Cultural Awareness and Health Literacy Level

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.With these thoughts in mind:Consider the following scenario: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.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.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.

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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
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
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.
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
Department of Family Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois.
College of Nursing, The Ohio State University, Columbus, Ohio.
College of Nursing, University of Illinois at Chicago, Chicago, Illinois.
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.
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
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
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
Table 1. Predictors of Mammography Use
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
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
Source: Champion Breast Health Survey65 modified/refined via focus groups.
Source: Ferrans Cultural Beliefs Scale.66
Source: Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA).67
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
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
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
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
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 ... Purchase answer to see full attachment

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