Mobile Web App Intervention to Promote Breast Cancer Screening Among American Indian Women in the Northern Plains: Feasibility and Efficacy Study.

BACKGROUND: Breast cancer is the most common cancer in the United States and the second leading cause of death for American Indian women. American Indian women have lower rates of breast cancer screening than other racial groups, and disparities in breast cancer mortality and survival rates persist among them. To address this critical need, a culturally appropriate, accessible, and personalized intervention is necessary to promote breast cancer screening among American Indian women. This study used mobile health principles to develop a mobile web app-based mammogram intervention (wMammogram) for American Indian women in a remote, rural community in the Northern Plains. OBJECTIVE: This study aimed to assess the feasibility and efficacy of the wMammogram intervention, which was designed to motivate American Indian women to undergo breast cancer screening, as compared with the control group, who received an educational brochure. METHODS: Using community-based participatory research (CBPR) principles and a multipronged recruitment strategy in a randomized controlled trial design, we developed the wMammogram intervention. This study involved 122 American Indian women aged between 40 and 70 years, who were randomly assigned to either the intervention group (n=62) or the control group (n=60). Those in the intervention group received personalized and culturally appropriate messages through a mobile web app, while those in the control group received an educational brochure. We measured outcomes such as mammogram receipt, intention to receive breast cancer screening after the intervention, and participants' satisfaction with and acceptance of the intervention. RESULTS: A significantly higher proportion of women who received the wMammogram intervention (26/62, 42%; P=.009) completed mammograms by the 6-month follow-up than the control group (12/60, 20%). The wMammogram intervention group, compared with the control group, reported significantly higher ratings on perceived effectiveness of the intervention (t120=-5.22; P<.001), increase in knowledge (t120=-4.75; P<.001), and satisfaction with the intervention (t120=-3.61; P<.001). Moreover, compared with the brochure group, the intervention group expressed greater intention to receive a mammogram in the future when it is due (62/62, 100% vs 51/60, 85%) and were more willing to recommend the intervention they received to their friends (61/62, 98.4% vs 54/60, 90%) with statistically significant differences. CONCLUSIONS: This study shows the feasibility and efficacy of the wMammogram intervention to promote breast cancer screening for American Indian women in a remote, rural community-based setting. Findings suggest that, with advancements in technology and the ubiquity of mobile devices, mobile web apps could serve as a valuable health intervention tool that builds upon low-cost technology and enhances accessibility and sustainability of preventive care to help reduce breast health disparities experienced in hard-to-reach American Indian populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT05530603; https://clinicaltrials.gov/ct2/show/NCT05530603.

Determinants of Life Satisfaction and Quality of Life Among American Indian Women Cancer Survivors: The Role of Psychosocial Resources.

PURPOSE: This study assessed the relationship of spirituality, social support, and sense of mastery to life satisfaction and quality of life to identify viable psychosocial coping resources among American Indian (AI) women cancer survivors. METHOD: We conducted a cross-sectional survey of 73 AI women cancer survivors residing in South Dakota. A series of multivariate hierarchical regression analyses was conducted. RESULTS: Findings indicated that lower self-rated physical health was consistently associated with lower levels of life satisfaction and quality of life. Spirituality was found to be the most influential predictor for life satisfaction, while social support and sense of mastery were two significant predictors for quality of life. DISCUSSION: Our data underscored the importance of spirituality, social support, and sense of mastery to the well-being of AI women cancer survivors and as effective coping strategies to mitigate life stressors. Implications of this evidence for the design of cancer preventions and interventions are discussed.

Andersen's Behavioral Model to Identify Correlates of Cervical Cancer Knowledge among American Indian Women.

OBJECTIVE: Using the Andersen's behavioral model of health services use as a framework, this study aims to examine factors (predisposing, needs, and enabling) related to American Indian (AI) women's cervical cancer knowledge. METHODS: Andersen's behavioral model of health services was used to examine factors predisposing, needs, and enabling related to AI women's cervical cancer knowledge. A sample of 259 AI women residing in the Northern Plains was recruited using a convenience sampling strategy. Cervical cancer knowledge was measured using guidelines from the American Cancer Society. Three predisposing factors, six enabling factors, and four need factors were observed.  Result: The mean score of knowledge was 9.11 out of 13. Higher cancer knowledge was associated with 3 enabling factors (higher education, higher HPV knowledge, and use of TV/radio to gain health literacy) and one needs factor (experience in hospitalization). CONCLUSION: Our findings indicate that culturally sensitive educational interventions, especially those using media, to increase cervical cancer knowledge are needed among AI women.

Developing Culturally Tailored Mobile Web App Education to Promote Breast Cancer Screening: Knowledge, Barriers, and Needs Among American Indian Women.

American Indian (AI) women face disproportionate rates of breast cancer mortality and cancer disparities. This study conducted qualitative research to assess perspectives of AI women towards breast cancer screening, knowledge, barriers, and needs about mobile web app-based education to promote breast cancer screening. This study, in collaboration with the Yankton Sioux Tribe (YST), followed a community-based participatory research approach and conducted two focus groups with a total of 22 YST women aged 40-70 years living on reservation in rural South Dakota. Each group consisted of 11 local professionals working in healthcare and social services and community members. A grounded theory was used for the qualitative analysis. A large portion of participants reported having prior knowledge about breast cancer and screening methods, yet lacked awareness of the detailed procedure and recommended guidelines. Competing priorities and cost of mammograms were noted as major barriers to screening. Participants wanted to learn-in a convenient and easy-to-understand manner-more about breast cancer and prevention from a credible source. Both groups were favorable toward novel educational tools, such as the mobile web app education, and cited potential health benefits, particularly for women aged 40s to 60s. Our findings highlighted the importance of creating effective, culturally tailored educational interventions built into programs specific to AIs to increase understanding about breast cancer screening and promote screening behaviors among AI women. Particular attention to how AIs' culture, beliefs, and barriers are implicated in screening behaviors could help with developing culturally tailored health education tools for this population.

Protective Factors against Depressive Symptoms in Female American Indian Cancer Survivors: The Role of Physical and Spiritual Well-being and Social Support.

BACKGROUND: This exploratory study examined how perceived physical well-being, spiritual well-being and social support relate to depressive symptoms among American Indian (AI) female cancer survivors. METHODS: Cross-sectional data were obtained from 73 AI female cancer survivors between 32 to 77 years of age in the Midwest of the United States. Standardized measures were used to assess for depression (Center for Epidemiologic Studies Depressive Symptoms Scale Short Form), spiritual well-being (Functional Assessment of Chronic Illness Therapy, Spiritual Well-being Scale), and social support (Medical Outcomes Study of Social Support Questionnaire). A single item measured physical well-being. After univariate and bivariate analyses, hierarchical multiple regression (HMR) was used for modeling. RESULTS: Approximately 47% of the sample scored higher than 10 on the depressive symptoms scale. HMR results indicated that perceived physical well-being, spiritual well-being, and social support were negatively associated with depressive symptoms, accounting for 47% of the variance in the final model (adjust R2 = 0.47). CONCLUSIONS: A high percentage of the sample exceeded the cut point for probable depression, highlighting the importance of addressing mental health in the aftermath of cancer treatments for AI women. Results suggest that perceived physical well-being, spiritual well-being, and social support serve as protective factors and possible levers to reduce depression in this population. Interventions designed to bolster existing social support and spirituality could improve the mental health of AI women in the aftermath of cancer treatment. Community-based, culturally appropriate health education programs should be developed to enhance AI women's physical health. 
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The Resilience of Indigenous Women of the U.S. Who Experience Cancer: Transcending Adversity.

Almost no research specifically explores resilience among Indigenous women of the U.S. who experience cancer. A qualitative descriptive study included a sample of 43 Indigenous women from the Northern Plains region of the U.S. Almost 90% (88%, n=37) of participants indicated personal growth in response to having cancer, indicating they valued relationships (n=3), had a stronger faith (n=5), were grateful and living in moment (n=21), were healthier (n=5), and helped others (n=6) in response to their cancer experience. Results indicate that factors that promote and facilitate resilience are critical for culturally responsive practice with Indigenous women.

American Indian Alcohol Use from a Sex-Specific Wellness Approach: Exploring Its Associated Physical, Behavioral, and Mental Risk and Protective Factors.

PURPOSE: The top causes of death for American Indians (AIs), including heart and liver disease, are associated with alcohol use. Using the culturally based Framework of Historical Oppression, Resilience, and Transcendence (FHORT), the purpose of this article was to examine AI alcohol use from a sex-specific wellness approach, exploring its associated physical, behavioral, and mental risk and protective factors. METHOD: Data were drawn from a cross-sectional survey with 479 AI adults in South Dakota. We employed a series of multiple hierarchical regression analyses to assess the associations of demographic (sex, age, marital status, income, and educational attainment), physical (Body Mass Index and cardiovascular risk), behavioral (smoking and health self-efficacy) and mental (depressive symptoms) factors with alcohol use. RESULTS: Results indicated that surveyed males tended to drink three times that of females, and depressive symptoms were associated with higher levels of alcohol use. DISCUSSION: This study highlights the need to examine AI alcohol use with sex in mind.

American Indian women cancer survivors' perceptions and experiences with conventional and non-conventional mental health care for depressive symptoms.

Background: Despite cancer and depression being disproportionately high for American Indian and Alaska Native (AI/AN) women, such cancer survivors' help-seeking practices and perceptions related to depression are absent in extant research. A broader context of historical oppression has set the stage for unequal health outcomes and access to quality services. The purpose of this article was to explore AI women cancer survivors' experiences with conventional mental health services and informal and tribally-based assistance, as well as barriers related to mental health service utilization.Methods: A qualitative descriptive study methodology, with qualitative content analysis, was used to examine the experiences of AI women cancer survivors as they related to help-seeking experiences for depressive symptoms. The sample included 43 AI women cancer survivors (n = 14 breast cancer, n = 14 cervical cancer, and n = 15 colon and other types of cancer survivors).Results: Since receiving a cancer diagnosis, 26 (62%) participants indicated they had feelings of depression. Some participants (n = 13) described mixed perceptions of the mental health service system. Generally, participants viewed families and informal support systems as primary forms of assistance, whereas conventional services were reported as a supplementary or 'as needed' forms of support, particularly when the informal support system was lacking. Participants received help in the forms of psychotropic medications and psychotherapy, as well as help from family and AI-specific healing modalities (e.g. sweat lodges and healing ceremonies). Stigma and confidentiality concerns were primary barriers to utilizing conventional services as described by 12 (29%) participants.Discussion: Participants' help primarily came from family and tribally-based entities, with conventional mental health care being more salient when informal supports were lacking. The mixed perceptions espoused by participants may be related to a broader context of historical oppression; family and social support and tribally-based services may be protective factors for cancer survivors with depression.

Family: The Bedrock of Support for American Indian Women Cancer Survivors.

Cancer disparities among American Indian (AI) women are alarming, yet a dearth of research focuses on the role of family support for such women. The purpose of this research was to examine the composition of AI women cancer survivors' family support networks and the types of support that they provided. We used a qualitative descriptive methodology with 43 AI women cancer survivors and qualitative content analysis, which indicated that 38 participants (approximately 90%) reported that their families provided integral and varied forms of support, especially instrumental support throughout cancer experiences. Families were the bedrock of support for AI women cancer survivors.

American Indian Women Cancer Survivors' Spiritual and Religious Coping Practices.

Despite AI women's cancer disparities being a public health concern, a dearth of research on this populations' spiritual coping poses a barrier to redressing such disparities. The purpose of this article was to explore AI women cancer survivors' spiritual and religious coping. This qualitative descriptive study included a sample of 43 AI women cancer survivors. Qualitative content analysis revealed that 93% of AI women cancer survivors used a variety of AI spiritual coping, religious coping, and/or a mixture of the two. Results reveal the prevalence of AI spiritual coping, with traditional AI spiritual practices being particularly common.

Andersen's Behavioral Model to Identify Correlates of Breast Cancer Screening Behaviors among Indigenous Women.

This study examined predictive models of utilization of mammograms among Indigenous women adapting Andersen's behavioral model. Using a sample of 285 Indigenous women residing in South Dakota, nested logistic regression analyses were conducted to assess predisposing (age and marital status), need (personal and family cancer history), and enabling factors (education, monthly household income, mammogram screening awareness, breast cancer knowledge, self-rated health, and cultural practice to breast cancer screening). Results indicated that only 55.5% of participants reported having had a breast cancer screening within the past 2 years. After controlling for predisposing and need factors, higher education, greater awareness of mammogram, and higher utilization of traditional Native American approaches were significant predictors of mammogram uptake. The results provide important implications for intervention strategies aimed at improving breast cancer screening and service use among Indigenous women.

American Indian Women Cancer Survivor's Needs and Preferences: Community Support for Cancer Experiences.

Cancer (the focus of this inquiry) is the leading cause of death among American Indian and Alaska Native women. The purpose of this study was to identify American Indian women cancer survivors' needs and preferences related to community supports for their cancer experience. This qualitative study examined female American Indian cancer survivors' needs and preferences about community support. The sample included 43 American Indian women cancer survivors (the types of cancer survivors included cervical cancer: n = 14; breast cancer: n = 14; and colon and other types: n = 15) residing in the Northern Plains region, in the state of South Dakota. Data were analyzed using qualitative content analysis and were collected between June of 2014 and February of 2015. When asked about their needs and preferences, 82% of participants (n = 35) of female American Indian cancer survivors reported at least one of the following most commonly reported themes: cancer support groups (n = 31, 72%), infrastructure for community support (n = 17, 40%), and cancer education (n = 11, 26%). In addition to the aforementioned themes, 33% of participants (n = 14) indicated the need for an improved healthcare system, with 11% (n = 5) of participants expressly desiring the integration of spirituality and holistic healing options. The majority of American Indian women cancer survivor participants of this study identified a need for more community-based support systems and infrastructures to aid with the cancer survivor experience. Results warrant a community approach to raise awareness, education, and support for American Indian cancer survivors.

Identifying risk and protective factors related to depressive symptoms among Northern Plains American Indian women cancer survivors.

Cancer is the leading cause of death among American Indian and Alaska Native (AIAN) women, and depressive symptoms have been linked to higher mortality, but research on depressive symptoms among AIAN cancer patients has been scant. The purpose of this exploratory study was, using the Framework of Historical Oppression, Resilience, and Transcendence, to examine risk and protective factors related to depressive symptoms in American Indian (AI) women cancer survivors. We examined the relationships of adverse childhood experiences (ACE), perceived health status, resilience, and social support with depressive symptoms in Northern Plains AI women cancer survivors. We used a cross-sectional design with purposive sampling of 73 female cancer survivors (aged 18 years or older) between June 2014 and February 2015. Hierarchical multiple regression was used to test three sets of variables in relation to depressive symptoms: (1) sociodemographics, (2) risk factors (ACE and perceived health), and (3) protective factors (psychological resilience and social support). Approximately 47 percent of participants had probable depressive symptoms. Depressive symptoms were inversely associated with perceived health, psychological resilience, and social support. These results support bolstering existing social support among AI cancer patients and survivors as well as prevention and intervention efforts that strengthen resilience.

American Indian women cancer survivors' coping with depressive symptoms.

OBJECTIVE: Depressive symptoms have been identified as a primary predictor of quality of life among cancer patients. Depression and cancer are co-occurring and disproportionately elevated for American Indian and Alaska Native (AI/AN) women. The purpose of this article is to examine American Indian (AI) women cancer survivors' coping mechanisms for depressive symptoms. RESEARCH APPROACH: The methodology included a qualitative descriptive approach with conventional content analysis to examine the coping strategies of AI women cancer survivors associated with depressive symptoms. The interview guide was semi-structured and developed in collaboration with a community advisory board (CAB). Data-derived qualitative analysis was used to generate codes inductively from the data. PARTICIPANTS: A sample of 43 AI women cancer survivors (n = 14 cervical cancer, n = 14 breast cancer, and n = 15 other cancers) from the Northern Plains region, in the state of South Dakota were interviewed. Data were collected from June 2014 to February 2015. Methodological approach: Qualitative content analysis was used for data analysis, which allowed themes to emerge inductively from the data. Analysis revealed 430 preliminary codes. After de-briefing, validation, and discussion among coauthors, these were then sorted into 67 codes. Member checks with all available participants were conducted to minimize misinterpretation. FINDINGS: A total of 26 participants (62%) indicated they had feelings of depression since their cancer diagnosis. Women coped with depressive feelings by (a) participating in faith traditions; (b) seeking creative and positive outlets; (c) martialing family and social support; and (d) keeping busy with other life activities. INTERPRETATION: AI women experienced depressive symptoms following a cancer diagnosis and used a variety of positive coping mechanisms to create personal meaning. Implications for Psychosocial Providers or Policy: AI women may need unique support following a cancer diagnosis, and interventions should incorporate AI beliefs and traditions, such as storytelling and talking with family and community members.

Understanding the social and community support networks of American Indian women cancer survivors.

Cancer is the leading cause of death among American Indian and Alaska Native (AI/AN) women. Although cancer disparities among AI women are alarming, there is littlle research focused on the topic of social support and cancer treatment and outcomes. A community advisory board was used to develop and administer the project, and a qualitative descriptive study methodology was used. This research was conducted in partnership with two community-based hospitals in the Northern Plains. The sample included 43 AI female cancer survivors who were interviewed with a semi-structured interview guide. The data were analyzed using content analysis. Emergent themes revealed that AI cancer survivors' non-familial support systems included friends (n = 12), support groups (n = 6), churches (n = 10), co-workers (n = 5), communities (n = 4), support from health practitioners (n = 3), and additional forms of support. Results indicate that survivors' networks are diverse and support broad prevention programs that reach out to churches, community groups, and online forums. These sources of supports can be enhanced through sustainable community-based infrastructures.

Prayer and Faith: Spiritual Coping among American Indian Women Cancer Survivors.

Although cancer disparities among American Indian (AI) women are alarming, research on spiritual coping among this population is virtually nonexistent. This is particularly problematic, given the importance of medical practitioners' discussing the topic with cancer patients, along with the centrality of spirituality to many AI patients. The purpose of this article was to explore AI women cancer survivors' spiritual coping with their experiences. Using a community-based participatory research approach, this qualitative descriptive study included a sample of 43 AI women cancer survivors (n = 14 breast cancer, n = 14 cervical cancer, and n = 15 colon and other types of cancer). Qualitative content analysis revealed that most participants (76 percent, n = 32) cited prayer as an important part of their cancer recovery and coping strategies. Many participants expressed how prayer and spirituality connected them to family, to faith communities, and to others. In addition to prayer, over a third (36 percent, n = 15) of participants emphasized faith as a recovery and coping strategy. Results indicate that most women drew great comfort, strength, hope, and relief from their spiritual and faith traditions, indicating that religious and spiritual practices may be an important protective factor against the strain of the cancer experience.

Healthcare barriers and supports for American Indian women with cancer.

Although American Indian (AI) women continue to experience cancer at higher rates and have not seen the same decline in cancer prevalence as the general U.S. population, little research examines how interactions with health care providers may influence and exacerbate these health disparities. The purpose of the study was to understand the experiences of AI women who receive cancer treatment, which is integral for eradication of AI cancer disparities among women. A qualitative descriptive methodology was used with a sample of 43 AI women with breast, cervical, colon, and other types of cancer from the Northern Plains region of South Dakota. Interviews were conducted from June 2014 to February 2015. Qualitative content analysis revealed that women experienced: (a) health concerns being ignored or overlooked; (b) lack of consistent and qualified providers; (c) inadequate healthcare infrastructure; (d) sub-optimal patient-healthcare provider relationships; (e) positive experiences with healthcare providers; and (f) pressure and misinformation about treatment. Results indicate the types of support AI women may need when accessing healthcare. Culturally informed trainings for healthcare professionals may be needed to provide high-quality and sensitive care for AI women who have cancer, and to support those providers already providing proper care.

Breast cancer literacy and health beliefs related to breast cancer screening among American Indian women.

The purpose of this article is to examine the health beliefs and literacy about breast cancer and their relationship with breast cancer screening among American Indian (AI) women. Using the Health Belief Model (HBM) and hierarchical logistic regression with data from a sample of 286 AI female adults residing in the Northern Plains, we found that greater awareness of breast cancer screening was linked to breast cancer screening practices. However, perceived barriers, one of the HBM constructs, prevented such screening practices. This study suggested that culturally relevant HBM factors should be targeted when developing culturally sensitive breast cancer prevention efforts.

Correlates of Receipt of Colorectal Cancer Screening among American Indians in the Northern Plains.

Research has consistently documented lower colorectal cancer (CRC) screening rates for racial and ethnic minority populations, with the lowest screening rates among American Indians (AIs). Given the low CRC screening rates among AIs residing in the Northern Plains region, the objective of this research was to identify CRC screening correlates for Northern Plains AIs. With a sample of 181 AIs age 50 years or older, the authors used Andersen's behavioral model to examine the following factors related to receipt of CRC screening: (a) predisposing factors-age, education, marital status, and gender; (b) need factors-personal and family history of cancer; and (c) enabling factors-having a particular place to receive medical care, annual health checkup, awareness of the availability of CRC screening, knowledge of CRC, and self-efficacy of CRC. Nested logistic regression identified the following correlates of receipt of CRC screening: (a) predisposing factors-older age; (b) need factors-having a personal history of cancer; and (c) enabling factors-having an annual health checkup, greater awareness of CRC screening, and greater self-efficacy of CRC. Given the findings, prevention and intervention strategies, including public awareness and education about CRC screening, are promising avenues to reduce cancer screening disparities among AIs.

The contribution of culture to Korean American women's cervical cancer screening behavior: the critical role of prevention orientation.

BACKGROUND: Despite the proven benefits of Pap testing, Korean American women have one of the lowest cervical cancer screening rates in the United States. This study examined how cultural factors are associated with Pap test utilization among Korean American women participants. METHODS: Quota sampling was used to recruit 202 Korean American women participants residing in New York City. Hierarchical logistic regression was used to assess the association of cultural variables with Pap test receipt. RESULTS: Overall, participants in our study reported significantly lower Pap test utilization; only 58% reported lifetime receipt of this screening test. Logistic regression analysis revealed one of the cultural variables--prevention orientation--was the strongest correlate of recent Pap test use. Older age and married status were also found to be significant predictors of Pap test use. CONCLUSION: Findings suggest cultural factors should be considered in interventions promoting cervical cancer screening among Korean American women. Furthermore, younger Korean American women and those not living with a spouse/partner should be targeted in cervical cancer screening efforts.