The Dimensions Model And Mammography Screening among Thai Women Mary Jo Clark, PhD, RN Bulaporn Natipagon-Shah, PhD, RN Public Health Nursing Section American Public Health Association Washington, DC November 6, 2007 Introduce self Introduce Bee

Presentation Purpose Introduce the Dimensions Model Discuss the use of the model in a study of mammography among Thai women in Southern California Purpose of today’s presentation Provide a brief overview of the dimensions model Describe how we used the model to analyze data from a study of factors influencing mammography use in the Thai population in southern CA.

Study Funding This research was supported by a Community Research Collaboration award from the California Breast Cancer Research Program Research supported by Community Research Collaboration award from California Breast Cancer Research Program

The Dimensions Model A model for community health nursing practice incorporating: A determinants of health perspective Levels of prevention Nursing intervention The dimensions model is a combination of principles from Nursing Public health Designed to direct community health nursing practice It includes A determinants of health perspective on factors influencing health and health behavior Public health concept of levels of prevention Nursing intervention to address public health problems

Model Components Dimensions of health care Dimensions of nursing Dimensions of health: a determinants of health view of factors influencing health status and health-related behaviors Dimensions of health care: levels of prevention Dimensions of nursing practice required to address public health problems

Dimensions of Health Biophysical Psychological Physical environmental Sociocultural Behavioral Health system Categories of factors that influence health Biophysical: maturation and aging, genetic inheritance (including gender – women for our purposes), physiologic health status (including immune status) Psychological: Internal and external psychological factors Physical environmental factors: physical environment and environmental hazards Sociocultural: social structure, social norms, culture, social action Behavioral: diet, substance use and abuse, recreation and exercise, sexual activity, use of protective measures Health system: availability, accessibility, affordability, appropriateness, adequacy, acceptability, and use of health services

Dimensions of Health Care Primary prevention Secondary prevention Tertiary prevention Levels at which health care services take place Primary Secondary Tertiary Don’t have capability of preventing breast cancer yet (primary prevention) We know early detection and treatment promote survival Focus in our study was on screening as an element of secondary prevention

Dimensions of Nursing Cognitive Interpersonal Ethical Skills Process Reflective Dimensions of nursing practice Cognitive: knowledge used by nurses Interpersonal: affective elements of practice, use of interaction skills Ethical: ethical decision making, advocacy Skills: manipulative, intellectual Process: processes used in nursing practice, e.g., nursing process, epidemiology, health education, change, leadership, group, political, etc. Reflective: theory development, research, evaluation

Dimensions of health influence assessment and diagnosis steps of nursing process Dimensions of health care come into play in the planning, implementation, and evaluation steps Dimensions of nursing influence all steps of nursing process

Study Purpose To identify factors that promote or impede mammography screening among older Thai women in Southern California Purpose of study: to identify factors influencing mammography screening in the Thai American population in So. Cal

Methods Focus groups with 36 Thai women aged 40-73 in Los Angeles and San Diego counties Content analysis of focus group transcripts Data gathered during four focus groups with 36 women 40 to 73 years old 3 in LA 1 in San Diego Language: 2 Thai, 1 English, 1 combination Translated and transcribed and subjected to content analysis based on dimensions of health

Findings: Biophysical Factors Maturation and aging: Belief that breast cancer only occurs in older women Older age brings greater health consciousness and concern Genetic inheritance: Belief that Thai women don’t usually get breast cancer Maturation and aging: Belief that breast cancer only occurs in older women (I’m too young) Older age brings greater health consciousness and concern (particularly in face of menopause) “We try to keep what we have” Genetic inheritance: belief that Thai women don’t usually get breast cancer. (“It’s not in our nature”)

Findings: Biophysical Factors Breast lump, leakage Large breasts Physical injury Pain Physical factors: Breast lump, leakage motivate care seeking and mammography Large breasts are more prone to cancer Physical injury to the breast causes breast cancer Pain associated with mammography impedes use Pain experienced in breasts motivated screening

Findings: Psychological Factors Fear Some women fear finding out that they have cancer Some fear having cancer and want to find out as early as possible Karma Stress as a cause of cancer Fear both motivated and impeded mammography use Some women fear finding out that they have cancer so don’t want to have a mammogram in case it shows disease Others fear having cancer and want to find out as early as possible Karma: believe if cancer is your fate you will get it, and early detection doesn’t make much difference Stress as a cause of cancer might motivate screening if one believes one is under a lot of stress

Findings: Physical Environmental Factors Distance to services (more relevant in Thailand than U.S.) Lack of transportation Only occasionally mentioned

Findings: Sociocultural Factors Knowledge Culture Language barriers Economic issues Social responsibilities Knowledge Personal knowledge of people with breast cancer Education about breast cancer and one’s risk of cancer Culture “Shyness” Reluctance to bare breasts (decreases with age and acculturation) Desire for female provider Definition of health: “I’m not sick yet” Breast cancer occurs in the context of marriage and sexual activity Stigma attached to breast cancer Assertiveness: being able to request a mammogram (only one woman) Language barriers Economic issues Cost of services Availability of insurance Social responsibilities Family responsibilities Work responsibilities and inability to request time off work for screening

Findings: Behavioral Factors Touching/squeezing breasts Prostitution Use of hormones Augmentation Diet Procrastination BSE substitution Touching the breasts Massaging or squeezing breasts causes cancer (e.g., by husband in marriage) Breast feeding accustoms women to having their breasts manipulated and decreases “shyness” Prostitution/sexual activity causes breast cancer, so unmarried women who are not sexually active do not need mammograms Use of hormones causes cancer (HRT most often mentioned, hormones in food also mentioned once) Breast augmentation can cause cancer Certain foods may cause cancer (e.g., strawberries, Vitamin E) Procrastination: Women put off mammography even if they think they should have one (usually due to anticipated pain) Some women use BSE as a substitute for mammography

Findings: Health System Factors Health insurance status Provider messages Mammography services Lack of insurance impedes mammography use Health care providers influence mammography use Recommending mammography (“The doctor keeps bugging on us”) Telling women they do not need a mammogram because they are too old, are on hormones, or have had a hysterectomy Factors related to mammography services Knowledge of service availability Convenience (decrease long waits) Understanding instructions prior to mammography

Next Steps Telephone interviews to determine prevalence of factors in the Thai community. Intervention study Conducted a telephone interview study of 360 Thai women in Southern CA to determine prevalence of factors derived from focus groups (poster presentation yesterday) Next: an intervention study

Intervention Will probably target 40-50 age group Will probably focus on Changing perceptions of susceptibility Decreasing perceptions of pain as an impediment to screening Redefining social responsibilities to include screening Younger women in phone study were less likely to have mammograms Focus on changing perception that Thai women don’t get breast ca Focusing on temporary, minimal pain vs pain and suffering of cancer Focusing on social responsibility to stay healthy for family and to keep working

Intervention Will incorporate the Cognitive dimension Interpersonal dimension Ethical dimension Process dimension, and Reflective dimension of nursing Cognitive: knowledge of factors influencing this population, knowledge of Thai culture Interpersonal persuasion skills , focus on attitude change Ethical: In LA services available In San Diego, may require advocacy to make services available to population Process: will require change process, leadership, educational, group process, and possibly political processes to promote screening Reflective: evaluation of outcomes of intervention