Native American Cancer Research, Corp., Pine, Colorado

N A W W A

Native Women's Wellness through Awareness (NAWWA) is a service and research project which focuses on the development and implementation of a culturally competent recruitment protocol for early detection breast cancer screening programs. This is a community-driven, collaborative project among three nonprofit 501(c)(3) organizations: Native American Cancer Initiatives, Inc. (NACI) (Pine, CO), the Denver Indian Center (DIC) (Denver, CO), and the Center for Healthy Aging (formerly known as 'Senior Health and Peer Counseling' (SHPC) (Santa Monica, CA).

The goal of the NAWWA is to develop a culturally acceptable model program to increase the number of urban Native American women who participate in early detection and breast cancer screening programs. The purpose of the project is to increase the number of urban Indian women who participate in a breast cancer screening program. The objectives of the study are: (1) to evaluate the impact of the "Low and "High Level" Breast Cancer Interventions (See Table 1) using an interrupted time series design; (2) to determine the cost-effectiveness of the "High" and "Low" Interventions for reaching under served women; (3) to assess under served Native American women's breast health attitudes and behavior; and, (4) to modify, implement and evaluate the ability of the breast cancer screening and tracking computer program to ensure follow-up on under served women who have received an abnormal clinical breast exam or mammogram. The target population for the project is American Indian women 40 years of age and older living in the Denver metropolitan area and the greater Los Angeles/Orange County area.

Total funding for this project (national monies are split fairly evenly among NACI, DIC, and the Center for Healthy Aging) for Phase I (development of survey and coordination for project implementation of "Low Level" intervention, Phase II ("Low Level" Intervention) and part of Phase III ("High Level" Intervention--includes eleven months in Denver and five months in Los Angeles). This project has been totally funded by the following foundations: National Alliance of Breast Cancer Organizations, The Avon Breast Health Access Fund, The Hearst Foundation, Inc., Kenneth Kendall King Foundation, the Blue Cross/Blue Shield Foundation, the Denver Chapter - Susan G. Komen Breast Cancer Foundation, Los Angeles Chapter - Susan G. Komen Foundation, A.V. Hunter Trust, Inc., the Colorado Cancer League, Robert Wood Johnson Foundation, and the National Susan G. Komen Breast Cancer Foundation.

The NAWWA project compared "Low Level" recruitment strategies with "High Level" recruitment strategies. The "Low Level" intervention incorporated protocols that are typically implemented by well-intentioned local, state, and federal agencies when attempting to increase recruitment of under-screened women into screening programs. The "Low Level" intervention consists of the basic necessities for breast cancer screening including culturally acceptable screening settings, such as the Denver Indian Center, generic informational materials, and promotion in Indian-specific newsletters and publications. Previous health-related projects have suggested that it may be more difficult to recruit American Indian women into health screening programs who live in the urban area as compared to those living on the reservation. The "Low Level" intervention was implemented in Denver from February 1995 through October 1995 (9 months) and in Los Angeles (the comparison site/delayed intervention) from February 1995 through April 1996 (15 months). The average number of American Indian women screened throughout the "Low Level" intervention in Denver was 3 women per month and in Los Angeles was 2.3 women per month. Clearly the intervention strategies were insufficient. Also, it is very evident that poverty is not the primary barrier to participation in early detection services.

The "High Level" intervention has the "basic necessities" (i.e., includes all of the "Low Level" strategies) with additional steps and cultural components that address barriers identified by Indian women. A variety of strategies were developed and implemented throughout the initial eleven months of the "High Level" intervention since it was not known which, if any, would have an effect on screening behaviors. These strategies were developed and implemented to address poverty, psychosocial, and sociocultural barriers to screening participation.

During the initial months of implementation of the "High Level" intervention, the number of women participating in screening immediately doubled and continues to increase and reach more women. The average number of women participating in screening in the Denver site is 9 women a month.

Indications of the Effectiveness of the NAWWA "High Level" Intervention Based on the quantitative and qualitative data collected during this time frame, the "High Level" intervention appears to be more effective than the "Low Level", and to gradually be increasing in its effectiveness. There are several indicators of this very gradual change in urban Indian women's screening behaviors. Among the indicators directly relating to the importance of providing a culturally comfortable intervention is the increasing number of women who currently have health insurance, but request to be screened through the NAWWA. Due to recent cost restrictions within the program, the NAWWA staff have started to refer these women to their own providers, but it is not known how many have actually complied. Also apparent during the last quarter of the project, is that some women appear to be providing misinformation about their insurance or poverty status so that they could be screened through NAWWA rather than through their HMO or PPO. There seems to be a cultural component of the NAWWA that influences screening behaviors and is not correlated with poverty barriers.

During the "Low Level" intervention, the percentage of women who were scheduled for a screening appointment, but did not appear on the day of screening (i.e., the "no show" percentage) was between 50-80 percent. During "High Level", women who were unable to comply with their scheduled appointment began to call in and notify NAWWA staff that they had to cancel (e.g., their daughters were sick and they had to take care of the grandchildren, or they were called into work unexpectedly, and so on). The actual "no shows" dropped this last quarter to less than 20 percent. During "Low Level, there typically was no such notification of cancellation of appointments. This type of behavior (i.e., calling and notifying that the appointment needs to be changed to another date and time) is one indication of community respect and acceptance for the NAWWA.

In addition, throughout the "High Level" of NAWWA, there continues to be an increase in the number of urban American Indian women who call the NAWWA staff simply to ask questions about breast cancer or about the project itself. These unsolicited calls or drop-in visits continued to grow through March 1997.

Also of interest is the number of requests for presentations on the NAWWA from Indian-specific gatherings in the greater Denver and Los Angeles area. NAWWA staff are requested to present information to both formal and informal gatherings of Native people for an average of three times each month. During the "Low Level" intervention in Denver there were approximately three requests during the nine months of its implementation, and in Los Angeles there were approximately five requests during the fifteen months of its "Low Level" implementation.

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