Walking the journey of womanhood: Yakama Indian women and Papanicolaou (Pap) test screening

Indigenous women's experiences of cervical cancer screening: Incorporating Indigenous ways of knowing into a systematic review and meta-synthesis of qualitative research

Due to historical and contextual factors, cervical cancer is typically detected at a later stage in Indigenous women, and so has higher morbidity and mortality. Increasing participation in cervical cancer screening (CCS) could ameliorate this health inequity by detecting cancer when it is more easily treatable. To understand the perspectives, preferences, and experiences of Indigenous women related to participation in CCS, we conducted a systematic review and meta-synthesis of nine qualitative research studies. To advance decolonised qualitative evidence synthesis approaches, we use a modified version of the Two Row Wampum-Covenant Chain Tradition, a Haudenosaunee two-eyed seeing analytic approach that integrates Western approaches with Indigenous worldviews. Using the metaphor of a network of forest plants, we illustrate the systemic and topical barriers and facilitators to CCS, as reported by Indigenous women. We use this metaphor to reiterate the importance of all levels of change to improve CCS experiences for Indigenous women.

Creating a safe space for First Nations youth to share their pain

Introduction:

Indigenous children and youth may be quiet about the way they express their pain and hurt which is in contrast to how health professionals are trained to assess it.

Objectives:

The aim was to understand how youth from 4 First Nation communities express pain using narratives and art-based methods to inform culturally appropriate assessment and treatment.

Methods:

This qualitative investigation used a community-based participatory action methodology to recruit 42 youth between 8 and 17 years of age to share their perspectives of pain using ethnographic techniques including a Talking Circle followed by a painting workshop. Physical pain perspectives were prominent in circle conversations, but emotional pain, overlapping with physical, mental, and spiritual pain perspectives, was more evident through paintings. Art themes include causes of pain and coping strategies, providing a view into the pain and hurt youth may experience. Youth were more comfortable expressing emotional and mental pain through their artwork, not sharing verbally in conversation.

Results:

Circle sessions and artwork data were themed using the Indigenous Medicine Wheel. Content of the circle conversations centered on physical pain, whereas paintings depicted mainly emotional pain (eg, crying or loneliness; 74% n = 31) with some overlap with physical pain (eg, injuries; 54%), mental pain (eg, coping strategies; 31%), and spiritual pain (eg, cultural symbols; 30%). Common threads included hiding pain, resilience, tribal consciousness, persistent pain, and loneliness.

Conclusion:

Once a safe space was created for First Nation youth, they provided a complex, culturally based understanding of the pain and coping experience from both an individual and community perspective. These engaging, culturally sensitive research methods provide direction for health providers regarding the importance of creating a safe space for young people to share their perspectives.

Strategies for Increasing Cervical Cancer Screening Amongst First Nations Communities in Northwest Ontario, Canada

The high burden of cervical cancer in Indigenous populations worldwide is due to underscreening and inadequate follow-up. Using qualitative, participatory action research, we interviewed health care staff to identify ways to increase screening recruitment in First Nations communities in Northwest Ontario, Canada. Our findings suggest the value of a multilevel social-ecological model to promote behavioral changes at the community, health care service and stakeholder, and decision-maker level. Participants emphasized the central role of First Nations women as nurturers of life and for the well-being of their family members. They stressed the importance of building awareness and motivation for cervical cancer screening through various activities including continuous education, hosting screening events specifically for women, improving the attitude and service of health care providers, and promoting screening tools and policies that complement and are respectful of First Nations women.

Conducting a Feasibility Study in Women's Health Screening Among Women in a Pacific Northwest American Indian Tribe

Breast and cervical cancers continue to contribute to high cancer mortality rates in American Indian/Alaska Native women; culturally appropriate interventions are needed to influence screening behaviors and to reduce delays in obtaining care. In a pilot feasibility study designed to influence Pacific Northwest American Indian/Alaska Native women's health screening knowledge and behaviors (breast and cervical), we employed a community-based participatory research approach. Data from interviews with study participants, those involved in implementation of the study and observations were included in the analysis. Study questions focused on training of staff, recruitment of participants, and implementation of the protocol and data management. The complexities of translational, transcultural research and the importance of reporting pilot feasibility studies to the advancement of transcultural research are highlighted in the findings of this research effort.

Living with diabetes in the 4-fold World of the Coeur d' Alene tribe

Despite national initiatives, diabetes disproportionately affects Native Americans. Although many studies have focused on the needs of Native Americans for culturally relevant diabetes programs, few have focused on Northwest tribes. This article presents the results of a phenomenological study exploring the experience of Coeur d'Alene tribal members living with type 2 diabetes. The main theme to emerge was perseverance while balancing tensions between burdens and strengths in 4 areas: valuing tribal traditions, being inattentively caring, struggling with disease burdens, and experiencing patient-provider tensions. This article provides new understanding about barriers and supports for diabetes self-management in one Native American tribe.

Development of culturally tailored educational brochures on HPV and pap tests for American Indian women

PURPOSE

Participatory formative research guided the creation of a culturally tailored educational brochure about human papillomavirus (HPV) at an American Indian women's clinic.

METHOD

A review of existing educational materials and in-depth interviews were conducted. Nine steps for creating health communications messages that were patterned after National Cancer Institute guidelines guided the brochure development process.

RESULTS

Of 95 women tested for HPV, 41% were positive, 32 (34%) agreed to the in-depth interview, and 9 agreed to the pretesting interview. Mean age was 41 years. Interviews revealed key themes concerning emotional reactions to abnormal Pap test results and HPV; need for basic information about HPV, Pap tests, and results; concerns about HPV stigma, sexual transmission, and communication with sexual partner; and the preferred source and format for HPV educational materials. A literature review revealed 12 areas of basic HPV content.

CONCLUSIONS

A participatory process successfully engaged nursing staff and patients in creating culturally appropriate brochures for clinic use.

IMPLICATIONS

This article provides specific steps for creating culturally tailored patient education materials.

Effect of tribal language use on colorectal cancer screening among American Indians

American Indians have one of the lowest colorectal cancer (CRC) screening rates for any racial/ethnic group in the U.S., yet reasons for their low screening participation are poorly understood. We examine whether tribal language use is associated with knowledge and use of CRC screening in a community-based sample of American Indians. Using logistic regression to estimate the association between tribal language use and CRC test knowledge and receipt we found participants speaking primarily English were no more aware of CRC screening tests than those speaking primarily a tribal language (OR = 1.16 [0.29, 4.63]). Participants who spoke only a tribal language at home (OR = 1.09 [0.30, 4.00]) and those who spoke both a tribal language and English (OR = 1.74 [0.62, 4.88]) also showed comparable odds of receipt of CRC screening. Study findings failed to support the concept that use of a tribal language is a barrier to CRC screening among American Indians.

Utilization of the Native American Talking Circle to teach incident command system to tribal community health representatives

The public health workforce is diverse and encompasses a wide range of professions. For tribal communities, the Community Health Representative (CHR) is a public health paraprofessional whose role as a community health educator and health advocate has expanded to become an integral part of the health delivery system of most tribes. CHRs possess a unique set of skills and cultural awareness that make them an essential first responder on tribal land. As a result of their distinctive qualities they have the capability of effectively mobilizing communities during times of crisis and can have a significant impact on the communities' response to a local incident. Although public health emergency preparedness training is a priority of federal, state, local and tribal public health agencies, much of the training currently available is not tailored to meet the unique traits of CHRs. Much of the emergency preparedness training is standardized, such as the Federal Emergency Management Agency (FEMA) Training Programs, and does not take into account the inherent cultural traditions of some of the intended target audience. This paper reports on the use of the Native American Talking Circle format as a culturally appropriate method to teach the Incident Command System (ICS). The results of the evaluation suggest the talking format circle is well received and can significantly improve the understanding of ICS roles. The limitations of the assessment instrument and the cultural adaptations at producing changes in the understanding of ICS history and concepts are discussed. Possible solutions to these limitations are provided.

Cervical Screening in Canadian First Nation Cree Women

Purpose: Attitudes and beliefs of First Nation Cree women living in a reserve community were explored to gain insights into how cervical screening could be better utilized. Method: Focused ethnography utilizing participant observation and interviews ( n = 8) with participants having experience with cervical screening and/or cancer was conducted. Results: Women did not believe they had adequate information and were resistant to screening because of embarrassment caused by the procedure and fear of cancer, which was viewed as a “death sentence.” Conclusions: Challenges faced by First Nation Cree women when contemplating cervical screening are presented. Nursing sensitivity is needed to strategize access to cervical screening that is culturally appropriate.

Development of a culturally specific instrument for mammography screening: an example with American Indian women in Vermont

This article presents the triangulation process for translating qualitative data about mammography screening from a grounded theory study with American Indian women in Vermont, into questionnaire items based on an existing model of behavior change, the Transtheoretical Model (TTM) Stages-of-Change. Qualitative data were used to derive a theory, Moving in Between Mammography, which suggested that traditionality influenced American Indian women's screening decisions. To examine the relationship between mammography and traditionality, new items were developed for each of three key TTM constructs: Pros, Cons, and Processes-of-Change. The process for developing the new TTM-based items, as well as traditionality items specific for American Indian women living off-reservation, are presented. This article provides one example of how an instrument can be developed within a culturally competent nursing framework.

Challenges in community-based participatory research implementation: experiences in cancer prevention with Pacific Northwest American Indian tribes

BACKGROUND

Much has been written about community-based participatory research (CBPR) history and principles, but few have addressed challenges in implementation in transcultural situations. The goal of this discussion is to address CBPR implementation issues in cancer prevention research with American Indian tribal communities in the Pacific Northwest.

METHOD

Information in this discussion is drawn from qualitative research conducted over a 10-year period in which CBPR was employed in cancer prevention research with Pacific Northwest Indian tribes. CBPR principles provide the framework for the discussion: establishing trusting relationships, assuring participation, sharing power, and communicating.

RESULTS

In this work, we found that CBPR is appropriate for use in Pacific Northwest Indian tribal communities and is compatible with cultural values. We also found that there are many challenges. Recommendations are provided on needed institutional and structural changes.

CONCLUSIONS

CBPR is an important research approach in addressing cancer prevention health disparities among American Indian tribal communities. Continued effort needs to be directed toward creating systems and structures to support researchers in utilizing this method. Findings are of value to researchers aiming to implement CBPR in Indian communities and to practitioners, policy makers, and administrators who make decisions about CBPR funding and support structures.

Environmental, social, and personal correlates of having ever had sexual intercourse among American Indian youths

OBJECTIVES

We examined the correlates of having ever had sexual intercourse among American Indians aged 13 to 18 years in Minnesota.

METHODS

To assess key environmental, social, and individual correlates of sexual experience, we analyzed data from 4135 American Indian youths who participated in the 1998 and 2001 Minnesota Student Surveys.

RESULTS

Forty-two percent of those aged 13 to 15 years and 69% of those aged 16 to 18 years reported that they had ever had sexual intercourse. Correlates of sexual experience varied by age and gender. School connections had the strongest negative associations with sexual experience in young girls, and living with a father had negative associations with sexual experience for younger, but not older, youths. Sexual experience was most strongly and positively associated with risk behaviors such as substance use, violence exposure, and violence perpetuation.

CONCLUSIONS

The strongest correlates of sexual experience for American Indian youths were high-risk behaviors and exposure to violence. Future work is needed to develop and employ measures that reflect youth assets and that specifically reflect the experiences of American Indian youths.

Building a community-based participatory research center to investigate obesity and diabetes in Alaska Natives

The Center for Alaska Native Health Research (CANHR) is a community-based participatory research project aimed at understanding current risk factors for obesity, diabetes, and cardiovascular disease in Alaska Natives living in Southwest Alaska. We utilize a multidisciplinary approach that includes assessment of genetic, nutritional and behavioral risk factors and their interrelationships with one another in the overall development of disease. The design of the CANHR project involved community participation in the development, implementation and interpretation of research results. We have developed a participatory research program that is designed to be culturally appropriate, relevant to community needs and interests, and respectful to our participants. This manuscript describes the organizational development of our CANHR study and the procedures employed in its progression to date.

Participatory development of a cervical health brochure for Apsáalooke women

BACKGROUND

One challenge for eliminating health disparities is increasing the cultural sensitivity of educational systems including printed educational materials. These materials can be effective in changing health knowledge, attitudes, and behaviors. Participatory community-based processes are vital in creating culturally sensitive interventions.

METHODS

We held community meetings in 4 communities on the Apsáalooke Reservation. We gave women examples of cervical health pamphlets and held modified focus groups to gather information on women's preferences.

RESULTS

Women provided detailed feedback and we developed an Apsáalooke-specific educational pamphlet.

CONCLUSION

These results support a participatory process for overall project guidance.

Participant experiences of Talking Circles on type 2 diabetes in two Northern Plains American Indian Tribes

The Talking Circle, a culturally appropriate, 12-week educational intervention, was employed on two Northern Plains American Indian reservations to provide information on type 2 diabetes. In a phenomenological study, funded as a minority supplement to the Talking Circle intervention, the authors asked 8 American Indian participants of the Talking Circle to describe their experience of being an American Indian Talking Circle participant. Seven common themes describe the phenomenon of participating in a Talking Circle diabetic intervention. The Talking Circle technique was effective in providing information on type 2 diabetes through culturally appropriate community sharing. Type 2 diabetes is viewed by both outsiders and those involved as a chronic disease of the utmost concern in American Indian communities.

The experience of native peer facilitators in the campaign against type 2 diabetes

CONTEXT

The use of peer facilitators in health programs has great potential. One important application is prevention and control of type 2 diabetes among American Indians.

PURPOSE

To explore the experience of American Indian facilitators in a culturally appropriate intervention (Talking Circles) on 2 Northern Plains reservations. The Talking Circles offered a forum for educational dialogue on diabetes risk factors and the management of type 2 diabetes.

METHODS

Phenomenology, a qualitative research approach, was used to answer the research question: "What did Native Talking Circle facilitators experience?" Participants were 4 lay health workers from the intervention reservations who had been trained to present a diabetes curriculum while coordinating and guiding the group discussion. During open-ended, taped interviews, the facilitators shared their experiences conducting the Talking Circles. Analysis categorized the experiences into common themes to explain the phenomena and cultural construction of oral discussions (Talking Circles) of diabetes.

FINDINGS

Themes included the concept of "a calling" to do the work, which included a self-growth process, a blending of 2 worldviews as a diabetes intervention strategy, the importance of translating educational materials in a liaison role, and commitment to tribal people and communities.

CONCLUSIONS

The experience of the facilitators was positive because they were knowledgeable about American Indian culture and worldview and were trained in both Talking Circle facilitation and type 2 diabetes.

Screening and early detection among racial and ethnic minority women

OBJECTIVES

To highlight sociocultural factors reported to influence and strategies to promote breast and cervical cancer screening and early detection behaviors of racial and ethnic minority women.

DATA SOURCES

Published articles, book chapters, and reports.

CONCLUSIONS

The most successful strategies for promoting screening and early detection among racial and ethnic minority women are collaborative and include approaches that are culturally sensitive and appropriate.

NURSING IMPLICATIONS

Intercultural and intracultural differences in racial and ethnic minority women challenge nurses to explore strategies that focus on the health care provider, the health care delivery system, and the individual woman within the context of the woman's culture.

'I got a letter...' a qualitative study of women's reasoning about attendance in a cervical cancer screening programme in urban Sweden

OBJECTIVE

This explorative study aims at investigating how 'healthy' women describe and reason about participation in a cervical cancer screening programme in Sweden. The study is part of a multidisciplinary research project studying a population-based cervical cancer-screening programme from the perspective of different actors.

SETTING AND METHODS

Data collection took place at three ante-natal health centres (ANHCs) in demographically diverse areas in the Stockholm region in spring 1995. Interviews were conducted and audiotaped with 66 'healthy' women at the ANHCs immediately before taking a Papanicolau test. Open questions such as 'Why have you come here today?' and 'What kind of test will you take?' were used to initiate the interview. Verbatim transcripts were analysed with a modified phenomenographical method to identify and describe qualitatively different ways of understanding cervical cancer screening.

RESULTS

Four different ways of reasoning about cervical cancer screening are described, with only one similar to the biomedical rationale for screening with focus on attending for the test/results. Two types of reasoning refer to the invitation letter as a catalyst, with one emphasizing benefits in attendance and the second emphasizing hinders to attendance. A final way of reasoning focuses on the individual's own proactive role in prevention. Common themes are also identified.

IMPLICATIONS

This study complements the research literature by providing a better knowledge base of the variations in reasoning among women attending screening, often seen as a homogenous group. It can contribute to better adapting the screening situation to the varied needs and expectations of the women who attend.

Recruitment of American Indians and Alaska Natives into clinical trials

Challenges in recruiting American Indians and Alaska Natives into cancer clinical trials are addressed in this article. Researchers, health care providers, and American Indian and Alaska Native patients face significant communication barriers when prevention or treatment trials are designed or implemented. For researchers, the challenges lie in understanding the cultural distinctiveness of individual tribes, coping with the family orientation of Indian subjects, dealing with the lack of standardized research measures, and defining the subject's pathway in seeking and obtaining healing and health care services. For providers, the challenges center on patient-provider communication, illness beliefs, transportation, and sociocultural barriers. This article explores these complex issues and offers recommendations for researchers and health care providers on conducting research in American Indian and Alaska Native populations.

An inpatient cervical cancer screening program to reach underserved women

Underserved women (e.g., African American, older women of all races) are less likely to be screened than other groups. The Johns Hopkins Hospital began the Cervical Cancer Screening Program (CCSP) to provide direct Papanicolaou (Pap) test screening to inpatient females. Over a 1-year period, 256 women received Pap tests as part of the CCSP. Of these, 56% (n = 144) were African American, 36% (n = 92) received medical assistance benefits, and only 47% (n = 120) had health insurance. The CCSP is an effective way to screen low-income and underserved females who otherwise may not be screened.

Breast and cervical cancer screening practices among American Indian and Alaska Native women in the United States, 1992-1997

BACKGROUND

Recent studies suggest that American Indian and Alaska Native women have important barriers to cancer screening and underuse cancer screening tests.

METHODS

We examined the breast and cervical cancer screening practices of 4,961 American Indian and Alaska Native women in 47 states from 1992 through 1997 by using data from the Behavioral Risk Factor Surveillance System.

RESULTS

About 65.1% [95% confidence interval (CI) 60.2 to 69.9%] of women in this sample aged 50 years or older had received a mammogram in the past 2 years. About 82.6% (95% CI 80.1 to 85.2%) of women aged 18 years or older who had not undergone a hysterectomy had received a Papanicolaou test in the past 3 years. Older women and those with less education were less likely to be screened. Women who had seen a physician in the past year were much more likely to have been screened.

CONCLUSIONS

These results underscore the need for continued efforts to ensure that American Indian and Alaska Native women who are elderly or medically underserved have access to cancer screening services.

Cultural views of cancer around the world

Social attitudes toward cancer, participation in early detection and screening services, and compliance with treatment are all known to be profoundly affected by cultural beliefs and norms. It is thus imperative that oncology nurses develop cultural competence and deliver culturally sensitive care. Cross-cultural nursing studies also require cultural sensitivity because they rely on the accurate choice of culturally relevant research methods. However, the specific steps that should be taken to enhance the cultural relevance of both nursing health care delivery and nursing research have yet to be elaborated. This article aims to clarify these issues on the basis of a critical survey of the literature on cultural views of cancer in multiethnic societies and in various countries around the world. The analysis of studies focusing on this subject illuminates misconceptions that may interfere with the application of cancer nursing to other cultures, and possible misinterpretations of cultural and cross-cultural research findings. The conclusions drawn from this analysis concern practical means for facilitating nurses' ability to properly address cultural diversity through the incorporation of culture-related variables into nursing interventions. They also relate to the education of nurses about cross-cultural aspects of cancer, culturally sensitive assessment tools, comparative studies, and theories in the field of international cancer nursing, all of which await further development.