Abstract A33: Promoting screening mammography in an American Indian community in Oklahoma: The Native Women's Health Project
Authors: Tolma Eleni L. , Engelman Kimberly , Thomas Cara , Joseph Stephanie , Stoner Julie , Li Ji , Neely Norma 
Published: May 2016

Abstract
Background: The stagnant breast cancer mortality rates and the increased number of younger American Indian (AI) women who are being diagnosed with breast cancer indicate that breast cancer remains an important public health issue among the AI community. This 4-year study is a continuation of two preliminary studies at a rural tribal clinic in Oklahoma. In the first study, we developed a culturally-sensitive survey of mammography screening practices and beliefs, entitled Women's Health Survey (WHS), based on the Theory of Planned Behavior. In the second study, we identified the salient mammography screening beliefs held by AI women. The results led to the development of a Logic Model of mammography screening behavior, involving both clinical and community components, which guided intervention development. In the current study, we implemented the intervention and evaluated its efficacy via Community-based Participatory Research.
Methods: A Community Steering Committee (CSC) was formed. The priority population consisted of AI women without a history of breast cancer who lived in the target region between the ages of 52-74 years, and who have not had a screening mammogram within the last 2 years. The study had four aims: 1) Conduct a needs and resource assessment of the priority population, 2) Utilize the needs and resource assessment data to develop a community-driven intervention program, 3) Pilot-test and refine the intervention, and 4) Evaluate the intervention using a one-group pre- and post-evaluation design and mixed research methodology. A modified version of the WHS was used as the evaluation tool.
Results: The results of the formative research (Aim 1) indicated that: a) AI women lack knowledge of mammograms, b) Fatalistic attitudes toward breast cancer exist among AI women, c) Many AI women prefer a holistic approach to their health, d) Physicians influence women's screening mammography decisions, and e) Social modeling is an important motivating factor. Using a prioritization process through the CSC and data triangulation, we concluded that the intervention would center on the concepts of social modeling, physician recommendation, breast cancer fatalism, and lack of knowledge about mammography screening. The Logic Model was finalized, educational intervention materials were developed, and alliances were built with regional grassroots initiatives (Aim 2). The intervention included four main strategies: a) Structured communication between medical practitioner and patient about screening mammography; b) Receipt of a breast cancer brochure and subsequent follow-up letter from the medical provider; c) Participation in a breast cancer discussion group at a community setting by using the Freire (raising consciousness) approach; and d) Receipt of a congratulatory bracelet upon receipt of a mammogram. Based on the evaluation results (Aim 4), the intervention is feasible despite its complexity; however, process evaluation revealed a shallow implementation of the clinic component. Almost half of the research participants (N=21) received a future mammogram, indicating moderate program success. Focus group research (N=4) showed that the participants became more conscious of their health and more vocal in discussing breast cancer with their friends and family. Moreover, sustainable environmental changes were introduced at the tribal clinic including a bulletin board poster on mammography and a screening mammography algorithm located in the exam rooms.
Conclusions: Designing, implementing and evaluating a theory-based culturally-sensitive multi-component intervention on mammography screening within a Native American community is an exciting, yet challenging process. Replications of the current study with a bigger sample size and a controlled, comparative evaluation design are needed to further establish the efficacy of the intervention.
Citation Format: Eleni L. Tolma, Kimberly Engelman, Cara Thomas, Stephanie Joseph, Julie Stoner, Ji Li, Norma Neely. Promoting screening mammography in an American Indian community in Oklahoma: The Native Women's Health Project. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A33.