101-01社區職能治療專題_課程講義

2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

1

Community-Based Practice: Definition, Historical Perspective, and Occupational Therapy Roles

By Hui-Fen Mao 2012/9/13

1. What is community-based rehabilitation (CBR)? (http://www.who.int/disabilities/cbr/en/) (WHO Library Cataloguing-in Publication data)

CBR: a strategy for rehabilitation, equalization of opportunities, poverty reduction and social inclusion of people with disabilities. (2004, Joint Position Paper/International Labour Organization, United Nations Educational, Scientific and Cultural Organization and the WHO)

CBR: implanted through the combined efforts of people with disabilities themselves, their families, organizations and communities, and the relevant governmental and non-governmental health, education, vocational, social and other services.

CBR, currently in practice in more than 90 countries around the world, is a comprehensive strategy for involving people with disabilities in the development of their communities.

2. What is the objective of CBR?

1) CBR seeks to ensure that people with disabilities (PWD) have equal access to rehabilitation and other services and opportunities -- health, education and income, and to become active contributors to the community and society at large -- as do all other members of society.

2) To activate communities to promote and protect the human rights of PWD through changes within the community, for example, by removing barriers to participation.

3. Who are the targets?

People with disabilities Families of people with disabilities Communities Disabled People's Organizations Local, regional and national governments International organizations Nongovernmental organizations (NGO)


2

Medical and other professionals Business and industry (private sector)

4. What kind of activities are included?

A wide range of activities is included beyond medical care and rehabilitation

Promoting positive attitudes towards people with disabilities Preventing the causes of disabilities Providing rehabilitation services Facilitating education and training opportunities Supporting local initiatives Monitoring and evaluating programmes Supporting micro and macro income-generation opportunities

5. What WHO is doing?

With regard to CBR, WHO is supporting Member States in the following areas:

Developing guidelines for CBR Conducting regional and country workshops to promote CBR and the

guidelines Supporting Member States to initiate CBR and/or strengthening existing CBR

programmes

6. What are the essential elements of CBR? 1) National level support through policies, co-ordination and resource allocation 2) Recognition of the need for CBR programmes to be based on a human rights

approach. 3) The willingness of the community to respond to the needs of their members with

disabilities. 4) The presence of motivated community workers.

National level: 1) Policies, legislation, and support to guide the priorities and planning of a CBR

programme. i.e. the UN Convention on the Rights of the Child, the UN standard Rules on the Equalization of Opportunities for Persons with Disabilities

2) The mechanism of co-ordinating committee (one or across ministry, health, social affairs, education or labour)

3) Collaboration among all of the sectors (intermediate/distract level where referral


3

services are provided, Non Governmental Organizations, NGO) 4) Allocation of resources

Intermediate levelkey point for coordination of support to communities CBR managers (i.e. ministry for social affairs), their duties include: Implementing and monitoring of the programme, supporting and supervising the training of workers, linking various community committees, and liaising between the communities and other resources.

Community level Representatives of community involving in the planning, implementation and evaluation of CBR programmes. Recognition of the need for CBR, raising the awareness Community involvement: respond the need * sharing information is a key component of CBR 7. Who will be community workers? Local government, Volunteers, PWD, and their family members, NGO, Media. Roles: 1) Acts as advocate by making contacts with schools, training centres, work places

and other organizations to promote accessibility and inclusion. 2) Provide information about the services available As liaison between the families of PWD and such services * CBR is now recognized by many governments as an effective strategy for meeting the needs of people with disabilities especially who live in rural areas. The expansion of programmes requires training for the people who will involved in the management and delivery of services. 8. What training programmes are needed for CBR? 1) Management training: identify need, co-ordinating with the community and

sectors, recording 2) Training for PWDs: to function as liaisons between community and other levels,

skills in advocacy, co-ordination, planning and evaluation, and fund raising. 3) Training for service delivery (community workers and the professionals)

CBR program/

Paradigm Shift: From the Medical Model to the Community Model Public Health, Community Health, and Occupational Therapy


Guiding Questions

1. Do you think there are paradigm shifts occurring in occupational therapy?

2. What are the characteristics of the emerging () paradigm in OT?

3. What are the basic components and/ or characteristics of a community practice

paradigm in OT? (* Table 2-1: Contrasting Paradigms)

4. What is Public Health? What are the strategies usually used in public health?

5. Describe the differences between public health and medical approaches to health

and disease. Discuss the implications of these two approaches with respect to

OT practice. (p.39)

6. What is community health? What are included in community-based approach

to enhance community health?

7. Describe the national health goals and objectives and potential roles for OT

practitioners within the Healthy People framework.


1

Paradigm Shift: From the Medical Model to the Community Model Public Health, Community Health, and Occupational Therapy


1. What is paradigm? - An example, pattern, or model - Conceptual framework that allows for explanation and investigation of

phenomena. - universally recognized scientific achievements that for a time provide

model problems and solutions to a community of practitioners (Tomas S. Kuhn, 1970, in The Structure of Scientific Revolutions)

- consensus-determined matrix of the most fundamental beliefs or assumptions of a field

- cultural core of the discipline and provides professional identity - Two essential characteristics: 1) a sufficiently unprecedented scientific

achievement that draws a large number of constituents from competing areas of inquiry, 2) adequately open ended enough to allow for the exploration of solutions to a variety of problems.

2. What can discipline-specific paradigm determine for a profession?

- How professionals view their phenomenon of interest

- What puzzles, problems, or questions practitioners will seek out in their work

- What solution will emerge

- What goals will be set for the direction of the profession

3. Describe the positive and negative aspects of having a well-developed paradigm.

- paradigm effect: paradigm act as filters of perception - When utilized appropriately, it distribute or provide information into

meaningful and useful guidelines for practice. - The danger is that their potential for limiting problem solving and innovation

by constraining thinking and perception.


2

4. Do you think there are paradigm shifts occurring in occupational therapy?

5. There are 4 stages of paradigm shifts.

6. Paradigm Shifts in OT

1) 18th and 19th centuries: moral treatment

2) 1900~1940--Paradigm of Occupation

Crisis (1950)

3) 1960sMechanistic Paradigm: more scientific, reductionism (Kinesiology, neurophysiological, and psychoanalytic approaches, exercise, talk groups, treatment technique, modality.)

Crisis (1970)

4) 1980-1990sEmerging paradigm, to understand the complexity of human behavior-- systems perceptive

1. Pre-paradigm: Competing schools of thought confronting the same range of phenomena

2. Paradigm : Consensus as to the nature of the phenomenon, problems to be addressed, and methods

3.Crisis: Rejection of the old paradigm

4.Crisis resolution through reorganization of the discipline under a new paradigm

External Factors: Social and epistemological demands on the discipline


3

7. What are the characteristics of the emerging () paradigm in OT?

Occupational performance results from the dynamic interaction between the person, the environmental context, and the occupations in which the person engages.

A more complex perspective on factors that impact occupational performance

All systems and components of systems are organized by levels and operate according to the laws of hierarchy (rather than cause-and-effect relationship)=> Dynamical systems theory: self-organizing processes

Input (Open system)=> Throughput=> Output, the interaction of the system with it environment is refined and guided by the feedback process

A broader range of potential solutions to occupational performance

8. The definition of public health: (Green and Anderson, 1982)

The science and art of preventing disease, prolonging life, and promoting health and well-being through organized community effort for the sanitation of the environment, the control of communicable infections, the organization of medical and nursing services for the early diagnosis and prevention of disease, the education of the individual in personal health, and the development of the social machinery to assure everyone a standard of living adequate for the maintenance or improvement of health.

9. Five phases of the modern era of public health:

1) Miasma phase (1850-1880): garbage collection, public sanitation, street cleaning, food handling, personal hygiene education

2) Disease control or health protection phase (1880-1920): Organisms causes disease and the science of bacteriology/ inoculations against diseases such as rabies and typhoid fever(), quarantine to prevent the spread of communicable illnesses

3) Health resources or medical phase (1920-1960): financial resources in construction of hospital, the development of health profession, the biomedical research (OT in medical model expanded significantly)


4

4) Social engineering phase (1960-1975): Medicare and Medicaid legislation in 1967 make health care services available to all citizens. Social concerns addressed at the federal level (housing, education, and poverty)

5) Health promotion phase (1975-present): recognition that health problems are attributable to an individuals lifestyle and behavior (leading causes of morbidity, mortality, and disabilityheart disease, cancer, stroke, HIV, and accidents), health promotion effortscombine social and environmental supports with strategies for health education and behavior changes to prevent disease and disability

10. Health-Care Delivery for Persons with Disabilities

1) Institutionalization

2) Deinstitutionalization and community develop (1975~to late 1980): homelike settings, professionals are still the planners of service and retained authority/ Guiding principlesdevelopmental theory, to develop skills and behaviors)

3) The era of community membership: focus on community supports to facilitate integration, autonomy, quality of life, and independence / Guiding principlesthe adaptation of the environment to meet the individuals needs, rather than education of the individual to adapt to the environment.

Dysfunction is a dynamic interplay between an individuals limitations and resources and the demands and constraints of the environment. (Systems approach: Social and environmental constraints than inherent in the physical disability)

11. The Vocational Rehabilitation (1980~)2 models of practice

1) Clinical model of vocational rehabilitation: PWD are unemployed, need to be assessed, counseled,, and treated to make him or her more employable/ to modify or restructure the psychological and vocational skills and behaviors.

2) Ecological or environmental model of vocational rehabilitation: numerous environmental, social,, and economic forces affect the PWD/ to modify all aspects of environment (physical, social,, and political)

12. Compare and contrast the paradigm shifts in OT with those of public health and vocational rehabilitation.


5

13. What are the basic components and/ or characteristics of a community practice paradigm in OT?

1) Broader perspectives: Client (vs. Patient), Intervention (vs. Treatment), Funding (vs. reimbursement)

2) Client-centered approach to practice: promote participation, exchange information, client decision-making, and respect for choice, focus on the issues which are most important to the person or family

3) The collaborative process to enable the client to identify occupational performance problems, engage in problem solving.

* OTs rolefacilitator, educator, and mentor in the process

(* Table 2-1: Contrasting Paradigms)

14. Discuss the usefulness of system theory to community practice. (p.31)

How to assess the client in the community? (Box 2-1)

=================================================== Public Health, Community Health, and Occupational Therapy

1. What is Public Health?

The process of mobilizing local, state, national, and international resources to ensure the conditions in which people can be health.

4 strategies:

1) Promoting health and preventing disease

2) Improving medical care

3) Promoting health-enhancing behaviors

4) Controlling the environment


6

* defined in terms of aims and goals, rather than grounded in a specific of knowledge=> many disciplines involved

2. Terms in Epidemiology

* Epidemiology the study of the distribution, frequencies, and determinants of disease, injury, and disability./ use health statistics, including measures of incidence and prevalence, to estimate disease, injury, and disability in a variety of population groups; analyze the health trends; plan and evaluate public health initiatives; and make informed health policy decisions

* Incidence refers to the number of new cases within a specified time frame (a year)

* Prevalence refers to the total number of cases at one point in time.

=> What is the purpose of preventive intervention? To reduce ________

=> What is the most effective approach to reduce overall prevalence?

* Public health intervention: to modify all types of risk factors and strengthen resiliency or protective factors to enhance the overall health and well-being of population.

- To decrease risk factors: -- precursors that increase an individuals or populations vulnerability to developing a disease(physical, behavior, or genetic, social, economic, political, and environmental)

- To increase resiliency () factors -- precursors that increase an individuals or populations resistance to developing a disease

* Health Promotionany planned combination of educational, political, regulatory, environmental, and organizational supports for action and conditions of living conductive to the health of individuals, groups, or communities.

* Preventionanticipatory action taken to reduce the possibility of an event or condition from occurring or developing, or to minimize the damage that may result from the event or condition if it does not occur

Primary preventionfocuses on healthy individuals who potentially could be at risk for a particular health problem/ to prevent the disease (example)


7

Secondary preventionfocuses on the detection and treatment of disease early on in its preclinical or clinical stages/ to slow the disease process, attempt to cure or control (example)

Tertiary preventionused in the advanced stages of disease (already ill), to limit disability and other complications/ to restore as much functionality as possible, and to prevent further damage (example)

3. Describe the differences between public health and medical approaches to health and disease. Discuss the implications of these two approaches with respect to OT practice. (p.39)

4. What is community health?

*CommunityNoninstitutional aggregations of people linked together for common goals or other purposes

* Healththe blending of a persons physical, emotional, social, intellectual, and spiritual resources so that he or she can master the developmental tasks necessary to enjoy a satisfying and productive life.

* Community Health the physical, emotional, social, intellectual, and spiritual well-being of a group of people who are linked together in some way

5. What are included in community-based approach to enhance community health?

1) Educational intervention

2) Social intervention (economic, political, legal, organization change)

3) Environmental supports

4) The health behavior of a community: actions of any person who may influence health behaviors,, resources or services ( police maker, ill persons, professionals,, employers,..)

6. Describe the history of the development of national health goals and objectives and potential roles for OT practitioners within the Healthy People framework.


8

1) Healthy People proposed by the Department of Health, Education and Welfare (Now the Dep. of Health and Human Services) in 1979.

- to identify national health goals and discuss health promotion and disease prevention in the US, and efficiently and effective use of the health-care resource

- morbidity and mortality can be attributed to four primary elements:

1) Inadequacies in the existing health-care system

2) Behavioral factors or unhealthy lifestyles: the leading cause of death for adolescents and young adults

3) Environmental hazards

4) Human biological factors

* Five major health goals according to life span (infants, children, adolescents and young adults, adults, and older adults)

2) In 1980, Objectives for the Nation -- a total of 226 specific goals

A mid course review in 1986

3) Healthy People 2000 in 1990: Focus is to improve the QOL, and peoples sense of well-being (rather than just reduction of mortality rate)

- Increase the span of healthy life for Americans

- Reduce health disparities among Americans (people with low income, disabilities, in minority groups)

- Achieve access to preventive health services for all Americans (social and environmental factors)

4) Healthy People 2010 in 2000: due to advances in preventive therapies, vaccines and pharmaceuticals, assistive technologies, and computerized systems.

* 28 Focus areas (Box 3-1), 467 goals

5) Healthy People 2020

Framework

The Vision, Mission, and Goals of Healthy People 2020 The vision, mission, and overarching goals provide structure and guidance for achieving the Healthy People 2020 objectives. While general in nature, they offer specific, important areas of emphasis where action must be taken if the United States is to achieve better health by the year 2020. Developed under the leadership of the Federal Interagency Workgroup (FIW), the Healthy People 2020 framework is the product of an exhaustive collaborative process among the U.S. Department of Health and Human Services (HHS) and other federal agencies, public stakeholders, and the advisory committee.

VisionA society in which all people live long, healthy lives.

MissionHealthy People 2020 strives to: Identify nationwide health improvement priorities; Increase public awareness and understanding of the determinants of

health, disease, and disability and the opportunities for progress; Provide measurable objectives and goals that are applicable at the

national, state, and local levels; Engage multiple sectors to take actions to strengthen policies and

improve practices that are driven by the best available evidence and knowledge; and

Identify critical research, evaluation, and data collection needs.

Overarching Goals Attain high-quality, longer lives free of preventable disease, disability,

injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages.

www.healthypeopl e.gov

2 www.healthypeople.gov

Healthy People 2020 Framework

The Importance of an Ecological and Determinants Approach to Health Promotion and Disease Prevention Health and health behaviors are determined by influences at multiple levels, including personal (i.e., biological, psychological), organizational/institutional, environmental (i.e., both social and physical), and policy levels. Because significant and dynamic inter-relationships exist among these different levels of health determinants, interventions are most likely to be effective when they address determinants at all levels. Historically, many health fields have focused on individual-level health determinants and interventions. Healthy People 2020 should therefore expand its focus to emphasize health-enhancing social and physical environments. Integrating prevention into the continuum of educationfrom the earliest ages onis an integral part of this ecological and determinants approach.

The Role of Health Information Technology and Health Communication Health information technology (IT) and health communication will be encouraged and supported as being an integral part of the implementation and success of Healthy People 2020. Efforts will include building, and integrating where feasible, the public health IT infrastructure in conjunction with the Nationwide Health Information Network; the ONC-Coordinated Federal Health IT Strategic Plan: 20082012 and any updates developed by the HHS Office of the National Coordinator; the various aspects of IT to meet the direct needs of Healthy People 2020 for measures and interventions; and health literacy and health communication efforts.

Addressing All Hazards Preparedness as a Public Health Issue Since the 2000 launch of Healthy People 2010, the attacks of September 11, 2001, the subsequent anthrax attacks, the devastating effects of natural disasters such as hurricanes Katrina and Ike, and concerns about an influenza pandemic have added urgency to the importance of preparedness as a public health issue. Being prepared for any emergency must be a high priority for public health in the coming decade, and Healthy People 2020 will highlight this issue. Because preparedness for all emergencies involves common elements, an all hazards approach is necessary.

3 www.healthypeople.gov

Healthy People 2020 Framework

Graphic Model of Healthy People 2020 The FIW developed a graphic model to visually depict the ecological and determinants approach that Healthy People 2020 will take in framing the national health objectives. This particular graphic was designed to emphasize this new approach, and is not meant as a comprehensive representation of all public health issues and societal domains. The graphic framework attempts to illustrate the fundamental degree of overlap among the social determinants of health, as well as emphasize their collective impact and influence on health outcomes and conditions. The framework also underscores a continued focus on population disparities, including those categorized by race/ethnicity, socioeconomic status, gender, age, disability status, sexual orientation, and geographic location.

$VLDQ3DFLF-RXUQDORI&DQFHU3UHYHQWLRQ9RO 1849

)DFWRUV&RQFHUQLQJ%UHDVW&DQFHU(DUO\'LDJQRVLV%HKDYLRULQ7XUNLVK:RPHQ

$VLDQ3DFLF-&DQFHU3UHY 12, 1849-1854

Introduction To ensure participation of women in early diagnosis behaviors of breast cancer by regular self breast examinations is among health promoting activities. Health promotion and disease prevention are basic concepts in basic nursing practice (Fawcett and Gigliotti, 2001). Recognizing the level of knowledge, beliefs and attitudes of women regarding breast cancer early diagnosis behaviors is effective in the applications of training and persuading women accordingly (Champion and Skinner, 2008). In this respect, the Health Belief Model and the Health Development Model can be effectively used in determining perceived inhibiting factors concerning breast cancer early diagnosis behaviors of women. According to the Health Belief Model, when perceived barrier, the person evaluates positive and negative consequences of the behavior. Consequently, he transforms the behavior into action or not. (Hochbaum, 1958). Perceived barriers are stated as the most powerful criterion of the model (Champion and Skinner, 2008). According to the Health Development Model, the perceived barriers of the individuals are important in maintaining the health behaviors directly or indirectly 1XUVLQJ'HSDUWPHQW'RNX](\OXO8QLYHUVLW\RI3XEOLF+HDOWK,]PLU7XUNH\)RUFRUUHVSRQGHQFHIDWPDHUVLQ#JPDLOFRP

Abstract Aim: The aim of the present study is to investigate the perceived inhibiting and facilitating factors concerning breast cancer early diagnosis behavior in women over age 40. Method: A qualitative focus group interview method was applied with 43 participating women, in the period between March-April 2010, using a semi-structured interview questionnaire based on the Health Belief Model and the Health Development Model. Content analysis was used to analyse study data. Results: Inhibiting factors such as womens lack of knowledge regarding breast FDQFHUDQGHDUO\GHWHFWLRQEHKDYLRUVODFNRIKHDOWKLQVXUDQFHDQGWUDQVSRUWDWLRQIDFLOLWLHVQDQFLDOGLIFXOWLHVGLIFXOW\WRPDNHDQDSSRLQWPHQWVFDUFLW\RIIHPDOHGRFWRUVIHHOLQJRIHPEDUUDVVPHQW ODFNRIDZDUHQHVVnegligence, forgetting, feeling of fear, and a fatalistic approach were frequently discussed. Among facilitating factors, informed level, concerned and tolerant health care personnel, free health services, free transportation to hospital, improved appointment system, telephone reminders were included. Conclusion and Recommendations: Focus group interviews were found to be effective in determining inhibiting and facilitating factors concerning EUHDVWFDQFHUHDUO\GLDJQRVLVEHKDYLRU1DWLRQDODQGUHJLRQDOWUDLQLQJSURJUDPVFRQJXUHGLQDFFRUGDQFHZLWKthe data obtained in the study may be effective in the implementation and maintenance of early diagnosis. Keywords: Barriers - facilitators - health belief model - health development model-nursing

RESEARCH COMMUNICATION

Inhibiting and Facilitating Factors Concerning Breast Cancer Early Diagnosis Behavior in Turkish Women: A Qualitative Study According to the Health Belief and Health Development ModelsFatma Ersin*, Zuhal Bahar

(Pender et al., 2006). Even though the Health Development Model is not widely used in breast cancer applications, it explained only 75% of the behavior changes in the studies conducted (Pender et al., 2006). Psychological, structural, institutional and socio-cultural factors are effective in breast screening rates and also directing women towards breast cancer early diagnosis behaviors (Lee et al., 2007; Remenninck, 2006). Psychological factors include fear of cancer, lack of information about early diagnosis applications, feeling of embarrassment, lack of sensitivity, disruption of family comfort, fear of losing the breast, fear of death, fear of change in the body image (Boraya et al., 2005; Champion et al.,2000; Maxwell et al., 2003; Ogedegbe et al., 2005; Park et al., 2007; Paskett et al., 2006). Among structural factors, lack of health insurance, transportation problems, VKRUWDJH RI WLPH KLJK FRVWV DUH LGHQWLHG 2JHGHJEHet al., 2005; Champion et al., 2000). Difficulties in understanding the health care system and language barrier EHWZHHQZRPHQDQGKHDOWKFDUHSURYLGHUVDUHVSHFLHGas institutional factors (Remennick, 2006). When we refer the socio-cultural factors; more dominant men in some cultures, dependent position of women upon men, subservient position of women in the family and at home

)DWPD(UVLQDQG=XKDO%DKDU

$VLDQ3DFLF-RXUQDORI&DQFHU3UHYHQWLRQ9RO1850

and lack of female caregivers (Borrayo et al., 2005; Remennick, 2006), false beliefs and perceptions, and fatalistic approach is seen (Ogedegbe et al., 2005). In addition, it is stated that facilitators (giving information, reminder letters, reminder telephone calls and mails, informative brochures, a home visits, combined interventions) are effective in the implementation and PDLQWHQDQFHRIWKHHDUO\GLDJQRVLVEHKDYLRUV%RQOOHWal., 2009; Champion et al., 2002; Kwok et al., 2005) and underlined that individuals should be conscious in this UHVSHFW2OLYHU9D]TXH]HWDO*|OEDHWDOLee et al (2007) reported womens breast screening rates would be increased by determining the barriers, and along with appropriate trainings and facilitators. Therefore, it is LPSRUWDQWWKDWEDUULHUVVKRXOGEHLGHQWLHGHGXFDWLRQDOprograms supported by models sould be structured and implemented by nurses in order to increase awareness regarding breast cancer early diagnosis in women, and maintain this behavior on a regular basis (Oliver-Vazquez et al., 2002). In this phenomenological study, it is aimed to investigate the perceived barriers and facilitators of women over age 40 with regard to breast self examination (BSE), clinical breast examination (CBE) and mammography within theoretical context of the Health Belief Model and the Health Promotion Model. The study questions with regard to BSE, CBE and mammography were: What are the womens perceived barriers?; What are the womens facilitators? Materials and Methods6WXG\3ODFHDQG&KDUDFWHULVWLFV The present focus group interview method qualitative study was conducted in the period between 17 March and $SULOLQ%DOoRYD5HJLRQRI]PLU3URYLQFH,QWKH UHJLRQ1DUOGHUH0XQLFLSDO 3DNL]H$WH:RPHQVCounseling Center in cooperation with the Department of Public Health Nursing, School of Nursing, DEU, provide health related services to women and their families. )RFXVJURXSLQWHUYLHZVZHUHSHUIRUPHGDW3DNL]H$WHWomens Counseling Center and recommended place by municipality.

6WXG\*URXSDQG6DPSOHV The study environment consisted of 10 639 women aged over 40, and living in Balcova Region. Criterion sampling method was used. Women who were voluntary to participate in the study and over 40 years of age, not diagnosed as breast cancer, not practiced mammography in the last one year were included in the sampling. We approached women through adress list obtained from 1DUOGHUHGLVWULFWDQGQHLJKERUKRRGDGUHVVV\VWHP)LYHfocus group interviews were conducted, a total of 43 women were approached. Around 7-11 women participated in each focus group interviews. Sociodemographic characteristics of participants are shown in Table 1.

'DWD&ROOHFWLRQ In this study, semi-structured interview questionnaire preapared in the guidance of the Health Belief Model and

the Health Development Model were used. The interview questionnaire consisted of open-ended questions and experts were asked for opinion. Some of the questions are hereby: What are the methods you know for early detection of breast cancer?, What are your reasons for not practicing BSE?, Why dont you regularly go to doctor for clinical breast examination?, Which requirements of \RXVKRXOGEHIXOOOHGWRPDNHPDPPRJUDSK\VFUHHQLQJeasier for you? Interviews were carried out as single sessions. Interviews were continued until any new data was obtained. At the point that no new data was obtained (data saturation), interviews were terminated.

6WUXFWXULQJ)RFXV*URXS,QWHUYLHZV :RPHQGHWHUPLQHGWKURXJKWKHRIFLDODGGUHVVV\VWHPof the district were visited at their homes, and asked for their consent to participate in the study after the aim of the study was explained. Women accepted to participate in the study were invited to the meetings at predetermined time and location. By telephone calls, women were reminded of the time and place of the meeting in the morning of the meeting day. Focus group interviews were carried out by two researchers who were educated on the subject. Tape recorder and interviewer notes were used during face-to-face interviews. Before using the recording device, women were asked for consent for recording interviews, and at the beginning of the recording, asking for the consent and aim of the study were repeated. At the time of interviews, the observer research assistant noted interactions among women. At the same time, food and beverages were offered in order to increase participation of the participating women in the interviews. Focus group interviews were lasted for approximately 45 minutes.

'DWD$QDO\VLV Deductive content analysis methodology was used in the analysis of the study data. Content analysis process consisted of analysing tape-recorded data into ZULWWHQ WH[W HGLWLQJ GDWD LGHQWLI\LQJ VLJQLFDQW GDWDvolumes, creating matrix analysis, encoding data of the matrix analysis in order to determine the barriers and the facilitators regarding breast cancer early diagnosis behaviors, reviewing the data encoded according to the matrix analysis, reporting the analysis process and the results (Polite and Beck, 2004).

5HVHDUFK9DOLGLW\ Validity of a qualitative research is evaluated with reliability and transferability (Elo and Kyngas, 2008). Reliability of this study was tested by including the expert opinions in the analysis of data and the participants confirmation. For transferability, criterion sampling, sample selection criteria and the data collection method ZHUHFOHDUO\GHQHG

5HVHDUFK5HOLDELOLW\ Reliability is evaluated with consistency and YHULDELOLW\LQDTXDOLWDWLYHUHVHDUFK



0

25.0

50.0

75.0

100.0

New

ly d

iagn

osed

with

out

trea

tmen

t

New

ly d

iagn

osed

with

tre

atm

ent

Pers

iste

nce

or r

ecur

renc

e

Rem

issi

on

Non

e

Chem

othe

rapy

Radi

othe

rapy

Conc

urre

nt c

hem

orad

iatio

n

same study, more than one researcher worked in obtaining data, different researchers cooperated in the analysis of the data obtained, in the data analysis pre-established and LQGHWDLOGHQHGFRQFHSWXDO IUDPHZRUNZDVXVHG6,0and SGM were used in the conceptual framework. In the end of the interviews, all data recorded was played for WZRWLPHVWRFRQUPDFFXUDF\DQGSUHFLVLRQRIWKHWH[WVconsequently reliability of the data was achieved. For the YHULDELOLW\RIWKHVWXG\WKHSRVLWLRQRIWKHUHVHDUFKHUWKHcharacteristics of the participants, the social environment of the research, conceptual framework and data analysis PHWKRGZDVFOHDUO\GHQHG

5HVHDUFK(WKLFV In order to carry out the research study, approval and LQIRUPHGFRQVHQWZHUHWDNHQIURP1DUOGHUH0XQLFLSDOLW\and the Ethical Committee of School of Nursing, DEU. In order to approach address and telephone information of 40 women living in the region, approval was taken IURP1DUOGHUHGLVWULFW2UDOFRQVHQWZDVWDNHQIURPWKHparticipating women which met the inclusion criteria of the study sampling.

Results %DUULHUVUHJDUGLQJ%UHDVW&DQFHU6FUHHQLQJ a) Psychological Factors: Majority of the women VWDWHGWKDWWKH\GLGQWKDYHVXIFLHQWLQIRUPDWLRQRIEUHDVWcancer, and as information source about early diagnosis behaviors regarding breast cancer, they pointed out mostly television, also doctors and nursing students. Moreover, ZRPHQFRXOGQWJLYHVXIFLHQWLQIRUPDWLRQDERXWHDUO\diagnosis behaviors and screening timing. On the other hand, some of the women mentioned about the importance of early diagnosis, even underlined potential life-saving impact. Some of the participants claiming that they knew how to perform BSE, did it wrong. Some others stated they knew how to perform BSE, but did not perform at all, while some others claimed they performed BSE, but did not understand what they were doing. One participant said ,GRQRWSHUIRUP%6(QRWEHFDXVHLWGRHVQWFRPHWRP\PLQGEXWMXVWEHFDXVH,GRQWNQRZKRZWRSHUIRUP. Concerning screening timing, almost none of the participating women could state exactly when, how often and how to perform BSE, CBE and mammography. Some of the participating women mentioned about the wory not to feel or detect the mass in practicing BSE. Regarding

BSE, some of the women expressed as HDFKVL[PRQWKVDIWHUHDFKEDWKZKHQP\VOHHSHGDVLWFRPHVVWRP\PLQG, while two of the participants noted that they performed once a month following menstruation in the bathroom. The women indicated they didnt know, even didnt hear about the clinical examination performed by the health personnel, named CBE. According to one of the women, mammography screening should be performed once a year over the age of 40, while for two other women every two years. Concerning lack of information, women blamed health personnel for not informing enough. The most emphasized concept in all focus group interviews was lack of sensitivity, neglecting. Among the prevalent causes leading to neglect participation in the behaviour of early diagnosis of breast cancer, some of the women discussed feeling no pain, feeling in general healthy, and feeling no need for screening, while a few of others mentioned about deeming it unimportant, radiation exposure in mammography, and ignoring their bodies. Three of the women expressed LI\RXGRQWIHHOSDLQ\RXQHYHUJRIRUVFUHHQLQJ, majority of the women underlined QHJOHFWLQJ. Five of the women stated that, although their health status had great importance, they didnt go for screening, but they should. One of the women expressed ZHKDYHWRWDNHFDUHRIKHDWKGHVSLWHEHLQJ\RXQJ. In YHRIWKHIRFXVJURXSLQWHYLHZVIRUJHWWLQJZDVSRLQWHGout as the most important reason not to perform screening tests. Neglecting, inability to read and write, no one around as a reminder, hectic and intensive housework were other reasons mentioned by different women. Majority of the women discussed the feeling of fear as a reason not to perform screenings. The fear of receiving a diagnosis of cancer was widely uttered. Moreover, some of the women implied that radiation exposure during mammography may also cause cancer. One of the women expressed this fact as GRFWRUVGRQWUHFRPPHQGIUHTXHQWPDPPRJUDSK\EHFDXVHLWGRHVKDYHDQLPSDFW. Six of the women pointed out the fear of death. Women tried to express their feling of fear with phrases like ZHGRQWJRWRGRFWRUIRUVFUHHQLQJEHFDXVHZHDUHDIUDLGRIDGLVHDVHWRRFFXU or ZHGRQWFRQVLGHUGLVHDVHPLJKWRFFXULQRXUERGLHV. Especially in two of the focus group interviews, some discomfort felt during the procedure was discussed. Some of the women had no complaints during screening of mammography, while some other experienced pain or discomfort, and commented as ZLWKWKHFRPSUHVVLRQH[HFXWHGLQWKHLQVWUXPHQWFDXVHGSDLQDQGGLVFRPIRUW.

b) Structural Factors: Majority of the women reported that lack of health insurance and high costs were inhibiting factors concerning early diagnosis behaviors. Women stated they couldnt easily pay for the screening and expressed as ,ZDQWWRJRWRGRFWRUIRUVFUHHQLQJEXW,FDQWEHFDXVH,DPXQLQVXUHG, ,FDQQRWJRWRGRFWRUIRUVFUHHQLQJGXHWRQDQFLDOGLIFXOWLHV, ,FRXOGRQFHJRWRSULYDWHGRFWRUIRUVFUHHQLQJEXW,FDQQRWDIIRUGLWYHU\\HDU. Particularly for old women, transportation problems was another barrier. Almost in all focus group interviews, GLIFXOWLHV LQ REWDLQLQJ DQ DSSRLQWPHQW RYHUFURZGHGclinics, uninterested and unconcerned health personnel,

Table 1. Sociodemographic Characteristics of the ParticipantsCharacteristics Number %Education Illiterate 25 58.1 Literate 2 4.7 Primary school graduate 12 27.9 Secondary school graduate 2 4.7 High school graduate or more 2 4.7 Income Income < expenditure 36 83.7 Income = expenditure 7 16.3 Income > expenditure 0 0.0



long-lasting procedures, prolonged waiting periods were among the issues frequently mentioned and emphasized. One of the women stated she wouldnt refer to health institutions and expressed as :HFDQQRWHDVLO\PDNHDQDSSRLQWPHQW3URFHGXUHVWDNHDORQJWLPHDWWKHKRVSLWDOV7KH\FDOODJDLQWKHQH[WPRQWK$Q\ZD\\RXJHWERUHGDQGJDYHXS7ZRRIWKHZRPHQSRLQWHGRXWGLIFXOWLHVWRleave the children at home due to their health problems and go to the hopitals for screenings. Irrelevant and intolerant approach of the health personnel was discussed as another barrier for the women. Some of the participants expressed as ,GLGQWJRWRWKHGRFWRUDJDLQEHFDXVHWKH\GLGQWJLYHDQ\SDSHUIRUWKHQH[WDSSRLQWPHQW, ,ZRXOGJRLI,ZHUHUHFDOOHGIRUWKHQH[W\HDU, 7KHUHLVQRRQHWRLQIRUPLQJPH:KHQ ,DSSO\ WRGRFWRUV WKH\GRQWSD\DWWHQWLRQDQGUHPDLQLQGLIIHUHQW.

c) Institutional Factors'LIFXOWLHVLQXQGHUVWDQGLQJthe health care system is another barrier for women regarding screening. Most of the women reported they didnt previously practice most of the procedures performed and also didnt know where these screening procedures were performed. One of the women expressed her situaton as I dont know where to go, how to go, and which procedures to conduct.

d) Socio-Cultural Factors: Throughout focus group interviews, one of the barriers for women to participate in the screening programs was underlined as cultural factors. During interviews, women noted that they should inform their husbands before they visited a doctor and moreover they were not allowed by their husbands to be examined by a male doctor. Some participants emphasized they didnt paricipate in the screening programs with the feeling of embarrassment, essentially based on traditional structure of Turkish society and religious beliefs. In fact, one of WKHZRPHQVLJQLHG WKDW VKHFRXOGQWEHQHW IURP WKHfamily health center for two years because of the male doctor on duty. Two other women stated its not religiously important if the doctor was male or female. She expressed this approach as LWLVQRWDVLQWREHH[DPLQHGE\DPDOH GRFWRUZKREHFDPHDGRFWRUZLWKWKH+LSSRFUDWLFRDWK7KHUHIRUH LWGRHVQWPDWWHUZKHWKHUP\GRFWRU LVPDOHRUIHPDOH. Most of the women participating in the study believed cancer is something from the God. They said LWRFFXULILWLVWKHLQHYLWDEOHIDWH, LWFRPHVIURPWKH*RG.

)DFLOLWDWRUVUHJDUGLQJ%UHDVW&DQFHU6FUHHQLQJ The participating women discussed their participation in breast cancer screening programs and forwarded their proposals, so that they should be informed by education programs, brochures and the media, as well as by seminars and reminders (telephone reminders, home visits) conducted by health care workers. They implied as ZHZRXOGOLNHWRKDYHLQIRUPDWLRQ, VHPLQDUVVKRXOGEHKHOG. In addition, having some disease symptoms was indicated as a facilitating factor. Women suggested that providing free health services regarding breast cancer, facilitated transportation facilities, improved appointment V\VWHPZRXOGSRVLWLYHO\LQXHQFHWKHLUSDUWLFLSDWLRQLQthe breast cancer screening programs. Furthermore, they

noted they necessarily go to doctor when they are called by the health personnel. They expressed as ,ZRXOGJRWRGRFWRUE\FRPSXOVLRQRUD[HGGDWHRIDSSRLQWPHQW, ,ZRXOGOLNHWRKDYHWHOHSKRQHUHPLQGHUV. The women demanded recommendations for screening programs provided by the health personnel, in a friendly and tolerant approach. One of the women expressed their expectations from health personnel as iIZHIDFHDJHQLDODSSURDFKZHZRXOGQWKHVLWDWHJRLQJWRDGRFWRUHYHQLI LW LVDPDOHGRFWRU, ZHPLJKWEH LJQRUDQWEXWRXUGRFWRUVKRXOGHQOLJKWHQXVLQGHWDLOZHQHHGLQIRUPDWLRQ. Additionally, the women asked to be informed about the procedures in the hospitals, also noted that practicing the screening procedures in a known institution would be more convenient for themselves One of the participants emphasized that, encouraging women is important to emancipate women from mens oppression, and she pointed out it could be achieved primarily by education. They also noted they would feel better if they could communicate with female doctors with regard to health services. One participant stated ,ZRXOGQW IHOO HPEDUUDVVHGZKHQH[DPLQHGE\D IHPDOHGRFWRU. Discussion

In order to motivate women to participate in the health improvement activities, it is highly important to recognize the inhibiting reasons for women regarding their participations in breast cancer screening programs. In this present study, the perceived barriers of the women were observed to influence their behaviors. Among WKH LPSRUWDQWFRQVHTXHQFHVRI WKLVVWXG\ LQVXIFLHQWknowledge of women regarding breast cancer early diagnosis and timing of screening should be mentioned. Similar results were also obtained in other studies (Paskett et al., 2006; Park et al., 2007). As information sources, ZRPHQLGHQWLHGIRUHPRVWWHOHYLVLRQGRFWRUVDQGQXUVLQJstudents. In some studies conducted, participating women reported that they generally get informed through media, friends, and acquaintances (Park et al., 2007; Sadler et al., 2007). The reason for media to be so widely used as an information source by the participating women might be the fact that it is an easily accessible tool, whereas the submission of health services to individuals might be inadequate and unsatisfactory. Furthermore, ignorance and wrong information might have an inhibiting role in the participation of women in breast cancer early diagnosis EHKDYLRUV DV D FRQVHTXHQFH RI LQXHQFLQJ DZDUHQHVVof individuals regarding breast cancer, and so causing inadequate perceptions of sensitivity and severity.

In the present study, lack of sensitivity along with neglecting and forgetting are substantially important barriers. Sensitivity is considerably effective in perceiving the likelihood of developing breast cancer. Almost all women reported they neglected screening programs, and they were not sensitive on this issue, which is supporting some study data (Park et al., 2007). This might be due to the low levels of risk perception of women. Women mentioned about disregarding, forgetting due to workload, ignorance, discomfort felt during the procedure, inevitable



pain and distress occurred in the procedure, the sense of feeling healthy among the reasons leading to negligence, which are also compatible with the data of other studies (Kwok et al., 2005; Ogedegbe et al., 2005). The sense of feeling healthy is considered very important in practicing health protecting behaviors. On this account, the fear of losing current health status and the accompanying worries may inhibit the participation in the screening programs. As a result of insensitivity and negligence, women forget to conduct screening activities, particularly practicing BSE. According to Pender, the importance attributed by the individuals to their own health status had a direct impact on the realization of their own health behaviors. In the realization of health improvement EHKDYLRUV3HQGHUUHSRUWHGWKDWKHDOWKGHQLWLRQVRIWKHindividuals were considerably important, moreover they generally recognized the importance of their health status whenever they became ill or had the feeling of death (Pender et al., 2006). In this present study, the feeling of IHDUZDVLGHQWLHGDVDEDUULHULQFRQFRUGDQFHZLWKWKHdata in literature (Maxwell et al., 2003; Ogedegbe et al., 2005). On the contrary, the feeling of fear was discussed as a facilitating factor in some other studies (Buki et al., 2004; Borraya et al., 2005; Kwok et al., 2005; Lamyian et al., 2007).

In this study, it is observed that, women had the expectation to be stimulated by the health care personnel to conduct screening procedures in terms of breast cancer early diagnosis behaviors. Similar results were obtained in other studies conducted (Maxwell et al., 2003; Paskett et al., 2006; Ogedegbe et al., 2005; Remennick, 2006; Park et al., 2007). Women who discussed particularly transportation facilities and cost of the procedures had lower socioeconomic conditions. Therefore, providing free transportation facilities may ensure screening behaviors of women. As a barrier detected in this study, GLIFXOWLHVUHJDUGLQJWRXQGHUVWDQGWKHKHDOWKFDUHV\VWHPsupports the study data of Remennick (2006). The reasons RIZRPHQZKRGHQHGWKHKHDOWKV\VWHPDVGLIFXOWPD\be based on the fact that they didnt frequently use health institutions, or else they were illiterate.

Similar to other studies, the dominant position of men, the feeling of embarrassment, lack of female health care personnels, wrong beliefs and perceptions, and fatalistic approach were all discussed in this study, as well (Remennick, 2006). In the implementation and maintenance of health behaviors, cultural characteristics and beliefs of Turkish society have great importance. In some studies conducted, beliefs were recognized as a barrier (Borrayo et al., 2005; Remennick, 2006), while in some other studies as a facilitator (Lamyian et al., 2007; Lee et al., 2007). Additionally, demand of the women for a female doctor support was compatible with the data of other studies (Maxwell et al., 2003; Borrayo et al., 2005). Womens claim for a female doctor may be due to religious factors, or customs and traditions, along with the feeling of embarrassment to show their bodies.

$QRWKHUQGLQJRIWKHVWXG\ZDV IDWDOLVWLFDSSURDFKand discussed widely among women. In the study of Ogedegbe et al (2005) fatalism was mentioned as an important barrier. Fatalism has a place in the religious

beliefs of the Turkish society and for some of the women it may lead to the recognition that she doesnt have the control of her own health, therefore, it may prevent women in the participation of screening programs. It can be effective if nurses would communicate with women and explain that fatalistic approach has no impact on health improvement practices. In the implementation and maintenance of health, in order to provide an effective health care service, public health nurse should first diagnose the society. Interviews with the individuals are important in the diagnosis of the society. For this reason, this present study is a guide for public health nurses.

Being informed by the health care personnel is determined as an important facilitator in this study. In the studies based on the Health Belief Model and the Health Development Model, it is oberved that informed and instructed individuals displayed positive health-related behaviors (Pender et al., 2006; Oliver-Vazquez et al., DQG UHIHUUHG HDUO\ GLDJQRVLV EHKDYLRUV %H\GDDQG.DUDRODQ(DUSHWDO*|OEDHWDO2009; Maxwell et al., 2003; Parlar et al., 2004; Paskett et al., 2006; Taylor, 1998; Tuong-Vi, 2007). In addition to being informed, being reminded by health care personnel (telephone reminders, home visits) was discussed by women as a poitive guidance in terms of participation in HDUO\GLDJQRVLVEHKDYLRUV7KLVQGLQJLVDOVRVXSSRUWHGE\YDULRXVVWXGLHV%RQOOHWDO&KDPSLRQHWDO.ZRNHWDO+RZHYHULQWKHVWXG\RI%RQOOet al (2009) it is reported that home visits as a reminder were not found effective. Furthermore, following focus group interviews, some of the women decided to conduct screening procedures. According to the explanations of the participants, it may be considered that the perceptions RIVHOIHIFDF\DQGVHULRXVQHVVRIZRPHQDUHLQXHQFHGpositively by these interviews.

In various studies similar to this present study, recommendations regarding breast cancer early diagnosis behaviors of women and using effective communication skills of the health personnel are emphasized as facilitating factors in the delivery of health service (Lamyian et al., 2007; Borrayo et al., 2005). The present study data indicated that, in the context of health services provision, besides the efforts of the health care personnel, evaluating the quality of the health services and searching for effective solutions are mandatory in the process of increasing womens participation in the breast cancer early diagnosis behaviors. Therefore, while providing health services as a public health nurse, recognition and application of the solutions, as well as the barriers, will be a facilitating factor in the implementation of health behaviors.

In conclusion, focus group interviews are observed to be effective in determining barriers regarding breast cancer early diagnosis behaviors. This present study is a guide to public health nurses in determining these barriers. Therefore, after determining the barriers in breast cancer early diagnosis behaviors, national and regional training SURJUDPVFRQJXUHGLQDFFRUGDQFHZLWKWKHVHGDWDPD\be organized. Randomized controlled studies including training programs for barriers may be conducted.

7KHIDFLOLWDWRUVLGHQWLHGLQWKLVVWXG\DUHUHSRUWHGWR



References%H\GD .' .DUDRODQ + (IIHFW RI EUHDVW VHOI

examination education to the knowledge and attitudes of female students. 76.3UHY0HG%XOO, 6, 106-11.

%RQOO&;0DU]R&03ODGHYDOO90HWDO6WUDWHJLHVIRUincreasing the participation of women in community breast cancer screening. Cochrane Database of Systematic Reviews 2001, Issue 1. Available from: http://www2.cochrane.org/reviews/en/ab002943.html.

Borrayo EA, Buki LP, Feigal BM (2005). Breast cancer detection among older Latinas: is it worth the risk? 4XDO+OWK5HV, 15, 1244-63.

Buki LP, Borrayo EA, Feigal B (2004). Are all Latinas the same? Perceived breast cancer screening barriers and facilitative conditions. 3V\FKRO:RPHQ4XDUW, 28, 400-12.

Champion V, Skinner C, Foster J (2000). The effects of standard care counseling or telephone/in-person counseling on beliefs knowledge and behavior related to mammography screening. 2QFRO1XUV)RUXP, 27, 1565-71.

Champion VL, Skinner CS (2008). The Health Belief Model. In: Glanz K., Rimer B.K., Viswanath K.V., eds. Health Behavior and Health Education: Theory, Research and Practice. 4th ed. San Francisco: Jossey-Bass, Inc. 46-65

Champion V, Skinner C, Menon U, et al (2002). Comparisons of tailored mammography interventions at two months post intervention. $QQ%HKDYLRXU0HG, 24, 211-18.

Earp JA, Eng E, OMalley MS, et al (2002). Increasing use of mammography among older, rural African American women: Results from a community trial. $P-3XEOLF+OWK, 92, 646-54.

Elo S, Kyngas H (2008). The qualitative content analysis process. -$GY1XUV, 62, 107-15.

Fawcett J, Gigliotti E (2001). Using conceptual models of nursing to guide nursing research: the case of the Neuman Systems Model. 1XUV6FL4XDUW, 14, 339-45.

*|OED=.XWODU=$NGHQL]+7KHHIIHFWRIHGXFDWLRQgiven by nursing students on womens knowledge and practice of breast cancer / breast self examination in a public training center. -%UHDVW+HDOWK, 3, 53-7.

Hochbaum GM (Subsequently modified by other authors) (1958). Health Belief Model, [ Update 2010 March 17] Available from http://www.courseweb.uottawa.ca/epi6181/images/Health_Belief_Model_review.pdf.

Kwok C, Cant R, Sullivan G (2005). Factors associated with mammographic decisions of Chinese-Australian women. +OWK(GXF5HV, 20, 739-47.

be effective in the implementation and maintenance of the breast cancer early diagnosis behaviors. Therefore, organization of national and regional breast cancer screening programs by the nurses, in which facilitators are kept in the forefront, furthermore, collaborations with different disciplines, may be effective in the implementation of health services.

In Turkey, we didnt encounter with the studies conducted about breast cancer early diagnosis behaviors, in which the barriers were first identified, and then initiatives are planned and accomplished, within the theoretical framework of the Health Belief Model and the Health Development Model. In this respect, this present study may lead to future qualitative and randomized controlled studies in nursing, regarding breast cancer early diagnosis behavior.

Lamyian M, Hydarnia A, Ahmadi F, et al (2007). Barriers to and factors facilitating breast cancer screening among Iranian women: a qualitative study. (DVW0HG+HDOWK-, 13, 1160-9.

Lee EE, Tripp-Reimer T, Miller A, et al (2007). Korean American womens beliefs about breast and cervical cancer and associated symbolic meanings. 2QFRO1XUV)RUXP, 34, 713-20.

Maxwell AE, Bastani R, Vida P, et al (2003). Result of randomized trail to increase breast and cervical cancer screening among Filipino American women. 3UHY0HG, 37, 102-9.

Ogedegbe G, Cassells AN, Robinson CM, et al (2005). Perceptions of barriers and facilitators of cancer early detection among low-income minority women in community health centers. -1DWO0HG$VVRF, 97, 162-70.

Oliver Vazquez M, Ayendez MS, Perez ES, et al (2002). Breast cancer Health Promotion Model for older Puerto Rican women: Results of a pilot programme. +HDOWK3URPRWLRQ,QW, 17, 3-11.

3DUODU 6%R]NXUW$2YD\ROX1 $Q HYDOXDWRQ2IHGXFDWRQ UHODWHG WR WKH EUHDVW FDQFHU DQG EUHDVW VHOIH[DPQDWRQ JLYHQ WR WKHZRPHQ DSSOLHG WRPRWKHU DQGFKOGKHDOWKFDUHFHQWHU-&XPKXU\HW8QY6FKRRO1XUVQJ, 8, 9-15.

3DUN60+XU+..LP*

RESEARCH ARTICLE Open Access

Community-based intervention to promotebreast cancer awareness and screening:The Korean experienceKeeho Park1*, Woi Hyun Hong2, Su Yeon Kye1, Euichul Jung3, Myung-hyun Kim1 and Hyeong Geun Park1

Abstract

Background: There are many differences in culture, community identity, community participation, and ownershipbetween communities in Western and Asian countries; thus, it is difficult to adopt the results of communityintervention studies from Western countries. In this study, we conducted a multicity, multicomponent communityintervention trial to correct breast cancer myths and promote screening mammography for women living in anurban community in Korea.

Methods: A 6-month, 2-city community intervention trial was conducted. In the intervention city, 480 womenwere surveyed at baseline and 7 months later to evaluate the effects of the intervention program. Strategiesimplemented in the intervention city included community outreach and clinic and pharmacy-based in-reachstrategies.

Results: This study showed a 20.4-percentage-point decrease in myths about the link between cancer and breastsize, a 19.2-percentage-point decrease in myths concerning mammography costs, and a 14.1-percentage-pointincrease in intention to undergo screening mammography. We also saw a 23.4-percentage-point increase in theproportion of women at the action stage of the transtheoretical model in the intervention city. In the comparisoncity, smaller decreases and increases were observed.

Conclusions: Our study showed the value of an intervention study aimed at reducing belief in breast cancermyths in an urban community in Korea. The invention also made women more likely to undergo mammographyin future.

BackgroundCancer has been the leading cause of death in theRepublic of Korea since 1983. Approximately 140,000people develop cancer annually with 65,000 annual fatal-ities. Cancer control is an important issue because of thecountrys rapidly aging society and the subsequentincreased burden of cancer. The National CancerScreening Program (NCSP) offers Medical Aid usersand those National Health Insurance (NHI) beneficiarieswho fall within the lower 50 percent income bracketfree screening for 5 common cancerscancer of the sto-mach, liver, colorectum, breast, and cervix uteri. ForNHI beneficiaries in the upper 50 percent income

bracket, the maximum cost of a mammogram is6 dollars. The NCSP recommends biennial mammo-grams for women over 40 years of age. However, only49.5% of women act in accordance with these guidelines.Although mass media health communication strategies

can effectively promote health education, and influencehealth awareness, decisions, practices, and care [1],interpersonal communication channels are regarded ashighly influential to persuade people to change health-related behaviors [2]. In addition, because it is difficultfor one-way mass communication strategies driven bythe central government to challenge strong beliefs orshifting attitudes [3], the Second Term (2006-2015) ofthe 10-year Comprehensive Plan for Cancer Control inKorea focuses on the idea of community-based healthcommunication to promote cancer screening.

* Correspondence: [email protected] Information and Education Branch, National Cancer Center, Goyang,Republic of KoreaFull list of author information is available at the end of the article

Park et al. BMC Public Health 2011, 11:468http://www.biomedcentral.com/1471-2458/11/468

2011 Park et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

There are more than 250 Public Health Centers(PHCs) in Korea. These organizations are part of theNational Health System and are operated by local gov-ernments to prevent and control diseases or tacklehygiene problems at the county/district level. Despitethe presence of this strong community-based health ser-vice network, most PHCs have struggled to use theoryor evidence-based approaches to promote cancerscreening. However, with the new emphasis on commu-nity-based health communication in the Second Term(2006-2015) of the 10-year Comprehensive Plan forCancer Control, these PHCs are now looking at ways togather evidence. One difficulty they face is that most ofthe research on community campaigns for promotingcancer screening has been conducted in Western coun-tries or in non-Asian populations. As there are manydifferences in culture, community identities, communityparticipation, and ownership between communities inWestern and Asian countries, it is not possible todirectly adopt the results of studies from Westerncountries.In this study, we conducted a community-based inter-

vention study to correct myths related to breast cancerand promote screening mammography for women livingin an urban community in Korea, Gunpo. The theoreti-cal framework for the community-based interventionsincluded the PRECEDE/PROCEED model for planning[4] as well as the health belief model (HBM) [5,6],Transtheoretical model (TTM) [7] and social marketing[8]. The PRECEDE/PROCEED model is a popular roadmap for health promotion programs. The model viewshealth behavior as influenced by both individual andenvironmental forces, and its 2 parts comprise an educa-tional (PRECEDE) and an ecological diagnosis (PRO-CEED). Using the model, we conducted social,epidemiological, behavioral, environmental, educational,ecological, administrative, and policy assessment withthe help of the Gunpo PHC. We also assessed the fac-tors that predict why people will take action to screenfor breast cancer using the HBM; these include suscept-ibility, seriousness, benefits and barriers, cues to action,and self-efficacy. The stage construct is importantbecause it represents a temporal dimension. In the past,behavior change often was construed as a discrete event.The TTM posits change as a process that unfolds overtime, with progress through a series of stages, althoughfrequently not in a linear manner. To stage the mam-mography, we identified the past history of breast cancerscreening, recent breast cancer screening, and futurebreast cancer screening intention.We chose the social marketing strategy approach to

promoting health behavior. We did not merely try toinform people or persuade them to change their beha-vior, but attempted to sell our services as products. We

analyzed the target population using segmentation byage and TTM stage of change, and developed interven-tion activities according to results of the analysis.Because breast screening with the NCSP is free forKorean women aged 40 years and over and becausecommunity health education is also free, we regardedplace and promotion as the main elements of themarketing mix (Product, Price, Place, and Promotion)needing to be addressed. Therefore, we adopted an out-reach education program and direct mailing as cam-paign activities.The Gunpo Cancer Screening Project (GCSP) aimed

to identify barriers to breast cancer screening andaddress these barriers in a multicomponent programdesigned to improve beliefs, attitudes, and screeningbehaviors for breast cancer.

MethodsSurveyWe used the HBM and the TTM to develop the ques-tionnaire for our quantitative research into health beha-viors. A cross-sectional face-to-face survey usingstructured questionnaires was conducted with randomlyselected sample of 503 women aged 30-69 years whowere permanent residents in the intervention city. Self-administered questionnaires were used to collect socio-demographic data. Survey was conducted to assess pre-disposing factors such as perceived risk of breast cancer,knowledge on breast cancer and breast screening, per-ceived severity of breast cancer, awareness of breast can-cer screening, perceived barriers to breast cancerscreening, satisfaction with recent breast cancer screen-ing, and self-efficacy, and reinforcing factors which arerecommendations from physician or pharmacist, pasthistory of cancer and other chronic diseases, past historyof benign breast diseases, and family history of breastcancer, and finally enabling factors, for example, per-ceived cues to action and factors affecting hospitalchoice for breast cancer screening.This study was approved by the Institutional Review

Board of the National Cancer Center.

InterviewsHealth workers from the health promotion and cancercontrol program department in the PHC were inter-viewed in their role as key administrative and policyinformants. We explored their current health promotionactivities including their cancer control program, policy,enabling factors for the regional cancer control program,perceived barriers to the regional cancer control pro-gram, and characteristics of the PHC organization andthose staff conducting health promotion. We conductedeleven focus group interviews; questions were based onstages of mammography adoption using the TTM and


Page 2 of 10

the HBM constructs. The results of both qualitative andquantitative research were used to develop educationalmaterials for small group education sessions. Since thisstudy represents only the quantitative data, we do notreport the findings of qualitative research.

MessageThe main message of the community campaign was thatscreening mammography can detect masses which arenot palpable. We brainstormed messages that matchedour communication campaign goal of correcting mythsabout breast cancer and screening mammography.These were pretested and we revised the message withthe members of the Community Advisory Committee.Posters were then drawn up.

Target areaGunpo was selected for the intervention for several rea-sons. First, the screening rate for breast cancer wasabout average for Korean PHCs. Second, physical acces-sibility to clinics or hospitals was not a significant bar-rier for cancer screening. Third, its geographic anddemographic characteristics allowed for generalizabilityfor urban Korea, which is where approximately half ofall Koreans live. Fourth, Gunpo is neither too large nortoo small to implement a community-based interventiontrial with a limited budget.With a land area of 36.38 km2, Gunpo is located in the

metropolitan area near Seoul. As of December 2007, ithad a total population of 275,351 (men 137,718; women137,633). Gwang Myeong was selected as a comparisonregion. We selected it because it has similar geographicand sociodemographic characteristics and because it isfar enough away from the intervention city to ensure thepresence of a buffer zone should the intervention con-taminate beyond the intervention citys boundaries.Gwang Myeong is also located in the metropolitan areaaround Seoul with a total population of 311,700 (men155,407; women 156,293) and a land area of 38.50 km2.

InterventionsTo develop effective interventions, we used results fromthe formative research, additional focus interviews, andinput from the Community Advisory Committee. Inter-ventions implemented in Gunpo over 6 monthsincluded: (a) posters on apartment billboards; (b) postersin clinic waiting rooms; (c) posters on pharmacy walls;(d) leaflets distributed at street events; (e) direct mailingto promote breast cancer screening; (f) street promotion;(g) outbound calls to women who signed applicationforms at the street promotions, monthly neighborhoodmeetings, or small group educational sessions; (h) smallgroup educational sessions; and (i) a blog on breast can-cer screening.

We obtained informed consent from all the partici-pants who were contacted by the study team.

EvaluationWe conducted pre-intervention baseline surveys inJune 2008. This cross-sectional face-to-face surveyusing structured questionnaires was conducted with arandom sample of 240 women aged 30-69 years fromthe intervention city and another 240 from the com-parison city. Phase 2 began at the conclusion of theintervention delivery, approximately 7 months after thebaseline survey was concluded, and involved a follow-up survey of women. The post-intervention survey wasconducted with an independent sample of 240 womenfrom each city.For campaign and non-campaign exposure, we

included items for measuring possible non-GCSP cam-paign activities in the questionnaire. This was done inorder to control the confounding effect of those extrin-sic activities, which could act as noise, and make itmore difficult to assess the effectiveness of the mainGCSP campaign. For dose-exposure questions, partici-pants were asked 3 questions with a 7-point Likert-typescale for each communication activity. The questionsasked: (a) if they had been exposed to the campaignactivity for breast cancer screening, ranging from neverseen to seen very frequently; (b) if they had been ableto see the activity in detail, ranging from never couldsee it in detail to could see very detailed information;and (c) if it was easy to remember the activity, rangingfrom could not remember the activity at all to couldremember the activity very clearly. Overall media expo-sure was measured as the average of each respondentsscores across this 3-item, 7-point Likert-type scale.There was no prompting for these questions. Theinstrument for measuring campaign exposure modifiedthe framework used by a top advertising agency inKorea.

Mammography myths and intention towardRespondents responded to the following 7 statements orquestions: (a) most lumps suspicious of breast cancerare painful; (b) women whose breast size is bigger aremore likely to get breast cancer; (c) the best time to geta mammogram is when there are breast symptoms; (d)we do not need to get a mammogram when no abnor-mal signs or symptoms are found in breast self examina-tion; (e) mammograms are expensive; (f) women olderthan 60 do not need a mammogram; (g) do you intendto get a mammogram within 2 years? These questionswere based upon formative research conducted in thefirst phase. The myth assessment items were included inthe questionnaire because they had received lowerscores in the formative quantitative survey on breast


Page 3 of 10

cancer awareness, health status, lifestyle, health con-sciousness, health behavior, knowledge on breast cancer,perceived barriers toward cancer screening, and selfefficacy.Stage of mammography adoption by TTM was

assessed using womens responses to the questionnaireon their intention of obtaining a mammogram in thecoming 2 years, asking whether they had been screenedin the previous 2 years, and looking at their reportedhistory of mammography use in the previous 2 years[7].

AnalysisThe basic characteristics on demography and past his-tory of mammography (see Table 1) were calculatedseparately at baseline and follow-up for both cities. Dif-ferences between cities were assessed using c2 tests. Weused t-tests to compare campaign recall scores betweenbaseline and follow-up for each city. To assess whetherthe intervention was related to a beneficial change inmyths with respect to breast cancer and screening mam-mography, c2 tests were used. The interventions mythbusting effect was assessed using unadjusted logisticregression models. Model factors included TIME (base-line/follow-up), CITY (intervention/comparison), and aTIME by CITY interaction term. This interaction termtested the differential effect of the intervention. Todetermine which intervention activity was related to cor-rect answers (correct understanding) for 6 questionsrelated to screening mammography, a series of logisticmodels was fitted. We developed models using forwardstepwise logistic regression for the following: subjectscharacteristics; CITY, TIME, CITY by TIME interaction;all of the intervention activities listed in Table 2; otherpossible non-campaign activities; and all of the 2- and3-way interactions of these variables with CITY, TIME,and CITY by TIME. Odds ratios and 95% confidence

intervals were produced in the final models. Theactivities were judged to be related to the outcomes ifthere were significant 3-way interactions between theactivities, CITY and TIME.

ResultsSociodemographic variables and past history of mammo-graphy of the sample in the pre- and post-interventionsurveys are shown in Table 1 by both city and time per-iod. There was no significant age difference betweenstudy samples in the intervention and control cities.However, there were more married women in the inter-vention city at the follow-up, and women in the com-parison city had lower levels of educated at bothbaseline and follow-up. While there were moreemployed women in the intervention city at baseline,more employed women were in the sample of the com-parison city at the follow-up. More women in the inter-vention city had a mammogram history. At follow-up,recall scores were significantly increased in the interven-tion city for all campaign activities except for seeingposters in clinic waiting rooms (Table 2). The baselineexposure scores for the intervention city were lowerthan scores for the comparison city on every activity.Scores for 5 of the 8 activities were significantlyincreased in the intervention city at follow-up. In addi-tion, the differences in average recall scores betweenbaseline and follow-up were greater in intervention cityfor all campaign activities.In terms of changes to beliefs in breast cancer myths,

there were significant decreases in the proportion ofwomen who believed that bigger breast size raised thelikelihood of breast cancer, and in the proportion ofwomen who thought that mammograms were expensivein the intervention city (Table 3). Significant change wasalso observed in the proportion of those who intended

Table 1 Demographic characteristics by city and timeVariable Intervention Comparison

Baseline(n = 240)n (%)

Follow-Up(n = 240)n (%)



Age (yr)

30-39 93 (38.8) 93 (38.8) 90 (37.5) 90 (37.5)

40-49 83 (34.6) 83 (34.6) 78 (32.5) 78 (32.5)

50-59 38 (15.8) 38 (15.8) 43 (17.9) 43 (17.9)

60-69 26 (10.8) 26 (10.8) 29 (12.1) 29 (12.1)

Currently marrieda 225 (93.8) 239 (99.6) 219 (91.2) 227 (94.6)

Education 12 yrb 139 (57.9) 135 (56.2) 172 (71.7) 173 (72.1)

Annual household income < $20000 27 (11.2) 7 (2.9) 15 (6.2) 16 (6.7)

Employedc 92 (38.3) 30 (12.5) 66 (27.5) 120 (50.0)

History of mammography (yes)d 147 (61.2) 176 (73.3) 122 (50.8) 128 (53.3)aP < 0.05 at follow-up between cities.b c d P < 0.05 at baseline and follow-up between cities.


Page 4 of 10

to have screening mammography. However, significantchanges in the opposite direction were observed for 4myths in the comparison city ("most lumps suspiciousof breast cancer are painful; women whose breast sizeis bigger are more likely to get breast cancer; the besttime to get a mammogram is when there are breastsymptoms; we do not need to get a mammogramwhen no abnormal signs or symptoms are found inbreast self examination). When we assessed whetherthere were differential effects of the intervention on thebeneficial changes in myths using unadjusted logisticregression models including TIME, CITY, and a TIMEby CITY interaction term, significant results wereobserved for 3 myths ("most lumps suspicious of breastcancer are painful; women whose breast size is biggerare more likely to get breast cancer; the best time toget a mammogram is when there are breast symptoms).While no beneficial change was observed in the

comparison for these 3 myths, the intervention cityshowed a significantly decreased level of belief of thosemyths. For example, people in the intervention city were3.87 times more likely to have decreased level of beliefof those myths most lumps suspicious of breast cancerare painful. Results for our comparison of changes inthe TTM stage of mammography adoption betweenintervention and comparison cities are shown in Table4. The proportions for contemplation and action whenadded together increased from 77.1% to 91.3% in theintervention city, while there was a small increase from82.9% to 90.0% in the comparison city.In particular, there was profound change in the

proportion for the TTM action stage in the interven-tion city.We explored whether the GCSP campaign activities

were related to correct understanding of the 6 myths,and to intention regarding screening mammography

Table 2 Recall scores for community activities by city and timeExposure Intervention Comparison

Baseline(n = 240)Mean (SD)

Follow-Up(n = 240)Mean (SD)

p value Baseline(n = 240)Mean (SD)

Follow-Up(n = 240)Mean (SD)

p value

Posters on apartment billboards 2.81 (1.72) 3.54 (1.34) < 0.001 3.07 (1.40) 3.40 (1.75) 0.023

Posters in clinic waiting rooms 3.74 (1.87) 3.97 (1.32) 0.128 4.13 (1.77) 3.85 (1.76) 0.084

Leaflets 2.55 (1.88) 3.71 (1.32) < 0.001 2.56 (1.32) 3.28 (1.87) < 0.001

Direct mail 2.50 (1.77) 3.53 (1.39) < 0.001 2.77 (1.43) 3.06 (1.86) 0.054

Street promotion 1.71 (1.08) 2.68 (1.11) < 0.001 2.33 (1.14) 2.92 (2.17) < 0.001

Website (National Cancer Information Center) 1.34 (0.86) 2.48 (1.35) < 0.001 1.61 (1.01) 1.71 (1.45) 0.382

Outbound call 1.38 (0.76) 2.65 (1.39) < 0.001 1.70 (1.00) 2.11 (1.65) 0.001

Small group education by GCSP 1.81 (1.22) 3.07 (1.29) < 0.001 2.30 (1.40) 2.70 (1.95) 0.010

SD, standard deviation; GCSP, Gunpo Cancer Screening Project.

Table 3 Percentage of survey respondents reporting outcomes pre- and post-campaign in intervention andcomparison citiesOutcomes Intervention Comparison



P Baseline(n = 240)n (%)


P OR (CI)*

Myth 1-Most lumps suspicious of breast cancer arepainful (No)

164 (68.3) 172 (71.7) 0.486 189 (78.8) 127 (52.9)

101-01社區職能治療專題_課程講義

Documents