Addressing cancer disparities in immigrants to Australia by integrating cancer literacy education into English as a Second Language programs

Author: Donna Hughes-Barton

Hughes-Barton, Donna, 2020 Addressing cancer disparities in immigrants to Australia by integrating cancer literacy education into English as a Second Language programs, Flinders University, College of Medicine and Public Health

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Australia’s changing immigration trends show more people are arriving from developing and non-English-speaking countries. Disparities exist in cancer prevalence and in cancer prevention and risk behaviours, with implications for future cancer burden. Traditional health education methods may not reach all immigrants. Abroad, partnership with immigrant English-as-a-Second-Language (ESL) providers to deliver health information shows evidence of efficacy for increased knowledge and feasibility, but interventions are limited in generalisability and reporting of implementation outcomes. A translational research approach could expand understanding of the utility of this novel education method by directing research focus to both intervention efficacy (internal validity) and aspects of implementation (external validity). This research followed four progressive stages, each underpinned by the translational research framework RE-AIM (reach, efficacy, adoption, implementation, maintenance), that promotes equal consideration to both internal and external validity.

Stage 1 was a qualitative scoping study with ESL teachers from the Adult Migrant English Program (AMEP), the provider of government-sponsored ESL education to new immigrants to Australia. Focus group questions addressed the development and acceptance of a cancer prevention ESL resource and were guided by RE-AIM, as were analyses. Results showed enthusiasm for the utility of this resource if designed to cater for multiple cultures, language levels, address national competencies, and incorporate varied communicative activities and media. In Stage 2, a draft curriculum was developed, and ESL teachers and students provided feedback about its potential reach to all immigrants who attend the AMEP. Results indicated high acceptability, although it may not be appropriate for older adults and those with very poor English.

In Stages 3 and 4, a randomised controlled trial was conducted to test the impact of the curriculum on two levels of outcome: individual (student) and organisation, thus addressing both internal and external validity. Individual (student) level results revealed, compared to the control group, a significant improvement in knowledge of cancer primary prevention strategies and a trend towards significance in improvement in knowledge of cancer symptoms and intentions to have a cancer screening test. Results also showed significant improvements in self-efficacy to screen for cancer and to increase physical activity, and in attitudes towards sun protection as important for health. Improvements were maintained three months later. Almost all students shared information from the course with family and friends, especially information about increasing fruit and vegetable consumption, physical activity and sun protection. Sharing information about sun protection was significantly associated with students’ increased engagement in sun protection behaviours.

Organisational level results showed that the curriculum was accepted by staff and students, and teachers reported intention to use it again. However competing curriculum demands showed that it was only taught for around four hours during the four-week trial by the, mostly part-time, teachers. Results further revealed that worksheets were not wholly taught as intended, impacting intervention fidelity.

Overall, results suggest that the utility of this approach as a viable method to address cancer disparities in immigrants to Australia is limited at present. Furthermore, results raise points to consider about using translational research to inform public health interventions.

Keywords: immigrant health, cancer prevention, health disparity, health literacy, English as a Second Language, RE-AIM

Subject: Health Education thesis

Thesis type: Doctor of Philosophy
Completed: 2020
School: College of Medicine and Public Health
Supervisor: Professor Carlene Wilson