Health Education & Behavior

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.

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.

Pathways to Early Cancer Detection in Four Ethnic Groups is a program project funded by the National Cancer Institute aimed at increasing the use of breast and cervical cancer screening among underserved African American, Chinese, Hispanic, and Vietnamese women. The program project core is dedicated to cross-cultural studies including development of survey questions that are comparable in four languages. This article describes the Pathways surveys, summarizes the challenges encountered in question translation, and presents an adapted approach to translation. Concurrent, multilingual, decentered translation was the process through which an English version of each question was selected only when it could be directly and meaningfully translated into Mandarin, Cantonese, Spanish, and Vietnamese. Examples of challenges and how these were addressed in the Pathways surveys are presented, along with lessons learned throughout this process.

Latinas have less breast cancer, have more cervical cancer, and obtain fewer screening tests at recommended intervals. This article reviews the epidemiology and use of screening tests for these cancers and cultural factors that affect screening. En Acción Contra el Cáncer was designed to increase use of breast and cervical cancer screening services by distributing free cancer educational materials in Spanish, implementing a media campaign, conducting community outreach, training lay networkers, and assisting clinicians. A survey of 1,601 Latinas, 20 to 74 years old, ascertained screening behavior and knowledge and attitudes about cancer. Comparison of intervention and control cities showed significant differences in proportion insured, married, born in the United States, and less acculturated. There were no significant differences in mammography and Pap smear use, knowledge, and attitudes. Culturally appropriate prevention interventions that target ethnic-specific concerns arc needed.

To promote breast and cervical screening among Vietnamese women, a neighborhood-based intervention was developed that included small-group education, distribution of Vietnamese-language educational materials, and health fairs. The rationale for these modes of intervention is described. A pretest/posttest controlled trial is used to evaluate the intervention. San Francisco, California, is the experimental community; Sacramento, California, is the comparison community. The study hypothesizes that postintervention measurements of screening rates will reflect significantly greater increases among women in the experimental community than in the comparison community. This article reports results from the 1992 baseline household survey of 306 Vietnamese women in San Francisco and of 339 Vietnamese women in Sacramento. There were no significant differences in screening rates between the two communities. Only 50-54% of women had received routine checkups; 44-55%, mammograms; 40-45%, clinical breast examinations; 40-46%, Pap smear tests; and 58-65%, pelvic examinations.

The authors used telephone interviews to investigate the knowledge, attitudes, beliefs, and practices regarding breast and cervical cancer screening among 775 Chinese American women in San Francisco. The rates of ever had a mammogram, ever had a clinical breast examination, and ever examined one's breasts among women aged 40 and older were 70%, 75% and 70%, respectively. The rates of ever had a Pap smear and ever had a pelvic examination were 67% and 85%, respectively. However, the rates of having had these cancer screening tests at regular intervals were much lower (25% for mammograms, 37% for Pap smears). Ability to speak English and insurance status were significantly associated with breast and cervical cancer screening knowledge and practices. Further analysis of the data, together with the data collected from a survey on physicians serving this population, will provide a basis for future interventions.

When access to primary care is limited, low-income women of all races and ethnicities seek care in public hospital emergency departments (EDs) in which preventive services are often unavailable. This project implemented and evaluated a cervical screening program in an inner-city ED. Clinicians were asked to offer Pap smears to women undergoing diagnostic pelvic examinations. Women with abnormal results were randomized to follow-up in one of two settings. Women with normal results received an intervention promoting annual rescreening. In 12 months, 1,523 Pap smears were performed on 1,442 women; 58% were African American; 21%, Hispanic; and 7%, Asian. Among these women, more than 22 languages were spoken, and 26% did not recall having a prior Pap smear. Preliminary findings suggest that cervical cancer screening can be incorporated into routine ED care, creating an important alternative pathway to early detection for a high-risk population.

Indigenous lay health workers are presumed to be effective communicators in their communities due to their cultural competence. Lay health worker programs in Vietnamese and Latino communities show the influence of each community's culture and structure on the intervention designs and recruitment and training of lay health workers. To promote cancer screening. Vietnamese lay health workers conducted educational sessions in neighborhoods, while Latina lay health workers served as networkers and media role models. The studies demonstrated ways to build upon cultural strengths of the community and to tailor interventions to meet community expectations and needs. The authors conclude that ongoing responsiveness to both cultural norms and structural conditions in the community is the sine qua non of successful community programs.

Health education materials designed for the general population may be perceived as unattractive, irrelevant, or unclear by members of certain cultural groups. Given the increasingly multicultural demographics of the United States, planners need to be aware of the specific characteristics of a target audience to address cultural differences and similarities in health messages. The authors describe the use of the subjective culture methodology and social marketing to develop health education materials targeted to multicultural populations, illustrate cultural factors that should be considered when designing printed materials, and outline steps in the design of attractive, stimulating, and culturally appropriate materials. The authors describe the challenges and problems in designing printed materials for multiethnic communities, give suggestions for written educational messages, present a summary of the lessons learned in the development of materials for ethnically diverse populations, and give examples of success stories in multiethnic communities.

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.