Breast Cancer Education Intervention Research Articles

Effectiveness of a telehealth patient education intervention for breast cancer awareness and screening uptake among Afghan refugee women: a cross-sectional survey and feasibility study

Refugee populations have low levels of cancer awareness, low cancer screening rates, and a high rate of advanced or metastatic cancer at diagnosis. Educational interventions to improve cancer awareness and screening have been successful in other nationality refugee populations but have never been implemented in Afghan refugee populations. We aimed to estimate the level of breast cancer awareness among Afghan refugee women and test the feasibility of a telehealth breast cancer educational intervention to increase breast cancer awareness in this population. A cross-sectional survey of Afghan refugee women residing in Istanbul, Türkiye who had no personal history of breast cancer and who presented to outpatient primary clinics for care between August 1, 2022, and February 10, 2023 was performed. Participant awareness of breast cancer (BC) was assessed using the validated BC awareness tool, Breast Cancer Awareness Measure (BCAM), during a telehealth encounter. After this baseline assessment, a BC educational intervention was administered to each participant during the telehealth encounter. Six months after the initial assessment and education, a follow-up BCAM was administered via telehealth in order to determine the effectiveness of the education intervention. One hundred participants were accrued to the study. Median age was 49 years (range: 40-64). All participants had no formal education, were married, and were not employed. Prior to the educational intervention, BC awareness was low; none of the participants were able to identify some common signs/symptoms and risk factors for BC. Prior to the educational intervention, zero participants had ever had a mammogram or seen a physician for a breast-related concern. Six months after the educational intervention, up to 99 percent of participants (99 of 100 participants) were able to correctly identify common signs or symptoms and risk factors for BC. Six months after the educational intervention, all one hundred participants had accepted the offer of a screening mammogram. A telehealth BC education intervention meaningfully increased BC awareness in Afghan refugee women. This increase in BC awareness was associated with a strong increase in completion of BC screening. Further implementation of educational interventions is warranted in order to increase participant awareness and improve screening rates. Dana Farber Cancer Institute Jay Harris Junior Faculty Research Grant.

The impact of a breast cancer educational intervention in Ghanaian high schools

IntroductionGlobally breast cancer is the leading cause of cancer with an estimated 2.3 million new cases and 685,000 deaths in 2020. Late presentation is the hallmark of breast cancer in Ghana for which ignorance and fear are the major reasons fuelled largely by myths and misconceptions. Breast cancer awareness and education needs to start early to bring about a change in knowledge, attitude and practices. However, Breast cancer awareness activities in Ghana have usually targeted adult women.This study assessed the impact of breast cancer education among adolescent high school girls in Ghana.MethodologyA pre- post-test quasi experimental study was conducted at two senior high schools. A self-administered pre-educational questionnaire was followed by an educational intervention consisting of a drama, PowerPoint lecture, question and answer session and distribution of breast cancer information leaflets. After 3 months the same questionnaire was administered as a post-education test to assess the impact of the educational intervention. The total score for each domain was categorised into adequate knowledge > 50% and inadequate knowledge < 50%.ResultsThe number of participants in the pre-test and post-test were 1043 and 1274; the median ages [IQR] were 16.0 [15.0–17.0] for both the pre and post-test students. General knowledge on breast cancer at pre-education (29.1%) improved to 72.5% (p < 0.001). Knowledge on signs and symptoms improved from 33.1 to 55% (p < 0.001); knowledge on risk factors improved from 55.3 to 79.2% (p < 0.001), and knowledge on breast self-examination and screening improved from 9.8 to 22.2% (p < 0.001). The overall performance of the students improved from 17.2 to 59.4% (p < 0.001).ConclusionThere is inadequate knowledge about breast cancer and self-examination among senior high school girls in Ghana. Our breast cancer educational intervention was effective in improving general knowledge of breast cancer, risk factors, signs and symptoms and breast self-examination. The overall knowledge base improved from 17.2 to 59.4% 3 months post intervention, accompanied by an increase in the reported practice of breast self-examination and a greater belief that breast cancer is curable. This study has demonstrated the need for a school breast cancer educational program and that breast cancer education in high schools is effective.

A Mobile Health Breast Cancer Educational and Screening Intervention Tailored for Low-Income, Uninsured Latina Immigrants.

Objective: To investigate the efficacy of mobile health (mHealth) intervention strategies that delivered either personalized, culturally, and linguistically tailored cell phone voice messages or text messages related to breast cancer and prevention, compared to the control group, to determine which strategy is more likely to increase breast cancer knowledge and screening mammography among low-income Latina immigrants.Methods: This randomized controlled trial assigned 256 Latina immigrants 40 years of age or older to one of three groups: an automated cell phone voice message group, an automated text message group, or the control group (mail). The mHealth intervention employed a comprehensive approach that included breast cancer and prevention education and free mammography screening. Outcome measures included knowledge of breast cancer and breast cancer prevention, and adherence to screening mammography.Results: There was a general increase in breast cancer knowledge after the educational intervention for all the groups [p = 0.01, t(199) = 3.996]. Knowledge increase and mammography adherence did not differ based on group.Conclusion: More important than the actual method of communication is how breast cancer and prevention messages are constructed, who the messenger is, and the enabling factors that facilitate screening adherence. A breast cancer preventive intervention program that is personalized, culturally and linguistically tailored, and offers a free or low-cost mammogram holds promise to be an effective method in reaching an underserved Latina population with a high breast cancer burden.

Community-based participatory design of a community health worker breast cancer training intervention for South Florida Latinx farmworkers.

ObjectiveCommunity health worker (CHW)-led education is an important strategy to increase awareness and access to breast cancer screening in medically-underserved communities. This study aimed to develop a context-specific, culturally-appropriate training intervention for South Florida CHWs to educate Latinx immigrant farmworkers on breast cancer and early detection.MethodsA community-based participatory research (CBPR) study, conducted 2017–2019, informed the design of a training curriculum for CHWs and educational dissemination materials. Twenty-two CHWs were trained and knowledge gains were measuring using a one-group pre-and post-test design. Triangulated evaluation consisted of field observations of CHW-client interactions, CHW self-reports, and rapid assessment surveys of community members.ResultsA community stakeholder-informed breast cancer training curriculum resulted in significant, sustained breast cancer knowledge gains among CHWs when comparing pre-, post-, and 4–6 month post-training follow-up test scores. Field observations of educational material dissemination, CHW self-reported evaluations, and community rapid assessment surveys at three health fairs demonstrated this was an effective strategy to engage female Latinx farmworkers in breast cancer education.ConclusionsCommunity and key stakeholder participation in the development of a breast cancer educational intervention allowed for tailored design priorities around knowledge-based content, comprehensiveness, relevance, appropriateness, and ease of dissemination to community members. This model of participatory CHW training intervention design can enable future train-the-trainer approaches to disseminate and scale-up evidence-based health education interventions.

An Intervention Tool to Increase Patient-Physician Discussion of Lifestyle Risk Factors for Breast Cancer.

Background: Risk assessment and discussion of lifestyle in primary care are crucial elements of breast cancer prevention and risk reduction. Our objective was to evaluate the impact of a breast cancer risk assessment and education tool on patient-physician discussion of behaviors and breast cancer risk. Materials and Methods: We conducted a randomized controlled trial with an ethnically and linguistically diverse sample of women, ages 40-74, from two primary care practices. Intervention participants completed a tablet computer-based Breast Cancer Risk Assessment and Education (BreastCARE) intervention in the waiting room before a scheduled visit. Both patients and physicians received an individualized risk report to discuss during the visit. Control patients underwent usual care. Telephone surveys assessed patient-physician discussion of weight, exercise, and alcohol use 1 week following the visit. Results: Among the 1235 participants, 27.7% (161/580) intervention and 22.3% (146/655) usual-care patients were high risk for breast cancer. Adjusting for clustering by physician, the intervention increased discussions of regular exercise (odds ratios [OR] = 1.94, 1.50-2.51) and weight (OR = 1.56, 1.23-1.96). There was no effect of the intervention on discussion of alcohol. Women with some college education were more likely to discuss their weight than those with high school education or less (OR = 1.75, 1.03-2.96). Similarly, non-English speakers were more likely to discuss their weight compared with English speakers (OR = 2.33, 1.04-5.22). Conclusions: BreastCARE is a feasible risk assessment tool that can successfully promote discussions about modifiable breast cancer risk factors between patients and primary care physicians.

Abstract B18: Exploring the lived experience of young African American breast cancer survivorship: Early results toward informing a psychoeducational intervention

Abstract Background/Purpose Recent data indicate that 11% of the 230,000 women diagnosed with breast cancer each year are young (18-44). Though the five-year survival rates of these young women are improving, there are large health disparities in breast cancer survivorship among young African American women in the United States (e.g. higher breast cancer incidence and mortality when compared with young Caucasians). Further, young African American breast cancer survivors (YAABCS) report poorer quality of life than young Caucasians. Despite recommendations to provide evidence-based and tailored survivorship care for cancer survivors, there are about 23,000 YAABCS between the ages of 20-49 living in a southern tri-state area (Alabama- AL, Louisiana- LA, and Mississippi- MS) for whom a comprehensive breast cancer survivorship education/support intervention does not exist. As few studies have examined YAABCS's survivorship experiences and/or tested intervention efficacy among this group, further study of their survivorship is warranted to inform the adaptation of an age- and culturally-specific survivorship psychoeducational intervention for YAABCS. As part of an ongoing dissertation study, a Research Tested Intervention Program called the Breast Cancer Education Intervention (BCEi) is being adapted into Y-AMBIENT (the BCEi for YAABCS). The purpose of this abstract is to describe early results of the lived experience of young African American breast cancer survivorship, which will be used to inform the adaptation of Y-AMBIENT. Methods A transcendental phenomenological study design guided by the conceptual framework of the BCEi (Quality of Life Model Applied to Breast Cancer [QOL-BC]) was used. A purposive and snowball sample of YAABCS was recruited from AL, LA, and MS. The study recruitment flyer was disseminated online and via email through breast cancer-affiliated organizations and support groups. Word-of mouth dissemination was also encouraged. Data collected included two semi-structured interviews, a sociodemographic survey, volunteered personal effects from YAABCS, and field/reflective notes. Data were analyzed using NVivo11 Software (qualitative data) and IBM SPSS Software v. 23 (quantitative data), then validated among participating YAABCS. Early Results Early results of the ongoing dissertation study were informed by 7 of 15 YAABCS (mean age= 32 years; mean survivorship= 4 years). These YAABCS perceived survivorship as a labile, new normal. Feeling as though survivorship was a burden, YAABCS described the need to be “strong” for themselves and others. These women actively structured their lives to manage changes to their physical, psychological, social, and spiritual selves. While YAABCS reported successful survivorship management to co-survivors and others, they acknowledged that survivorship was an ongoing “struggle” in which spirituality and survivorship education were key. Discussion/Conclusion Early results indicated a fluid and complex experience of survivorship among YAABCS. While most reported an intensive need for spiritual connection, all reported a need for more comprehensive survivorship education. Thus, a tailored survivorship education intervention may be needed for YAABCS. Future Directions The ongoing dissertation study to adapt Y-AMBIENT will be informed by the lived experience of young African American breast cancer survivorship. Future research examining YAABCS's perceptions of the BCEi and the inter-relation of QOL-BC constructs may inform this and future interventions that aim to decrease quality of life health disparities among YAABCS. Acknowledgements This research is funded by an American Cancer Society Doctoral Degree Scholarship in Cancer Nursing (DSCN-15-073-01), Susan G. Komen Graduate Traineeship in Disparities Research, Jonas Nurse Leaders Scholarship, and Gladys Farmer Colvin Doctoral Fellowship. Citation Format: Timiya S. Nolan, Tiffany L. Carson, Susan Davies, Comfort Enah, Nataliya Ivankova, Karen Meneses. Exploring the lived experience of young African American breast cancer survivorship: Early results toward informing a psychoeducational intervention. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr B18.

Adapting an evidence-based survivorship intervention for Latina breast cancer survivors.

About 120,000 Latina breast cancer survivors (LBCS) live in the USA with the numbers expected to increase. LBCS experience survivorship disparities and report poor quality of life outcomes. Despite poor outcomes, few survivorship interventions for LBCS are available. Adapting evidence-based interventions for Latinas may be one strategy to reduce disparities. An evidence-based intervention called the Breast Cancer Education Intervention was adapted for Latinas. First, certified translation and cognitive interview to assess cultural relevance were conducted. Next, a pilot sample of 40 Latinas who participated in the intervention were asked to provide follow-up evaluation of their satisfaction with and usefulness of the translated education manual and intervention. Thirty LBCS completed the intervention, and 14 LBCS submitted an evaluation summary expressing satisfaction with usefulness, readability and relevance. The process by which translation and cultural adaptation of an evidence-based intervention provides beginning foundation to support and reduce disparities among LBCS.

A randomized, controlled trial to increase discussion of breast cancer in primary care.

Assessment and discussion of individual risk for breast cancer within the primary care setting are crucial to discussion of risk reduction and timely referral. We conducted a randomized controlled trial of a multiethnic, multilingual sample of women ages 40 to 74 years from two primary care practices (one academic, one safety net) to test a breast cancer risk assessment and education intervention. Patients were randomly assigned to control or intervention group. All patients completed a baseline telephone survey and risk assessment (via telephone for controls, via tablet computer in clinic waiting room before visit for intervention). Intervention (BreastCARE) patients and their physicians received an individualized risk report to discuss during the visit. One-week follow-up telephone surveys with all patients assessed patient-physician discussion of family cancer history, personal breast cancer risk, high-risk clinics, and genetic counseling/testing. A total of 655 control and 580 intervention women completed the risk assessment and follow-up interview; 25% were high-risk by family history, Gail, or Breast Cancer Surveillance Consortium risk models. BreastCARE increased discussions of family cancer history [OR, 1.54; 95% confidence interval (CI), 1.25-1.91], personal breast cancer risk (OR, 4.15; 95% CI, 3.02-5.70), high-risk clinics (OR, 3.84; 95% CI, 2.13-6.95), and genetic counseling/testing (OR, 2.22; 95% CI, 1.34-3.68). Among high-risk women, all intervention effects were stronger. An intervention combining an easy-to-use, quick risk assessment tool with patient-centered risk reports at the point of care can successfully promote discussion of breast cancer risk reduction between patients and primary care physicians, particularly for high-risk women. Next steps include scaling and dissemination of BreastCARE with integration into electronic medical record systems.

The effects of breast cancer educational intervention on knowledge and health beliefs of women 40 years and older, Isfahan, Iran.

Introduction:Breast cancer is an international health problem in the world over. Mammography screening behavior has critical role in early detection and decreasing of its mortality. Educational programs play an important role in promoting breast cancer screening behaviors and women health. Health belief models (HBM) is the most common models that have been applied in Mammography screening behaviors. The aim of this study was to determine the effect of breast cancer screening education using HBM on knowledge and health beliefs in 40 years women and older.Materials and Methods:In this Population-based controlled trial, 290 women of 40 years and older were divided randomly into experimental and control groups. Health beliefs determined using the Persian version of Champion's health belief model scale (CHBMS). Questionnaires were completed before and 4 weeks after intervention. Four educational sessions were conducted each session lasting 90 min by lecturing, group discussion, showing slide and educational film based on HBM constructs. The obtained data were analyzed by SPSS (version 18) and statistical test at the significant level of α = 0.05.Results:Mean scores of perceived susceptibility, perceived severity, perceived benefits, barriers and self-efficacy of mammography and health motivation in the experimental group had significant differences in comparison with the control group after educational intervention (P ≤ 0.001).Conclusion:The results of this study have confirmed the efficiency of educational intervention based on HBM in increasing of knowledge and health beliefs about breast cancer and mammography screening behavior. Hence, implementing appropriate educational programs with focus on benefits of Mammography in early detection of breast cancer and creating positive motivation for health among women, can increase their practice of having mammography screening.

Assessing the fidelity of the Kin KeeperSM prevention intervention in African American, Latina and Arab women.

We evaluated a randomized controlled treatment, utilizing Community Health Workers (CHW) to deliver breast and cervical cancer education intervention to African American, Latina, and Arab women in Detroit and Dearborn, Michigan. The main objectives of the study are to: (1) examine fidelity and consistency of treatment delivery and (2) assess qualitative elements of the intervention. We surveyed 305 women who received the intervention and 16 CHWs Survey included questions regarding the treatment integrity, treatment received, and training provided. Surveys included both quantitative and questions. The intervention group (n = 305) was made up of 48% Black, 11% Latina, and 41% Arab women. Almost all (≥ 90%) women agreed that they received the treatment in the way that it was intended. Sixteen CHWs responded affirmatively as well. Both participants and CHWs indicated that the program was mutually rewarding, indicating that there was "cross fertilization and cross benefit" of working with each other. These benefits served to endorse and confirm that CHWs are a very important mechanism in increasing health literacy in the community and referring underserved individuals to health providers. Second, with strong treatment fidelity the Kin Keeper(SM) program and has the potential to be replicated for a number of diseases in a variety of venues especially for those facing health disparities.

The Effectiveness of a Community-Based Breast Cancer Education Intervention in the New York State Capital Region

We determined the effectiveness of a community-based breast cancer education intervention among understudied populations in the New York State (NYS) Capital Region by assessing and comparing baseline and post-education breast cancer knowledge. Participants included 417 students recruited from five colleges/universities and 67 women from four community group organizations. Baseline and post-education knowledge was assessed via self-administered mostly multiple-choice questionnaires. An open-ended question soliciting opinions about public health prevention strategies against breast cancer was included on college/university students' questionnaires. Effectiveness of education intervention was estimated through a paired t test. Stratified analysis was done using demographic and descriptive variables. Answers to the open-ended questions were analyzed qualitatively. The mean percentage of correct answers increased from 39.9% at baseline to 80.8% post-education (P < 0.0001) among college/university students and from 43.5% to 77.8% (P < 0.0001) among community group members. Effectiveness remained statistically significant in all stratified analyses with similarly high percentage of correct answers achieved post-education irrespective of knowledge level at baseline. Stratified analysis also revealed similar patterns of improvement in overall knowledge and narrowing of the gap in post-education knowledge. Primary prevention emerged as the dominant theme post-education in students' responses to the open-ended question, signifying the effectiveness of our education in raising awareness about modifiable risk factors and inspiring proactive thinking about public health prevention strategies. This community-based education intervention was effective in increasing breast cancer knowledge among demographically diverse groups with low levels of baseline knowledge in the NYS Capital Region. Our findings provide leads for future public health prevention strategies.

Abstract 1361: Treatment fidelity evaluation of the cancer prevention intervention in African American, Latina, and Arab women.

Abstract Background: Cancer education is important, especially for those facing health disparities. CHWs are increasingly utilized to educate and monitor cancer screening and surveillance for underserved populations. Here, we evaluate a randomized controlled treatment, utilizing Community Health Workers (CHW) to deliver breast and cervical cancer education intervention to African American (herein called Black), Latina, and Arab women in Detroit and Dearborn, Michigan. The main objectives of the study are to: 1) examine fidelity and consistency of treatment delivery and 2) assess qualitative elements of the intervention. Methods: CHWs and their clients recruited additional family members into the intervention. After randomization at total of 514 women were included in the study (305 intervention, 209 control). We surveyed only the intervention group because they received a behavioral intervention whereby the control group was given only reading materials. Family clusters received two home visits. The first session related to breast cancer education and the second session to cervical cancer. After each session, all women completed an evaluation of the fidelity and integrity of the education using the NIH Treatment Fidelity Workgroup Tool (Borelli, 2005). The CHW Survey included questions regarding their training, fidelity in treatment delivery and qualitative items. Results: The intervention group (n = 305) was made up of 48% Black, 11% Latina, and 41% Arab women. Almost all (&amp;gt; 90%) women agreed that they received the treatment in the way that it was intended. All 16 CHWs responded affirmatively as well. The greater majority (&amp;gt;90%), felt that they delivered the treatment the way it was intended and delivered it in the same way other Kin KeeperSM CHWs did. Qualitatively, 91% of CHWs felt they made an impact on participants’ cancer literacy and were satisfied with the project. In addition, CHWs indicated that “serving and educating their community” was personally important. Conclusions: First, both participants and CHWs indicated that the program was mutually rewarding, indicating that there was “cross fertilization and cross benefit” of working with each other. These benefits served to endorse and confirm that CHWs are a very important mechanism in increasing health literacy in the community and referring underserved individuals to health providers. Second, with strong treatment fidelity, these findings further validate the Kin KeeperSM program and its instruments (Williams, et al., 2011) and thus has the potential to be replicated for of number of diseases and in a variety of venues especially for those facing health disparities. Citation Format: Sabrina Ford, Cristian Meghea, Tamika Estes, Hiam Hamade, Mulisa Lockett, Karen Patricia Williams. Treatment fidelity evaluation of the cancer prevention intervention in African American, Latina, and Arab women. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1361. doi:10.1158/1538-7445.AM2013-1361

Abstract 2527: Impact of community-based breast cancer education intervention in New York State Capital Region.

Abstract Objectives: We conducted a community-based education intervention among targeted understudied groups in the New York State Capital Region to assess baseline knowledge of breast cancer and determine the effectiveness of newly developed educational tools in improving knowledge. Methods: We recruited 417 students from five participating colleges/universities and 67 women from four community group organizations. Educational intervention involved about an hour-long lecture on breast cancer using Microsoft PowerPoint® presentations tailored to each of the two participating groups of colleges/universities and community group organizations. Baseline and post-education knowledge was assessed via self-administered questionnaires. In addition to multiple choice questions, pre- and post-education questionnaires designed for college/university students also contained an open-ended question soliciting their suggestions for public health preventive actions against breast cancer. The effectiveness of our education intervention in improving breast cancer knowledge was estimated using a paired t-test. Descriptive and qualitative analyses of demographic variables and answers to the open-ended questions were also conducted. Results: Our analyses revealed a statistically significant improvement (P&amp;lt;0.0001) in mean percentage of correct answers among both participating groups of college/university students (from 39.9% at baseline to 80.8% post-education) and community group members (from 43.5% at baseline to 77.8% post-education). The effectiveness remained statistically significant in stratified analyses (by demographic variables as well as by other variables such as being or knowing a breast cancer survivor or having attended a breast cancer lecture or seminar in the past). Analysis of the answers to the open-ended questions revealed a shift in the attitudes of college/university students, brought about by our education intervention, regarding preventive efforts. While secondary prevention was the major theme pre-education (mentioned by ∼51% of respondents), primary prevention emerged as the major theme post-education (mentioned by ∼80% of respondents). Conclusions: This community-based education intervention was motivated by lack of a readily available breast cancer educational tool as well as lack of information about baseline knowledge of breast cancer among communities in the New York State Capital Region. Our findings of low levels of both baseline knowledge and prior attendance in a breast cancer lecture/seminar by participants in our study underscore the importance of education interventions. Our community-based education intervention was effective in increasing knowledge about breast cancer among college students and community group members in upstate New York. Our findings provide leads for public health prevention strategies. Citation Format: Nur Zeinomar, Roxana Moslehi. Impact of community-based breast cancer education intervention in New York State Capital Region. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2527. doi:10.1158/1538-7445.AM2013-2527

Abstract P5-12-03: Developing the ePromotora: Increasing Promotora's Access to Breast Cancer Electronic Resources

Abstract Background: Disparities in breast cancer screening and survival have been attributed to multiple factors including limited access to breast health education. Innovative information technologies facilitate health education; however, access to information technology is not uniform. The resultant systematic gap in health knowledge has led to a new health disparity where higher socioeconomic individuals acquire health information electronically more easily than the disadvantaged. Promotoras or Community Health Workers (CHWs) facilitate access to culturally appropriate cancer health information, screening and care. Hypothesis: An electronic asynchronous breast cancer educational intervention developed by the Arizona Telemedicine Program and the Arizona Health Sciences Library will improve CHW computer literacy and will enhance health education communication. Specific Aims: to develop, implement and assess a 6-session e-promotora training curriculum with a focus on breast health. Methods: The first step in developing a training curriculum was a needs assessment and a computer literacy assessment. This assessment served as the foundation for the computer literacy curriculum which focused on breast health content. The educational intervention was delivered as a combination of on-line, webinar, and face-to-face seminars. To meet the needs of the participants all sessions were delivered bilingually, Spanish and English. Program evaluation included pre and post knowledge assessments, session assignments, program satisfaction and 6-month follow up focus groups or structured interviews to evaluate the utility, implementation and dissemination of knowledge gained. Results: 26 CHWs have completed the training. All participants identified as Latinas, average age – 51 years of age and educational attainment – 58% (15/26) reported high school or less. Pre and post assessment data reveal high program satisfaction scores, increased participant knowledge and confidence in knowledge, consistent and ongoing use of information learned and computer skills gained and effective dissemination of health information gained. Conclusions: The e-promotora training curriculum effectively improves CHW computer literacy, facilitates dissemination of electronic health information and helps address the disparities in electronic health information. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-12-03.

Does economic burden influence quality of life in breast cancer survivors?

GoalsEconomic burden is emerging as a crucial dimension in our understanding of adjustment to cancer during treatment. Yet, economic burden is rarely examined in cancer survivorship. The goal of this paper is to describe the effect of economic hardship and burden among women with breast cancer. MethodsWe examined baseline and follow-up (3 and 6month) data reported by 132 stage I and II breast cancer survivors assigned to the Wait Control arm of the Breast Cancer Education Intervention (BCEI), a clinical trial of education and support interventions. Repeated measures models fitted with linear mixed models were used to examine relationships between aspects of economic burden and overall quality of life (QOL) scores. Structural equation models (SEM) were used to examine the relationship between overall economic burden and QOL. ResultsNineteen economic events were reported. The proportion of survivors who reported increase in insurance premiums increased in the 6-month study period (p=.022). The proportion of survivors reporting change in motivation (p=.016), productivity (p=.002), quality of work (p=.01), days missed from work (p<.001) and sacrificing other things (p=.001) declined. An increase in economic events was significantly associated with poorer quality of life at each of the study time points. ConclusionEconomic burden of breast cancer extends into post-treatment survivorship. Better understanding of economic impact and managing economic burden may help maintain QOL.

Abstract A22: The Kin KeeperSM Intervention: Women move beyond psychological barriers to Pap screening

Abstract Cancer health disparities are underlined by structural and conceptual barriers, such as: Adequate cancer awareness and education, functional cancer literacy, appropriate and timely access to cancer screening and follow-up care, and psychological aspects of the decision to undergo cancer screening. Cervical cancer health disparities can be impacted by early detection and screening with the Papanicolaou (Pap) test. The Kin KeeperSM Cancer Prevention Intervention is a culturally and linguistically tailored breast and cervical cancer educational intervention designed to improve functional cancer literacy. The Health Belief Model (HBM) was used as a framework to explore potential associations between responses to a cervical Cancer Literacy Assessment Tool (C-CLAT) item assessing a psychological barrier to Pap screening and a woman's screening accomplishments. Methods: The Kin KeeperSM model has three levels of participants: community health worker (CHW), CHW's female clients (“kin keepers”), and female family members of female clients. Trained CHWs recruited 543 Black, Latina, and Arab women from Detroit and Dearborn, MI to participate in the two-year study. Analysis included only women with two years of data, thus the final number of participants was 446 (117 Black, 157 Latina, 172 Arab). Kin keepers recruited female family members in year one and delivered the cervical cancer educational intervention in year two. After recruitment, CHWs from three local agencies administered the C-CLAT to all participants in English, Spanish, or Arabic before administering an educational intervention (pre-C-CLAT) and after the educational intervention (post-C-CLAT 1); and provided women with Personal Action Plans (PAPs) to identify screening goals based on three statements: Find a health care provider to do first-ever Pap; schedule first-ever Pap; and continue getting yearly Pap. The outcome of interest was indication of these goals as accomplishments in year two. After kin keepers delivered the educational intervention in year two, CHWs administered a post-C-CLAT 2 and an accomplishment-oriented PAP to all participants. Using multivariable logistic regression, we observed the potential effect of responses to a C-CLAT item and sociodemographic covariates on PAP accomplishments. The C-CLAT item “Getting a Pap test is very painful,” suggests a psychological barrier to screening, thus it is relevant to a classic HBM construct, perceived barriers. Post-C-CLAT 1 responses to this item were scored with an answer key and SPSS (PASW Statistics 18) was used for statistical analyses. Results: In year one, the most significant covariates affecting the goals women selected were race, relationship to the kin keeper, and health insurance status. Response to the C-CLAT item “Getting a Pap test is very painful” was not significant to the goal to continue annual Pap tests, yet race and possibly relationship to the kin keeper were significant (with an alpha of .105, p-values were .038 and .104, respectively). Analysis of women's PAP accomplishments 12 months later indicates the majority of women found a health care provider for a first-ever Pap test, scheduled a Pap in the past 12 months, and had a Pap in the past 12 months. Relationship to the kin keeper was the only statistically significant covariate (p = .035) in analysis of having had a Pap test in the last 12 months. Conclusions: Future interventions designed to impact cervical cancer health disparities should support women's intentions to pursue screening despite potential psychological barriers. Such studies should explore dynamics between female family members and how these relationships might modify screening decisions and accomplishments. This research was funded by National Institutes of Health (NIH), National Institute for Nursing Research (NINR), 1R01NR011323. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A22.

Abstract A21: The Kin KeeperSM Intervention: Multiple interventions may be necessary to generate permanent increases in cancer literacy

Abstract A number of studies have shown that greater cancer knowledge is correlated with increased rates of screenings and regular check-ups for the general population, which in turn is correlated with increased rates of early cancer detection and thus higher rates of cancer survival. However, a number of other studies suggest that a disproportionate burden of cancer morbidities and mortalities are borne by minority populations in the United States, and in order to address this, the Kin KeeperSM Cancer Prevention Intervention, a culturally and linguistically tailored breast and cervical cancer education intervention, was developed to address this burden at its source, cancer knowledge through literacy. The main objective of this study was to investigate the effect of the Kin KeeperSM program on breast and cervical cancer knowledge retention (i.e. literacy levels over time) among African American, Arab American, and Hispanic American women in the Detroit metropolitan area. The program involves three levels of participants: the community health worker (CHW) responsible for recruiting clients to participate as Kin Keepers; the Kin Keepers, who are responsible for recruiting female family members to participate; and the female family members. In all, trained CHWs recruited 543 participants of Black/African American, Hispanic, and Arab descent at the start of the study, to include Kin Keepers and recruited family members; the number of respondents participating in the study at follow-up (CHWs were only responsible for recruitment and did not otherwise participate in the study) dropped to 446 (117 African American, 157 Latina, 172 Arab) in the second year. Participant responses for cancer literacy assessment tests (CLATs) for both breast cancer and cervical cancer were collected three times: a pre-test, a first-year post-test, and a second-year post-test. Between the pretest and the first-year post-test the Kin KeeperSM intervention in the form of cancer education was administered to participants. No other education was administered after the first-year post-test. After one year, the second-year post-test was given to participants and their responses collected. Once all participant responses for all tests were collected, they were scored and literacy between the three tests for each eligible participant was analyzed. Overall, the cancer literacy trend for all participants increased dramatically between the pre-test and the first-year post-test, then returned to pre-test literacy levels for the second-year post-test. For instance, for the breast cancer CLAT (BCLAT), a number of individuals from all ethnic groups (n = 52 over all groups) scored 100% on the first-year posttest, but none scored 100% on the second-year post-test. When looking at scores above 75%, the number of individuals scoring at or above this level increases (n = 339 over all groups), but there are still no individuals scoring at or above 75% on the second-year post-test. This trend appears to be consistent across all ethnic groups sampled in the study. The most consistently significant (p ≤ 0.05) covariates correlated with literacy were ZIP code (i.e. location), age, level of education, and insurance status. It is likely that a lack of education intervention in the months between the first-year post-test and the second-year post-test are responsible for the return of literacy to pre-test levels. It is also possible that, because all questions on all tests were given equal value, literacy may have appeared to return to pre-test levels but in fact masks increased functional literacy related to certain sets of questions that should be given more weight than others. In order to realize permanently-increased cancer literacy in women of these ethnic groups, recommendations include more than a single application of Kin KeeperSM intervention education and the introduction of a weighting system for CLAT questions. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A21.

An Introduction to Tree-Structured Modeling With Application to Quality of Life Data

Investigators addressing nursing research are faced increasingly with the need to analyze data that involve variables of mixed types and are characterized by complex nonlinearity and interactions. Tree-based methods, also called recursive partitioning, are gaining popularity in various fields. In addition to efficiency and flexibility in handling multifaceted data, tree-based methods offer ease of interpretation. The aims of this study were to introduce tree-based methods, discuss their advantages and pitfalls in application, and describe their potential use in nursing research. In this article, (a) an introduction to tree-structured methods is presented, (b) the technique is illustrated via quality of life (QOL) data collected in the Breast Cancer Education Intervention study, and (c) implications for their potential use in nursing research are discussed. As illustrated by the QOL analysis example, tree methods generate interesting and easily understood findings that cannot be uncovered via traditional linear regression analysis. The expanding breadth and complexity of nursing research may entail the use of new tools to improve efficiency and gain new insights. In certain situations, tree-based methods offer an attractive approach that help address such needs.

Interaction Trees: Exploring the Differential Effects of an Intervention Programme for Breast Cancer Survivors

SummaryThe breast cancer education intervention (BCEI) is a tailored psychoeducational intervention programme aiming to improve the quality of life of breast cancer survivors. Borrowing the idea of recursive partitioning and following the convention of classification and regression trees, an exploratory procedure, termed interaction trees, is proposed to understand better the differential effects of the BCEI on longitudinal quality-of-life data. The resultant tree model identifies several objectively defined subgroups: in some groups the BCEI is quite effective whereas in others it may not be. Based on the final tree structure, a permutation test is used to assess the overall treatment-by-covariate interaction. In addition, a variable importance ranking feature is facilitated via random forests of interaction trees to help to determine important effect modifiers of the BCEI.

Out of pocket cost comparison between Caucasian and minority breast cancer survivors in the Breast Cancer Education Intervention (BCEI)

The purpose of this article is to: (1) describe out of pocket (OOP) costs among minority and Caucasian participants in the BCEI, the Breast Cancer Education Intervention, a randomized clinical trial of psychoeducational quality of life interventions for breast cancer survivors (BCS); and (2) examine the OOP burden, as measured by the proportion of income spent OOP, between the two racial/ethnic groups. We examined baseline OOP costs reported by 261 early-stage I and II breast cancer survivors who participated in the BCEI trial. Data were collected using the Breast Cancer Finances Survey and the Breast Cancer Sociodemographic and Treatment Tool. OOP costs averaged $316 per month since diagnosis. Direct medical costs were $281, and direct non-medical were $66. There were no significant differences in total OOP costs or direct medical and non-medical OOP costs between minority and Caucasian BCS. Minority BCS with incomes of $40,000 or less spent a greater proportion of income in total OOP and direct medical OOP costs (31.4 and 27% for BCS with incomes ≤ $20,000; 19.5 and 18.8% for BCS with incomes $20,001-40,0000) compared to their Caucasian counterparts (12.6 and 9.2% for BCS with incomes ≤ $20,000; 8.7 and 8.2% for BCS with incomes $20,001-40,0000). OOP costs can be a considerable burden for breast cancer survivors representing as much as 31% of monthly income depending on BCS' income levels. Future studies can investigate how this burden affects the quality of life of breast cancer survivors, especially minorities.