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Developing and Evaluating an Individually Tailored Intervention to Increase Mammography Adherence Among Chinese American Women

Wu, Tsu-Yin PhD, RN; Lin, Chiuman MSN, RN

doi: 10.1097/NCC.0000000000000126
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Background: Breast cancer consistently is the most commonly diagnosed cancer and the second most common cause of cancer mortality among Asian Americans in the United States. The incidence of breast cancer in Asian American women has been increasing at a much higher rate than in white women.

Objectives: A randomized control single-blind study was conducted comparing the efficacy of an individually tailored telephone counseling and National Cancer Institute brochure.

Methods: The sample consisted of 193 Chinese American women with no breast cancer history. The participants were randomly assigned to either an intervention or a control group. Self-reported data that included demographic variables, knowledge, beliefs, and screening behaviors were collected at baseline and 4 months.

Results: The intervention group had increased screening to 40% compared with 33% for the control group at 4 months; the difference was not statistically significant. When the subanalyses were performed, the intervention is effective in certain demographic groups (ie, elderly women aged ≥65 years and recent immigrants). The study intervention was well accepted by participants and perceived as feasible and culturally appropriate based on process evaluation.

Conclusions: The study also demonstrates the feasibility of recruiting and retaining eligible women to participate, and the results show that both study intervention and printed materials increase awareness of the importance of breast cancer screening and screening behaviors for Chinese American women.

Implications for Practice: Oncology nurses and advanced practice nurses can play critical roles on this medically underserved population that experiences disparities in breast cancer mortality by providing culturally appropriate counseling to promote screening adherence.

Author Affiliations: School of Nursing, Eastern Michigan University, Ypsilanti, Michigan.

The project described was supported by 5R21CA127825-02 from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.

The authors have no conflicts of interest to disclose.

Correspondence: Tsu-Yin Wu, PhD, RN, School of Nursing, Eastern Michigan University, 328 Marshall, Ypsilanti, MI 48197 (twu@emich.edu).

Accepted for publication November 21, 2013.

The cancer burden among Asian Americans is unique; of all racial and ethnic groups in the United States, only among Asian Americans cancer is the leading cause of death.1,2 In addition, breast cancer consistently is the most commonly diagnosed cancer and the second most common cause of cancer mortality among Asian Americans in the United States.3,4

Although Asian Americans have been considered to be at lower risk for breast cancer than other non-Hispanic whites and African Americans, the incidence of breast cancer in Asian Americans during the past decade has been increasing at a much higher rate.5 A recent population-based epidemiologic study has verified that Asian American women experienced a rapid increase in breast cancer incidence, particularly among US-born Asian American women younger than 45 years.6 Data from the California Cancer Registry indicate that among 6 Asian-ethnic populations, foreign-born Asian American women had consistently more advanced breast cancer at diagnosis and, consequently, lower survival rates than their US-born counterparts did.6 Migrant studies have shown that breast cancer risk increases in women who move from countries with low incidence rates to countries with high incidence; Asian American women born in the West had a breast cancer risk 60% higher than Asian American women born in the East.7

Evidence suggests that the disparity in the late-stage diagnosis and poor survival of breast cancer is associated with utilization of mammography. Numerous uncontrolled trials and retrospective series have documented the ability of mammography to diagnose small early-stage breast cancers, which have favorable clinical outcomes.8 In addition, more recent data from screening programs in Sweden and Canada demonstrate that 40% of deaths due to breast cancer were prevented in patients who obtained regular mammography screenings.9 Although the US Preventive Services Task Force (2009) recommended biennial instead of annual mammography screening for women aged 50 to 74 years and starting mammography screening at the age of 50 years, several medical authorities such as the American Cancer Society and the American College of Obstetricians and Gynecologists continue to recommend that mammography screening be offered annually to women beginning at age 40 years.

The American Cancer Society annual report shows that minority and immigrant women underuse mammography screening.10 According to the California Health Interview Survey, white, African, and Latina women have met the national objective of having a mammogram in the past 2 years (≥70%), whereas Asian American women still lag behind (67.2%).11 Statewide and local data also verify the underuse pattern in mammography screening among Asian American women.12,13

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Chinese American Women and Breast Cancer Screening

Breast cancer is the leading cancer for Chinese American women (77.6/100 000),14 and numerous studies report low breast cancer screening rates among Chinese American women. Only 52% of Chinese American women reported having mammograms in the past year in the California Behavioral Risk Factor Survey,15 42% in the study by Su and colleagues16 in Philadelphia (2006), and 53% in the study by Yu and Wu17 in Michigan (2005).

Previous research studies have identified factors associated with the nonadherence to mammography screening among Chinese American women. Acculturation factors such as language, length of residency in the host country, and cultural and logistic barriers are commonly reported to be associated with low utilization of mammographic screening services among Chinese American women.18–20 In addition, studies report misconceptions and lack of knowledge specific to recommended intervals for mammography screening as factors related to screening adherence.21,22

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Individually Tailored Intervention

Because promotion of cancer screening and early detection have proven to be more difficult in ethnic minority groups,23 effort is needed to address the special needs of Asian American populations and to determine the appropriateness and efficacy of screening interventions. Tailored interventions, designed to reach an individual based on her unique characteristics, have shown promise. Distinct from targeted interventions, which are directed at a particular population and involve less personally relevant content, individually tailored interventions deliver messages based on unique characteristics derived from an individual assessment that are unique to that person and are considered personally applicable. The results from a meta-analysis showed the evidence of tailored intervention for promoting mammography screening because health messages tailored to cognitive and behavioral factors are effective in decreasing barriers to mammography screening.24 To date, fewer cancer-control interventions have been conducted and developed for Asian American women that integrate the concept of the individually tailored intervention. Therefore, the purpose of this study was to develop and test a tailored intervention for Asian American women.

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Theoretical Framework

The Health Belief Model (HBM) provides the foundation to guide the development of intervention strategies in promoting mammography adherence. According to the HBM, 4 main constructs influence an individual’s decisions about whether to take action to prevent, screen for, or control illness. In mammography screening, individuals are more likely to adhere to mammography guidelines if they perceive that they are susceptible to breast cancer (perceived susceptibility) and that breast cancer is a serious disease (perceived seriousness), believe that mammography screening will reduce their susceptibility or the severity of breast cancer (perceived benefits), and believe that the costs of mammography screening (perceived barriers) are outweighed by the benefits. Self-efficacy was first conceptualized and developed by Bandura and later added to the HBM in 1988 to increase its explanatory power.25 Bandura emphasizes self-efficacy as the belief about an individual’s ability to exercise control over a set of skills to complete a specific task. In terms of mammography screening, individuals require a set of skills to perform this behavior; for example, in some cases, women may need to locate and contact mammography centers and schedule an appointment after physician’s order for obtaining a mammogram. Perceived seriousness was not included as an intervening variable in current study. The decision was based on previous findings that there is no variance with the level of seriousness in breast cancer among Chinese women because of the fact that Chinese women may have considered it a serious condition (as ceiling effect).17 In terms of susceptibility, findings from the previous focus groups suggested that when these women immigrate to the United States, they need to be educated about breast cancer risk and current recommendation guidelines for mammography screening.17,18

Tailored interventions that are designed to reach an individual based on his/her unique characteristics have shown effectiveness in promoting mammography screening; however, such modality has not been tested in Asian or Chinese American women. The current study aims to implement and evaluate an individually tailored intervention developed for Chinese American women in addressing characteristics such as ethnicity, attitudes, misconceptions, and barriers toward breast cancer screening. The tailoring vehicle (via telephone counseling) with interactive features allows for the delivery of individualized messages that address each individual’s specific cultural beliefs and attitudes that have been associated with participant’s screening behavior.

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Methods

Sample and Setting

The study used prospective randomized controlled trial with 2 groups of Chinese American women to test the feasibility and efficacy of the proposed intervention designed to improve mammography. After recruiting subjects and obtaining the baseline assessment, eligible women were randomized to receive either (1) an interactive, individually tailored telephone counseling intervention (intervention group) or (2) the control condition. Eligibility criteria included (1) self-identification as either Chinese or Taiwanese American, (2) 41 years or older, (3) had not had a mammogram within the past 15 months, (4) never been diagnosed to have breast cancer, and (5) can read and speak English or Chinese. Two community coordinators who were integrated into the Chinese community attended community events and meetings and local English as Second Language classes offered particularly for Chinese to recruit potential participants. The community coordinators gave short presentations in Mandarin or Cantonese (available for presentation in English when requested) to provide information about the study purpose and procedures and to recruit potential study participants. One community coordinator is a well-known radio speaker who also went to several radio shows to make short announcements. Study flyers with announcements about the study were distributed to Chinese organizations and community centers and posted at local ethnic grocery stores, restaurants, beauty salons, and churches/temples. Women who were interested in the study provided their contact information for the study team to conduct eligibility screening and baseline interviews.

During the 19-month recruitment period (March 2010 to July 2011), the project team approached 632 women. Of them, 292 were identified as meeting study eligibility criteria. A total of 193 consented to participate and enrolled in the study (response rate of 66%); among them, 96 were randomized to the intervention group (who received individually tailored telephone counseling) and 97 were randomized to the control group (who received the National Cancer Institute [NCI] mammography brochure). Ninety-five percent of the women (n = 187) completed the baseline surveys and 91% (n = 167) completed the 4-month follow-up survey.

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Intervention Development

A health communications firm worked closely with the research team to develop a Web-based, individually tailored program for the telephone counseling component. The development process included the following steps: (1) Application (computer program) functionality and parameters were specified based on counseling objectives and usability requirements. (2) Application flow and content were outlined to specify the progression of the counseling call and the areas of content to be included in each call. (3) An application concept was produced with a set of interface designs and a partially functioning application. (4) The assessment questionnaire, individually tailored messages, and message selection algorithms were finalized. A group of women (n = 6) who met the study eligibility criteria participated in a field test to identify and correct any items that might be missing or inappropriate from the original message pool and to evaluate appropriateness, usefulness, clarity, and acceptability of the messages and ensure accurate translation of messages into Chinese. Eight-member Advisory Board (consisting of 2 medical professionals, 2 survivors, 2 researchers in cancer control, and 2 community health leaders with backgrounds in Chinese culture) meetings were convened to discuss the results from the field testing and provide recommendations to the research team. During the meetings, the board members reviewed the scripts of messages and provided suggestions on wording revision to ensure accuracy and appropriateness. Their feedback was used to finalize the messages before intervention delivery. (5) A preliminary application was programmed to be fully functional and tested by the research team staff for functionality and accuracy. (6) A feasibility study tested the full application with 20 eligible participants to ensure that the intervention was delivered successfully; any accessibility or usability issues were identified and fixed before full implementation. The final intervention content was revised in an iterative fashion and finalized based on 3 sources: (a) field testing key messages with members of the target community, (b) feedback from the advisory board (both in step 4), and (c) feasibility pilot study of the full application (in step 6).

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Procedure

The study protocol was reviewed and approved by the institutional review board. After screening for eligibility among potential participants and obtaining consent, the research staff conducted the baseline surveys using the Computer-Assisted Telephone Interviewing system. The study team consisted of 2 senior investigators whose specialty was in cancer control intervention and cancer screening disparities in Asian American women and who were consultants in psychology, oncology nursing, and statistics. The staff who conducted interviews were individuals who had at least a bachelor’s degree in health-related field and completed a 2-day intensive training.

Participants were randomized either to the tailored telephone intervention or to the control condition. The intervention group members received an intervention tailored to the results of their baseline interviews. For example, women with responses of “agree or strongly agree” on barriers items and “disagree or strongly disagree” on benefits and self-efficacy items or who incorrectly answered knowledge items were provided with counseling messages related to those items. Cultural issues specific to Chinese American women include perceived barriers (eg, modesty, language) and misconception about the risks of breast cancer were assessed at baseline (using knowledge scale); as a result, the counseling content provided individualized messages that are pertinent to the individual participant based on her responses at baseline assessment. For example, if a woman identified her personal barriers as not being comfortable with a male practitioner during mammography screening and does not know where to go for a mammogram, specific messages were provided to her addressing facilities staffed by female professionals and the locations of mammography screening facilities. The control group received a mammography pamphlet on breast health developed by the NCI. The NCI brochure explains the procedure of mammography and the importance of early detection through mammography. Both groups received assessments at baseline and at 4-month follow-up; at both points, data were collected through structured telephone interviews, and each interview lasted approximately 20 to 30 minutes, whereas the intervention telephone calls could have lasted up to 1 hour. All the interviews and telephone interventions were conducted in Mandarin, Cantonese, or English. The participants were given $30 gift cards as an incentive to participate in the study after completing 2 phases of telephone interviews (Figure 1).

Figure 1

Figure 1

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Instrument

The survey instruments used in this study were developed and validated in previous studies18,26 and translated into Chinese with standard back-translation technique, which included the following subscales:

Outcome variables: The outcome variable was measured by self-report of mammography screening behaviors; in addition, participants indicated whether their last mammogram was screening or diagnostic.

Sociodemographics: Participants’ age, marital status, education, income level, and years of immigration to the United States were assessed with previously used measures.

Knowledge: A 13-item scale developed by the principal investigator was used to measure the women’s knowledge of breast cancer and the risk factors (8 items) and mammography screening guideline recommendations (5 items). An example of an item from the knowledge of breast cancer is “Do you think a woman who has had ovarian cancer is more likely to get breast cancer?” The responses were constructed as yes, no, or don’t know. An example from the mammography screening guideline recommendations is “If a woman your age does not have any family history of breast cancer or other types of cancers, how often do you think she should get a routine mammogram?” Responses included every 1 to 2 years, 3 to 5 years, never, and other. These items were tested in a preliminary study conducted with Chinese, Filipino, and Asian Indian women, and the results have shown excellent internal consistency (Cronbach’s α = .88).21

Mammography-related cognition variables (perceived benefits, barriers, and self-efficacy): Benefits were measured by 5 items that address the positive aspects of mammography screening, such as finding breast cancer early and decreasing chances of dying, for example, “Having a mammogram will help me to find breast lumps early.” Barriers were measured by 15 items that address the negative aspects of mammography screening, such as discomfort, pain, inconvenience, and modesty. An example of an item from this subscale is “It’s difficult to find transportation to go for a mammogram.” Both subscales use 4-point Likert-type scale items and were drawn from previous studies18 and from subsequent qualitative work,27 and the results demonstrated excellent internal consistency, with Cronbach’s α values for the benefit subscale ranging from .86 to .87 and for the barrier subscale from .90 to .91.17,28 Construct validity was supported by exploring the factor structure of the instrument using confirmatory factor analysis and testing correlations with mammography compliance.17 Perceived self-efficacy was measured by the Champion’s 10-item measure, self-efficacy for mammography screening, which measures women’s perceived ability to obtain a mammogram.29 An example of an item from this subscale is “You can arrange other things in your life to have a mammogram.” The responses use a 4-point Likert-type scale (strongly disagree to strongly agree). The subscale demonstrated an internal consistency reliability of .91 and a unidimensional factor structure with all items loaded at .60 or above.30

Intervention evaluation: Participant’s satisfaction toward the intervention was measured using an 18-item process evaluation adopted from the instrument of Brug and colleagues31 for the telephone session and Champion’s current tailored intervention project. The evaluation instrument was translated with standard back-translation procedure to ensure reliability during the process. The instrument included 11 structured Likert-type items that assessed whether participants felt the content was appropriate, relevant, thorough, useful, and clear and 7 open-ended questions.

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Data Management and Analysis

All telephone interview data were entered, and double data entry was completed with SPSS software (version 18) to ensure that the entered data are correct and as clean as possible. Appropriate scales and subscales were computed before data analysis using SPSS. All data files, syntax files (recording computations and data management procedures), and output files were maintained on secure servers. Descriptive statistics including frequency, means, standard deviations, and ranges were used to describe sociodemographic characteristics, screening history, and breast cancer and screening–related knowledge and beliefs.

Power analysis was calculated based on intervention studies in non-Asian American women because effect sizes associated with interventions similar to the current one proposed cannot be found in previous studies of Chinese Americans. At baseline, all participants will be noncompliant according to the eligibility definition. Power for the χ2 test with a sample size of 64 per group (total sample size of 128) to detect a difference computed using PASS software indicated a power of 71% to detect this difference with 2-tailed α of .05.

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Results

There were no statistically significant differences among the intervention and control groups in terms of demographic variables, health access, and other key cognition, knowledge, and previous mammogram intake variables, suggesting that the randomization was successful (Table 1). Most (74%) were between the ages of 41 and 65 years, with a mean (SD) age of 54.6 (9.6) years and a range of 41 to 81 years. Most (78%) were married and 64% had least at least a high school diploma. Almost half of the women reported an annual household income of less than $15000. The study sample consisted of first-generation Chinese American women; more than half of them (55%) had lived fewer than 10 years in the United States (mean [SD] length of residency, 12.4 [9.5] years, range, 1–48 years). Only 58% of them reported that their insurance covered the mammogram. Sixty-seven percent of the women had regular healthcare providers, but only 39% of them reported that they receive recommendations to obtain mammograms from their providers. About one-third (35%) had received their last mammograms 1 to 2 years before the study, 40% of the participants reported 2 years and longer, and 25% had never received 1 in the past.

Table 1

Table 1

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Evaluation of the Individually Tailored Intervention

The postsurvey was conducted at 4 months after the baseline survey was performed using 4-point Likert-scale questions and open-ended questions that measure appropriateness, relevance, thoroughness, usefulness, and clarity of the intervention content. The intervention participants rated all the structured Likert-scale items positively, with more than 90% of agreement on their responses except 1 item (Table 2). Overall, most participants reported that the content was appropriate (93%), relevant (85%–93%), comprehensive in covering various aspects of breast cancer and screening (92%–98%), useful (94%–98%), and clear (91%). Eight-six percent of participants reported that during the telephone call, they received new information about mammography screening that they were not aware of before. One quotation from 1 of the open-ended questions showed how this individually tailored telephone counseling benefits the participant, “What a nice intervention, I really appreciate what you’ve done because it will benefit many other women to learn more of what they need to know about getting mammogram. It also corrects the misconceptions what I previously had and gain correct and updated information about mammogram so I won’t continue to distribute the incorrect information to other friends/women. Because of this project, I learn so much about mammogram and now I can be confident to share what I know with others.”

Table 2

Table 2

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Mammography Utilization at 4 Months After the Interviews

At the baseline, all the women reported that their last mammograms were taken more than 13 months previously. At the 4-month follow-up interviews, 40% of the women (n = 34) in the intervention group compared with 33% of the women in control (n = 27) went to obtain mammograms (χ21 = 1.81, P = ns). It is also noted that more women dropped from the first to the follow-up telephone survey in the control group (16%) versus 10% in the intervention group.

When subanalyses were performed on examining the effects between 2 groups based on insurance status, age group, and the length of residency in the United States, several interesting trends were found. For example, the results showed that for women with insurance covering mammograms, there was a larger difference in the intervention effect (56% in intervention group vs 34%, a 22% difference) (Figure 2). The intervention produced larger effects than control print materials did based on the length of residing in the United States; that is, the results showed the trend that for newer immigrants (ie, women who have stayed in the United States ≤10 years), there was a larger difference of intervention effect (Figure 3). In terms of the age effect (Figure 4), the results showed that for older women (≥65 years), there was a larger difference of intervention effect (51% in intervention group vs 25%, a 25% difference). The χ2 analyses did not find significant differences except among for those who have insurance, in whom the difference between the intervention and control groups is significant (χ21 = 4.98, P = .03).

Figure 2

Figure 2

Figure 3

Figure 3

Figure 4

Figure 4

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Discussion

The Chinese American population is one of the fastest growing populations in the United States; nevertheless, mammography screening is lower compared with mainstream populations. Distinct from culturally targeted interventions that are redirected at a particular population, individually tailored intervention is designed to deliver messages that are more actively processed and considered personally applicable.32,33 A plethora of such studies in the literature have been conducted with the evidence on the effectiveness of tailored telephone interventions to promote compliance with screening mammography34–38; however, none has been conducted in the immigrant Asian American women population. The results presented in this article are the first to report the efficacy of an individually tailored intervention designed to promote mammography screening among Chinese American women in the United States. The study intervention was carefully designed to provide individually tailored counseling for Chinese American women, an underserved immigrant population with limited English ability and limited knowledge toward breast cancer screening.13 Following the guide on the National Cancer Institute, Research-Tested Intervention Program, the mammography telephone counseling protocol was divided into 2 sections: (1) an opening and descriptive section and (2) a theory-guided counseling program, which was based on HBM39 and first assesses the woman’s current state of mammography readiness (perceived benefits, barriers, self-efficacy, and knowledge related to breast cancer screening) and provides appropriate messages, including the importance of complying with mammography screening guidelines, information on low-cost/no-cost mammography programs, and strategies to overcome participant’s identified barrier(s) to getting a mammogram.

Our randomized trial advances previous research by testing and documenting individually tailored intervention effects on a group of Chinese American women in the community and was not limited to one health institution.35,40 Although identifying immigrant Chinese women who have not been adherent to mammography screening is challenging, recruitment through community liaisons who are connected in the Chinese community represents an important culturally sensitive approach. In the current study, we had excellent completion rates at 4-month follow-ups (ie, >90% for both intervention and control groups). Most participants in our study chose to speak Mandarin or Cantonese when they were on the telephone with our study bilingual research staff.

The study results indicate that more women in the intervention group (40%) than in the control group (33%) reported having screening mammograms based on a 4-month follow-up interview; the current study findings were slightly higher than another tailored counseling program,41 which was designed to promote mammography screening among women in the Los Angeles area (37% in the tailored group vs 29% in the control group), and another study42 with tailored messages conducted by advanced practice nurses (29% in the intervention group vs 21% in the control group at 3–6 month follow-up). Similar to the studies of Carney and colleagues43 and Allen and Bazargan-Hejazi,41 the current study found no differences between the print materials and telephone counseling groups, indicating that both interventions had an effect. Maxwell and colleagues44 found that after a print intervention, 38% of Korean women received a mammogram screening compared with 32% in the comparison period, whereas no intervention was implemented. For the women in our control group, the experience of being assessed on study variables at the baseline and receiving an NCI-printed mammogram brochure in Chinese seems to have prompted these women to obtain mammography screening. The current study findings also pointed out that the intervention may be more effective in certain demographic groups (eg, elderly women aged ≥65 years and recent immigrants who have immigrated to the United States for <10 years). The tailored telephone counseling provides more detailed information about screening recommendations specific to participants’ characteristics (eg, being older and immigrants) than the standard mammogram brochure does. Nevertheless, there were only 13% to 15% of study sample in the age 65 years or older groups for both intervention and control; therefore, future studies with a larger sample size will help to better understand best-practice strategies to promote adherence of mammography compliance to those immigrant Chinese women who were nonadherent to routine screening in diverse community-based settings.

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Nursing Implications

Our tailored messages appear to have provided relevant information for motivating specific demographic groups of nonadherent Chinese American women in obtaining mammography screening; in particular, the study findings showed that the individually tailored intervention may be more effective in certain demographic groups, for example, elderly group 65 years or older and recent women who have come to the United States for fewer than 10 years. Oncology nurses and advanced practice nurses can play critical roles in increasing mammography adherence on this medically underserved population that experiences disparities in breast cancer mortality. In particular, they can work collaboratively with Chinese American communities and use the assessment tools developed in this study for Chinese American women on their beliefs and knowledge-related breast cancer screening behaviors and provide individually tailored counseling on breast cancer prevention and early detection to women to change their attitudes and correct any misconceptions regarding mammograms and motivate them in getting the recommended breast cancer screening.

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Limitations

Several factors should be considered. First, we used self-reports of screening mammography instead of chart reviews with medical record verifications. Women may have overreported receiving mammography screening because of social desirability bias. The project team emphasized the importance of accurate reporting during the telephone encounter, a factor that may minimize potential bias. Nevertheless, the magnitude of any inaccuracy in self-report should be similar in both the intervention and control groups. Because of the nonrandomized sample, the findings of this study may not be generalized to Chinese American women with different demographic characteristics. Another possibility of bias lies in the self-selection to participate in the study, and we do not have any data concerning nonrespondents to evaluate potential response bias. The study used a cross-sectional design; future studies with a longitudinal cohort design could provide data to detect intervention effects on the adherence to or repeat mammography screening in this underserved population.

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Conclusion

In conclusion, the study tested a theory-guided individually tailored counseling intervention to promote mammography screening for Chinese American women. The study intervention was well accepted by study participants and was perceived as feasible and culturally appropriate based on process evaluation. The study also demonstrates the feasibility of recruiting and retaining eligible women to participate, and the results show that both study intervention and printed materials increase awareness of the importance of breast cancer screening and screening behaviors. Although both printed and telephone counseling strategies seemed to successfully move the immigrant Chinese population from nonadherence to taking action toward receiving regular mammography screening, future studies with a longitudinal design are needed to elucidate the active ingredients and demonstrate cost-effectiveness to widen our knowledge on regular breast cancer screening in this underserved population.

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ACKNOWLEDGMENTS

This project would not have been possible without the extensive involvement and dedication of Lei-Chun Fung, Shu-Lan Hung, Mei Lun Mui, Ophelia Ng, Carrie Tang, and Joyce Wu. Special thanks to all the Chinese Americans who participated in the study and provided helpful feedback. We appreciate the editorial assistance of Alethea Helbig, who helped the authors to review and improve the manuscript.

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Keywords:

Beliefs; Breast cancer screening; Knowledge

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