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Bird, J. A. O.-S., R. Ha, N.T. McPhee, S.J. (1996). "Tailoring Lay Health Worker Interventions for Diverse Cultures: Lessons Learned from Vietnamese and Latina Communities." Health Educ Q. 23(Supplement): S105-S122.  Abstract

Jenkins, C. N., Kagawa-Singer, M. (1994). Cancer. Confronting Critical Health Issues of Asian and Pacific Islander Americans. N. W. S. Zane, Takeuchi, D.T., Young, K. N. J. Thousand Oaks, California, SAGE Publications, Inc.: 105-147.

Jenkins, C. N., S. J. McPhee, et al. (1990). "Cancer risks and prevention practices among Vietnamese refugees." West J Med 153(1): 34-9.  Abstract 
Although Vietnamese refugees are the fastest-growing Asian minority in the United States, little is known about their health knowledge and practices, especially regarding cancer prevention. To address this problem, we interviewed a randomly selected sample of 215 Vietnamese adults living in the San Francisco Bay Area. Results indicated that 13% had never heard of cancer, 27% did not know that cigarette smoking can cause cancer, and 28% believed that cancer is contagious. Although hepatitis B-related liver cancer is endemic among Vietnamese, 48% had never heard of hepatitis B. Among men (n = 116), 56% were smokers (versus 32% in the general US population). Male cigarette smoking was significantly associated with incomes below the poverty level (P less than .01), residence in the US for 9 years or less (P less than .05), not knowing that smoking causes cancer (P less than .05), and limited English proficiency (P less than .01). Binge drinking was reported by 35% of men. Young Vietnamese of both sexes reported consuming diets higher in fat and lower in fiber than when they lived in Vietnam. Among eligible women, 32% had never had a Papanicolaou test (versus 9% of US women), 28% had never had a breast examination (versus 16%), and 83% had never had a mammogram (versus 62%). Education about cancer and its risk factors, smoking cessation, and cancer screening are high priorities for this population.

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Jenkins, C. N., S. J. McPhee, et al. (1995). "Cigarette smoking among Vietnamese immigrants in California." Am J Health Promot 9(4): 254-6.
 

Jenkins, C. N., S. J. McPhee, et al. (1999). "Effect of a media-led education campaign on breast and cervical cancer screening among Vietnamese-American women." Preventive Medicine 28(4): 395-406.  Abstract 
BACKGROUND: Previous research has shown that breast and cervical cancer screening rates are low among Vietnamese women. METHODS: Over a 24-month period, we implemented a media-led community education campaign to promote recognition, intention, receipt, and currency of routine checkups, clinical breast examinations, mammograms, and Pap tests among Vietnamese-American women in Alameda and Santa Clara Counties in northern California. Women in Los Angeles and Orange Counties in southern California served as controls. To evaluate its impact, pretest telephone interviews were conducted of 451 randomly selected women in the intervention area and 482 women in the control area and posttest interviews with 454 and 422 women, respectively. RESULTS: At posttest, after controlling for demographic differences in the surveyed populations, the odds ratios for the intervention effect were statistically significant for having heard of a general checkup, Pap test, and clinical breast examination (CBE); planning to have a checkup, Pap test, CBE, and mammogram; and having had a checkup and Pap test. The intervention had no effect on being up to date for any of the tests. CONCLUSIONS: A media-led education intervention succeeded in increasing recognition of and intention to undertake screening tests more than receipt of or currency with the tests. Copyright 1999 American Health Foundation and Academic Press.

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Jenkins, C. N., S. J. McPhee, et al. (1997). "The effectiveness of a media-led intervention to reduce smoking among Vietnamese-American men." Am J Public Health 87(6): 1031-4.  Abstract 
OBJECTIVES: This study evaluated an anti-tobacco campaign targeting Vietnamese men in San Francisco, Calif. METHODS: The intervention included Vietnamese-language media, health education materials, and activities targeting physicians, youth, and businesses. Evaluation involved pretest and posttest cross-sectional telephone surveys and multiple logistic regression analyses designed to identify variables associated with smoking and quitting. RESULTS: At posttest, the odds of being a smoker were significantly lower (odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.68, 0.99), and the odds of being a quitter were significantly higher (OR = 1.65, 95% CI = 1.27, 2.15), in San Francisco than in a comparison community. CONCLUSIONS: Despite modest success, further efforts are needed to reduce smoking among Vietnamese-American men.

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Abstract  "Health care access and preventive care among Vietnamese immigrants: do traditional beliefs and practices pose barriers?"
Some have speculated that underutilization of Western health services among non-Western populations can be explained by traditional health beliefs and practices rooted deep within cultures. These beliefs and practices may act as barriers to access to and utilization of services. Among Vietnamese, in particular, a number of traditional health beliefs and practices have been identified which are said to pose barriers to Western medical care. No studies to date, however, have examined this hypothesis empirically. To examine this hypothesis, we measured traditional health beliefs and practices among Vietnamese in the San Francisco Bay area and analyzed the relationships between these factors and access to health care and use of preventive health services. The results of this study show clearly that many Vietnamese possess traditional health beliefs and practices which differ from those of the general U.S. population. Yet, the data do not support the hypothesis that these traditional beliefs and practices act as barriers to access to Western medical care or to utilization of preventive services. Being married and poverty status were the most consistent predictors of health care access. Furthermore, the components of access to health care (having some form of health insurance or having a regular doctor, for example) were the strongest predictors of preventive health care services utilization. Importantly, the cultural attributes of individuals did not explain either lack of health care access or underutilization of preventive health care services.

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Abstract  "Hepatitis B immunization coverage among Vietnamese-American children 3 to 18 years old."
OBJECTIVE: Persons with chronic hepatitis B virus (HBV) infection are at increased risk of chronic hepatitis, cirrhosis, and liver cancer. Although HBV infection is relatively uncommon in the United States, the disease is endemic in persons born in Southeast Asia, including Vietnamese-Americans. Current US infant immunization recommendations and state-mandated school-entry programs have left many nontargeted age-cohorts unvaccinated and at risk of infection. To assess the need for catch-up hepatitis B immunizations, this study reports the hepatitis B immunization rates of Vietnamese-American children 3 to 18 years old living in the metropolitan areas of Houston and Dallas, Texas, and the Washington, DC, area. DESIGN: We conducted 1508 telephone interviews with random samples of Vietnamese households in each of the 3 study sites. We asked for hepatitis B immunization dates for a randomly selected child in each household. Attempts were made to verify immunization dates through direct contact with each child's providers. Low and high estimates of coverage were calculated using reports from providers when reached (n = 720) and for the entire sample (n = 1508). RESULTS: Rates of having 3 hepatitis B vaccinations ranged from 13.6% (entire sample) to 24.1% (provider reports, Dallas), 10. 3% to 26.4% (Houston), and 18.1% to 37.8% (Washington, DC). Children living in the Texas sites, older children, children whose families had lived in the United States for a longer time, and children whose provider was Vietnamese or who had an institutional provider were less likely to have been immunized. The odds of being immunized were greater, however, for children who had had at least 1 diphtheria, tetanus toxoid, and pertussis shot, and whose parents had heard about HBV infection, and were married. CONCLUSIONS: The low rates of hepatitis B vaccine coverage among children and adolescents portend a generation which, too old to benefit from infant programs and school entry laws, will grow into adulthood without the protection of immunization. Increased efforts are needed to design successful catch-up campaigns for this population.

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Abstract  "Liver carcinoma prevention among Asian Pacific Islanders. Getting hepatitis B shots into arms."
BACKGROUND: For the past 20 years, the hepatitis B virus (HBV) has infected at least 250,000 persons annually in the United States. Persons with chronic HBV infection are at increased risk for liver carcinoma. Among immigrants to the United States from countries with high HBV endemicity, high rates of chronic HBV infection account in large part for their high incidence rates of liver carcinoma. Among those who have not been infected, hepatitis B and hepatitis B-related liver carcinoma can be prevented through hepatitis B vaccine immunizations. In this article, the authors examine hepatitis B vaccine coverage rates from surveys of Asian and Pacific Islander children in Houston, Texas and Los Angeles County, California. METHODS: In Houston, the authors surveyed the parents of 300 students aged 10 to 18 years at a Vietnamese-language school. In Los Angeles County, they surveyed parents of 471 fourth grade students from 6 different Asian and Pacific Islander ethnic groups in 8 public elementary schools. RESULTS: In Houston, 55% of responding parents submitted immunization records indicating that their child had had 3 hepatitis B shots; 3% reported that their child had had no shots. In Los Angeles County, 37% (Filipino) to 67% (Japanese) had had 3 shots; proportions of children having had no shots ranged from 5% to 15%. CONCLUSIONS: Under current immunization practices, the authors estimate that nearly 13,000 Asian and Pacific Islander children living in the United States today will become infected with HBV in the future, resulting in more than 600 liver carcinoma deaths. It is essential that cancer control agencies in the United States take leadership in raising awareness about the role of HBV in the etiology of liver carcinoma and that of the hepatitis B vaccine in preventing it.

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Abstract  "Tobacco use in Vietnam. Prevalence, predictors, and the role of the transnational tobacco corporations."
OBJECTIVE: To describe tobacco use in Vietnam and the impact of transnational tobacco corporations there. DESIGN: In cities, a multistage cluster design; in communes, a systematic sample design, using face-to-face interviews in all sites. SETTING: Hanoi, Ho Chi Minh City, and 2 rural communes in Vietnam. PARTICIPANTS: Random samples totaling 2004 men and women aged 18 years or older. MAIN OUTCOME MEASURES: Prevalence and correlates of tobacco smoking, amount and duration of smoking, age at initiation, quitting behavior, knowledge of health hazards of and attitudes toward smoking, and cigarette brand smoked, preferred, and recognized as most widely advertised. RESULTS: Smoking prevalence among men (n=970) was 72.8% and 4.3% among women (n=1031). Male smokers had smoked a mean of 15.5 years; the median age at initiation was 19.5 years. Among male smokers, 16% smoked non-Vietnamese cigarettes. More than twice as many (38%), however, said that they would prefer to smoke a non-Vietnamese brand if they could afford the cost. Among those who recalled any cigarette advertising (38%), 71% recalled a non-Vietnamese brand as the most commonly advertised. Male smokers who were significantly more likely to smoke non-Vietnamese brands lived in the south, were engaged in blue collar or business/service occupations, earned higher incomes, and lived in urban areas. CONCLUSIONS: Vietnam has the highest reported male smoking prevalence rate in the world. Unless forceful steps are taken to reduce smoking among men and prevent the uptake of smoking by youth and women, Vietnam will face a tremendous health and economic burden in the near future. Implementation of a comprehensive national tobacco control campaign together with international regulation will be the keys to the eradication of the tobacco epidemic in Vietnam and throughout the developing world.

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Abstract  "Barriers to breast and cervical cancer screening among Vietnamese-American women."
INTRODUCTION: We investigated barriers to breast and cervical cancer screening among Vietnamese women in San Francisco and Sacramento, California. METHODS: Face-to-face interviews were conducted in 1992 of 306 Vietnamese women in San Francisco and of 339 women in Sacramento. RESULTS: In both communities, only about one half of Vietnamese women had ever had routine check-ups, clinical breast examinations, mammograms, and Pap smear tests, and only about one third were up-to-date for these screening examinations. Among women age 40 or older, 35% had never even contemplated having a mammogram. This study identified several significant barriers to recognition, receipt, and currency of screening tests. Negative predictors of test recognition included low level of education and not having a regular physician. Negative predictors of test receipt included low level of education, not having a regular physician, short duration of residence in the United States, and never having been married. A major negative predictor of test currency was low level of education. With a few exceptions, attitudes and beliefs generally were not important predictors. CONCLUSIONS: Health education and screening programs for early breast and cervical cancer detection among Vietnamese women must be culturally appropriate and conducted in the Vietnamese language. Special outreach efforts are needed to assist recent immigrants in obtaining recommended breast and cervical cancer screening examinations.

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Abstract  "Cancer, Cancer Risk Factors, and Community-Based Cancer Control Trials in Vietnamese Americans."
 

Abstract  "Caring for a 70-year-old Vietnamese woman."
 

Abstract  "The costs and risks of medical care: an annotated bibliography for clinicians and educators."
 

Abstract  "Factors associated with breast and cervical cancer screening practices among Vietnamese American women."
PURPOSE: To investigate predictors of breast and cervical cancer screening tests among Vietnamese women in California in preparation for developing and testing interventions to promote such screening. METHODS: Cross-sectional telephone survey of 933 randomly selected Vietnamese women in four California counties. RESULTS: Overall, 70% of the respondents had had at least one prior clinical breast examination, but only 30% had had a mammogram and 53% a Pap test. Among women who had been screened, more than two-thirds were up-to-date and among those who had not been screened, more than two-thirds were planning future tests. Factors positively associated with receipt of one or more of the tests included age (among women < 40 years old), number of years in the United States, having ever married, and having health insurance. Factors negatively associated with test receipt included having a Vietnamese doctor, being unemployed, and being of Chinese-Vietnamese background. CONCLUSION: The multiple factors associated with utilization suggest intervention targets for promoting breast and cervical screening among new immigrant women. Increasing screening test receipt to recommended levels will require a two-pronged approach directed at both Vietnamese consumers and Vietnamese physicians.

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Abstract  General Approach to the Patient: Health Maintenance & Disease Prevention.
 

Abstract  "How good is communication between primary care physicians and subspecialty consultants?"
We prospectively studied the communication between 27 referring practitioners and their consultants for 464 consecutive patient referrals from a general internal medicine group practice at a university medical center. The rates of referral among practitioners varied from 0 to 28.1 per 100 patients visits. Though referring physicians provided patient background information in 98% of the cases, they made explicit the purpose of the referral in only 76% of the cases. They contacted consultants directly in only 9% of the cases. In return, consultants communicated their findings to referring practitioners in only 55% of the consultations. Referring physicians who personally contacted consultants or who supplied them with more clinical information were more likely to learn the results of the consultation. While communication between the referring physicians and consultants in this setting is limited, it may be improved if referring physicians supply more clinical information to consultants and contact them directly.

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Abstract  "Implementation of cancer prevention guidelines in clinical practice."
Data from several sources, including consumer surveys, physician surveys, and medical record audits, indicate that consumers do not receive cancer screening tests as recommended by the National Cancer Institute, the American Cancer Society, and the U.S. Preventive Services Task Force. Performance rates are consistently below published standards for all tests except Pap tests. Major reasons physicians do not perform the recommended tests include physician forgetfulness, disagreement with recommendations, lack of time, and patient refusal. Physicians also tend to overestimate their own performance rates. Barriers to screening test performance can be categorized into patient factors, physician factors, test factors, and health care delivery system factors. Interventions, such as computerized reminder systems, physician audits with feedback, and patient education and reminders, can be effective in promoting performance of such screening. Interventions that target both physician and patient may be particularly effective.

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Abstract  "Influence of a 'discharge interview' on patient knowledge, compliance, and functional status after hospitalization."
Physicians commonly assume that they can educate hospitalized patients to follow prescribed treatment plans after discharge. In a prospective, controlled study, we assessed the effectiveness of a discharge interview given to each of 545 hospitalized patients assigned to one of four groups: a group in which the physicians caring for the patients received a 35-minute tutorial on how to conduct a discharge interview (n = 181), a group that received a 15-minute discharge interview from an investigator (n = 53), a group that received both interventions (n = 63), or a control group (n = 248). One month after discharge, all patients were telephoned, and a standardized questionnaire was administered. Results revealed that, 1 month after discharge, there were no significant differences among the four groups in knowledge of diagnosis, symptom status, activity level, medication knowledge and compliance, appointment keeping, and rates of rehospitalization. These results suggest that effective inpatient education may require more than a discharge interview.

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Abstract  "Lessons for Teaching Cost Containment."
 

Abstract  "Pathways to Early Cancer Detection for Vietnamese Women: Suc Khoe La Vang! (Health is Gold)."
 

Abstract  "Performance of cancer screening in a university general internal medicine practice: comparison with the 1980 American Cancer Society Guidelines."
The authors evaluated use of seven cancer screening tests by 52 providers in a university general internal medicine practice, using 1980 American Cancer Society (ACS) recommendations as standards for comparison. Performance rates were determined by retrospective medical record reviews of a stratified random sample of 525 patients. In addition, the 48 physicians and four nurse-practitioners in the practice were interviewed to determine their opinions, knowledge and perceived use of the tests. Performance rates were low, significantly below the ACS guidelines for all tests except Pap smear. Providers used the tests significantly more often to evaluate patients with cancer risk factors or for new patients. They significantly overestimated their own performances of six tests. More than a fourth of the providers disagreed with the use of mammography, sigmoidoscopy, pelvic or rectal examinations for screening asymptomatic adults. Their knowledge about cancer screening and the ACS recommendations was highly variable, and frequently quite limited. Providers offered four major reasons for not performing the screening tests: provider forgetfulness, lack of time, inconvenience and logistical difficulties, and patient discomfort or refusal.

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Abstract  "Promoting cancer prevention activities by primary care physicians. Results of a randomized, controlled trial."
BACKGROUND. Previous interventions to promote performance of cancer prevention activities have largely targeted physicians in university-based practices. METHODS. We randomly assigned 40 primary care physicians in community-based practices to either (1) Cancer Prevention Reminders, computer-generated lists of overdue screening tests, and smoking and dietary assessment and counseling, supplemented by cancer education materials; or (2) controls. For each physician, we reviewed a random sample of 60 medical records for data about screening test, assessment, and counseling performance during 12-month preintervention and intervention periods. We calculated performance scores as percentage compliance with American Cancer Society and/or National Cancer Institute recommendations. Multiple regression analyses provided estimates of incremental differences in performance scores between intervention and control groups. RESULTS. Controlling for preintervention performance levels, significant incremental differences in performance scores between intervention and control groups (P less than .05) were achieved for nine maneuvers: stool occult-blood test, +14.5; rectal examination, +10.5; pelvic examination, +11.8; Papanicolaou's smear, +30.7; breast examination, +8.7; smoking assessment, +10.2; smoking counseling, +17.3; dietary assessment, +12.3; and dietary counseling, +13.9. Increments for sigmoidoscopy and mammography were not significant. CONCLUSION. Computerized reminders can significantly increase physicians' performance of cancer prevention activities in community-based practices.

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Abstract  Reminder Interventions to Improve Delivery of Cancer Prevention Services.
 

Abstract  "Screening for colorectal cancer: an annotated bibliography for clinicians and educators--Part II."
 

Abstract  "Smoking Cessation Intervention Among Vietnamese Americans: A Controlled Trial."
 

Abstract  "Successful promotion of hepatitis B vaccinations among Vietnamese-American children ages 3 to 18: results of a controlled trial."
OBJECTIVE: Chronic infection with the hepatitis B virus is endemic in Southeast Asian populations, including Vietnamese. Previous research has documented low rates of hepatitis B vaccine coverage among Vietnamese-American children and adolescents ages 3 to 18. To address this problem, we designed and tested in a controlled trial 2 public health outreach "catch-up" campaigns for this population. DESIGN: In the Houston, Texas metropolitan area, we mounted a media-led information and education campaign, and in the Dallas metropolitan area, we organized a community mobilization strategy. We evaluated the success of these interventions in a controlled trial, using the Washington, DC metropolitan area as a control site. To do so, we conducted computer-assisted telephone interviews with random samples of approximately 500 Vietnamese-American households in each of the 3 study sites both before and after the interventions. We assessed respondents' awareness and knowledge of hepatitis B and asked for hepatitis B vaccination dates for a randomly selected child in each household. When possible, we validated vaccination dates through direct contact with each child's providers. RESULTS: Awareness of hepatitis B increased significantly between the pre- and postintervention surveys in all 3 areas, and the increase in the media education area (+21.5 percentage points) was significantly larger than in the control area (+9.0 percentage points). At postintervention, significantly more parents knew that free vaccines were available for children in the media education (+31.9 percentage points) and community mobilization (+16.7 percentage points) areas than in the control area (+4.7 percentage points). An increase in knowledge of sexual transmission of hepatitis B virus was significant in the media education area (+14.0 percentage points) and community mobilization (+13.6 percentage points) areas compared with the control area (+5.2 percentage points). Parent- or provider-reported data (n = 783 for pre- and n = 784 for postintervention surveys) suggest that receipt of 3 hepatitis B vaccinations increased significantly in the community mobilization area (from 26.6% at pre- to 38.8% at postintervention) and in the media intervention area (28.5% at pre- and 39.4% at postintervention), but declined slightly in the control community (37.8% at pre- and 33.5% at postintervention). Multiple logistic regression analyses estimated that the odds of receiving 3 hepatitis B vaccine doses were significantly greater for both community mobilization (odds ratio 2.15, 95% confidence interval 1.16-3.97) and media campaign (odds ratio 3.02, 95% confidence interval 1.62-5.64) interventions compared with the control area. The odds of being vaccinated were significantly greater for children who had had at least 1 diphtheria-tetanus-pertussis shot, and whose parents were married, knew someone with liver disease, had heard of hepatitis B, and had greater knowledge about hepatitis B. The odds of being vaccinated were significantly lower for older children. CONCLUSIONS: Both community mobilization and media campaigns significantly increased the knowledge of Vietnamese-American parents about hepatitis B vaccination, and the receipt of "catch-up" vaccinations among their children.

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Abstract  "Validation of recall of breast and cervical cancer screening by women in an ethnically diverse population."
BACKGROUND: Screening mammogram and Pap smear rates are lower for women in underserved racial and ethnic groups, yet may be overestimated due to reliance on patients' self-reports. The purpose of this study was to determine accuracy of self-reports of mammograms and Pap smears in a multiethnic, multilingual population of African American, Latina, Chinese, Filipina, and White women residing in low-income census tracts of Alameda County, California. METHODS: Following a baseline telephone survey of 1,464 women regarding receipt of mammograms and Pap smears, we examined computerized and written medical records to validate the dates and locations of tests reported by women. RESULTS: Of 1,464 subjects, 94.9% reported having had a Pap smear, and 87% reported having had a mammogram. For Pap smears, in a subsample of 448 cases, we validated only 69.4% of the women's self-reports, and for mammography, in a subsample of 846 women, we validated only 75.4% of the self-reports. Validation rates differed significantly by ethnicity and site of care for both Pap smears and mammograms. CONCLUSIONS: Population estimates of breast and cervical cancer screening rates based upon patient self-reports need to be adjusted downward, by as much as one-quarter to one-third, for low-income, ethnic women.

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Abstract  "Predictors of cervical Pap smear screening awareness, intention, and receipt among Vietnamese-American women."
BACKGROUND: Compared with white women, Vietnamese women in the United States have a higher rate of cervical cancer and lower Papanicolau (Pap) test utilization. We evaluated factors associated with awareness of the Pap test, intention to obtain it, and its receipt in Vietnamese-American women.METHODS: In 2000, we conducted a telephone survey of Vietnamese-American women aged >/=18 years living in Santa Clara County, California, and Harris County, Texas. We collected data on sociodemographics, healthcare system access and attitudes, as well as Pap test awareness, attitudes, intentions, and practices. RESULTS: Of 1566 subjects, 74% had heard of the Pap test, and 76% had had at least one. Only 42% of those who never had a Pap test had considered obtaining one. There were no significant differences between the two sites. Women aged >/=65 had the lowest rates for all three outcomes. For all women, younger age, being married, having requested a Pap test, physician recommendation, and preferring a female standby if the doctor was male were associated with Pap test intention. Being married, higher level of education, having a female doctor, having a respectful doctor, having requested the test, and physician recommendation were associated with Pap test receipt.CONCLUSION: Vietnamese-American women have low rates of Pap test awareness, intention, and receipt. The patient-doctor interaction is an important determinant. Efforts to increase Pap test utilization in this population need to be directed at encouraging physicians to offer the Pap test and empowering women to ask for the test.

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Abstract  "Promoting Cancer Prevention Activities among Vietnamese Physicians in California."
 

Abstract  "Promoting early detection of breast cancer among Vietnamese-American women. Results of a controlled trial."
BACKGROUND: Although breast cancer is the second most common cancer among Vietnamese-American women, previous research has shown that they are less likely to have ever had, and to be more often overdue for, clinical breast examinations (CBE) and mammograms than women in the general population. METHODS: Over a 2.5-year period, the following intervention activities were targeted at both Vietnamese women and physicians in Alameda County, California: neighborhood-based educational activities; dissemination of health education materials; a media campaign; and continuing medical education seminars for physicians. Women in Los Angeles and Orange Counties served as controls. Preintervention telephone interviews were conducted with 384 randomly selected Vietnamese women in the intervention community and 404 women in the control community in 1996, and post-test intervention interviews were conducted with 405 and 402 women, respectively, in 1998. RESULTS: Multiple logistic regression analyses of postintervention surveys showed the intervention community women at posttest were no more likely to recognize, receive, plan, or be up-to-date for CBE or mammograms than women in the control community. However, women who reported greater exposure to the various intervention elements were significantly more likely to have heard of, have had, and to plan CBE and mammograms than women with less exposure. CONCLUSIONS: Although the effect on the women in the intervention group was not significant, the intervention did have a modest positive impact on women who had more exposure to it.

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