The Power of a Pear

Editor’s Note: This article is adapted from a presentation given by the author at the Oncology Nursing Society’s Cancer Prevention and Early Detection (CPED) Program for HBCU/MSI Nurses: Dissemination Colloquium, May 30-31, 2003 in Miami. Funded through a grant from the National Cancer Institute, the CPED Program is designed to provide nursing educators, academic staff and clinicians with information and resources they can use in collaboration with students at historically black and minority-serving institutions to help eradicate racial differences in cancer outcomes through preventive education and screening. For more information, visit the ONS Web site at www.ons.org (click on “Education”).

In spite of today’s tremendous medical advances, cancer remains the second leading cause of death in the United States. More than 1,500 people per day were expected to die of cancer in 2003. In addition to loss of lives, the economic costs of cancer are sky-high. In 2002, the National Institutes of Health estimated the annual costs of cancer care and treatment in the U.S. at $171.6 billion.

Cancer also ranks high on the list of racial and ethnic minority health disparities that the federal government hopes to eliminate by the year 2010. According to the American Cancer Society (ACS), African Americans have a higher overall cancer mortality rate and a lower five-year relative survival rate than the general population. Asian Americans/Pacific Islanders are the only ethnic minority in the U.S. for whom cancer is the number one cause of death. In terms of specific types of cancers, women who are African-American, Hispanic, Native American/Alaskan Native, Vietnamese or Korean are more likely to develop cervical cancer than white women. Cervical cancer and breast cancer are the two most common types of cancer suffered by Taiwanese women.

Fortunately, there is much data showing that cancer survival rates are higher if the disease is diagnosed at a localized stage. If a lesion is found and completely treated at a precancerous stage, the prognosis is even better. Early detection of certain cancers truly can save lives and improve quality of life. It is apparent that cancer prevention and early detection hold a tremendous value in terms of health promotion for human beings, and especially for people of color.

Knowledge about the vital importance of cancer prevention and early detection can be disseminated to people through health teaching. Because nurses have traditionally played the role of patients’ health educators, we can empower people to stand against cancer. Nursing students are future nurses. If they are well trained during their nursing school years, they will function competently as patient educators after graduation. Therefore, it is imperative for nursing faculty to be equipped with up-to-date information about cancer prevention and early detection in order to better teach the students.

The Oncology Nursing Society’s Cancer Prevention and Early Detection (CPED) Program for nurse educators at historically black colleges and universities (HBCUs) and minority-serving institutions (MSIs) has the vision and the mission to train the nursing teachers. I first participated in this program in June 2002. Besides providing me with abundant knowledge, the CPED program has cultivated my interest and enthusiasm in the field of cancer prevention and early detection

This involvement has inspired me to conduct several activities in my local community to disseminate knowledge about cervical cancer prevention and early detection. Some of these activities have been targeted to the local Taiwanese population here in New Orleans. Others have been conducted for Delgado Community College, where I am on the faculty. The School of Nursing at this community college is located in the metropolitan area of New Orleans. Around 560 students are enrolled in the nursing program; more than 30% of them are African Americans.

From the Classroom to the Clinic

My dissemination activities began in October 2002, when I conducted a seminar on the topic of “Pap Test for Early Detection of Cervical Cancer” for faculty, staff and students at the college. A total of 21 people attended the seminar–four administrators, seven faculty members, seven staff members and three students. Fifteen of the participants were Caucasians and six were African Americans.

I delivered a PowerPoint presentation, based on ACS and National Cancer Institute (NCI) guidelines, covering such issues as cervical cancer statistics, risk factors, the ACS recommendations for early detection of cervical cancer, symptoms of the disease, the importance of getting a Pap test and what is involved in the procedure, treatment of precancerous conditions, etc.

The statistical data helped the participants to visualize the fact that African- American women are more likely to develop cervical cancer than white women and that the earlier the diagnosis, the better the prognosis. I focused on conveying the message that cervical cancer is preventable and that the Pap test is important, worthwhile and easy to have done. I also emphasized that the cost and discomfort of the Pap test are outweighed by the benefits of detecting cervical cancer when it is still in an early stage. In the Health Belief Model, susceptibility, value of the benefits, barriers (e.g. regimen complexity) and costs are factors considered important to health care decision-making.¹

To help make the learning experience more real to the participants, I supplemented my presentation with several visual aids. I showed the participants a model of the female reproductive system for a brief review of the anatomy of the human uterus, because the lecture was built on this basic foundation of knowledge. A speculum, a Pap test kit and a liquid-based thin-layer slide preparation container were all shown to demonstrate the Pap test procedure.

While describing how a Pap test is performed, I used a pear to represent the uterus, because of the similarity in shape. I discovered from this presentation experience that a pear could be an innovative and effective teaching aid. The participants were delighted to see the pear during the demonstration process. Teaching aids can be so valuable if they are used appropriately.

At the end of the seminar, I allowed some time for questions and answers. I also distributed the NCI brochure “Having a Pelvic Exam and Pap Test” to all the participants, along with copies of a self-designed feedback form for evaluation purposes.

The evaluation forms showed that some participants actually had positive changes in their beliefs about the preventability of cervical cancer. Most of the participants responded that the information provided in the seminar was helpful. All of the respondents said they would apply the knowledge they had gained about Pap tests to themselves and 93.7% commented that they would like to attend similar seminars on prevention and early detection of other types of cancers.

As a result of this positive response, I repeated the Pap test presentation as part of a faculty program meeting at the School of Nursing in November 2002. I used this presentation as an opportunity to introduce the new ACS recommendations for early detection of cervical cancer to the faculty. The faculty members were very interested in this detailed and updated information.

Now it was time to get the students involved in implementing what they had learned. A group of nursing students performed clinical practice in the Pap test clinic of a teaching hospital in New Orleans one or two days each semester. There were approximately 50 to 60 patients in the clinic, about 90% of whom were African Americans.

The students performed patient teaching using the “Having a Pelvic Exam and Pap Test” brochure. They also assisted the physicians in giving Pap tests to the patients. This allowed the students to play an independent role in helping the patients go through the procedure more comfortably. The clinic staff and the patients were very grateful for the students’ assistance. In turn, the students reported that they were very satisfied with their health teaching experiences and their accomplishments.

Opening the Dialogue

Presenting this same information about cervical cancer prevention and screening to Taiwanese women in the community required a different approach–one that was culturally and linguistically competent.

The Taiwanese are a minority population in the New Orleans area. Most of the Taiwanese women maintain their traditional Asian culture. Being more conservative than the general population, Taiwanese women usually hesitate to seek medical attention from a gynecologist, especially a male gynecologist. Language barriers are also an influencing factor in their reluctance to seek care. As a result of these cultural barriers, few Taiwanese women receive regular Pap tests during their lifetime.

With these factors in mind, in November 2002 I gave a presentation on “Prevention and Early Detection of Cervical Cancer” at a conference of the North American Taiwanese Women’s Association, Louisiana Chapter. The presentation, which was given in the Chinese language, focused on the Pap test as well. For this audience, a brief report about a study of interventions to promote cervical cancer screening among Chinese women was added to the content.²

A total of 25 Taiwanese women attended the conference, accompanied by their husbands. They asked many questions during the question-and-answer period. After the presentation, some of the women met with me individually to discuss their personal gynecological problems.

As with the presentations at the college, the evaluation results showed positive changes in the participants’ beliefs about the preventability of cervical cancer. It seemed that these women were inspired to learn more about cancer prevention and early detection. Nearly all of the participants (96%) indicated that they would like to attend seminars about preventing other types of cancers in the future.

As a result, I expanded my focus to include prevention and early detection of breast cancer, the second most common type of cancer affecting Taiwanese women. In December 2002 I gave a presentation on breast self-examination (BSE) to the women’s group at a local Taiwanese church. The presentation contents included breast cancer statistics from ACS, risk factors, signs/symptoms, ACS guidelines for the early detection of breast cancer, the importance of BSE and the right time for performing the self-exam.

The women watched an ACS videotape that demonstrated the procedure of breast self-examination. Other teaching aids included informational handouts, brochures (“ABCs of Breast Health”) and shower cards printed with the ACS guidelines. The participants were very interested in this topic. Many questions relating to women’s health were raised and discussed during the meeting.

Recommendations and Lessons Learned

Since Fall 2002, the lecture hours for oncology nursing in our School of Nursing have been reduced. This presented me with the challenge of finding new, alternative ways to disseminate knowledge about cancer prevention and early detection to our students, who feel this information is beneficial not only for their patient care but also for their own health care.

One solution was to expand the lecture content dealing with cancer prevention and early detection and then put the detailed lecture notes online where the students could review them. As a result, the students’ learning in oncology nursing has not been compromised despite the reduction of lecture hours in the classroom.

To disseminate updated information to even more students, I delivered a two-hour guest lecture on the topic of “Cancer Risk Factors, Prevention and Early Detection” to the LPN students in the School of Nursing. The students were very grateful for the opportunity to obtaining this knowledge.

Based on my positive experiences with spreading the word about the importance of early detection, both at my educational institution and in my local community, I offer these recommendations to other minority nursing educators who want to become more involved in helping to eliminate racial and ethnic disparities in cancer outcomes:

• I believe the ONS’ Cancer Prevention and Early Detection Program for HBCU/MSI Nurses has contributed tremendously to the reduction of cancer mortality among Americans of color by teaching nursing faculty, clinicians and students to conduct successful prevention programs in their communities. These efforts are effective and worthwhile. It is my hope that this program will continue in the coming years so that more nursing educators will become involved in this important work.

• Nursing students’ health teaching activities related to cancer prevention and early detection could be further incorporated into a college’s health fair so that students could teach their peers on a college-wide basis.

• Besides school and health care settings, nursing students’ cancer prevention teaching could be extended into the community–for example, at a shopping mall.

References

1. Rankin, S.H., and Stallings, K.D. (Eds.). 2001. Patient Education: Principles and Practices (4th ed.). Philadelphia: J.B. Lippincott.
2. Taylor, V.M., Hislop, T.G., Jackson, J.C., Tu, S.P., et al. 2002. “A Randomized Controlled Trial of Interventions to Promote Cervical Cancer Screening Among Chinese Women in North America.” Journal of the National Cancer Institute, 94, 670-677.