Intravaginal practices are associated with greater odds of high-risk HPV infection in Haitian women.

OBJECTIVE: Haitian women have the highest incidence of cervical cancer within the Western hemisphere. Intravaginal hygiene practices have been linked with human papilloma virus (HPV) infection and cervical dysplasia. These practices, known as 'twalet deba' in Haitian Creole, are common among Haitian women and are performed with various natural and synthetic agents. As part of a community-based participatory research initiative aimed at reducing cervical cancer disparities in rural Haiti, we explored the use of intravaginal agents and their associations with high-risk HPV infection. DESIGN: Community Health Workers recruited 416 women for cervical self-sampling from two neighborhoods within Thomonde, Haiti. Participants were interviewed regarding intravaginal hygiene practices and completed a cervical self-sampling procedure. Cervical samples were analyzed for the presence of high-risk HPV infection. Associations between each intravaginal agent and high-risk HPV infection were examined via univariate logistic regression analyses, as well as via multivariate analyses controlling for sociodemographic factors and concurrent agent use. RESULTS: Nearly all women (97.1%) performed twalet deba, using a variety of herbal and commercially produced intravaginal agents. Approximately 11% of the participants tested positive for high-risk HPV. Pigeon pea and lime juice were the only agents found to be associated with high-risk HPV in the univariate analyses, with women who used these agents being approximately twice as likely to have high-risk HPV as those who did not. Only pigeon pea remained significantly associated with high-risk HPV after controlling for sociodemographic factors and concurrent agent use. CONCLUSION: Two agents, pigeon pea and lime juice, may contribute to risk for HPV infection in this population. Results suggest that in addition to cervical cancer screening interventions, future preventive initiatives should focus on minimizing risk by advocating for the use of less-toxic twalet deba alternatives.

Contextualizing the survivorship experiences of Haitian immigrant women with breast cancer: opportunities for health promotion.

PURPOSE/OBJECTIVES: To examine challenges faced by Haitian immigrant women managing a breast cancer diagnosis. RESEARCH APPROACH: Trained community health workers conducted focus groups with Haitian women who were breast cancer survivors. A grounded theory approach guided analysis of transcripts. SETTING: A large community-based organization in Miami, FL. PARTICIPANTS: 18 women took part in three focus groups. Participants were 40 years or older, were ethnically Haitian, and had been diagnosed with breast cancer 6-12 months prior to the study. METHODOLOGIC APPROACH: Data were collected as part of an ongoing community-based participatory research initiative in Little Haiti, the largest enclave of Haitian settlement in Miami, FL. Community health workers, integral to the initiative, recruited participants through their extensive social networks and community contacts. MAIN RESEARCH VARIABLES: Screening knowledge, illness beliefs, social and economic consequences of a breast cancer diagnosis, and advice for breast health education. FINDINGS: Emergent themes suggest that Haitian breast cancer survivors face multiple challenges, including misperceptions about screening guidelines, disease etiology, and risk; a reduced capacity to earn a living because of physical debility; and diminished social support. CONCLUSIONS: Future research must continue to examine the impact of breast cancer on Haitian immigrant women and identify key strategies, such as community outreach and support programs, to improve their quality of life. INTERPRETATION: Nurses can play an essential role in such strategies by providing culturally relevant clinical care and partnering with community stakeholders to define the scope and focus of public health intervention.

Increasing cervical cancer screening in a Hispanic migrant farmworker community through faith-based clinical outreach.

OBJECTIVE: Partnerships between academic medical centers and faith-based community organizations have been associated with increased screening rates in low-income minority women. We describe clinical outcomes of an outreach partnership between a cancer center and a faith-based outreach clinic offering gynecologic screening services in central Florida to increase cervical cancer screening adherence in a priority population of primarily Hispanic farmworker women. METHODS: Data sources included a retrospective chart review. This descriptive study examined patterns of cervical cancer screening behavior among the patient population of the faith-based outreach clinic. RESULTS: Findings suggest that among this group of patients, the demographic factors that predict adherence with cervical cancer screening recommendations are number of years having lived in the United States and marital status. Women residing in the United States for more than 5 years were significantly more adherent with cervical cancer screening recommendations compared with women who have resided in the United States for 5 years or less (p = .05), and married women were more likely to be adherent than unmarried women (p = .02). CONCLUSIONS: The partnership was successful in increasing cervical cancer screening adherence in this medically underserved population. When enabling barriers to screening adherence are removed through faith-based clinical outreach and engaged continuously for a number of years, uninsured, low-income Hispanic women are more likely to receive recommended preventive services.

Creating community-academic partnerships for cancer disparities research and health promotion.

To effectively attenuate cancer disparities in multiethnic, medically underserved populations, interventions must be developed collaboratively through solid community-academic partnerships and driven by community-based participatory research (CBPR). The Tampa Bay Community Cancer Network (TBCCN) has been created to identify and implement interventions to address local cancer disparities in partnership with community-based nonprofit organizations, faith-based groups, community health centers, local media, and adult literacy and education organizations. TBCCN activities and research efforts are geared toward addressing critical information and access issues related to cancer control and prevention in diverse communities in the Tampa Bay area. Such efforts include cross-cultural health promotion, screening, and awareness activities in addition to applied research projects that are rooted in communities and guided by CBPR methods. This article describes these activities as examples of partnership building to positively affect cancer disparities, promote community health, and set the stage for community-based research partnerships.

Knowledge of HPV among United States Hispanic women: opportunities and challenges for cancer prevention.

In the United States, Hispanic women contribute disproportionately to cervical cancer incidence and mortality. This disparity, which primarily reflects lack of access to, and underutilization of, routine Pap smear screening may improve with increased availability of vaccines to prevent Human Papillomavirus (HPV) infection, the principal cause of cervical cancer. However, limited research has explored known determinants of HPV vaccine acceptability among Hispanic women. The current study examines two such determinants, HPV awareness and knowledge, using data from the 2007 Health Interview National Trends Survey (HINTS) and a cross-section of callers to the National Cancer Institute's (NCI) Cancer Information Service (CIS). Study data indicate that HPV awareness was high in both samples (69.5% and 63.8% had heard of the virus) but that knowledge of the virus and its association with cervical cancer varied between the two groups of women. The CIS sample, which was more impoverished and less acculturated than their HINTS counterparts, were less able to correctly identify that HPV causes cervical cancer (67.1% vs. 78.7%) and that it is a prevalent sexually transmitted infection (STI; 66.8% vs. 70.4%). Such findings imply that future research may benefit from disaggregating data collected with Hispanics to reflect important heterogeneity in this population subgroup's ancestries, levels of income, educational attainment, and acculturation. Failing to do so may preclude opportunity to understand, as well as to attenuate, cancer disparity.

The sociocultural context of gynecological health among Haitian immigrant women in Florida: applying ethnographic methods to public health inquiry.

OBJECTIVE: Twalet deba, a culturally mediated feminine hygiene practice, is widespread in Little Haiti, the predominately Haitian neighborhood in Miami, Florida. This practice may have important implications for susceptibility to sexually transmitted infections, including human papillomavirus, the principal cause of cervical cancer. Previous research has not examined the full context of twalet deba in consideration of cultural beliefs and norms about women's hygiene and sexual health. DESIGN: Ethnographic methods guided two phases of exploratory research. The first phase included observation, participant observation, and semi-structured in-depth interviews, which were conducted with key consultants (n=6) and a subsequent purposive sample of 35 women regarding gynecological health beliefs, hygiene practices, and associated home remedy agents. These data informed the second research phase, which involved observation and informal interviews with owners of botanicas in Little Haiti, Miami, FL, USA, to assess the availability of various ethnomedical remedies, their preparation, and preferred uses. All data were analyzed qualitatively to discern patterns in interview responses and using grounded theory to identify key themes. RESULTS: Cultural constructions of gynecological health and illness were generally incongruent with the biomedical model and emphasized the control of self-defined non-specific vaginal infections through routine hygienic practices using ethnobotanical and commercial agents to avert illness, including cancer. Such practices also encourage vaginal tightness and dryness, characteristics desired by male sexual partners, on whom women were frequently economically dependent. Data from the second phase of research reinforced these findings and revealed a wide variety of feminine hygiene agents available for purchase in local botanicas. CONCLUSION: The results suggest that cultural beliefs about gynecological health and dependence on male partners influence women's routine feminine hygiene practices. Botanicas are culturally salient sites for health information. Ethnographic methods were critical for collecting personal sensitive data that are necessary to inform future intervention.

Barriers to cervical cancer screening among Haitian immigrant women in Little Haiti, Miami.

Previous research has not examined barriers to Pap test screening among Haitian immigrant women through their own discourse. Community Health Workers conducted in-depth interviews with Haitian women in Little Haiti, Miami. We used a grounded theory approach to analyze data from the in-depth interviews. Emergent themes coalesced into three core categories of screening barriers: structural, psychosocial, and sociocultural. We developed a model of screening barriers to depict the themes within each core category. Screening barriers must be examined and understood from the social contexts in which they are produced in order to create meaningful interventions.

One size does not fit all: differences in HPV knowledge between Haitian and African American women.

BACKGROUND: Historically, all black persons, regardless of ancestry or country of origin, have been categorized as one group for cancer research and control efforts. This practice likely masks variability in exposure to determinants of disease, as well as in risk of cancer incidence and mortality. The current study examines potential differences in knowledge of human papilloma virus (HPV) between Haitian women living in Little Haiti, Miami, Florida, and a national sample of predominately African American women. METHODS: Data for Haitian women were collected in 2007 as part of an ongoing community-based participatory research initiative in Little Haiti. For purposes of comparison, we used data from a largely African American subsample of the 2007 Health Information National Trends Survey (HINTS). These data sources used identical items to assess HPV knowledge, providing a unique opportunity to examine how this outcome may vary between two very distinct populations who are often grouped together for research and disease surveillance. RESULTS: Relative to the HINTS sample, Haitian women were far less likely to have heard about HPV. CONCLUSIONS: Study data highlight important differences in Haitian and African American women's knowledge of HPV, a known determinant of cervical cancer risk. Such findings suggest that continuing to classify persons of similar phenotype but different cultural backgrounds and lifetime exposures as one group may preclude opportunity to understand, as well as attenuate, health disparity.

Barriers to breast cancer screening among Haitian immigrant women in Little Haiti, Miami.

Previous research has not examined barriers to mammography screening among Haitian immigrant women through their own discourse. Community Health Workers conducted in-depth interviews with Haitian women in Little Haiti, Miami. We used a grounded theory approach to analyze data from the in-depth interviews. Emergent themes coalesced into three core categories of screening barriers: Structural, Psychosocial, and Socio-Cultural. We developed a model of screening barriers to depict the themes within each core category. Screening barriers must be examined and understood from the social contexts in which they are produced in order to create meaningful interventions.

Assessing the acceptability of self-sampling for HPV among Haitian immigrant women: CBPR in action.

OBJECTIVE: To determine whether pairing self-sampling for HPV with community health workers (CHWs) is a culturally acceptable method for cervical cancer screening among Haitian immigrant women residing in Little Haiti, the predominately Haitian neighborhood in Miami, FL. METHODS: As part of a larger, ongoing community-based participatory research (CBPR) initiative in Little Haiti, Haitian CHWs recruited 246 eligible women to this study. Participants provided self-collected cervical specimens for HPV testing and answered a series of questions about their experience with self-sampling for HPV. RESULTS: The vast majority of women (97.6%) was comfortable using the self-sampler at home, would recommend this screening method to their friends and/or family members (98.4%), and described the sampler as easy to use (95.1%). Additionally, 97% of all self-collected specimens were deemed adequate for HPV testing. CONCLUSIONS: When paired with CHWs, who are of Haitian descent and well respected in Little Haiti, self-sampling is a highly acceptable method of cervical screening for Haitian women in this ethnic enclave. This approach addresses critical access barriers, including poverty, language difficulties, and sociocultural concerns about modesty, that may similarly affect Pap smear utilization among other immigrant or medically underserved population sub-groups. Coupled with generally positive reviews of the device, the low rate of insufficient specimens for testing suggests that this device is promising for use in non-clinical settings.

Strategies for assessing community challenges and strengths for cancer disparities participatory research and outreach.

Interventions involving community-academic partnerships must be driven by a participatory approach that is informed by a comprehensive understanding of the perspectives of communities or focus populations. Often research agendas of academics are different from perceived priority needs of community members. Successful and sustainable interventions are made possible with initial open dialogue among all collaborators so that roles are clearly defined and concerns are addressed. This article describes approaches used in the development of a participatory assessment of health and social issues as defined by community and academic partners, current findings, and lessons learned. The assessment is one initial activity of the Tampa Bay Community Cancer Network (TBCCN) to guide network directions through 2010. The TBCCN is one of 25 programs nationwide addressing cancer disparities through sustainable community-based participatory research, outreach, and screening activities.

Mammography use among Haitian women in Miami, Florida: an opportunity for intervention.

When compared to other racial/ethnic minorities and immigrants in Miami, Florida, Haitian women are more likely to be diagnosed with late-stage breast cancer when the prognosis for survival is poor. This disparity likely reflects mammography underutilization. Previous research has not examined the frequency of mammography use among Haitian women in Miami. Our study addresses this gap. In 2007, Community Health Workers (CHWs) recruited nearly 1,000 Haitian women from community venues across Little Haiti, the predominantly Haitian area in Miami, to participate in Rapid Assessment Surveys (RAS). RAS are a quick, cost-efficient method for assessing the prevalence of health behaviors in communities with high-rates of illiteracy and/or distrust of research. Our data indicate Haitian women are less likely than other women in Florida to report regular mammography. Such findings, though not surprising, suggest that grouping all black persons, regardless of ancestry, into one research category may mask variation in disease risk.

Addressing cancer disparities through community engagement: improving breast health among Haitian women.

PURPOSE/OBJECTIVES: To describe processes for fostering community engagement among Haitian women to facilitate breast health education and outreach that are consonant with Haitians' cultural values, literacy, and linguistic skills. DATA SOURCES: Existing breast cancer education and outreach efforts for Haitian immigrant communities were reviewed. Local community partners were the primary source of information and guided efforts to create a series of health-promoting activities. The resultant partnership continues to be linked to a larger communitywide effort to reduce cancer disparities led by the Tampa Bay Community Cancer Network. DATA SYNTHESIS: A systematic framework known as the CLEAN (Culture, Literacy, Education, Assessment, and Networking) Look Checklist guided efforts for improved communications. CONCLUSIONS: Community engagement forms the foundation for the development and adaptation of sustainable breast education and outreach. Understanding and considering aspects of Haitian culture are important to the provision of competent and meaningful care. IMPLICATIONS FOR NURSING: Nurses should expand their skills, knowledge, and competencies to better address the changing demographics of their communities. Nurses also can play a critical role in the development of outreach programs that are relevant to the culture and literacy of Haitian women by forming mutually beneficial partnerships that can decrease health disparities in communities.

Patnè en Aksyon: addressing cancer disparities in Little Haiti through research and social action.

Haitian women living in Miami, Florida, experience an increased risk of developing and dying from cervical cancer compared with women in other racial/ethnic minority and immigrant groups in the area. In response to this disparity, academic investigators from a local university-based cancer center and community leaders from Little Haiti, the predominately Haitian neighborhood in Miami, created Patnè en Aksyon (Partners in Action), a campus-community partnership. We describe the partnership's effort to document the prevalence of lifetime and routine Papanicolau test use using community-based participatory research methods. Community health workers indigenous to the area recruited participants from various community venues throughout Little Haiti and administered informal, brief interviews to assess their screening practices. The results indicate that Haitian women are underscreened and underscore the importance of community involvement in study implementation.

Community-based participatory research in Little Haiti: challenges and lessons learned.

BACKGROUND: Community-based participatory research (CBPR) is an effective methodology for developing relevant interventions with socially marginalized communities. However, implementing CBPR methods is challenging for several reasons. This paper presents challenges encountered in the context of an ongoing CBPR initiative in Little Haiti in Miami, Florida, and describes the solutions used to address them. OBJECTIVES: We sought to describe the challenges faced and lessons learned while conducting CBPR in Little Haiti. METHODS: Community-academic partnerships were created to guide the creation of culturally relevant cancer interventions and research. LESSONS LEARNED: Historical distrust of research, cultural constructions of health and illness, and literacy issues are key considerations when developing partnerships with Haitian and other marginalized, immigrant communities. CONCLUSIONS: Partnerships are fostered over time through demonstrated mutual commitment to improving health and building community capacity. Communities must play an active role throughout the research process to ensure that studies are culturally relevant, and ensuing intervention, sustainable.

Impacting health disparities through community outreach: utilizing the CLEAN look (culture, literacy, education, assessment, and networking).

BACKGROUND: Community outreach programs are important vehicles for reducing the discovery-delivery disconnect by bringing cancer education and screening services directly to community members. Such programs are consistent with the priority areas of the Department of Health and Human Services' initiatives for reducing health disparities by 2010, and they support the use of culturally, linguistically, and literacy-specific approaches for eliminating cancer health disparities. METHODS: This article reviews the important tenets of culture and literacy when developing community outreach programs for medically underserved populations, examines a health education empowerment model for community program planning, and describes the use of the CLEAN Look Checklist (in which CLEAN is an easy-to-remember mnemonic of culture, literacy, education, assessment, and networking) for identifying cues and strategies to achieve relevant outreach. RESULTS: This article illustrates the application of this approach with an example of outreach strategies for reaching at-risk Haitian American women in our community. CONCLUSIONS: Meeting the challenge of a strong health disparities agenda requires integration of cultural and literacy considerations in outreach program, message, and intervention development. The use of a checklist may help clinicians, educators, and researchers create a sustainable model of community outreach guided by a paradigm that incorporates a multilevel approach to address cancer outcomes for disenfranchised populations.