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      Using Intervention Mapping to Develop Health Education and Health Policy Components to Increase Breast Cancer Screening and Chemotherapy Adherence Among Syrian and Iraqi Refugee Women in Beirut, Lebanon

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          Abstract

          Introduction: Despite the continuous increase in the incidence of metastatic breast cancer among Syrian and Iraqi refugee women residing in camp settings in Lebanon, mammography and chemotherapy adherence rates remain low due to multiple social, economic, and environmental interfering factors. This in turn led to an alarming increase in breast cancer morbidity and mortality rates among the disadvantaged population.

          Methods: Intervention mapping, a systematic approach which guides researchers and public health experts in the development of comprehensive evidence-based interventions (EBIs) was used to plan a health education and health policy intervention to increase breast cancer screening and chemotherapy adherence among Iraqi and Syrian refugee women aged 30 and older who are residing in refugee camps within the Beirut district of Lebanon.

          Results: The generation of the logic model during the needs assessment phase was guided by an extensive review of the literature and reports published in peer-reviewed journals or by international/local organizations in the country to determine breast cancer incidence and mortality rates among refugee women of Syrian and Iraqi nationalities. The underlying behavioral and environmental determinants of the disease were identified from qualitative and quantitative studies carried out among the target population and also aided in assessing the sub-behaviors related to the determinants of breast cancer screening and chemotherapy completion as well as factors affecting policy execution to formulate performance objectives. We then developed matrices of change objectives and their respective methods and practical applications for behavior change at the intrapersonal, interpersonal, organizational, and societal levels. Both educational components (brochures, flyers) and technological methods (videos disseminated via Whats app and Facebook) will be adopted to apply the different methods selected (modeling, self-reevaluation, consciousness raising, persuasion, and tailoring). We also described the development of the educational and technological tools, in addition to providing future implementers with methods for pre-testing and pilot-testing of individual and environmental prototype components.

          Conclusion: The use of intervention mapping in the planning and implementation of holistic health promotion interventions based on information collected from published literature, case reports, and theory can integrate the multiple disciplines of public health to attain the desired behavioral change.

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          Most cited references38

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          Socio-Economic and Health Access Determinants of Breast and Cervical Cancer Screening in Low-Income Countries: Analysis of the World Health Survey

          Background Breast and Cervical cancer are the two most common cancers among women in developing countries. Regular screening is the most effective way of ensuring that these cancers are detected at early stages; however few studies have assessed factors that predict cancer screening in developing countries. Purpose To assess the influence of household socio-economic status (SES), healthcare access and country level characteristics on breast and cervical cancer screening among women in developing countries. Methods Women ages 18–69 years (cervical cancer screening) and 40–69 years (breast cancer screening) from 15 developing countries who participated in the 2003 World Health Survey provided data for this study. Household SES and healthcare access was assessed based on self-reported survey responses. SAS survey procedures (SAS, Version 9.2) were used to assess determinants of breast and cervical cancer screening in separate models. Results 4.1% of women ages 18–69 years had received cervical cancer screening in the past three years, while only 2.2% of women ages 40–69 years had received breast cancer screening in the past 5 years in developing countries. Cancer screening rates varied by country; cervical cancer screening ranged from 1.1% in Bangladesh to 57.6% in Congo and breast cancer screening ranged from 0% in Mali to 26% in Congo. Significant determinants of cancer screening were household SES, rural residence, country health expenditure (as a percent of GDP) as well as healthcare access. Discussion A lot more needs to be done to improve screening rates for breast and cervical cancer in developing countries, such as increasing health expenditure (especially in rural areas), applying the increased funds towards the provision of more, better educated health providers as well as improved infrastructure.
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            Age at diagnosis of breast cancer in Arab nations.

            The impression among Arab Physicians dealing with breast cancer is that it presents at an earlier age and at a more advanced stage as compared to western countries. However, the statistical data to support this impression is remarkably scarce. We performed a comprehensive literature review of reports of breast cancer in Arab countries. Articles were identified from Saudi Arabia, Bahrain, Qatar, Kuwait, Emirate, Oman, Yemen, Iraq, Syria, Jordan, Lebanon, Egypt, Libya, Algeria, Tunis, Morocco, and Sudan. Twenty eight articles were identified and reviewed. The average age at diagnosis of breast cancer was available in 18 articles; the average age was 48 (SD = 2.8), range 43-52, median 48.5 and mode 45 years among the 7455 patients included. The median age of diagnosis of breast cancer was available in 8 articles; here, the average age was 45.4 (SD = 4.8), range 40-54.5, median 44.5 years among the 5379 patients included. The percentage of patients that were younger than 50 years old was reported in 11 articles from 8 countries and included 5144 patients; 65.5% (SD = 11) were less than 50 years old (range 49-78%, median = 66%). In this literature review, the average age at presentation of breast cancer in Arab countries appears to be a decade earlier than in western countries. If this is true, this has important implications for screening and cancer management strategies in these countries, including the ideal age at which to begin screening. Adoption of Western guidelines "without critical amendment" in planning breast cancer programs will waste resources without achieving desired outcomes. Determination of the true frequency and age of onset of breast cancer in Arab women should be an important research priority. Copyright © 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
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              Effectiveness of Cultivando la Salud: a breast and cervical cancer screening promotion program for low-income Hispanic women.

              We tested the effectiveness of a lay health worker intervention to increase breast and cervical cancer screening among low-income Hispanic women. Participants were women 50 years and older who were nonadherent to mammography (n = 464) or Papanicolaou (Pap) test (n = 243) screening guidelines. After the collection of baseline data, lay health workers implemented the Cultivando la Salud (CLS; Cultivating Health) intervention. Data collectors then interviewed the participants 6 months later. At follow-up, screening completion was higher among women in the intervention group than in the control group for both mammography (40.8% vs 29.9%; P < .05) and Pap test (39.5% vs 23.6%; P < .05) screening. In an intent-to-treat analysis, these differences remained but were not significant. The intervention increased mammography self-efficacy, perceived susceptibility, perceived survivability, perceived benefits of mammography, subjective norms, and processes of change. The intervention also significantly increased Pap test self-efficacy, perceived benefits of having a Pap test, subjective norms, and perceived survivability of cancer. It did not change Pap test knowledge, perceived susceptibility, or perceptions about negative aspects of Pap test screening. Our results add to the evidence concerning the effectiveness of lay health worker interventions for increasing Pap test screening and mammography. Future research should explore the effectiveness of CLS in other Hispanic groups, the mechanisms through which interpersonal communication influences decisions about screening, and how effective interventions such as CLS can best be adopted and implemented in community-based organizations or other settings.
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                Author and article information

                Contributors
                Journal
                Front Public Health
                Front Public Health
                Front. Public Health
                Frontiers in Public Health
                Frontiers Media S.A.
                2296-2565
                15 April 2020
                2020
                : 8
                : 101
                Affiliations
                [1] 1The University of Texas Health Science Center at Houston School of Public Health, Department of Health Promotion and Behavioral Sciences , Houston, TX, United States
                [2] 2The University of Texas MD Anderson Cancer Center, Department of Infectious Disease, Infection Control, and Employee Health , Houston, TX, United States
                Author notes

                Edited by: Rosemary M. Caron, University of New Hampshire, United States

                Reviewed by: Krista Mincey, Xavier University of Louisiana, United States; Barbara E. Bond, Bridgewater State University, United States

                *Correspondence: Lea Sacca Lea.sacca@ 123456uth.tmc.edu

                This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health

                Article
                10.3389/fpubh.2020.00101
                7174686
                32351923
                0ee39cdf-0e23-400e-9a54-9118a30d4342
                Copyright © 2020 Sacca, Markham and Fares.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 23 April 2019
                : 12 March 2020
                Page count
                Figures: 1, Tables: 11, Equations: 0, References: 65, Pages: 25, Words: 20153
                Categories
                Public Health
                Original Research

                intervention mapping,breast cancer,education,policies,refugee women

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