The Systematic Cultural Adaptation of a UK Public Health Cancer Awareness Raising Programme for Malaysia: the Be Cancer Alert Campaign
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applyparastyle "fig//caption/p[1]" parastyle "FigCapt" applyparastyle "fig" parastyle "Figure" TBM ORIGINAL RESEARCH The systematic cultural adaptation of a UK public health cancer awareness raising programme for Malaysia: the Be Cancer Alert Campaign Désirée Schliemann,1, Tin Tin Su,2,6 Darishiani Paramasivam,2 Saunthari Somasundaram,3 4 2,7 5 1 Nor Saleha Binti Ibrahim Tamin, Maznah Dahlui, Siew Yim Loh, Michael Donnelly 1Centre for Public Health and Abstract UKCRC Centre of Excellence for Increasingly, policy and research attention is being directed Implications Public Health, Queen’s University Belfast, Belfast, UK toward improving global health in low- and middle-income Practice: An evidence-based culturally ac- 2 ceptable cancer mass media campaign is avail- Centre for Population Health countries. This study investigated the cultural adaptation (CePH), Department of Social and of a UK-designed and developed evidence-based mass able, which may be adapted to assist efforts in Preventive Medicine, University of media campaign with the aim of improving colorectal cancer other countries and contexts to improve health Malaya, Kuala Lumpur, Malaysia and breast cancer awareness in Malaysia. Guided by the behaviors. 3National Cancer Society Malaysia, heuristic framework of cultural adaptation, a multidisciplinary Kuala Lumpur, Malaysia team adapted the UK Be Cancer Aware programme for 4 Ministry of Health, Kuala Lumpur, implementation in the Malaysian context. The approach Policy: Adaptation of an evidence-based pro- Malaysia included five steps: (a) information gathering and needs 5 gramme facilitates the time-efficient implemen- Department of Rehabilitation assessment; (b) preliminary design; (c) preliminary testing; tation and delivery of urgently needed public Medicine, Faculty of Medicine, (d) refinement; and (e) final trial. Key findings from the University of Malaya, Kuala health interventions in resource-poor settings. Lumpur, Malaysia information gathering stage related to the need to take into 6South East Asia Community account differences in ethnicity, religion, and beliefs about Observatory (SEACO), Monash cancer. Discussions with experts indicated that particular University Malaysia, Bandar words were not acceptable in Malay culture and that specific Research: Cultural appreciation and adaptation Sunway, Malaysia aspects were “taboo” (e.g., showing pictures of breasts in is a key investigative activity in the successful 7Facultas Public Health, University relation to breast cancer on TV). Stage 3 of the analysis implementation of public health programmes Airlangga, Surabaya, Indonesia revealed that the presentation of cancer survivors rather than and should follow rigorous implementation and health professionals on programme materials was preferred evaluation processes. by Malaysians and that there was a poor level of awareness Correspondence to: D. Schliemann, d.schliemann@ about colorectal cancer. The results were used systematically qub.ac.uk to adapt two culturally suitable cancer awareness mass media involves altering and testing systematically an campaigns for implementation in Malaysia. The developed evidence-based intervention (EBI) that has been Cite this as: TBM 2019;9:1087–1099 materials were in line with government priorities and took doi: 10.1093/tbm/ibz134 proven to be successful for one population to make into account the local health care system structure. The it culturally appropriate and relevant for a different establishment of a partnership with key stakeholders (e.g., the © The Author(s) 2019. Published by population [1,2]. It is important to acknowledge that Oxford University Press on behalf of Ministry of Health and the lead patient advocacy organization) the Society of Behavioral Medicine. and the application of a systematic approach to address cultural culture is not a fixed set of characteristics limited to factors and resource constraints contribute to the successful race and ethnicity but, rather, a constantly evolving This is an Open Access article distrib- uted under the terms of the Creative implementation of public health programmes in global health and dynamic concept which encompasses the col- Commons Attribution License (http:// settings. lective views, beliefs, norms expectations, tradi- creativecommons.org/licenses/ tions, customs, and interactions that distinguish by/4.0/), which permits unrestricted reuse, distribution, and reproduction in Keywords population groups [1,3,4]. The first framework to any medium, provided the original work guide this process by Barrera and Castro [5] and Cultural adaptation, Mass media, Breast cancer, is properly cited. similar frameworks since [6,7] have been reviewed Colorectal cancer, Interdisciplinary research, extensively across different health care disciplines Malaysia and settings [8–11]. Importantly, empirical studies indicate that a culturally adapted EBI is similarly INTRODUCTION effective to its original version [4,12]. Recently, the Cultural adaptation is an important process in im- various frameworks were used to develop a con- plementation science in recognition of the often sensus approach to the stages of cultural adaptation neglected role of context and, so, the process fo- by Barrera et al. [13]. cuses explicitly on the cultural context of trans- The main benefits of cultural adaptation are the in- lating an intervention for delivery and uptake by a creased chance of interventions being successful and new target population [1]. In essence, this process the saving of resources (e.g., time, costs, and staff) TBM page 1087 of 1099 ORIGINAL RESEARCH to support intervention design. Therefore, countries science guidelines for global health practice in terms with a lack of resources for preventative and diag- of involving policy makers and other stakeholders nostic services (i.e., low- and middle-income countries [14], the panel that advised the adaptation process [LMIC]) may particularly benefit from evidence- comprised experts from the UK (i.e., QUB and the based interventions developed in high-income coun- PHA NI) and Malaysia [i.e., UM, National Cancer tries with a greater budget allocated to health care Society Malaysia (NCSM) and Ministry of Health and preventative services [14]. Mindful of these Malaysia (MOH)]. benefits, collaborators from Queen’s University Belfast (QUB) and the University of Malaya (UM) Stage 1: information gathering and needs assessment identified the Be Cancer Aware Campaign (BCA) Methods run by the Public Health Agency Northern Ireland Researchers from QUB and UM met with pro- (PHA NI) that was informed by the Be Clear on gramme coordinators from the PHA NI in June Cancer (BCOC) campaign in England as successful 2016 to gather information (including all campaign mass media campaigns to improve awareness about materials and internal PHA NI evaluation reports) different types of cancer in NI. Findings from these to learn about the development, implementation, campaigns reported increased awareness about the and evaluation of the BCA campaign (PHA NI. signs and symptoms of cancer [15] (Public Health Evaluation Report Breast Campaign; Evaluation Agency. Evaluation Report Breast Campaign; Report Primer and Lung Campaign). Panel mem- Evaluation Report Primer and Lung Campaign). bers from both countries co-conducted research Furthermore, patients who attended general prac- workshops in order to understand the local context titioner practices reported key campaign-related and to identify similarities and differences between symptoms correctly [16] and appropriate referrals of the two countries, particularly regarding the popu- patients with suspected cancer increased in the im- lation and health care system. Furthermore, we plementation areas. Also, an increase in diagnostic conducted two systematic literature reviews to gain investigation activity and a shift toward earlier stage a better understanding of the cancer landscape in diagnosis was reported [17]. Breast cancer (BC) and Malaysia and to identify gaps in cancer knowledge colorectal cancer (CRC) were the two commonest and the health education needs of Malaysians and cancers in Malaysia in 2011 (i.e., 17.7% and 13.2% of how to address them. The first systematic review all cancer cases, respectively) [18]. Stage of cancer aimed to identify the level of BC and CRC awareness detection in Asia, including Malaysia, is late com- in Malaysians as well as barriers towards screening pared to western countries, and it is estimated that [25]. The objective of the second systematic review up to 50% of premature cancer deaths could be pre- was to examine the effectiveness of mass and small vented if diagnosed and treated early [19]. One of media campaigns to improve cancer awareness and the main barriers toward early diagnosis is the lack screening rates in Asia [22]. This process helped the of awareness of signs and symptoms as well as bar- research team to identify mismatches between the riers toward cancer screening, such as negative per- different target populations. The evidence from the ceptions, fear, denial, and trust in complementary systematic review activity contributed to the cultural alternative medicine [20,21]. However, evidence adaptation process by, for example, facilitating the about the effectiveness of mass media cancer aware- identification of similarities and differences between ness campaigns to improve cancer awareness and populations and providing a research-informed beliefs in South East Asia is lacking [22]. Therefore, rationale for amendments