Public Health Intervention

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Breast Cancer Prevention for Korean American Women in Flushing, Queens

1. Scope of the Problem

• Breast cancer is the most commonly occurring cancer in Korean American women. They consistently have reported relatively low rates of breast cancer screening, which indicates they may be at high risk for cancer mortality and morbidity because of delayed diagnosis.

• Mammogram screening rate in Korean American women age 65 and older: 12% to 69% had ever had a mammogram, and 7% to 35% were estimated to have had a mammogram in the preceding year.

• Lower rates of clinical breast examination and breast self-examination were also reported.

• Older Korean American women were less likely to be married and employed, they were also less educated and had lower incomes. A significantly higher proportion of older Korean American women reported that they could not speak English at all or only a little.

• Study shows that lack of significance and lack of knowledge are significant barriers to having a mammogram.

• Different health beliefs also contributed to their lower screening rates, such as lack of belief in benefits of mammography.

• Other barriers to mammogram: fear of finding something wrong, fear of embarrassment or lack of modesty, not knowing where to go for screening, believing that mammography is only needed when symptoms are presented.

• Mammography screening is the only screening method that has proven to be effective, which reduce breast cancer mortality by around 20%.

2. Planning.

Identify changes:

Promote breast cancer awareness in Flushing, Queens, where many Korean American immigrants resided. Fliers and brochures with pictures in Korean will be given out. This will be needed to take care of the residents that do not speak English.
Encourage primary care physicians in the area to stay up-to-date and adhere to screening guideline. Motivational interviewing will be use to find the internal motivation they need to change their behavior. PCPs will be offering culturally sensitive educational materials and consider patients’ literacy levels. Medical translators should be provided if the physician is not able to communicate in Korean. Offer flexible mammography screening hours such as evenings and Saturdays.
Emphasize importance of having a mammogram and high incidence rates of breast cancer in older age. It is also necessary even when one does not have symptoms. Emphasize the benefits such as detect early, live longer. Address negatives and outdated beliefs about cancer and cancer treatment.
Mail reminders to patients that are overdue for a mammogram.
Use flu season as an opportunity to promote screenings, offer mammography appointments and brochures.
Culturally tailored education, outreach program and intervention. Establish programs in the area to assist minorities with translating, scheduling for doctor’s appointment, educating breast cancer and promoting screening, giving out brochures and booklets, applying for insurance coverage, provide financial assistance/transportation.
These changes will be focused on behavioral changes because different health belief and cultural disparities are the main barriers to having a mammography. Promoting and educating will raise awareness of breast cancer in Korean American women, and thus will lead to higher screening rate.

Stakeholder

Will include legislators, gynecologists/PCPs, women right organizations, Minority Rights Group, Korean American women, local and community educators, imaging centers
Stakeholders will accept this program because breast cancer should be highly attentive in minority group. However, white women have the highest percentages of receiving a mammography, while other minority ethic groups have lower percentages. Korean American women have a lower screening percentage compared to Asian women as a whole and the state average. Additional effort and attention should be given to this minority group because cultural difference should not impact the access and quality of care. Finding breast cancer early reduces risk of dying from the disease by 20-30% or more. Increasing breast cancer screening rate and awareness of the benefit can save lives by finding breast cancer as early as possible.
The program/plan will be funded by state and local funds, county and city revenues, Prevention and Public Health Fund.

I believe my program will be feasible in the long-run because cancer rate of the minority group is an important public health topic to receive funding and support from the related foundations and funding agencies, as well as state and local public health funding. Screening tests should not be available to specific race or populations. This program will possibly influence the awareness of screening tests for other types of disease and cancer as well.
To obtain important information within the population, surveys and qualitative research will be done in both patients and providers. Surveys questions that include the knowledge of breast cancer screening will be asked to the patients before and after the intervention. For providers, they will be asked about the support and assistance that they are offering to the patients, and the effect on the rate of breast cancer screening and patient outcome and care.

3. Development & Dissemination of the Intervention

The goal of this program is to promote breast cancer screening in Korean American and increase awareness by educating breast cancer in a culturally sensitive direction. Since Korean American women reported a low screening rate, we would want to focus our intervention at an area (Flushing, Queens) with excessive amount of Korean American women. It is necessary to monitor the rate of breast cancer screening and the incidence of breast cancer. Surveys will be given out to the patients to measure their awareness of breast cancer.
We would be collecting data in patients within several domains: knowledge of symptom, confidence/skills/behavior in relation to detecting a breast change, anticipated delay in contacting the doctor, knowledge of risk factors, knowledge of breast screening programs, frequency of breast checking, age-related risks. This will help to measure the level of patient awareness on breast cancer. The score for the level of awareness will be increased after a promoting intervention.
Monthly group education will be established in the neighborhood to encourage and motivate patients to seek recommended screening. It will be conducted by a health care professional (with a translator/interpreter if needed) who use presentations or other teaching aids in a lecture or interactive format, and often incorporate role modeling or other methods. The purpose of educating the Korean American women is to ensure that they understand the risks of cancer. Group education will also emphasize the fact every woman in this class will need to have mammogram and they shouldn’t feel embarrassed to have a breast exam.
Primary care providers should be aware of cultural sensitivity. Translating/interpreting services should be available to the patients. They should also ensure that adequate amount of time of the annual check-up appointment (or flu-shot appointment) is spent on patient counseling and education. Providers should also offer flexible hours and mail mammography reminders to patients.
The program will also have hotline service. Multilingual representatives are available Monday to Friday 9AM to 5PM to assist the patients in scheduling doctor appointments, applying for low-income health insurance coverage, answering questions, providing instructions of where to go for screening, planning for transportation, and even providing a medical translator/interpreter for the doctor’s appointment etc. These supports will increase the access of care in the hope of increase breast screening and patient outcome.
Every week, brochures/booklets/posters/fact sheets with the applicable information on breast cancer will be mailed and emailed to the patients. Materials included will be symptoms, screening and recommendation, prevention and promotion, breast self- examination, risk factors, and other relevant facts.

4. Evaluation & Maintenance

Semiannual Evaluations: Data will be collected overtime, from the start of the program and after program implementation. It is important to consider the program’s focus, the needs of the audience or funders, and the time frame and training available for meeting program goals. Population health measures may be also used in evaluation. Patients data will include demographic data, biological markers, health status, medical history and knowledge. Program process measures will include the level of awareness, program activities, patient outcome, screening rates, incidence of breast cancer, access of care, policies and implementations, types of resources and contributions provided by stakeholder groups, perceived health status, number of people aware of program messaging and intend to take action
Future Improvement: if the interventions are unsuccessful, future improvement and adjustment will be made based on the data collection. If the breast cancer screening rate is not increasing within expectation or the incidence rate is increasing, further promotion and education on genetic counseling and testing for BRCA 1 and BRCA 2 mutation may need to be implemented. This will allow people to learn if their breast cancer is due an inherited gene mutation. In addition, more future research might need to be funded to find out the reasons for the minorities to deny screening.
Program Maintenance: The sources of funding will mainly be local and state, but also minority group foundation, and other funding agencies. There will be continuation of data collection to monitor the program process and to suggest future adjustment.

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