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    Awarded Grants
    Determining The Impact of Health System Navigation Skills of Asian Americans on Breast Cancer Screening

    Scientific Abstract:
    Background. Asian American women are the only ethnic population with breast cancer as the primary cause of death, yet they have the lowest rates of screening for clinical breast exam and mammograms of all ethnic groups. Wide variations in the rates of screening exist among the highly heterogeneous Asian American subgroups. Predictors of these lower rates of screening have proved elusive, since most data do not have sufficient or representative samples of various Asian American subgroups to allow robust models and unequivocal results. Thus far, identified predictors of screening in the literature include length of residence in the US, poverty, health insurance, usual source of care, and acculturation. However, predictors such as length of residence in the U.S. are proxies for an array of other unidentified and unexplored factors. The high rates of immigrants among some Asian American groups indicates populations who are from vastly different cultures and systems of care and have little familiarity with the US health care system. In particular, the current focus on secondary prevention in US -- specifically breast cancer -- may not be shared in many Asian countries that are struggling with availability of resources to provide acute care and primary prevention. The Asian Americans’ ability to obtain breast cancer screening is further compromised by linguistic isolation and limited English proficiency, as well as competing priorities faced by new immigrants. Existing acculturation measures account for some differences in rates of screening, but do not necessarily indicate factors that can be modified in a timely fashion to increase screening. Objective. To develop a scale of health acculturation and navigation skills (HANS) of Asian Americans that could be used to predict obtaining breast cancer screening. We will examine the validity and reliability of this scale, and assess its predictive power in relation to breast self-exam, clinical breast exam, and mammograms for all Asian American and specific subgroups such as Koreans and Vietnamese. We will identify elements of HANS that could be used in lieu of or in conjunction with current acculturation scales to identify malleable factors for breast cancer screening targeted intervention programs. Specific aim. To develop a health acculturation and navigation skills scale Asian American groups that would predict breast cancer screening practices with elements that are more responsive to education intervention than standard acculturation scales. Study design. We will conduct a review of the literature on predictors of screening among Asian Americans to fully conceptualize HANS. We will further identify these components in data from the California Health Interview Surveys 2001 and 2003 -- the largest representative surveys of Asian Americans in the U.S. to date— to examine the possibility of combining such factors into a cohesive scale. These factors will represent personal characteristics such as education, immigration status, length of residency in the US, and English proficiency, health behaviors such as smoking, drinking and diet, access to care such as use of alternative medicine, having a usual source of care, and dental and medical visits, and experiences with health care providers such as difficulties communicating with a doctor, satisfaction with overall health care, and perceptions of discrimination. We will further examine the validity of the variables to be included in HANS and the predictive power of these variables in measuring rates of cancer screening among Asian American subgroups. Next, we will conduct 16 focus groups of about 10 individuals each, with Korean and Vietnamese women in Los Angeles and Orange Counties where the majority of these populations live. Both groups have high rates of immigrants and limited English proficient members. Each group will be stratified by age and education level and two focus groups will be conducted for each stratification. We will examine the validity and reliability of HANS and explore other aspects of health acculturation and navigation skills that are not captured in the literature and surveys such as the level of confidence or fear in interacting with the providers and the system or knowledge of where to go for screening. We will combine the findings of data analysis and focus groups to fully develop HANS. Outcome and benefits. This study will identify new barriers to breast cancer screening for Asian Americans that are more modifiable than variables used in acculturation scales, , e.g. language or cultural beliefs will build on the successful navigation functions of community outreach workers. We plan to test the impact of HANS on breast cancer screening in follow up studies of Asian Americans and test its viability for use with other ethnic groups with low rates of breast cancer screening.

    Lay Abstract:
    Background. Breast cancer is the number one cause of death of Asian American women, yet they have the lowest rates of clinical breast exams and mammograms of all ethnic groups. The reasons for these lower rates of screening have proved elusive, because of great variation among Asian Americans of different nationalities and since most data have insufficient numbers of Asian American subgroups or existing research has used small groups with unique characteristics. The reasons for these low rates of screening include length of residence in the US, poverty, health insurance, usual source of care, and acculturation. Reasons such as length of residence in the U.S., however, represent an array of other unidentified and unexplored factors. The high rates of immigrants among some Asian American groups indicates populations who are from vastly different cultures and systems of care and are not familiar with the US health care system. In particular, the current focus on early disease identification in the US -- specifically breast cancer -- may not be shared in many Asian countries that are struggling with availability of resources to care for the very sick and preventing infectious diseases. The Asian Americans’ ability to receive breast cancer screening is further compromised by high rates of non-English speakers or lack of fluency in English. Level of acculturation, as measured by existing scales, may be a reason for differences in rates of screening, but existing scales do not always measure “health” acculturation and not all components of such scales are necessarily open to modification to increase screening. Objective. To identify the level of health acculturation and navigation skills (HANS) of Asian Americans and its role in receiving breast cancer screening. We will develop HANS and examine how well it predicts breast self-exam, clinical breast exam, and mammograms for Asian Americans and specific subgroups such as Koreans and Vietnamese. We will identify elements of HANS that could be used in lieu of or in conjunction with current acculturation scales to identify malleable factors for breast cancer screening targeted intervention programs. Specific aim. To develop and test a health acculturation and navigation skills scale for Asian American groups that would predict breast cancer screening practices with indicators that are more responsive to education intervention to increase breast cancer screening than standard acculturation scales. Study design. We will first conduct a review of the literature on factors that determine breast cancer screening rates among Asian Americans to fully identify the components of HANS. We will further identify these components in data from the California Health Interview Surveys 2001 and 2003 -- the largest surveys of Asian American subgroups in the U.S. to date— to examine the possibility of combining such factors into a cohesive scale. These factors will represent personal characteristics such as education, immigration status, length of residency in the US, and English proficiency, health behaviors such as smoking, drinking and diet, access to care such as use of alternative medicine, having a usual source of care, and dental and medical visits, and experiences with health care providers such as difficulties communicating with a doctor, satisfaction with overall health care, and perceptions of discrimination. Next, we will conduct 16 focus groups of about 10 individuals each, with Korean and Vietnamese women in Los Angeles and Orange Counties where the majority of these populations live. Both groups have high rates of immigrants and limited English proficient members. Each group will be separated by age and education level and two focus groups will be conducted for each. We will test how well HANS predicts rates of breast cancer screening and explore other aspects of health acculturation and navigation skills that have not previously been studied such as the level of confidence or fear in interacting with the providers and the system or knowledge of where to go for screening. We will combine the findings of data analysis and focus groups to fully develop HANS. Outcome and benefits. This study will identify new barriers to breast cancer screening of Asian Americans. The measures in HANS are proposed to be more responsive to change – and may be more effective in increasing breast cancer screening – than existing acculturation scales, which identify cultural beliefs . We plan to test the impact of HANS on breast cancer screening in follow up studies of Asian Americans and test its viability for use in other populations with low rates of breast cancer screening.