Smoking Cessation Program for Chinese Senior Citizens in ... · lowest mortality rates for many diseases, they have a higher lung cancer mortality and higher smoking rates than other

SmokingCessationProgramforChineseSeniorCitizensinPimaCounty

CPH350-Group23

TiffanyCastro,KaelynGarner,MeganLaw,HaleyOura,&AlyssaSalazar

UniversityofArizona

1

TABLEOFCONTENTS

Introduction…………………..…………………………..……………………….…………………..………………………2

Table1…………..……………………..……………………..……………………..……………………..…………2

Literature

Review…………………..…………………………..………………………..………………………….………………………6

ProblemStatement…………………..…………………………..…………………………..…………………………….9

TheoreticalFramework…………………..…………………………..…………………………..…………………….10

ProgramDescription…………………..…………………………..…………………………..………………………...12

ProgramImplementation…………………..…………………………..…………………………..………………….16

ProgramEvaluation…………………..…………………………..…………………………..………………………….18

Figure1……………………………………………………………………………………………………………..19

References…………………..…………………………..…………………………..…………………………..…………...20

Appendices…………………..…………………………..…………………………..…………………………..…………..23

2

INTRODUCTION

OurcommunityassessmentofPimaCountyindicatedthatresidentsinPimaCounty

tendtobesignificantlyhealthierinmanyareas,includinghealthbehaviors,physical

activity,andsocial/economic/environmentalfactors,comparedtotherestofthestate.

However,PimaCountyfallsshortinregardstolackinghealthcareservicesamongstits

residents,whichmaybeduetocommunicationissuesandthedisabilitytoaffordhealth

care.Inadditiontothat,thepopulationwiththemosthealthchallengesappearedtobe

whitemen,aged18andup.Thisisderivedfromourresearchthatindicatedwhitemen

havethehighestmortalityratesformostofthediseasesthatwerelistedintheassessment,

thehighestratesoffetaldeath,andthehighestratesofcancer.

ThetargetpopulationofourprogramisChineseseniorcitizensinPimaCounty.

ChineseAmericansmakeup22.7%oftheoverallAsianAmericanpopulationintheUnited

States(USCensus,2010).ConsideringthatChinesearethelargestsubgroupwithinthe

Asianraces,dataonAsianAmericanswasusedtocreatethefollowingprogramplan.

Thetop5leadingcausesofdeathforAsianAmericansincludingbothsexesarelisted

below.

Table1:TopCausesofDeathforAsianAmericanPopulation(Source:ADHS)

Rank Cause Per100,000

1 Cancer 100

2 Diseasesoftheheart 82.5

3 Stroke 30.7

4 Chroniclowerrespiratorydiseases 19.4

5 Alzheimer’sdisease 18.2

3

ThecancerdiagnosisforAsianAmericansinPimaCountyis183per100,00(Pima

CountyCancerReport,2010).WhiletheaverageageatdeathfortheAsianAmerican

populationspecifictoPimaCountycouldnotbefound,theaverageageofdeathforAsian

AmericansinArizonais62.4yearsold(HealthDisparities,2005).AccordingtotheArizona

HealthStatusandVitalStatistics,AsianAmericanshavethelowestageadjustedmortality

ratesforheartdiseaseandcancer,unintentionalinjuries,diabetes,influenza,and

pneumoniathananyrace(ArizonaHealthStatus,2013).WhileAsianshavesomeofthe

lowestmortalityratesformanydiseases,theyhaveahigherlungcancermortalityand

highersmokingratesthanotherracialgroups.WithinPimaCounty,“lungcancerrates

amongSoutheastAsiansare18%higherthanamongWhiteAmericans”(StateofAsian

Americans,2008).Whilethesmokingratesforthetargetpopulationhavenotincreased,

theyhavenotdecreasedeither(StateofAsianAmericans,2008).Thisemphasizestheneed

forasmokinginterventioninthecommunity.

TheChinesecultureisconsideredtobeahighcontextculture,asopposedtoalow

contextculturesuchastheUnitedStates(Kim,1998).Thismeansthathighcontextculture

memberstendtoplaceahighvalueonrelationshipsandtrust.Theyalsotypicallyprefergroup

harmonyandconsensusasopposedtoindividualachievement.Intermsofcommunication,

highcontextculturemembersemphasizecontextoverwords.Forexample,theywouldplace

moreimportanceonaspeaker’stoneofvoice,facialexpressions,andbodylanguagethanthe

actualwordsofthespeaker(Kim,1998).Thesefactorsofcommunicationareextremely

importanttoconsiderwheninteractingwiththetargetpopulation.Theprogramrecruitment

4

effortsandcounselingsessionswillbebasedontheknowledgethatChineseseniorcitizensare

mostlikelyhighcontextculturemembers.

ThemajorityofAsiancultures,includingChinese,believeinYinandYangforceswhere

YinrepresentscoldanddarknessandYangrepresentshotandlight.However,thisbeliefof

balanceintheworld,innature,andinthebodycanpotentiallyworkagainsthealthybehaviors

suchaspreventativescreenings.Preventativescreeningsarenotalways“culturallyconsistent

becausetheculture’ssayingyou’llknowwhenyou’resickbecausesomethingwillhappen

toalertyou,andthatworksagainstthenotionofpreventivescreening”(StateofAsian

Americans,2008).

SomehealthcharacteristicsofChinese-AmericansincludetraditionalChinese

medicineforexampleacupuncture.AstudyrevealedthatChineseAmericanimmigrants

usedtraditionalChinesemedicinetomanageillness,maintaintheirmoralstatus,fulfill

theirsocialroles,andpassdownhealthknowledgeandculturalheritage(TheHealthand

HealthcareofAsianAmericansandPacificIslandersAge50+,2015).Whencomparedwith

otherracialandethnicgroups,AsianAmericanswhichencompassChinese-Americanstend

tohaveabetterhealthstatus(Race,EthnicityandHealthCare,2008).AsianAmericansare

lesslikelytoratetheirhealthstatusasfairorpoor(Race,EthnicityandHealthCare,2008).

About11%ofAsianAmericansratedtheirhealthstatusasfairorpoor(Race,Ethnicityand

HealthCare,2008).23%ofAmericanIndian/AlaskaNatives,22%ofAfricanAmericans,

18%ofHispanicsand13%ofNon-HispanicWhitesratedtheirhealthstatustobefairor

poor(Race,EthnicityandHealthCare,2008).

ThehealthstatusofChineseseniorcitizenschangedwhenthispopulationadopted

theWesternwayofliving("HealthandHealthCareforChineseAmericanElders",2014).

5

Breast,colon,andprostatecancershowedanincreasewhencomparedtoillnesspatterns

inChineselivinginmainlandChinaandChineselivinginAmerica("HealthandHealthCare

forChineseAmericanElders",2014).TherearesomespecificdiseasesthataffectChinese

seniorcitizensgreatlyintheUnitedStates.Chinese-Americanwomenaged65+havethree

timesthesuiciderateofwhitewomenintheU.S("HealthandHealthCareforChinese

AmericanElders",2014).Chineseseniorcitizensarelesslikelytotalkaboutdepression

andsuicidethantheWesternculture.DepressioninChinese-Americaneldersismostofthe

timenotreported,therefore,theydonotreceiveappropriatetreatment.Smokingisan

issueamongChinese-Americans.TherateofsmokinginChinese-Americanmalesisaround

28%withtheU.Saveragebeing30%foradults.Smokingcancauselungcancerwhich

happenstobeoneoftheprominentcancersthatelderlyChinese-Americansdevelop

("HealthandHealthCareforChineseAmericanElders",2014).Othercancerssuchas,

colon,liver,nasopharyngeal,breast,prostateandcoloncancerhavebeenanissuefor

Chinese-Americansinthegeneralpopulationaswellasintheelderly("HealthandHealth

CareforChineseAmericanElders",2014).Therehasalsobeenanincreasedincidenceof

cardiovascularandhypertensioninChinese-Americanelders.AccordingtotheAARP

research,someoftheneedstheChinese-Americanseniorcitizenshavearesupport

for/fromfamily,healthinsurance,resourcesandtoolstopromotehealthandwell-being,

physicalandmentalfitness,aswellastransportationandsavingstoaccessmedicaland

dentalservices,informationonsupportandavailableservices,andin-languageservices

andculturallysensitiveoutreachandservicesforhealthcare(HealthRisks,Disparitiesand

CommunityResponses,2011).InArizona,theADHSandAHDCalongwithothercommunity

organizationsareworkingtogethertocreateanimprovedlanguageaccessandqualityof

6

care(HealthRisks,DisparitiesandCommunityResponses,2011).Throughaneeds

assessmenttheADHSandAHDCwilldeveloppoliciesforlanguageaccess(HealthRisks,

DisparitiesandCommunityResponses,2011).Itisobviousthatlanguagebarriersare

sometimesthecauseastowhyChinese-Americansorotherethnicgroupsarenotseeking

helpfortheirhealthneeds.InordertoreducecancerratesamongChinese-Americansenior

citizensinArizonaitisimportantforthemtoattendscreenings(HealthRisks,Disparities

andCommunityResponses,2011).However,screeningratesamongAsianAmericanswhich

includeChinese-Americansarelowerthanthoseofotherminoritygroupsandnon-

HispanicWhites(HealthRisks,DisparitiesandCommunityResponses,2011).Moreover,in

PimaCounty,AsianAmericansfacesimilarneedsasthestate.Someofthoseneedsinclude,

culturalandlanguagebarriers,lackofawarenessabouthealthcoverage,limitedawareness

abouthealthcoverageavailability,andlimitedhealthknowledge("ThePimaCountyAAPI

NavigatorGrant",n.d.).

LITERATUREREVIEW

IntheUnitedStates,Asiansubpopulationsarenotanalyzedseparatelyonthe

nationallevelorevenonthestatelevel,butChineseAmericansarethelargest

subpopulationamongAsianAmericanssoaggregatedAsianAmericandatacanbeusedto

determinehealthneeds(Panget.al,2002).ChineseAmericansareoneofthefastest

growingethnicgroupsintheUnitedStateswitha72%increaseinpopulationoveraspan

of10yearsandamongChineseAmericans,theelderlypopulationisthefastestgrowing

(Wuet.al,2009)(Panget.al,2002).

AmongtheChineseAmericanpopulation,therearehigherratesofsmoking,higher

incidenceratesforlungcancer,andhighermortalityrates.AccordingtoWu,thegeneral

7

Americanpopulationhasasmokingratebetween18-23.9%whileChineseAmericans

exhibitaratebetween22-34%(Wuet.al,2009).MaleChineseAmericanshavean

incidencerateof61.6casesper100,000peopleforlungcancerandlungcanceristhe12th

leadingcauseofdeathamongthispopulation(McCrackenet.al,2009).Forfemales,the

incidencerateislowerat36.1casesper100,000people,butthemortalityrateismuch

higher,thehighestamongAsianAmericangroups,makingthistheleadingcauseofdeath

amongChineseAmericanwomen(McCrackenet.al,2009).

Therearemanyriskfactorsforthetargethealthproblem,lungcancer.Accordingto

theCDC,smokingislinkedto90%oflungcancer,leadingtoanincreasedriskof15to30

timeshigherthanthosewhorefrainfromsmoking(CDC,2014).McCrackenliststhe

followingriskfactorsforlungcancer:smoking,second-handsmoke,exposuretocooking

oilathightemperatures(suchaswhenusedforfrying),andheatingwithcoal(McCracken

et.al,2009).Otherriskfactorsinclude:exposuretoradon(the2ndleadingcauseoflung

cancer),asbestos,arsenic,exhaustfromdieselfuel,andfamilyhistory(CDC,2014).Another

riskfactorisadeficiencyinvitaminA,anessentialfactorintheregulationofthethelung

cancercells(deBittencourtPasqualiet.al,2013).

Inadditiontotheseriskfactors,ChineseAmericansfaceseveralbarrierstocare.A

studyintheeffectivenessofacessationprograminChinaindicatedthatmanyChinese

peoplewerenotawarethattheline“lowtarequalslowharm”isuntrue.86%ofthe

participantsoftheirstudybelievedthistobecorrect,including54.7%ofphysicians(Liet.

al,2015).Anothersignificantbarriertocarewasthat,manyChineseAmericansthatvisited

aphysician’sofficewerenotaskedabouttobaccouseandofthosewhowere,onlyabouta

thirdwereadvisedtoquit(Liet.al,2015).

8

OneprogramthathadhighlevelsofsuccessinsmokingcessationamongChinese

AmericanswasanemployerbasedinterventionthatwasmirroredafteranAmericanbased

program.LiandhisteammimickedtheprogramandimplementeditthroughtheEmployee

AssistancePrograminChina.Theinterventionconsistedofapharmacologicalintervention

andcounselingfromlocalcounselors(Liet.al,2015).Effectivenesswasdeterminedbythe

quitrates,reductionintheamountsmoked,andreductioninnicotinedependence.Based

onthe90dayfollowup,thosewhoparticipatedintheprogramweremorelikelytonever

smoke,stopdailysmoking,andhadastatisticallysignificantreductioninnicotine

dependence(Liet.al,2015).

Similarly,asecondsuccessfulinterventioncomparedtheeffectivenessofnicotine

replacementtherapywhencombinedwitheitherindividualizedcounselingsessionsor

generalinformationsessions.Thegroupthatreceivedtheindividualizedcounseling

exhibitedquitratesalmostdoubleofthoseinthegroupsessions(Wuet.al,2009).This

studyfoundnodifferenceinquitratesbetweengenders,socioeconomicstatus,levelsof

formaleducation,ormaritalstatus(Wuet.al,2009).

Similaritiesbetweenthetwostudiesincludethecostoftheintervention,whichwas

freetoparticipantseitherthroughtheiremployersorthelocalculturalcenter,the

utilizationoflocalhealthcareworkers,andacombinationofnicotinereplacementand

counseling.AstudybyShelleyalsoindicatedthatacculturationthatoccursonceChinese

AmericanshaveimmigratedtotheUnitedStatesleadstoanincreaseinthenumberofthe

peoplethatneversmoke(Shelleyet.al,2003).Thisisattributedtoincreasededucation

aboutthenegativeconsequencesofsmoking(Shelleyet.al,2003).

9

AsianAmericansingeneralareconsideredtobethe“modelminority”meaningthat

theytendto“haveagoodeducation,workagoodjob,andearnagoodliving”(Lee,2009).

Whilestatisticallythisprovestrue,AsianAmericans,includingthetargetpopulation,still

facehealthcarebarriersandserioushealthconsequences.Thetopfivecausesofdeathin

theAsianAmericanpopulationarecancer,diseasesoftheheart,stroke,chroniclower

respiratorydiseases,andAlzheimer’sdisease(ArizonaHealthStatus,2013).

TraditionalChinesecultureisgreatlyinfluencedbyConfucianismwhichpossessesfour

basicvirtues:loyalty,respect,benevolence,andrighteousness(Fan,2000).Chinesecultureis

alsoconsideredtobeahighcontextculture(Kim,1998).Asahighcontextculture,members

have“highuseofnonverbalelementssuchasvoicetone,facialexpressions,gestures,andeye

movements”(Westbrook,2014).Theyalsoprefergroupworkfor“learningandproblem

solving”andbuildrelationshipsbasedonmutualtrust(Westbrook,2014).

PROBLEMSTATEMENT ThetargetpopulationforthisprogramiselderlyChineseAmericans,whoare65

yearsofageandolder,residinginPimaCounty,thatsmokecigarettes.Theprogramwill

aimtoreducetheincidenceoflungcanceramongthetargetpopulationthroughsmoking

cessation.Smokingcessationwasselectedbecausesmokingisoneoftheleadingcausesof

lungcancerwith90%ofcasesbeinglinkedtosmoking.Unlikeinmanyotherpopulations,

theprevalenceofsmokingamongChineseAmericansisnotdecliningbutremaining

constantdespitethemortalityduetocancer.

Forthosewhoarediagnosedwithlungcancer,therearemanyconsequences

includingfurtherhealthcomplications,treatment(eitherchemicals,surgery,radiation,or

10

painmanagement/endoflifecare).Thecostsforthesetreatmentsfluctuatedependingon

thestageofcancerandstageoftreatment,but,evenonceinremission,carewillcostan

additional$678permonth(Yabroffet.al,2011).Healthcomplicationscaninclude

shortnessofbreath,pleuraleffusion(fluidinthelungs),andmetastasis(spreadofcancer)

(MayoClinic,2015)

Notonlycansmokingdirectlycausecancer,thesecondhandsmokeisalsoamajor

concernaswellastheeffectsonsmokingonotherriskfactorslikeworkplaceexposures

likechromiumandarsenic,thatwhencombinedwithsmokingcanleadtohigherriskfor

lungcancer(CDC,2015).Inaddition,thosewhosmokethatalsotakebeta-carotene

supplementsareatevengreaterrisk(CDC,2015).Becausesmokinghasaneffectonmany

ofthecausesoflungcancer,reducingtheprevalenceofsmokingamongelderlyChinese

Americansmayresultinareductioninincidenceoflungcancersincesmokingisthecause

of90%oflungcancer(CDC,2014).

THEORETICALFRAMEWORK

ThemodelthatservesthebasisofthisprogramplanistheHealthBeliefModel.The

programisaimedtoreducesmokingamongthetargetpopulationofChinesesenior

citizensinPimaCounty.TheHealthBeliefModelhighlightsthatbehaviorssuchassmoking

tobaccoaredeterminedbyanindividual'sperceptionsregardingthesefiveareas.These

fiveareasarepersonalsusceptibilitytotheillnessordiseasecausedbysmoking,the

significanceoftheproblemregardingsmoking,howmuchthetreatmentwillcostandits

effectiveness,thebarriersthatsurroundsmokingcessationandcuestochangesmoking

behaviors("HealthBeliefModel",2016).Thefirststepoftheprogramistoinformthe

programusersoftherisksofsmokingtobacco-thosecanincludelungcancer,butcanalso

11

causeissuessuchas,gumdisease,CVD,etc.Itisalsoimportanttoaddressperceived

severity.Inthisstepthegoalistohighlighttheseriousnessofsmokingandits

consequences("HealthBeliefModel",2016).Thesetwostepswillbeachievedthroughthe

counselingaspectoftheprogram.Thecounselorsaretrainedtoinformtheprogramusers

oftheseverityandconsequencesofsmoking.

Moreover,inordertomakeasmokingcessationplan,perceivedbenefitsand

barriershavetobeaddressed("HealthBeliefModel",2016).Theperceivedbenefitscan

include,reducingtheriskofdevelopingaseriousdiseasesuchaslungcancer.The

perceivedbarrierscanincludetheuser’stangibleandpsychologicalopinionofthecosts

thatcomewithquitting("HealthBeliefModel",2016).Itiscrucialtohelptheprogram

usersunderstandthatisitpossibletostopsmokingandthatthereareotheralternativesto

smoking.Theprogramalsointegratestechniquesthatcanhelpindividualsfindotherways

todealwithstressorotherproblemsthatcausesmokinghabits.Thefinaltwostepsare

helpingtheprogramusersdevelopaplantostopsmokingbydevelopingcuestoactionand

strengtheningself-efficacy("HealthBeliefModel",2016).Intheprogramthecounselors

andparticipantswillworktogethertodevelopaSmokingQuitPlan,whichincludes

componentssuchas,settingaquitdate,choosingthereasonsforquitting,howtofight

cravingsandusingtemporarysmokingreplacementssuchas,useofnicotinepatch.Other

servicessuchasstressmanagementwillalsobeofferedinordertoincreaseself-efficacy.

PROGRAMDESCRIPTION

StatementofPurpose ThepurposeofthisprogramistoeducateandprovideservicestotheelderlyChinese

citizensinPimaCountyinordertoreducetheincidenceoflungcanceramongthis

12

population.Itisexpectedthattheincidencewillbereducedamongstthetargetpopulation

bypromotingandenablingthecessationofsmokinganduseoftobaccoproducts.

Goal

TodecreasetheincidenceoflungcancerinChineseseniorcitizensinPimaCounty.

Objectives

OutcomeObjective:

ByJulyof2017,therewillbea25%decreaseintheincidenceoflungcanceramong

ChineseseniorcitizensinPimaCounty.

ImpactObjectives:

A. BehavioralObjectives

1. Bytheendoftheprogram,50%oftheprogramparticipantswilleliminatetheuseof

tobaccoproducts.

2. Bytheendoftheprogram,50%oftheprogramparticipantswillshowanincrease

ornochangeinlungfunctionduetothecessationofsmoking.

B.EnvironmentalObjectives

1. Bytheendofthepilottestingstage,theTucsonChineseConventionCenter(TCCC)

willserveasarecruitingcenterforChineseseniorcitizens,aswellasthemain

facilityinwhichthegroupandindividualcounselingsessionswilltakeplace.

2. Bytheendofthepilottestingstage,100counselorswhoarebilingualinChinese

andEnglishandhavebeentrainedbycertifiedhealtheducationspecialistsonhow

13

toteachsmokingquithabitswillprovidecounselandguidancetothetarget

population.

3. Bythestartofthephasinginstage,theSunVanParatransitServicewillprovide

transportationtoprogramparticipantswhodonothavetheirownsourceof

transportationtogettoandfromtheTCCC.

C.LearningObjectives

1. AwarenessLevel

Bytheendofthepilottestingstage,80%oftheseniorcitizensparticipatinginthe

programwillbeabletoidentifytheriskfactorsassociatedwithlungcancer.

2.KnowledgeLevel

Bytheendofthepilottestingstage,80%willbeabletodescribetheimpact

smokinghasonthehealthofseniorcitizens.

3.AttitudeLevel

Bytheendofthefourthgroupcounselingsession,programparticipantswillexpress

theirviewsonhowsmokingcessationcanbenefitthem.

4.Skilldevelopment/AcquisitionLevel

Bytheendoftheprogram,85%participantswillbeabletodemonstratetwo

methodsusedinordertoresistthecravingorurgetosmoke.

14

ProcessObjectives

1. Bytheendofthepilotingtestingstage,allstaffingpositionswillbefilled.These

staffingpositionsincludetheprogramdirector,programmanager,marketer,

planningteam,healtheducationspecialist,nurses,studentinterns,andcounselors.

2. Bytheendofthephasinginstage,approximately200Chineseseniorcitizenswillbe

enrolledintheprogram.

3. Bytheendofthephasinginstage,1counselorwillbeassignedto5participants,

totalinganumberof40counselors.

ProgramMethodology

Thefollowingaretheinterventionstrategiesthatwillbeusedinordertomeetourgoaland

objectives:

Method1:Individualcounselingsessions

Themainfocusoftheseindividualsessionsisforeachparticipanttoworkone-on-onewith

abilingualandculturallycompetentcounselorinordertoconstructasmokingquitplan.

Thisplaysintothetargetpopulation’sbeliefinahighcontextculture,whichemphasizesa

valueinrelationshipsandtrust.Thecessationplanadherestothehealthbeliefmodelby

conveyingtotheparticipantsthebenefitsofquitting,andbyofferingalternativesthatmay

overcomethebarrierstoquitting.Thecounselorswillguidetheparticipantsthrough

settingagoalquitdate,identifyingreasonswhytheysmoke,andprovidingsolutionsto

combatcravingsortheurgetosmoke.Participantswillbeginwithmeetingwiththeir

counselorsonceaweek,andwillcontinuetodosowiththeadditionofgroupcounseling

sessionsastheprogramadvances.

Method2:Groupcounselingsessions

15

Thegroupsessionswillbeheldbetweeneachcounselorandtheir5assignedparticipants.

InadditiontotheChinesebeliefinahighcontextculture,thissettingwillcatertotheir

beliefingroupharmonyandconsensus.Thegroupsessionsinvolveeducatingthe

participantsontheseverityofsmokingandtheconsequencesthatmayresultbecauseofit.

Itisduringthesesessionsthattheparticipantswilllearnaboutriskfactorsassociatedwith

lungcancer,howsmokingimpactstheirhealthandthehealthofthosearoundthem,and

techniquesthatcanbeusedtomanagethestressthatsmokingmayrelieveandtofight

cravings.Oneofthelearningactivitiesthatwillbeimplementedisagroupbreathing

session.Asthecounselorguidesthemthroughbreathingtechniques,theparticipantswill

beabletopracticeandutilizeatool(focusedbreathing)thatcanbeusedtohelpmanage

theirstressorserveasareplacementtosmokinganothercigarette.Thisactivitycanbeled

bythecounselor,orthecounselormaychoosetoutilizetheDoAsOnewebsite,whichisan

onlineuniversalbreathingroomthatguidestheparticipantsthrougharelaxingexperience

inwhichtheyallbreathetogether(asone)witheachotherandessentiallyeveryone

aroundtheworldwhoisonthewebsiteatthesametime.

PROGRAMIMPLEMENTATION TheprogramaimstodecreasetheincidenceoflungcancerinChineseseniorcitizens

inPimaCounty.Sincesmokingisthemaincauseoflungcancer,theprogramwillfocuson

smokingcessation.Theprogramwillbeimplementedinthethree-stepprocessofpilot

testing,phasing-in,andinitiatingtotalprogramimplementation(Parkinsonet.al.,1982).

Thepilottestingwillconsistof10participantsovera3-monthperiod.Afterreceiving

feedbackfromparticipantsonthispilottest,theprogramstaffandplanningpersonnelwill

16

makenecessaryadjustmentsandbeginthenextstepofphasing-intheprogram.

ParticipantswillinitiallyberecruitedonlyfromTucson,expandingtoOroValley,Marana,

andSahuaritaaftereverymonth.Theprogramwillofferonlyindividualcounseling

sessionstobeginwith,andthenslowlyexpandtoincludegroup-counselingsessionsas

well.Afterevaluationandthelastcomponentofthephasingin,initiationoftotal

implementationwillbegin.

TheprogramwillbeconductedintheTucsonChineseCulturalCenter(TCCC),using

theclassroomsforindividualcounselingandthemultipurposeroomforgroupcounseling.

TheTCCCalreadyservesasagatheringplaceforChineseseniorsofferingweeklysenior

programs,weeklylunches,guestspeakers,andTaiChiclasses.AccordingtotheTCCC

website,ThursdaylunchesareapopulareventthatattractsmanyChineseseniorcitizensof

PimaCounty.Takingthisintoconsideration,theprogramwilltakeplaceonaweeklybasis

directlyaftertheThursdaylunch.InadditiontousingTCCCasthelocationof

implementation,thefacilitywillalsoserveastherecruitmentcenter.Duringthepilot-

phase,participantswillberecruitedduringtheTCCCeventslistedabove,especiallyafter

theThursdaylunches.Astheprogramexpandsinthephasing-instage,participantswillbe

recruitedatChineseculturaleventsthroughoutthecountysuchasChineseHealthDayat

theUniversityofArizonaortheTucsonChineseNewYearFestival.

InadditiontoroomusageintheTCCC,additionalfacilityandequipmentneeds

includeatransportationservice,medicalequipmentneededforpulmonarytesting,and

basicactivityequipmentsuchaschairsandtables.Atransportationservice,suchastheSun

VanParatransitService,willbeprovidedforparticipantstoandfromtheprogramifthey

donotalreadyhaveareliablesourceoftransportation.Theprogramcontractorwill

17

contractwiththeSunVanCompanytosetupthisservice.Aswellascontractingwiththe

SunVanParatransitService,theprogramcontractorwillalsocontractwithalocalhealth

clinicsuchasElRio.Theprogramwillusethehealthcenter’shealthcareprofessionals

(mainlynurses)toconductthephysicalexaminationsandpulmonarytesting.TheSunVan

willprovidetransporttothehealthcarefacilityforparticipantsandallparticipantswill

signacontractallowingtheprogramevaluatortoviewtheirtestresultsandmedical

records.Themedicalequipmentwillbepurchasedafterconsultingthenursesandthe

programmanagerwillpurchasetheactivityequipmentsuchaschairs,tables,laptops,and

marketingmaterials.

Thestaffingneedsincludeplanningpersonnel(programdirector,programmanager,

marketer,planningteam)andtheprogramstaff(counselors,healtheducationspecialists,

nurses,studentinterns,programcontractor,programevaluator).Duringthepilot-testing

phase,allstaffwillbehiredandtrained.Thegoalistohave200programparticipants

enrolledbytheendofthephasing-instage,whichmeansapproximately40counselors

wouldbeneededtokeepa5to1ratio.ThesecounselorsmustbebilingualinEnglishand

ChineseandbeabletoidentifywiththeChineseculture.Thecounselorswillhavereceived

trainingbycertifiedhealtheducationspecialistsonhowtoteachsmokingquithabits.The

marketerwillberesponsibleforcreatingbrochuresandpamphletstouseduring

recruitment.Themarketermustbeabletocreateculturallyrespectfulpromotionsforthe

programandhaveexperienceingraphicdesign.Thenurseswillcompleteinitialandfinal

physicalsofeachparticipanttodetermineanychangesinlunghealth.Throughpulmonary

functiontestssuchasspirometryandexercisestresstests,thenurseswillbeableto

determineanyincreaseordecreaseinlungfunction.Thestudentinternswillberecruited

18

fromtheUniversityofArizonaculturalcenters,specificallyAPASA(AsianPacificAmerican

StudentAffairs).Theseundergraduatestudentinternsmayaidtheprogramwith

recruitment,officemanagement,dataentry,andsetupandbreakdownofactivitiesin

exchangeforschoolcredit.

PleaseseeAppendixBforthecompleteprogramimplementationtimeline.The

timelineisseparatedintoYear1forthepilottestingandYear2forthephasing-instage.

PROGRAMEVALUATION

Thisevaluationaimstodeterminewhetherornottheprogramplancanreduce

incidenceoflungcancerfromsmokingamongelderlyChineseAmericansinPimaCounty.

Thepurposeoftheevaluationisnotonlytodeterminewhetherornotourprogramplanis

capablereducingtheincidenceoflungcanceramongelderlyChineseAmericans,butalsoto

understandwhatwasdoneright,whatwasdonewrong,andhowthesethingscanbe

continuedoraltered.Thefindingswillhelptodeterminewhataspectsoftheprogramplan

workinordertoobtainourgoal,andhowwecancontinuetoimplementtheseaspects.The

findingswillalsoaidindiscoveringwhatwasdonewrong,orwhatcouldbedonebetter,

andthenhowtoachievethesethings.

Figure1:TypesofEvaluations

19

January2017:afterfeedbackisreceivedfromparticipantsandstaffofpilottest,evaluation

iscreated.Thisanalyzesalldatareceived,evaluateswhatseemedtoworkforparticipants

andstaffandwhatdidnot,andwhatproblemswerefoundthroughouttheprocessthat

couldbealtered.

August2017:afterphasinginprogramconcludesanddataandfeedbackisreceivedfrom

participantsandstaff,evaluationisconducted.Thisanalyzesalldatareceived,evaluates

newfoundknowledgeofpatients,evaluateschangesinlunghealthandchangesintobacco

use,andassesseswhatwentwrong,whatwasdoneright,andhowlikelyeachpatient

seemstoupkeeptheirlunghealth.

Samplesofevaluationswillincludepreandpostsurveysofknowledgeoftheeffects

ofsmokingtobacco.Evaluationswillincludehealthtests,anddataregardingincidenceof

lungcanceramongthetargetpopulationbeforeandaftertheprogram.

Process Evaluation

Impact Evaluation

Outcome Evaluation

Post-pilot testing evaluation will include evaluation of staff, evaluation of activities, and evaluation of participation. Post-phasing-in evaluation will be conducted. This evaluation will include

Pre-test of pilot test and phasing in participants, their knowledge of lung cancer and tobacco’s effect, and attitudes towards lung cancer and tobacco. Pre-test of aspects of pilot test and phasing in program and staff attitudes.

3 months, 6 months, and one year after phasing in program concludes participants are interviewed and/or surveyed on current smoking habits, knowledge of smoking and tobacco along with lung cancer, and any upkeep of helpful health aspects learned from the program.

20

REFERENCES

ArizonaHealthStatusandVitalStatistics(2013).ArizonaDepartmentofHealthServices.

Retrievedfromhttp://www.azdhs.gov/plan/report/ahs/ahs2013/pdf/text2b.pdf

DeBittencourtPasqualiM,GelainD,Zeidán-ChuliáFetal.VitaminA(retinol)

downregulatesthereceptorforadvancedglycationendproducts(RAGE)byoxidant-

dependentactivationofp38MAPKandNF-kBinhumanlungcancerA549cells.

CellularSignalling.2013;25(4):939-954.doi:10.1016/j.cellsig.2013.01.013

DivisionofCancerPreventionandControl,CentersforDiseaseControlandPrevention.CDC

-WhatAretheRiskFactorsforLungCancer?.Cdcgov.2014.Availableat:

http://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm.AccessedApril30,

2016

Fan,Y.(2000).AclassificationofChineseculture.CrossCulturalManagement:An

InternationalJournal,7(2),3-10.

HealthDisparitiesinArizona’sRacialandEthnicMinorityPopulations(2005).Arizona

PublicHealthAssociation.Retrievedfrom

https://drive.google.com/a/email.arizona.edu/file/d/0B_AaPIdYPqPXNTFiMDA1N

DUtYjg2ZS00MjE1LTkwZTMtZGFiNzc4ZGU2NmE4/view

HealthBeliefModel.(2016).MDQuit.org.Retrieved1May2016,from

http://mdquit.org/health-behavior-models/health-belief-model

Kim,D.,Pan,Y.,&Park,H.S.(1998).High-versuslow-contextculture:Acomparisonof

Chinese,Korean,andAmericancultures.PsychologyandMarketing,15(6),507-521.

Lee,S.J.,Wong,N.W.A.,&Alvarez,A.N.(2009).Themodelminorityandtheperpetual

foreigner:StereotypesofAsianAmericans.

21

LiP,LarrisonC,LennoxR,MollenhauerM,ShararD.Effectivenessofanemployment-based

smokingcessationassistanceprograminChina.familymedcommunhlth.

2015;3(1):53-62.doi:10.15212/fmch.2015.0103.

MayoClinic.LungcancerComplications-MayoClinic.Mayoclinicorg.2016.Availableat:

http://www.mayoclinic.org/diseases-conditions/lung-

cancer/basics/complications/con-20025531.AccessedMay2,2016.

McCrackenM,OlsenM,ChenMetal.CancerIncidence,Mortality,andAssociatedRisk

FactorsAmongAsianAmericansofChinese,Filipino,Vietnamese,Korean,and

JapaneseEthnicities.CA:ACancerJournalforClinicians.2007;57(4):190-205.

doi:10.3322/canjclin.57.4.190.

PangE,Jordan-MarshM,SilversteinM,CodyM.Health-SeekingBehaviorsofElderly

ChineseAmericans:ShiftsinExpectations.TheGerontologist.2003;43(6):864-874.

doi:10.1093/geront/43.6.864.

Parkinson,R.S.(1982).Managinghealthpromotionintheworkplace.MayfieldPub.Co.

PimaCountyCancerReport(2010).ArizonaDepartmentofHealthServices.Retrievedfrom

https://webcms.pima.gov/UserFiles/Servers/Server_6/File/Health/Health%20Dat

a,%20Statistics%20and%20Reports/Pima%20Cancer%20Data%202001-10%20-

%20FINAL%20-%208-1-14.pdf

ShelleyD,FahsM,ScheinmannR,SwainS,QuJ,BurtonD.AcculturationandTobaccoUse

AmongChineseAmericans.AmJPublicHealth.2004;94(2):300-307.

doi:10.2105/ajph.94.2.300.

StateofAsianAmericansandPacificIslandersinArizona(2008).ArizonaStateUniversity

AsianPacificArizonaInitiative.Retrievedfrom

22

https://outreach.asu.edu/sites/default/files/SAAPIAZ_vol_1_part_1.pdf

UnitedStatesCensusBureau(2010).UnitedStatesQuickFacts:RaceandHispanicOrigin.

Retrievedfromhttps://www.census.gov/quickfacts/table/PST045215/00

Westbrook,T.P.(2014).GlobalContextsforLearning:ExploringtheRelationshipBetween

Low-ContextOnlineLearningandHigh-ContextLearners.ChristianHigher

Education,13(4),281-294.

WuD,MaG,ZhouK,ZhouD,LiuA,PoonA.Theeffectofaculturallytailoredsmoking

cessationforChineseAmericansmokers.Nicotine&TobaccoResearch.

2009;11(12):1448-1457.doi:10.1093/ntr/ntp159.

YabroffK,LundJ,KepkaD,MariottoA.EconomicBurdenofCancerintheUnitedStates:

Estimates,Projections,andFutureResearch.CancerEpidemiologyBiomarkers&

Prevention.2011;20(10):2006-2014.doi:10.1158/1055-9965.epi-11-0650.

HealthBeliefModel.(2016).MDQuit.org.Retrieved1May2016,from

http://mdquit.org/health-behavior-models/health-belief-model

Race,EthnicityandHealthCare.(2008)(1sted.,p.1).Retrievedfrom

https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7745.pdf

HealthRisks,DisparitiesandCommunityResponses.(2011)(2nded.,pp.10,21).Retrieved

fromhttp://www.apcaaz.org/resources/HealthRisksDisparitiesandCommunity

Responses.pdf

ThePimaCountyAAPINavigatorGrant.TheUniversityofArizonaMel&EnidZuckerman

CollegeofPublicHealthCenterForRuralHealth.Retrieved4May2016,from

http://crh.arizona.edu/programs/pima-county-aapi-navigator-grant

TheHealthandHealthcareofAsianAmericansandPacificIslandersAge50+.(2015)(1sted.,

23

pp.18,27).Retrievedfromhttp://www.aarp.org/content/dam/aarp/

home-and-family/asian-community/2015-01/AARP-Report-Health-and-

Healthcare-AAPIs-50-Jan2015.pdf

24

APPENDICES AppendixA:ProblemMap

25

AppendixB:ProgramImplementationTimeline

ProgrammingTasksYear1

ProgramPersonnel

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Securegrantmoney Programdirector&manager

X

Hireallplanningpersonnelandprogramstaff

Programdirector&manager

X

ConductassessmentofChineseseniorcitizenpopulationinPimaCounty

Interns

X

Assembleallnecessaryresourcessuchasfacilityandequipmentneeds

Projectmanager

X

Createpromotionalmaterialsandoutreach/recruitmentplan

Marketer X

Recruit10programparticipantsforpilottest

Interns&programstaff

X

Beginpilottest Programstaff X

Administerinitialphysicalandlungtests Nurses X

Distributeinitialsurveyoftobaccoproductsuse

Projectmanager&counselors

X

Distributeinitialsurveyofsmokingconsequences


X

Distributeinitialsurveyoflungcancerriskfactors


X

Reportfinalnumberofparticipantsinthepilottest

Programevaluator

X

Administermidpointphysicalandlungtests Nurses X

26


ProgramPersonnel

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Distributemidpointsurveyoftobaccoproductsuse


X

Distributemidpointsurveyofsmokingconsequences


X

Distributemidpointsurveyoflungcancerriskfactors


X

Concludepilottest Programstaff X

Administerfinalphysicalandlungtests Nurses X

Distributefinalsurveyoftobaccoproductsuse


X

Distributefinalsurveyofsmokingconsequences


X

Distributefinalsurveyoflungcancerriskfactors


X

Distributesurveytoidentifymethodstoresistsmokingcravings


X

Participantsgivefeedbackaboutprogram

Programmanager&participants

X

Analyzedataforpilotprogram

Programevaluator

X

Completeprocessevaluationforpilotprogram

Programevaluator

X

Reviseprogramforphasing-instage

Planningpersonnel

X

27


ProgramPersonnel

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Createnewpromotionalmaterialsandoutreach/recruitmentplan

MarketerX

Recruitparticipantsforphasing-inprogram

Interns&programstaff

X

Beginphasing-inprogram Programstaff X

Administerinitialphysicalandlungtests Nurses X

Distributeinitialsurveyoftobaccoproductsuse

Programmanager&counselors

X

Distributeinitialsurveyofsmokingconsequences


X

Distributeinitialsurveyoflungcancerriskfactors


X

Administermidpointphysicalandlungtests Nurses X

Distributemidpointsurveyoftobaccoproductsuse


X

Distributemidpointsurveyofsmokingconsequences


X

Distributemidpointsurveyoflungcancerriskfactors


X

Expandphasing-inprogramtooutsideofTucsonintoOroValley

Programstaff X

Expandphasing-inprogramtooutsideofTucsonintoSahuarita

Programstaff X

Ensureeachbehavioralhealthcounselorhasbeenassignedtofiveparticipants

Counselors

X

28


ProgramPersonnel

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Ensureallparticipantshavecreatedtheirsmokingcessationplanwiththeircounselor

Counselors&participants

X

Reportthefinalnumberofparticipantsforphasing-in

Programevaluator

X

Concludephasing-inprogram Programstaff X

Administerfinalphysicalandlungtests Nurses X

Administerfinalsurveyoftobaccoproductsuse


X

Administerfinalsurveyofsmokingconsequences


X

Administerfinalsurveyoflungcancerriskfactors


X

Distributesurveytoidentifymethodstoresistsmokingcravings


X

GathercurrentdataonincidenceoflungcanceramongChineseseniorcitizensinPimaCounty

Interns

X

Createanevaluationreport

Programevaluator

X

Publishevaluationreportanddistributedtoallstakeholders

Programevaluator&director

X

Documents

Smoking Cessation Program for Chinese Senior Citizens in ... · lowest mortality rates for many diseases, they have a higher lung cancer mortality and higher smoking rates than other