This project demonstrates that community-based organizations and university-based researchers can use CBPR effectively to promote cervical cancer screening among Vietnamese-American women.1–5
Working in equal partnership, community representatives and researchers combined their complementary skills to elicit ideas and support from community members, and created effective media education and lay health worker outreach programs.
The combined effects of the media education and lay health worker outreach increased women's knowledge about cervical cancer prevention, motivated significant numbers of women to obtain Pap tests, and motivated others to consider obtaining them. Media education alone was effective in raising women's general awareness about cervical cancer and about Pap tests, but was less effective at motivating women to obtain them. These results are consistent with our previous findings among Vietnamese Americans that media alone, while equally effective for increasing their recognition of, and intentions to undergo, cervical and breast cancer screening, was less effective than a lay health worker intervention, for improving receipt and maintenance of screening.8,16,28
Using CBPR can help Vietnamese-American community members and community-based organizations build important capacities. Lay health workers can use their new-found health knowledge, organizational skills, and facilitation experiences to organize future outreach programs. Many participants said that they wanted to become LHWs. Partner agencies developed capacities to conceptualize and organize lay health worker outreach. Researchers developed the capacity to organize an effective coalition, develop intervention content, and formulate and implement protocols that meet both community and scientific standards.
Fortunately, in undertaking this CBPR project, we did not have to start from scratch. These components succeeded partly because of the Coalition members' knowledge of the Vietnamese-American community and years of capacity building in their agencies, including 16 years of staff development in the UCSF Vietnamese Community Health Promotion Project.
We believe that the LHWO model reaches Vietnamese-American women effectively because it replicates their established cultural patterns of seeking and sharing reproductive health information within their social networks.27,29
This pattern is vital for many women to survive in the United States because they face barriers of limited formal education, limited ability to speak or read English, no health insurance, and limited access mainly to male Vietnamese physicians who primarily provide curative services.20
We believe that media education is effective in raising general awareness because most Vietnamese Americans are avid consumers of the many Vietnamese-language TV, radio and print media.
This study has several limitations. First, participants in the LHWO program were self-selected. Therefore, data obtained from them may not completely represent changes among Santa Clara County's population of Vietnamese-American women. However, self-selecting participants are most likely to be “change agents” in their communities, thus allowing us to measure change among those who were most likely to spread the word about cervical cancer. We will conduct a more complete assessment of the whole community by comparing data from our pre-intervention random survey of 1,556 women9
in 2000 with data we will collect in a post-intervention survey in 2004. Second, results presented here are from 2 of 5 agencies (400 of 1,000 women). We will only be able to determine how each agency's characteristics influence LHWO when all 5 agencies have completed the program. Third, some of the gains among the LHWO+ME group may be attributable to somewhat higher exposure to newspaper articles and ads. We believe it is more likely that higher rates of self-reported exposure to newspaper articles and ads reflect the effects of the lay health worker outreach in priming women to seek information. Fourth, we rely on self-reports to measure women's receipt of Pap tests. Like other ethnic groups,30
some Vietnamese Americans may wish to please the project organizers by over-reporting their testing. To address this measurement issue, we will validate the self-reports through another component of the project, the Pap registry. Fifth, the time span between pre- and post-intervention questionnaires was only 3 to 4 months. In Santa Clara County, some women must wait more than 3 months after making an appointment to receive a Pap test. Thus, we may have undercounted those who obtained a Pap test following the interventions.
Community-based participatory research developed in the United States as a product of American culture, having been undertaken mainly with native-born Americans. We have found that some aspects of CBPR can be applied with immigrants from Vietnam, but CBPR must be adapted to work within their cultural context. It is not enough for researchers working in ethnic communities to use CBPR; researchers must modify CBPR according to the culture of each ethnic community. A “one-size-fits-all” approach to CBPR is unlikely to be effective.
We modified CBPR to fit the cultural norms and expressed needs of the Vietnamese-American community. We had to strike a balance between respecting the dominant cultural pattern of deferring to authority figures (e.g., senior community leaders and physicians) and their interest in encouraging community members to contribute their views. The standard expectation in CBPR is that coalition members should “empower” themselves by taking control of a project. We found that the Coalition members were not inclined to struggle with the research staff or one another to seize power to run this project. Instead, they established a one-member one-vote governance structure in which the research team had one vote. Most Coalition members, already having a sense of their own power, chose to participate by formulating and implementing the project, and allowed the university-based researchers and community-based organizations to engage their complementary capacities to develop content, manage logistics, and evaluate outcomes. The Coalition also asked the research staff to report the research findings back to them so that they could monitor and modify the project. Coalition members valued harmony and efficiency, and considered interpersonal conflicts counterproductive. The maxim for this Vietnamese approach to CBPR is “everyone does what they do best, and grows by doing it with others in the process.”
Vietnamese-American community members and community agency representatives often lacked a basic understanding of scientific research methods. Learning to become researchers was not a high priority for people who are focused on their own pressing priorities: reuniting family, earning a living, raising children, and building successful organizations. Accordingly, the research team had to respect the community members' limited time and their varying levels of interest in research. The “science gap” between the community members and the research staff presented a challenge when we asked the agencies and LHWs to adhere to the protocol for randomizing women into the intervention and control arms of the study. To address this gap, we added a training module on basic research concepts. As this population becomes more familiar with research concepts and exposed to CBPR projects, we expect that their understanding of research methods will increase.
The university structure prevented us from involving the community representatives in all aspects of the research. We had intended to involve LHWs and agency staff in data collection. However, the university's institutional review board would not allow us to engage lay health workers and agency staff to collect data from women in their community without first undergoing human subjects training and receiving National Institutes of Health human subjects certification. Given that many of the participants have limited or no ability to read English, and limited scientific literacy, and that no human subjects training materials are available in Vietnamese, we could not provide them such training in the time frame of this project. Research staff conducted all surveys and interviews, and managed all data collection and entry. In the future, we may surmount this barrier by developing a Vietnamese-language human subjects training program.
University-based researchers can work as equal partners with community members to develop effective media education and lay health worker outreach projects for Vietnamese Americans. However, CBPR must be adapted for the cultural context in each community. Community input is essential for developing culturally and linguistically appropriate media and lay health worker programs. Lay health workers can use their cultural knowledge, sensitivity, and social networks to reach underserved women and improve their peers' knowledge and screening behaviors. Together, researchers and community members benefit from sharing their respective expertise, and can expand one another's capacities to address health challenges.