Although members in the experimental arm were more likely to rate the intervention as culturally appropriate, both arms realized similar gains in CRC knowledge, attitudes, intent, and self-efficacy and, at the end of the study, control clubs had fewer unscreened members than experimental clubs. Thus, we conclude that for Native Hawaiian individuals belonging to a network of civic clubs, the SLT-based intervention was less effective than the culturally targeted education delivered by a knowledgeable and caring non-Hawaiian nurse.
In discussing these findings, several limitations of this study must be acknowledged. First, 64% of participants were up to date with screening prior to their participation in the study, which reduced our ability to test the difference between the experimental and control conditions and, in fact, caJled into question the need for a CRC screening intervention for this segment of the Native Hawaiian community. Second, we lacked a no-treatment control group. Finally, we had difficulties getting participants to complete the follow-up knowledge and attitude questionnaire by mail, lengthening the time it took to complete data collection.
Participants attributed the fact that 64% of participants were up to date with CRC screening to celebrity attention to the issue (e.g., Katie Courie and Loyal Gamer) and the CRC experience of the civic club president. Both interventions perhaps reinforced the behavior of the majority of participants, motivating 31 individuals to get re-screened and 13 to get screened for the first time. We certainly helped increase knowledge about CRC, and perhaps participants were receptive to new knowledge about CRC given their pre-intervention exposure to CRC. However, findings also suggest that we were working with a very health conscious subgroup of Native Hawaiians. Civic club members appeared to be vely active people and proud of their broad interests and involvement. All 121 participants had health insurance, and many had worked in jobs requiring annual physicals. Perhaps, greater benefits would realized by Native Hawaiians who are not members of civic clubs and/or have lower rates of employment and insurance coverage [10
Because we relied on self-report to determine prior screening rates, we wondered if the 64% figure was accurate. Research on the level of agreement between self-reported screening and medical records suggests fairly high sensitivity (> 0.90) but low specificity (between 0.50 and 0.60), with individuals tending to underestimate the time since last screening [28
]. Working with a local Health Maintenance Organization (HMO), we obtained an aggregated summary of CRC screening rates for the 54 members in our sample who were also HMO members, which suggested that about one third of those who reported being up to date with CRC screening really were not. Future projects should determine the accuracy of self-reponed CRC screening and/or get permission from participants to verify screening participation through medical record review.
Another challenge to our study was the lack of a no-treatment control. So, although both the experimental and the control arms produced a modest improvement in screening, we cannot say for certain that either condition was better than no treatment. It is conceivable that secular trends may be working to increase screening rates among all Native Hawaiians, although per BRFSS, the 2002 rates of ever completing an FOBT or endoscopic CRC screening procedure were similar to the 2001 rates (39% vs. 35% for FOBT, and 34% vs. 35% for screening endoscopy, respectively). We chose against a no-treatment control because of expressions in the Native Hawaiian community of a distrust of research and researchers [16
]. Native Hawaiians have voiced concerns ubout huving little or no input into research ideas, design, dissemination, or interpretation of research findings, and those who have participated in research fell they were “used as guinea pigs” and exploited to advance the researcher's career [19
]. Additionally. rescarch has been criticized because it has not addressed the concerns of the group. has been conducted in culturally inappropriate ways, and in some cases has caused harm by perpetuating stereotypes of Hawaiians as unhealthy [19
]. Thus, the Native Hawaiian investigators on this project (MEK and MLK) proposed the current design, which was well received by the AHCC und likely contributed to the civic clubs’ willingness to panicipate in this study.
Third, we had difficulty obtaining adequate completion rates when post-tests were mailed to participants. Best response was obtained through in-person contact (i.e., having members complete questionnaires at club meetings) and secondarily by telephone (although it took several calls before finding the participant at home). Given the preference of Native Hawaiians and other Pacific peoples for personal contact and oral communication [14
], we recommend that future studies collect data through personal interviews, meetings, or telephone rather than by mail.
Why did the SLT-inspired intervention not produce better results? It appears that the culturally targeted presentation, regardless of who presented it, worked well in both arms. This presentation included a slide show and brochure fealuring Native Hawaiian facts and faces. The speakers, regardless of ethnicity, were perceived as respectful and caring toward Native Hawaiians and individual club members. FOST kits were free, and study results were shared at a club meeting. It was not costly to develop a culturally targeted slide show and brochure, and it is gratifying to know that etlective delivery of a culturally targeted message is not dependent on having multiple presenters or featuring Native Hawaiians physicians and survivors.
The SLT-inspired components—having information presented by a Native Hawaiian physician and survivor, demonstrating how to use the FOBT, challenging participants to encourage a family member to take part in free FOBT screening, and making multiple telephone calls to address fears and barriers—did not result in bettcr results for the experimental group. The latter two components were not even successful, in that few experimental arm participants took materials for family members, even fewer engaged family members in free screening, and participants did not admit to having fears about screening and did not identify barriers other than lack of time. The finding of fewer unscreened participants in control clubs (15%) compared to cxperimcntal clubs (33%) at the end of the intervention is especially provocative. Perhaps, the SLT-inspired components of the family-member challenge and the multiple reminder phone calls made the experimental arm too invasive and burdensome, leading some to passively resist calls for screening participation. It also is possible that there were differences across clubs that we did not anticipate and control for. Future work is needed to understand more about people who do and do not change their patterns of screening behavior.
In conclusion, Native Hawaiians belonging to civic clubs had higher rates of CRC screening than the general Native Hawaiian population, and an intervention based on SLT was less effective at furthcr increasing compliance than was a targeted educational scssion. Still, BRFSS data suggest that CRC screening rales among Native Hawaiians lag behind those of other ethnic groups in Hawaii. The project may have had better success with an underserved segment of the Native Hawaiian community.