1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Methods
Focus groups with 36 Thai women aged 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

12. 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”)

13. 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

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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