCCEDP, is updated on a weekly basis, and is completely separate from the patients’ charts. Matching the database and charts by name and date of birth, we found that the address information was identical in both documents for 34 women only (58% of total). Eleven women had moved, six women had similar addresses but with spelling or numeric discrepancies (e.g., wrong zip codes) that could prevent mail to reach the correct address, and eight women did not have address information in their chart or no chart was found.
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Table 3 Rates of repeat mammography screening (12–15 months after index mammogram) among Korean-American Women in one community clinic N
%
Control period (2003–2004) Clinic records
94/296
32
Intervention period (2004–2005) Clinic records Self-reports
136/360 30/59
38 51
There was no significant difference between the control and intervention periods based on clinic records, p = .108, chi-square test.
tiveness, it should be noted that in the small subsample of women who completed the debriefing survey, 51% reported receipt of a repeat screening mammogram. 3.3.3. Adoption, implementation and maintenance of the print intervention The clinic manager at clinic 2 reported that it was very easy to include the print intervention in the reminder mailing. She stated that they continued to mail their entire supply of brochures to Korean American women for several months after completion of the study.
4. Discussion Fig. 1. Cover of Print Intervention to Encourage Annual Mammography Screening.
3.3.2. Effectiveness In the 3 months intervention period, 136/360 women (38%) received a repeat screening mammogram. In the 3 months comparison period, 94/296 women (32%) received a repeat screening mammogram. Thus, the repeat screening rate was 6 percentage points higher in the intervention period than in the control period, representing a relative increase of 18% ( p = .108, chi-square test, see Table 3). Although we used NBCCEDP records to determine effec-
We were able to obtain detailed input from Korean American women that shaped the content and layout of a theoretically based print intervention to encourage annual mammography screening. This print intervention was subsequently disseminated through a community clinic that provides free mammograms to eligible Korean American women through the NBCCEDP. Clinic personal confirmed that the print intervention can easily be integrated into the routine clinic protocol. Thus, the clinic continued to include the print intervention in their reminder mailings after the study ended. Debriefing interviews with Korean American women who received the print intervention showed that most women understood the messages of the brochure and would recommend it to a friend. It should be noted that
Table 2 Content of the print intervention and corresponding theoretical constructs Theoretical construct
Content
Knowledge
Information on screening guidelines, incidence of breast cancer, risk factors (age, length of stay in the U.S., family history of breast cancer) and locations that offer free mammograms is provided Brochure includes a letter from a Korean American female physician urging women to have a mammogram every year Graph shows that breast cancer is the most commonly diagnosed cancer among Korean American women and that the incidence is increasing Information showing higher survival rates for earlier stages of breast cancer Encouragement from a Korean American woman who gets a mammogram every year (with picture) Importance of women for the well being of the family is stressed. Picture on the cover of the brochure shows a three generation Korean American family with women in the center Strategies on how to deal with lack of insurance, lack of time and being embarrassed are suggested. Myths of not needing a mammogram because one is too young or too old or because woman has breast fed are addressed
Recommendation by provider Health beliefs: perceived susceptibility Efficacy of early detection Social norms and support Cultural factors Barriers
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literacy levels are high in Korea, with less than 10% being illiterate [27]. The effect that was achieved with the print intervention was encouraging but not statistically significant. The 6 percentage point increase is comparable to the effect of educational or motivational print materials that was reported by the Guide to Community Preventive Services based on their systematic review of 19 studies that employed small media. Small media interventions that were not tailored to individual women were effective in increasing breast cancer screening by a median 5.3 percentage point increase http:// www.thecommunityguide.org/cancer/screening/ default.htm, accessed 13 February 2008). Partin et al. [28] tested the effect of two low-cost mailed interventions on repeat mammography screening among women enrolled in a federally funded screening program in Minnesota. Their intervention achieved a similar effect as our intervention, 5– 7% increased screening rates compared to a control group, but in a predominantly (89%) white population [28]. Glasgow et al. [24] suggest that a low-intensity intervention that is less efficacious but can be delivered to large numbers of people can still have a sizable impact. We hypothesized that the NBCCEDP, which served about 90,000 women in Los Angeles County in 2005 (72% Hispanic, 14% Asian, 6% White, 3% Black), would be an excellent mechanism for dissemination of a low cost print intervention. However, our pilot study indicated that the reach of the print intervention was severely limited, most likely due to inaccurate or outdated address information. It is possible that other reasons contribute to the problem, such as family members screening the daily mail. The limited reach also decreased the effectiveness of the intervention in the intent-to-treat analysis, which included all women who were mailed the intervention, regardless of whether or not they received it or read it. An important strength of our study is that the outcome was assessed through clinic records rather than relying on self-report. Prior studies have shown that self-reports tend to overestimate screening [29]. Our data also suggest overreporting, although the subgroup that completed the debriefing interview may be a selected group of women who may have been more likely to be screened than all women who were included in the clinic record analysis. A limitation of our research was the lack of a randomly assigned control group, which was not feasible within the funding timeframe and available budgetary resources. Thus, we cannot exclude the possibility that the increase in screening observed may be due to a secular trend or changes in personnel or clinic procedures, other than our intervention. According to clinic staff, personnel changes did occur but the clinic procedures remained the same. Overall, we found that involving Korean American women in intervention development resulted in print materials that were well accepted by their peers. Dissemination of print information through the NBCCEDP is very feasible. However, the reach and effectiveness of the
intervention was limited which we attributed to incorrect or outdated address information.
Acknowledgements We would like to thank the clinic staff and the Korean American patients who participated in this study. This research was supported by funds from the California Breast Cancer Research Program of the University of California, Grant No. 9AB-2101.
Conflict of interest None declared.
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Impact of a print intervention to increase annual mammography screening among Korean American women enrolled in the National Breast and Cervical Cancer Early Detection Program Annette E. Maxwell DrPHa,*, Angela M. Jo MD, MSHSb, Soo-Young Chin PhDc, Kyeong-Soo Lee MD, PhDd, Roshan Bastani PhDa a
Division of Cancer Prevention & Control Research, School of Public Health/Jonsson Comprehensive Cancer Center, University of California, Los Angeles, United States b Department of Family Medicine, School of Medicine, University of California, Los Angeles, United States c Visiting Scholar, Asian American Studies Center, University of California, Los Angeles, United States d Department of Preventive Medicine & Public Health, College of Medicine, Yeungnam University, South Korea Accepted 20 April 2008
Abstract Background: Although Korean American women have one of the lowest rates of mammography screening, only few interventions have been developed for them. We developed a theory-based Korean-language print intervention to increase annual mammography screening with the goal to disseminate it through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Methods: Korean American staff and patients at a community clinic advised on the content and layout of the brochure. We pilot tested the intervention from July to September 2005 at a community clinic in Koreatown, Los Angeles County that provides free mammograms through the NBCCEDP. The proportion of Korean American women who received a repeat mammogram during the intervention period was compared to the preintervention period using a NBCCEDP database. Results: We found a non-significant 6 percentage point increase in repeat screening from 32% to 38%. A debriefing survey with a subsample of 59 women revealed that only 32% recalled receipt of the brochure and a subsequent investigation revealed that only about 60% had identical address information in the NBCCEDP records and in their charts. Conclusions: Although dissemination of print information through NBCCEDP is very feasible, the reach and effectiveness of the intervention was limited due to incorrect or outdated address information. # 2008 Elsevier Ltd. All rights reserved. Keywords: Korean American low-income women; Print intervention; Annual mammography screening; National Breast and Cervical Cancer Early Detection Program; Effectiveness; Reach; Focus group; Debriefing interview; Brochure development; Patient education
1. Introduction One of the goals of Healthy People 2010 is to increase the proportion of women aged 40 years and older who have received a mammogram within the preceding 2 years to 70% [1]. Although screening mammography rates have increased dramatically over the past decade in general, they remain far * Corresponding author at: 650 Charles Young Drive South, Room A2125, CHS, Los Angeles, CA 90095-6900, United States. Tel.: +1 310 794 9282; fax: +1 310 206 3566. E-mail address: [email protected] (A.E. Maxwell). 0361-090X/$ – see front matter # 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.cdp.2008.04.003
below this goal among Korean American women. Based on data from the 2001 California Health Interview Survey, only 53% of Korean American women over the age of 40 had a mammogram in the past 2 years [2], as compared to 80% of White, 79% of African-American, and 74% of Hispanic women [3]. These data demonstrate that a large screening disparity exists. Surveys among Korean American women have identified factors associated with low mammography screening rates, including being a more recent immigrant, low levels of education, lack of health insurance, lack of visits to a health care provider for regular check-ups, lack of a doctor’s
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recommendation to get a mammogram, lack of knowledge of mammography screening guidelines, being embarrassed about getting mammograms, and being uncomfortable talking to a doctor about mammograms [4–10]. While some of these factors are not modifiable, others are good targets for interventions to increase screening. We found only three published programs to increase screening specifically among Korean American women, who were predominantly recruited through churches [11–13]. One large community health education program launched in 1996 over a 4-year period included educational materials, relationship building with Korean churches, lay health counselors, educational workshops, mammography facility negotiations, medical provider information, and a media campaign. It did not result in significant improvements in screening utilization, which the authors contributed to inadequate reach of the intervention [11]. Kim and Sarna [12] implemented a peer-group educational program that also provided access to a free or low-cost mobile mammography service at one church, and a mobile mammography-only group at another church. In both groups, mammography utilization at 2-month follow-up was significantly improved (87% and 72%, no significant difference between the two intervention arms) as compared to the control group (47%) based on self-reports. The result of this small study (N = 141) suggests that access to low-cost mammograms may be sufficient to improve mammography utilization. The third study developed a Korean-language photonovel to promote breast cancer screening that was passed out in small group educational presentations which also included a Koreandubbed videotape on how to perform breast self-examination. At 6-month follow-up (N = 186), significantly more women in the intervention group had intentions to have mammograms than in the delayed intervention control group [13], but actual mammography screening was not assessed. In recent years, the importance of disseminating effective cancer screening interventions has been stressed as one strategy for bridging health disparities [14,15]. Therefore, we tried to develop an intervention to increase annual mammography screening among Korean American women that could be disseminated through an existing mechanism, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which is administered through the Centers for Disease Control and Prevention (CDCP). This program was established by Congress in 1990, and provides free mammograms every 12 months to low-income women 40 years and older who do not have health insurance. All 50 states, the District of Columbia, 13 Native American tribes and tribal organizations, and 4 territories have provided screening services with the support of the NBCCEDP. In 2005, NBCCEDP has screened almost 400,000 women for breast cancer [16]. In Los Angeles County, about 14% of all women enrolled are Asian American, and Korean American are the largest Asian group served. We partnered with two community clinics in Koreatown, Los Angeles County, that offer free mammograms under this program with the common goal to
increase annual rescreening among Korean American women. The clinics already use several strategies to encourage rescreening in their early detection programs and to help patients overcome barriers to screening they may have: screening is provided free of charge to eligible women every 12 months (free access); most personnel is bi-cultural and bi-lingual in Korean and English (no language barrier; staff is culturally competent); and Korean American women receive a reminder postcard 1–2 months prior to their due date in English and Korean language (reminder systems have increased compliance to various health behaviors in many settings). Despite these strategies, clinic records showed that only about 30% of Korean American women received mammograms annually when we applied for funding for the study. Patient education has been shown to consistently improve the use of mammography screening in two meta-analyses. In an analysis of 14 randomized trials, mailed educational materials resulted in significantly higher attendance of mammography screening (odds ratio 2.81, 95% confidence interval 1.96–4.02) [17]. The other analysis included 33 studies and also found a significant effect of educational materials, although at a more moderate level (odds ratio 1.31, confidence interval 1.12–1.52) [18]. Educational print material is also recommended as an evidence-based intervention strategy in the Guide to Community Preventive Services [19]. Their analysis of 19 studies with small media interventions (including print interventions or videos) showed a median increase in screening of 5.3 percentage points for untailored interventions (http://www.thecommunityguide.org/cancer/screening/default.htm, accessed 13 February 2008). The studies that were included in these reviews assessed receipt of a mammogram within a pre-specified time period, and delivered patient education in different settings (hospital versus community settings) and in combination with other intervention strategies (e.g., nurse involvement, transportation assistance, chart reminders, etc.). However, none of the studies cited above focused on immigrants. Given the evidence base, we conducted a pilot study to develop educational print materials for and with Korean American women, disseminated it through the NBCCEDP, and evaluated its impact. We gathered pilot data on the intervention’s acceptability, potential effectiveness, and the feasibility for a clinic to implement the intervention on an ongoing basis. To our knowledge, this is one of the first studies examining the impact of educational print information on repeat mammography screening in a low-income, predominantly immigrant Korean American sample.
2. Materials and methods 2.1. Intervention development in clinic 1 In 2004, we conducted one-on-one semi-structured indepth interviews with a convenience sample of 11 Korean American women who had received one or more mammo-
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grams through the NBCCEDP at a community clinic in Koreatown to gain an initial understanding of the barriers and supports of regular screening and preferences for intervention strategies. We then developed a print intervention with the help of six Korean American clinic staff members and six Korean American women who were patients at the clinic. This group met four times over a 6-month period to advise on the content and layout of the intervention. All activities were conducted in Korean language by one of the authors (AMJ), who is a female Korean American physician and a researcher interested in health disparities. Both the one-on-one interviews and the intervention development sessions were audiotaped, transcribed, and translated into English. All subjects who participated in the one-on-one interviews and the development of the intervention were immigrants. 2.2. Conceptual framework The print intervention addressed several constructs from the Health Behavior Framework [20,21], which draws from the Health Belief Model [22] and the Theory of Reasoned Action/Planned Behavior [23]. The specific theoretical constructs that were addressed in the intervention are shown in Table 2. 2.3. Intervention implementation Clinic 1 had to discontinue their free mammography program due to internal restructuring for several months during the study period. Therefore, the intervention was implemented at clinic 2 which was also located in Koreatown. Clinic staff identified all patients with Korean first or last names from the NBCCEDP database who had an index mammogram 12 months ago and were due to receive a reminder mailing. This was deemed to be the most feasible method for identifying Korean American women in a busy clinic setting and the only method for identifying women if the intervention was going to be institutionalized in the future. During the 3 months intervention period (July–September 2005), clinic staff mailed the print intervention together with the routine reminder postcard to 360 women who were due to return for their annual mammogram, using address information from the NBCCEDP database. All women were 40 years of age or older, had no health insurance, and a self-reported income of less than 200% poverty level. 2.4. Impact evaluation in clinic 2 Glasgow et al. [14] propose that the public health impact of health promotion programs should be evaluated by examining five dimensions of the RE-AIM model: reach, efficacy or effectiveness, adoption, implementation and maintenance [24,25]. We used the RE-AIM framework to comprehensively evaluate the impact of the print intervention on repeat screening rates because it emphasizes factors at both the individual level (reach and effectiveness) and the
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setting level (adoption, implementation, and maintenance) that are important for translating research into practice. 2.4.1. Evaluation of reach We conducted debriefing telephone surveys with 59 women who were mailed the print intervention 3 months after the mailings, between October and December 2005, to assess reach and acceptability of the print intervention. Interviews were limited to the first wave of women who were potentially exposed to the intervention in order to complete all interviews within the timeline of the study. 2.4.2. Evaluation of effectiveness In clinic 2, we matched electronic NBCCEDP records from the past 15 months by name, date of birth, and women’s unique ID number to determine if women received a repeat mammogram 12–15 months after the index mammogram. Women were classified as repeat screeners if at least one mammogram between 12 and 15 months following the index mammogram was recorded. We allowed a 3 months time period for women to obtain their repeat mammogram which was feasible because the clinic was able to schedule all women who called to make an appointment within a 2–4week period. All women who had obtained a mammogram during the index period were included in the analysis, although some could have moved or passed away. Given the pilot nature of the study, a quasi-experimental design was used. Repeat screening rates among women who were mailed the print intervention in 2005 were compared with the rates achieved with the reminder postcard only during the same 3 months in 2004 using a chi-square test. The effectiveness of the intervention was computed in an intent-to-treat analysis, which included all women who were mailed the intervention in the denominator, regardless of whether or not they received it or read it. Intent-to-treat analysis is widely regarded as the best way to measure the impact of an intervention under realistic, real world conditions [26]. We were only authorized to receive screening data on the group level, not on individual women. The study protocol and all study materials were approved by the Committee for the Protection of Human Subjects of the University of California, Los Angeles. 2.4.3. Adoption, implementation and maintenance Print intervention was assessed at the institutional level by questioning the manager of the NBCCEDP program at clinic 2 about the initial and ongoing implementation of the print intervention.
3. Results 3.1. Intervention development: one-on-one interviews and focus group sessions Barriers to repeat screening cited by participants included access and financial barriers, perceived low importance of
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breast cancer screening, embarrassment, fear of pain while getting a mammogram, fear of finding breast cancer, and lack of knowledge on program eligibility. Women suggested several intervention channels, including Korean media, reminder calls to schedule an appointment, and a brochure describing the importance of regular breast cancer screening. Findings from the first focus group session confirmed the results of the one-on-one interviews. Focus group members strongly favored developing an educational brochure that can be mailed together with the NBCCEDP routine reminder postcard. 3.2. Additional focus group sessions to develop the print intervention In a series of focus group sessions, women provided input for the content and layout of the print intervention, developed quotes and slogans, and reacted to drafts of graphs, pictures, and messages that we showed them. In the second focus group session, women developed a number of phrases to stress the importance of regular screening, such as: ‘‘A wife needs to be healthy in order for the family to be at its best’’ and ‘‘If you don’t have your health, you have nothing’’. In the final two focus group sessions we obtained women’s feedback on various drafts of a print intervention regarding the wording and the graphics used. Each focus group session lasted 1–2 h (see Table 1). Working with a Korean graphic artist, we produced a Korean language print intervention (Fig. 1). Table 2 illustrates how the content of the brochure corresponds to health beliefs and barriers to obtain annual mammograms that were identified in the early phase of the study.
Table 1 Brochure development through focus group input Session 1: Barriers to repeat screening and intervention strategies Confirming results of the one-on-one interviews, woman stated several barriers including access and financial barriers, perceived low importance of breast cancer screening, embarrassment, fear of pain while getting a mammogram, fear of finding breast cancer, and lack of knowledge on CDP eligibility Session 2: Phrases and slogans that stress the importance of regular screening Women discussed the importance of females for the well being of the family, the importance of health, and the importance of not only breast cancer screening but regular check-ups. They developed the following slogans: ‘‘A wife needs to be healthy in order for the family to be at its best.’’ ‘‘If you don’t have your health, you have nothing.’’ ‘‘If you get a regular check up you won’t have to worry that you are sick.’’ Session 3: Discussion of drafts of print intervention Women discussed the use of a cartoon of a Korean family versus photographs for the cover page. Some women stated that they liked a cartoon better because ‘‘you can look at them without any feelings or judgments’’. There was a suggestion to have the picture of the family in color and the woman with breast cancer in grey, but others stated that that would be unlucky, and that no family would pose for such a picture. After we explained that we would be able to obtain such a picture (not using a real family), focus group members agreed that a photograph would be very convincing. The facial expression of the family pictured was discussed but there was no agreement if the family should look happy or concerned
3.3. Pilot evaluation of the print intervention
Session 4: Finalizing of text and further discussion of picture for cover page Women approved the text overall and did not want to make any more changes. They looked at various family pictures for the cover page and discussed the approximate age of the woman who was at risk for getting breast cancer. They felt that the woman at risk should be around 40 years old because ‘‘at 40 you still have one child in high school, middle school and maybe elementary school’’. Another woman stated ‘‘you need younger children in order to make them look helpless.’’ Another woman confirmed that and stated ‘‘I’m 70 right now and it’s an age where you wouldn’t feel cheated if you caught something and died.’’
3.3.1. Reach and acceptability Debriefing telephone interviews were conducted with 59 women out of the first 128 women who were mailed the intervention for a response rate of 46%. Of the 69 women who did not complete the debriefing interview, 34 had numbers that were disconnected or they had moved, 26 never answered the telephone, 4 were not reached but an informant confirmed their residence and 5 refused to be interviewed. The 59 women who were interviewed were, on average, 53 years old (range 41–65 years) and had resided in the U.S., on average, 17 years (range 4–35 years). Only 19 women (32%) recalled that they had received a small brochure from the clinic about mammography screening. Of these women, 60% read the entire brochure, another 30% most of the brochure, and 10% little or nothing. All women who had read the entire or most of the brochure understood everything (67%) or mostly everything (33%). Almost all women (90%) were encouraged to have regular mammograms and appreciated the information. About one third of the women discussed the brochure with somebody and 78% stated that they would
recommend it to a friend. During the debriefing interview, several of the women described in detail the messages and the pictures of the print intervention. In order to investigate why only one-third of the respondents remembered receipt of the brochure, we compared the addresses in the NBCCEDP database that were used for the reminder mailing with address information in patients’ charts. The NBCCEDP database is used for online reporting of screening and follow-up activities for billing purposes to the NBCCEDP, is updated on a weekly basis, and is completely separate from the patients’ charts. Matching the database and charts by name and date of birth, we found that the address information was identical in both documents for 34 women only (58% of total). Eleven women had moved, six women had similar addresses but with spelling or numeric discrepancies (e.g., wrong zip codes) that could prevent mail to reach the correct address, and eight women did not have address information in their chart or no chart was found.
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Table 3 Rates of repeat mammography screening (12–15 months after index mammogram) among Korean-American Women in one community clinic N
%
Control period (2003–2004) Clinic records
94/296
32
Intervention period (2004–2005) Clinic records Self-reports
136/360 30/59
38 51
There was no significant difference between the control and intervention periods based on clinic records, p = .108, chi-square test.
tiveness, it should be noted that in the small subsample of women who completed the debriefing survey, 51% reported receipt of a repeat screening mammogram. 3.3.3. Adoption, implementation and maintenance of the print intervention The clinic manager at clinic 2 reported that it was very easy to include the print intervention in the reminder mailing. She stated that they continued to mail their entire supply of brochures to Korean American women for several months after completion of the study.
4. Discussion Fig. 1. Cover of Print Intervention to Encourage Annual Mammography Screening.
3.3.2. Effectiveness In the 3 months intervention period, 136/360 women (38%) received a repeat screening mammogram. In the 3 months comparison period, 94/296 women (32%) received a repeat screening mammogram. Thus, the repeat screening rate was 6 percentage points higher in the intervention period than in the control period, representing a relative increase of 18% ( p = .108, chi-square test, see Table 3). Although we used NBCCEDP records to determine effec-
We were able to obtain detailed input from Korean American women that shaped the content and layout of a theoretically based print intervention to encourage annual mammography screening. This print intervention was subsequently disseminated through a community clinic that provides free mammograms to eligible Korean American women through the NBCCEDP. Clinic personal confirmed that the print intervention can easily be integrated into the routine clinic protocol. Thus, the clinic continued to include the print intervention in their reminder mailings after the study ended. Debriefing interviews with Korean American women who received the print intervention showed that most women understood the messages of the brochure and would recommend it to a friend. It should be noted that
Table 2 Content of the print intervention and corresponding theoretical constructs Theoretical construct
Content
Knowledge
Information on screening guidelines, incidence of breast cancer, risk factors (age, length of stay in the U.S., family history of breast cancer) and locations that offer free mammograms is provided Brochure includes a letter from a Korean American female physician urging women to have a mammogram every year Graph shows that breast cancer is the most commonly diagnosed cancer among Korean American women and that the incidence is increasing Information showing higher survival rates for earlier stages of breast cancer Encouragement from a Korean American woman who gets a mammogram every year (with picture) Importance of women for the well being of the family is stressed. Picture on the cover of the brochure shows a three generation Korean American family with women in the center Strategies on how to deal with lack of insurance, lack of time and being embarrassed are suggested. Myths of not needing a mammogram because one is too young or too old or because woman has breast fed are addressed
Recommendation by provider Health beliefs: perceived susceptibility Efficacy of early detection Social norms and support Cultural factors Barriers
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literacy levels are high in Korea, with less than 10% being illiterate [27]. The effect that was achieved with the print intervention was encouraging but not statistically significant. The 6 percentage point increase is comparable to the effect of educational or motivational print materials that was reported by the Guide to Community Preventive Services based on their systematic review of 19 studies that employed small media. Small media interventions that were not tailored to individual women were effective in increasing breast cancer screening by a median 5.3 percentage point increase http:// www.thecommunityguide.org/cancer/screening/ default.htm, accessed 13 February 2008). Partin et al. [28] tested the effect of two low-cost mailed interventions on repeat mammography screening among women enrolled in a federally funded screening program in Minnesota. Their intervention achieved a similar effect as our intervention, 5– 7% increased screening rates compared to a control group, but in a predominantly (89%) white population [28]. Glasgow et al. [24] suggest that a low-intensity intervention that is less efficacious but can be delivered to large numbers of people can still have a sizable impact. We hypothesized that the NBCCEDP, which served about 90,000 women in Los Angeles County in 2005 (72% Hispanic, 14% Asian, 6% White, 3% Black), would be an excellent mechanism for dissemination of a low cost print intervention. However, our pilot study indicated that the reach of the print intervention was severely limited, most likely due to inaccurate or outdated address information. It is possible that other reasons contribute to the problem, such as family members screening the daily mail. The limited reach also decreased the effectiveness of the intervention in the intent-to-treat analysis, which included all women who were mailed the intervention, regardless of whether or not they received it or read it. An important strength of our study is that the outcome was assessed through clinic records rather than relying on self-report. Prior studies have shown that self-reports tend to overestimate screening [29]. Our data also suggest overreporting, although the subgroup that completed the debriefing interview may be a selected group of women who may have been more likely to be screened than all women who were included in the clinic record analysis. A limitation of our research was the lack of a randomly assigned control group, which was not feasible within the funding timeframe and available budgetary resources. Thus, we cannot exclude the possibility that the increase in screening observed may be due to a secular trend or changes in personnel or clinic procedures, other than our intervention. According to clinic staff, personnel changes did occur but the clinic procedures remained the same. Overall, we found that involving Korean American women in intervention development resulted in print materials that were well accepted by their peers. Dissemination of print information through the NBCCEDP is very feasible. However, the reach and effectiveness of the
intervention was limited which we attributed to incorrect or outdated address information.
Acknowledgements We would like to thank the clinic staff and the Korean American patients who participated in this study. This research was supported by funds from the California Breast Cancer Research Program of the University of California, Grant No. 9AB-2101.
Conflict of interest None declared.
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