Rena J. Pasick

Similarities and Differences across Cultures: Questions to Inform a Third Generation for Health Promotion Research

The increasing diversity of American communities raises an important question about the efficiency, appropriateness, and feasibility of tailoring messages and intervention strategies to target groups identified by race and ethnicity. To explore this issue, this article distinguishes race and ethnicity from culture and then discusses four questions: (1) What is the meaning of culture in health promotion? (2) What is the role of culture in understanding health behavior? (3) What is the role of culture in the design of interventions? and (4) What do the relationships of culture to behavior and to intervention mean for cultural tailoring? Based on this analysis, the authors suggest that effective health promotion will tailor interventions by culture as necessary but reach across cultures when possible and appropriate. A framework is presented to assess the need for cultural tailoring, and a new generation of health promotion research is proposed to facilitate cross-cultural comparisons.

Theorizing Social Context: Rethinking Behavioral Theory

Major behavioral theories focus on proximal influences on behavior that are considered to be predominantly cognitive characteristics of the individual largely uninfluenced by social context. Social ecological models integrate multiple levels of influence on health behavior and are noted for emphasizing the interdependence of environmental settings and life domains. This theory-based article explains how social context is conceptualized in the social sciences and how the social science conceptualization differs from and can broaden the analytic approach to health behavior. The authors use qualitative data from the Behavioral Constructs and Culture in Cancer Screening study to illustrate our conceptualization of social context. We conclude that the incorporation into health behavior theory of a multidimensional socioculturally oriented, theoretical approach to social context is critical to understand and redress health disparities in multicultural societies like the United States.

How Do Older Chinese Women View Health and Cancer Screening? Results from Focus Groups and Implications for Interventions

Objective. To qualitatively assess Chinese American womens views of health and illness and the potential influences of culture and language on cancer screening behavior. Design. Data were generated by five focus groups, each consisting of 9–12 Chinese American women aged 50 and older. Participants responded to open‐ended questions assessing their perceptions of health and illness, knowledge about cancer, beliefs about and barriers to cancer screening, and screening and healthcare experiences in the USA. All conversations were tape‐recorded and analyzed in the context of PRECEDE framework concepts of predisposing, enabling, and reinforcing factors. Results. The 54 participants had a mean age of 65 years, with an average age of immigration to the USA at 51 and average length of residence in the USA of 15 years. Participants considered outdoor exercise in the morning for fresh air and a hot–cold balanced diet as important means to health. None mentioned the importance of regular medical checkups or cancer screening. When talking about cancer prevention, a sense of fatalism was evident, such as ‘no control of life and death’ and ‘what will happen will happen’. Lack of English capability was a major enabling barrier to healthcare. In addition, these women reported the need for help with transportation, especially for those living in suburban areas where public transportation is not readily available. Physician recommendation was identified as the most important reinforcing factor for cancer screening. Conclusion. Our results suggest traditional Chinese beliefs, such as those pertaining to fatalism, self‐care, and the hot and cold balance, influence the perceptions of older Chinese women regarding health, illness, and use of preventive healthcare. Interventions to improve cancer screening in this population should be tailored to the specific predisposing, enabling, and reinforcing factors of this population, including cultural views, language barriers, doctor–patient communication, and access to healthcare.

Pathways to early cancer detection in the multiethnic population of the San Francisco Bay Area

The Pathways project studied the relationship of race/ethnicity, socioeconomic status, and culture to breast and cervical cancer screening. A multidisciplinary, multicultural team of investigators assessed the knowledge, attitudes, and practices of women from five race/ethnic groups (N = 4,228) and their barriers to screening utilization. A planning framework guided the development of interventions and analyses of the similarities and differences in screening behaviors across race/ethnic groups. Baseline data for women ages 18 to 74 years showed that levels of screening were higher than national averages for Latina, white, and black women but lower for Chinese and Vietnamese women. Analyses revealed the importance of education and insurance in obtaining recommended screening regardless of race/ethnicity. However, race, ethnicity, and culture are important to the tailoring of effective interventions.

Quality of data in multiethnic health surveys.

Objective. There has been insufficient research on the influence of ethno-cultural and language differences in public health surveys. Using data from three independent studies, the authors examine methods to assess data quality and to identify causes of problematic survey questions. Methods. Qualitative and quantitative methods were used in this exploratory study, including secondary analyses of data from three baseline surveys (conducted in English, Spanish, Cantonese, Mandarin, and Vietnamese). Collection of additional data included interviews with investigators and interviewers; observations of item development; focus groups; think-aloud interviews; a test-retest assessment survey; and a pilot test of alternatively worded questions. Results. The authors identify underlying causes for the 12 most problematic variables in three multiethnic surveys and describe them in terms of ethnic differences in reliability, validity, and cognitive processes (interpretation, memory retrieval, judgment formation, and response editing), and differences with regard to cultural appropriateness and translation problems. Conclusions. Multiple complex elements affect measurement in a multiethnic survey, many of which are neither readily observed nor understood through standard tests of data quality. Multiethnic survey questions are best evaluated using a variety of quantitative and qualitative methods that reveal different types and causes of problems.

Lessons Learned from Community-Based Cancer Screening Intervention Research

Behaviors associated with cancer screening have been the focus of intensive research over the past 2 decades, primarily in the form of intervention trials to improve screening based in both clinical and community settings. Meta‐analyses and literature reviews have synthesized and organized the resulting literature. From the accumulated work, this review distilled lessons learned from cancer screening intervention research in community settings. The authors posed the question, “What do we know about the development of effective community‐based interventions (the level of good over harm achieved in real‐world conditions)?” Framed around the concept of focal points (the simultaneous combination of target population, behavioral objective, and setting for an intervention), 13 lessons were derived. One lesson was cross‐cutting, and the other lessons addressed the three focal‐point components and the major intervention categories (access‐enhancing strategies, mass media, small media, one‐on‐one and small‐group education, and combinations of these categories). To build more systematically on existing research, recommendations are made for new directions in basic behavioral and intervention research. Cancer 2004.

Healthy colon, healthy life: a novel colorectal cancer screening intervention.

BACKGROUND Colorectal cancer (CRC) screening rates are increasing, but they are still low, particularly in ethnic minority groups. In many resource-poor settings, fecal occult blood test (FOBT) is the main screening option. INTERVENTION Culturally tailored telephone counseling by community health advisors employed by a community-based organization, culturally tailored brochures, and customized FOBT kits. DESIGN RCT. Participants were randomized to (1) basic intervention: culturally tailored brochure plus FOBT kit (n=765); (2) enhanced intervention: brochure, FOBT plus telephone counseling (n=768); or (3) usual care (n=256). SETTING/PARTICIPANTS Latino and Vietnamese primary care patients at a large public hospital. MAIN OUTCOME MEASURES Self-reported receipt of FOBT or any CRC screening at 1-year follow-up. RESULTS 1358 individuals (718 Latinos and 640 Vietnamese) completed the follow-up survey. Self-reported FOBT screening rates increased by 7.8% in the control group, by 15.1% in the brochure group, and by 25.1% in the brochure/telephone counseling group (p<0.01 for differences between each intervention and usual care and for the difference between brochure/telephone counseling and brochure alone). For any CRC screening, rates increased by 4.1% in the usual care group, by 11.9% in the FOBT/brochure group, and by 21.4% in the brochure/telephone counseling group (p<0.01 for differences between each intervention and usual care and for the difference between the basic and the enhanced intervention). CONCLUSIONS An intervention that included culturally tailored brochures and tailored telephone counseling increased CRC screening in Latinos and the Vietnamese. Brochure and telephone counseling together had the greatest impact. Future research should address replication and dissemination of this model for Latinos and Vietnamese in other communities, and adaptation of the model for other groups.

The effect of access and satisfaction on regular mammogram and Papanicolaou test screening in a multiethnic population.

Background:Access and satisfaction are determinants of preventive service use, but few studies have evaluated their role in breast and cervical cancer screening in multiethnic populations. Objectives:We sought to investigate the relationship between race/ethnicity, access, satisfaction, and regular mammogram and Papanicolaou test receipt in 5 racial/ethnic groups. Research Design:We conducted a telephone survey in 4 languages. Subjects:Our subjects were black, Chinese, Filipino, Latino, or white women aged 40 to 74 residing in Alameda County, California. Measures:Outcome: regular mammograms (last test within 15 months and another within 2 years prior) and Papanicolaou tests (36 months and 3 years, respectively). Independent: race/ethnicity, sociodemographic variables, access (health insurance, usual site of care, regular doctor, check-up within 12 months, knowing where to go, copayment for tests), and satisfaction (overall satisfaction scale, waiting times, test-related pain and embarrassment, test satisfaction). Results:Among women who had ever had a mammogram or Papanicolaou test, 54% and 77%, respectively, received regular screening. In multivariate analyses, regular mammography was positively associated with increased age (odds ratio [OR] 1.05 per year), private insurance (OR 1.7), check-up in the past year (OR 2.3), knowing where to go for mammography (OR 3.0), and greater satisfaction with processes of care (OR 1.04 per unit), and negatively with not knowing copayment amount (OR 0.4), too many forms to fill out (OR 0.5), embarrassment at the last mammogram (OR 0.6), and Filipino race/ethnicity. Similar results were found for regular Papanicolaou tests. Conclusions:Access and satisfaction are important predictors of screening but do little to explain racial/ethnic variation. Tailored interventions to improve regular mammography and Papanicolaou test screening in multiethnic populations are needed.

Intention, Subjective Norms, and Cancer Screening in the Context of Relational Culture

Research targeting disparities in breast cancer detection has mainly utilized theories that do not account for social context and culture. Most mammography promotion studies have used a conceptual framework centered in the cognitive constructs of intention (commonly regarded as the most important determinant of screening behavior), self-efficacy, perceived benefit, perceived susceptibility, and/or subjective norms. The meaning and applicability of these constructs in diverse communities are unknown. The purpose of this study is to inductively explore the social context of Filipina and Latina women (the sociocultural forces that shape people’s day-to-day experiences and that directly and indirectly affect health and behavior) to better understand mammography screening behavior. One powerful aspect of social context that emerged from the findings was relational culture, the processes of interdependence and interconnectedness among individuals and groups and the prioritization of these connections above virtually all else. The authors examine the appropriateness of subjective norms and intentions in the context of relational culture and identify inconsistencies that suggest varied meanings from those intended by behavioral theorists.

Unsolved problems in early breast cancer detection : focus on the underserved

SummaryIn the last decade, numerous research and programmatic efforts have attempted to improve cancer screening practices among women from diverse race/ethnic backgrounds on the assumption that observed differences in breast cancer survival were largely due to differences in early detection practices. Recent data from the 1992 National Health Interview Survey and a 1992 survey in San Francisco Bay Area multiethnic communities indicate that rates of self-reported breast cancer screening tests among African American, Hispanic, and white women no longer differ significantly. However, there are large, persistent socioeconomic differences as reflected in educational and income levels, the recency of immigration, and English language proficiency. This emphasizes the continuing need for interventions tailored specifically for the underserved, with the racial, ethnic, and cultural composition of the intended audience informing educational messages and strategies. However, effective research interventions are complex and costly throughout the spectrum of outreach, inreach, and follow-up. Thus the generalizability of these strategies to under-funded providers and agencies in low-income communities may be limited. Therefore, as ongoing research continues to refine strategies, the application of effective community-based intervention should seek out potential partnerships with programs that provide the critical access to services. Cancer control scientists are well positioned to advocate for community-based infrastructures that facilitate translation of research into practice.In the last decade, numerous research and programmatic efforts have attempted to improve cancer screening practices among women from diverse race/ethnic backgrounds on the assumption that observed differences in breast cancer survival were largely due to differences in early detection practices. Recent data from the 1992 National Health Interview Survey and a 1992 survey in San Francisco Bay Area multiethnic communities indicate that rates of self-reported breast cancer screening tests among African American, Hispanic, and white women no longer differ significantly. However, there are large, persistent socioeconomic differences as reflected in educational and income levels, the recency of immigration, and English language proficiency. This emphasizes the continuing need for interventions tailored specifically for the underserved, with the racial, ethnic, and cultural composition of the intended audience informing educational messages and strategies. However, effective research interventions are complex and costly throughout the spectrum of outreach, inreach, and follow-up. Thus the generalizability of these strategies to under-funded providers and agencies in low-income communities may be limited. Therefore, as ongoing research continues to refine strategies, the application of effective community-based intervention should seek out potential partnerships with programs that provide the critical access to services. Cancer control scientists are well positioned to advocate for community-based infrastructures that facilitate translation of research into practice.