Can we address cancer disparities in immigrants by improving cancer literacy through English as a second language instruction?

Can we address cancer disparities in immigrants by improving cancer literacy through English as a... Abstract In many Western countries, immigrants exhibit disparities in cancer incidence and mortality, and variable uptake of cancer prevention services. New immigrants may not be aware of cancer risks pertinent to their new country, or prevention resources. Traditional cancer prevention health messaging may not be accessible for cultural, language, or literacy reasons. New methods are needed. In North America, health message delivery via English classes for immigrants is showing potential as an efficacious and a feasible way to reach immigrants at the same time improving language skills. Interventions published to date are promising but limited in their ability to generalize or be adapted to a variety of populations and settings. This concept paper aims to synthesize previous findings and identify ways to improve and advance the translation potential of this approach. We propose that this could be achieved by (i) using a translation framework to guide intervention planning, development, implementation, and evaluation; (ii) encouraging and evaluating health message spread throughout language learners’ social networks; and (iii) incorporating cultural sensitivity into the curriculum. A pilot project following these recommendations is planned for Australia and will be discussed. These recommendations could serve as a framework to fit the requirements of immigrant language programs in other countries and other health topics. Implications Practice: Providers of English as a second language (ESL) instruction have the capacity to improve cancer outcomes among non–English-speaking immigrants by addressing cancer literacy through English language instruction, and the provision of a curriculum that can be readily implemented across diverse language instruction settings is a critical first step. Policy: Literacy service providers should work closely with health service providers to develop policy that incorporates education about important health messages within English language curricula. Research: Future research studies should be guided by a translation framework such as RE-AIM from the planning stage to identify potential barriers and facilitators to adoption and implementation within diverse migrant ESL providers. BACKGROUND Immigration trends are changing globally [1]. For example, Australia now hosts a cultural diversity not seen before; recent immigrants (people who come to a foreign country to live permanently) largely hail from China and India, but also from Middle Eastern, African, and Asian countries [2], many of which are developing nations. Currently, a third of Australia’s population were born abroad; a fifth of whom arrived since 2012. Twenty-one percent of the population speak one of over 300 languages other than English at home [3]. There are health implications associated with this current immigration pattern, particularly in relation to cancer incidence and mortality. Whilst the mortality rate is falling, cancer is still a major cause of illness in Australia and in 2011 was the leading cause of disease burden [4]. Although many immigrants from countries arrive to Australia and other “immigrant nations” with a lower risk of some cancers linked to lifestyle behaviors (known as the “healthy immigrant effect” [5]), this lower risk typically dissipates over time, and lifestyle-related cancer incidence tends to worsen as people adopt local lifestyle behaviors [6]. In addition, although some immigrants arrive with the knowledge and skills required to manage their health needs within a new society, many do not participate as readily as others in cancer prevention behaviors such as healthy eating and physical activity, or accessing health services that assist in reducing cancer prevalence such as screening [7]. For example, an Australian survey of adults aged over 45 found reduced mammography and bowel-screening rates in women from North African, Middle Eastern, and some Asian countries, and bowel screening in men from all parts of Asia compared with the rest of the population [8]. One reason underlying this observation is the likelihood of poorer health literacy within these communities [9]. Health literacy can be understood to be both task- and skills-based—the possession of adequate literacy (reading and writing) skills and the ability to utilize these literacy skills to be able to acquire, process, and apply health information to make informed health decisions and actions [10]. At a functional level, the skills enable individuals to obtain and apply basic health information (e.g., getting a prescription filled). More advanced interactive health literacy skills enable people to interact with and understand health professionals and communicative sources. Critical health literacy skills are still more advanced, enabling individuals to seek and critically analyze available health information to make greater health decisions for themselves and others [11]. Immigrants who have suffered reduced or disrupted education may not only have reduced literacy skills but also be challenged in the application of these skills at even the most basic functional level [9]. Low engagement in cancer-preventive behaviors and services may also be influenced by other factors such as cultural differences in beliefs about cancer, illness, and illness prevention [12] and/or resistance to use local health services due to mistrust or a perception that they are culturally inappropriate [13]. Furthermore, low functional English proficiency may limit awareness of available health services and materials, and the ability to comprehend and access public health information and services [9, 14]. Health information provided to new immigrants must therefore be understandable, culturally sensitive, and, for those with limited English proficiency (LEP), merge English literacy and health service literacy needs. Ideally, the information should also be made available soon after the immigrants’ arrival. Current resources for immigrants, such as translated cancer prevention fact sheets or professional interpreter use, may not achieve these aims for several reasons. For example, they may not be accessible to immigrants with reduced health literacy, reduced or disrupted education, and reduced literacy in their native language or those who speak a dialect, and they may not be culturally sensitive, especially if materials have been translated literally without cultural modification [15]. In addition, they do not equip individuals with the language to use health information to interact confidently within a potentially alien health care system. With the changing immigration environment, we need to consider different ways to deliver health messages so that all adults can feel confident to access available health resources and feel empowered to make their own, informed, health decisions. Immigrant English as a second language (ESL) instruction has been suggested as a possible vehicle to tackle health vulnerabilities of adult immigrants to English-speaking countries [16]. This may be a particularly useful mode of education in multicultural countries such as Australia, where new immigrants with LEP are offered around 510 hours of free government-sponsored language classes through the Adult Migrant English Program (AMEP) soon after arrival in the country. The aim of the language education, which can be accessed on a full- or part-time basis, is to facilitate settlement by equipping English language learner (ELL) immigrants with information about local services as well as English language skills to access these services. Settlement information provided to immigrants covers a wide range of topics including the Australian health care system and services. While many immigrants arrive with more pressing immediate needs such as securing employment, the classes address basic health service acquisition, and providing additional information and language regarding cancer prevention and available services could be a natural addition to the curriculum and a means to help improve timely uptake of available resources such as population-based cancer-screening programs. Although no studies have been completed in Australia, a recent systematic review conducted by Chen and colleagues [17] of 18 reports of curricula designed to blend health literacy with ESL highlighted four curricula that were subject to evaluation trials in North America. Results from these trials provide initial promising evidence of the efficacy and feasibility of this approach [17]. Three of these four curricula concentrated on physical outcomes and knowledge acquisition. Briefly, a significant increase in hepatitis B knowledge was found in a pretest–posttest trial (of a 3-hr session) of 56 Chinese immigrants aged over 50 [18], in a group-randomized trial assessed after 6 months among 298 adult Chinese immigrants [19], and among 218 Asian immigrants, also assessed 6 months after intervention [20]. Evaluations of an ESL cardiovascular health curriculum (designed to be taught over 6 weeks) reported significant improvements in functional health literacy in a pretest–posttest trial of 49 [21] and a randomized controlled trial of 155 adult ELLs [22]. A third curriculum, concentrating on nutrition for cardiovascular health, was evaluated in a multicenter cluster randomized parallel groups trial with 408 [23] and in a two-group repeated measures trial with 732 adult Latino ELLs [24]. Results indicated short-term (3 months) improvements in blood pressure and cholesterol readings and 6-month improvements in fat avoidance and nutrition knowledge [24]. The evaluation of a fourth curriculum extended beyond health knowledge and also assessed health behavior outcomes. This curriculum was evaluated via a 12-week pretest–posttest trial of 227 adult immigrants. Outcomes included English language fruit and vegetable vocabulary (scores on a U.S. statewide standardized reading and listening test), health knowledge, fruit and vegetable consumption, and action and coping planning skills in their evaluation of a cancer prevention healthy eating ESL curriculum Healthy Eating 4 Life (HE4L) [25]. The researchers found improvements in ELLs’ vocabulary of fruits and vegetables (reading scores as well as knowledge), self-reported intake of fruit and vegetables, and health-related planning skills following the intervention. This result is important because it highlights the potential of this blend of education to leverage health outcomes from achievement of the language aspirations of recently arrived immigrants with LEP. This additive success is likely to support sustainability, particularly where cancer literacy curricula are delivered in the context of English language instruction. In the conclusion of their systematic review, Chen et al. [17] recommended that future work consider both English and health outcomes, target more demographic groups, and include a greater variety of health topics [17]. With the exception of a hepatitis B intervention curriculum [26, 27], the cancer prevention topics covered to date tend to be general in nature, mainly targeting healthy eating and physical activity. In addition, the North American context and culture-specific nature of existing interventions could make translating them to another country difficult. In addition to Chen et al.’s recommendations [17], the following section identifies four further potential limitations that should be addressed to improve effectiveness and the translational potential of this approach. We outline these additional gaps and then sketch the components of a cancer prevention ESL curriculum being developed in Australia. LIMITATIONS IN CURRENT ESL HEALTH LITERACY INTERVENTIONS Limitation 1: theory has not been fully utilized to explain observed behavior change Interventions to change behavior will be more effectively understood if grounded in an appropriate theory and applied to program development and evaluation. Otherwise, it is difficult to identify the underlying psychological constructs that might explain observed behavioral changes, which has implications for successful replication in future interventions [28]. A systematic review of the use of theory to guide development and evaluation of dissemination and implementation interventions was conducted in 2010 by Davies and colleagues [29]. In this review, a study was classified to have “used theory” if the researchers cited a theory with references and explained how the theory was used to design a study or explain the change(s) observed in the study. In total, 235 health implementation intervention studies were reviewed. Davies and colleagues reported that less than a quarter (53/235, 22.5%) had openly used a theory of behavior or behavior change to guide the research process, and only 14 of these (14/53, 26.4%) used theory “explicitly,” meaning that a theory was explicitly described and one or more of the intervention’s research hypotheses tested constructs relating to that theory. The remaining 39 studies had some conceptual basis in theory, where theory was used to guide aspects of the research process but not tested [29]. Applying Davies et al.’s (2010) criteria [29] to the four curricula subject to review by Chen et al. [17], only one used theory explicitly. Both the curriculum development and a subsequent evaluation trial were based on the Health Action Process Approach (HAPA [30]), a stage model that attempts to bridge the gap between intentions and behavior by utilizing strategies targeting both motivational (e.g., self-efficacy) and volitional (e.g., planning) factors. In this study, ELLs were encouraged to plan their intended fruit and vegetable consumption, as well as plan what to do when faced with challenges. At 12 weeks, the researchers found improvements in self-reported fruit and vegetable intake as well as planning skills. Although longer-term outcomes were not reported, the theoretical basis of this study provides curriculum developers with an evidence-based rationale for including planning skills in future health curricula. These results support findings from other research in health behavior change which suggests that planning can lead to dietary and other health behavior changes [30] and provide evidence to encourage ESL curriculum writers to include planning activities in health topics. The other three curricula reviewed by Chen and colleagues [17] also reported using theory, but in a conceptual way, to inform aspects of the curriculum development, intervention or trial, but not tested explicitly. The theories used to inform aspects of these curricula and interventions varied. For example, Elder et al.’s nutrition curriculum [23, 24] was informed by social cognitive theory [31] that describes learning occurring in a social context (such as the ESL classroom) and health literacy and health behavior theory [32]. A health literacy curricula development trial conducted by Soto Mas and colleagues [21, 22] was reported as being informed by sociocultural approaches to literacy and communication [33], describing the communicative nature of the ESL classroom, health literacy [34], health behavior theory [31], and adult learning theory [35, 36]. Finally, the cancer prevention hepatitis B ESL course developed by Coronado et al. [26] was based on the health behavior framework (HBF [37]). While the elements of the HBF were explicitly described by the researchers clearly in the design of the curriculum, only knowledge was assessed in the curriculum’s evaluation [18, 19] or knowledge and self-reported screening behavior [20]. Aside from the one study by Duncan and colleagues [25], it is unclear whether the results reported in the other three ESL health literacy interventions discussed here [18–22, 24] were related to the psychological constructs underpinning the chosen theory(ies) because components of the theory were not fully evaluated. It is also worth noting that none of the ESL health evaluations to date included details of effect sizes, power analyses, or cost–benefit analyses, limiting conclusions about effectiveness and translation potential. Without attention to each of these areas, the possibility for replication in different settings or estimating likely public health impact is reduced [28]. In addition, as recommended by several authors [37, 38], behavior change interventions are more likely to have a greater public health impact if they simultaneously target and evaluate factors at the wider community and system levels as well as at the individual level. Furthermore, to evaluate the initial and long-term impact of these interventions and their likely translation capacity, it is important that an assessment of ELLs’ English language proficiency be included alongside health literacy as program outcomes. Explicit reference to theories of curriculum development or second language acquisition has not been made in the aforementioned health literacy ESL evaluations to date and could warrant attention. However, all of them were designed to exploit the content-based communicative methodological approach currently used in ESL teaching and curriculum design. This approach emphasizes the importance of creating realistic communicative opportunities in the classroom and arose from Krashen’s theory of second language acquisition [39]. It could be helpful to investigate this further and tease out the most useful aspects of this approach by evaluating the impact of different classroom activity types. Limitation 2: impacts on and from language learners’ wider social networks have not been evaluated We believe that the translation potential of this work to date can be further advanced by investigating and evaluating the nature and impact of learners’ social networks on the adoption and maintenance of health intentions and behaviors. The extent to which health messages learned in the classroom are shared with the ELLs’ family, friends, and community may also be important. In a recent study [40] that investigated the spread of health information within family groups, participants reported a strong dependence on their family and social networks for seeking, understanding, and using health information. Results from other studies have also demonstrated the interconnection between an individual’s health, health communication, and health-related behaviors and that of their familial and wider social networks [41–43]. For example, social network influences were found to be associated with the uptake (or not) of health prevention services among immigrants from a number of cultural backgrounds in the USA [44]. The mechanisms underlying the influence that social networks can have on health are suggested to be “social support, social influence, access to resources, social involvement, and person-to-person contagion” [45] (p. 417). Exploiting this influence, Campbell and colleagues [46] used social network methods to identify influential peer leaders at high schools and the leaders’ networks to successfully spread new nonsmoking behavioral norms among classmates. In addition, results from a recent study among 40 long-term health volunteers from Latino and African communities in the USA suggested that one individual can act as a key agent to feasibly disseminate health information to their wider community [47]. Within the ESL classroom, Santos and colleagues gave ELLs a post-lesson survey and found that about two-thirds of the class (n = 105,63.6%) anecdotally reported sharing some information from the diabetes lesson with their social networks [48]. Overall, these results highlight a potentially feasible opportunity to utilize existing immigrant English programs to activate the spread of cancer prevention health messages to new immigrant communities via a language learner in the position of agent of change. Limitation 3: cultural health beliefs and attitudes have not been adequately addressed There is evidence in the literature that cultural beliefs about health and illness affect engagement in chronic disease prevention behaviors [12]. For example, one recent study [49] found an association between traditional Chinese or Western cultural health beliefs and the degree to which university students engaged in physical activity, and another reported a link between cultural health beliefs and engagement in mammography [50]. Cultural differences in health beliefs and attitudes may contribute to difficulties with, and misunderstandings during, communication between health care provider and patient, and in the capacity of the immigrant to follow health care recommendations [12]. In the published ESL interventions, the potential of addressing cultural health beliefs and attributions in the curriculum has not yet been fully realized, although curricula have often been tailored for a particular cultural group. To date, in these programs, cultural tailoring could be considered to be “surface” level only [51], addressing language of delivery [22] or certain culturally linked health behaviors such as food choices [24]. In a recent meta-analysis of 36 studies investigating the persuasive impact of culturally tailored cancer messages [51], it was reported that incorporating “deeper tailoring,” such as embedding cultural norms, values, and religious beliefs into messaging, had a significantly stronger impact on persuasiveness. This suggests that efficacy may be best achieved when cultural influences, including barriers to uptake, are considered in content development. Some community health literacy interventions, not developed for the ESL classroom, have incorporated cultural norms, health beliefs, and values as an integral part of their curricula and have been well accepted within their intended immigrant audience. For example, Wang and colleagues [52], in conjunction with traditional Chinese medicine (TCM) practitioners, developed an educational resource flipchart to show, side-by-side, the relationship between TCM and biomedical views of colorectal cancer, its causes, risks, and prevention strategies. In another study [53], a Vietnamese-language video resource, entitled Honoring Tradition, Accepting New Ways, was developed to deliver health messages about hepatitis B for immigrants from Vietnam to the USA via a soap-opera. It depicted the lives of a three-generation family balancing and maintaining their cultural values, beliefs, and traditions while learning how to access the local health care system. Considering the predominantly multicultural enrolment character of many immigrant language programs in Western countries, the challenge now becomes how to best embed cultural sensitivity into an ESL cancer prevention literacy curriculum, so that its health messages will be accessible to ELLs from different countries. The development of strategies to achieve this requires comprehensive engagement at the development and planning stages of stakeholders of ESL education including teachers, students, and immigrant health providers, as well as the immigrant communities themselves. Limitation 4: current curricula are not easily generalizable The ESL health literacy interventions to date have been developed for specific groups and may not be readily applicable to other immigrant populations with LEP or other ESL settings [17]. In a multicultural country such as Australia, and in ESL classes that are multicultural, these interventions may therefore have limited uptake, not only by student groups, but by teachers as well. Developing a curriculum that can be generalizable to different language learners, as well as to different teachers and language schools, would improve the likelihood that it will be used and reused widely in the classroom, or used across different sites, and thus improving the public health impact. Its potential will be further enhanced by allowing flexibility within the curriculum for local customizations and adaptions to meet the requirements of ELLs or language providers or without losing the main tenets of the curriculum and its goals [54]. Addressing the limitations: a translational research framework An implementation science framework [55] used to guide aspects of health intervention could help address these limitations. One such framework is the RE-AIM evaluation framework, widely used and considered to be more operational than others [56]. This framework was developed by Glasgow and colleagues in 1999 [55] with the aim of improving the reporting of aspects of implementation and external validity of health research trials and is considered useful in this context due to its potential to be applied at all stages of the research process, from planning to evaluation. Briefly, RE-AIM is designed to encourage equal consideration of threats to external and internal validity; the latter of which is the benchmark by which most research is generally judged. The model requires that research testing intervention effectiveness (and ecological validity) report data on five dimensions: (i) reach to representative community populations, (ii) demonstrated efficacy (i.e., internal validity), (iii) adoption by settings and intervention agents, (iv) demonstrated effect on implementation in settings, and (v) demonstration of longer-term maintenance of individual and setting outcomes [57]. These five dimensions are spread across individual, organizational, and community levels to provide researchers with an estimation of the overall public health or policy impact of a health intervention [55, 58]. As an example of the utility of the RE-AIM framework, the HE4L ESL curriculum evaluation trial [25] was assessed using RE-AIM [59]. Through a combination of qualitative and quantitative methods, the researchers concluded that their curriculum had reached into their target population and provided a representative sample. In addition, they concluded that it had been efficacious at improving vocabulary, reading skills, fruit and vegetable intake, planning and coping skills at 3 months and in planning skills and knowledge at 6 months, and that it had been adopted by representative numbers of sites and locations for the US state of Connecticut. By tracking use of each curriculum component, the researchers concluded that they were able to assess which components were implemented as intended and which had been adapted. As it was a pilot study, there were no data for maintenance of the curriculum in settings and by staff over time. The RE-AIM framework has been used to evaluate translatability of other health literacy interventions focused on a wide variety of topics including weight loss [60], eHealth impact [61], and smoking [62]. It has also been used to guide investigation of health interventions via systematic reviews [38, 63]. The systematic reviews have highlighted that the RE-AIM factors of adoption, implementation, and maintenance, issues pertaining to external validity, have tended to be overlooked or poorly reported [63, 64]. To address this limitation, it has been recommended that RE-AIM be included at the planning stage of an intervention [63, 64]. An example of this approach is the study conducted by Belza and colleagues [65] who utilized RE-AIM from the planning stage to guide dissemination of an evidence-based physical activity program for older adults. They worked closely with key stakeholders to identify potential implementation challenges before they occurred and reported 12 months later that the stakeholders were still running the program with new groups of participants. Applying RE-AIM carefully from the outset to the planning of immigrant ESL health interventions could be instrumental in helping to develop an accessible education program relevant to the needs and requirements of learners, teachers, and education settings, and more likely to last. Maximizing translation of a curriculum using RE-AIM The aforementioned limitations within the health literacy ESL field could be addressed by looking through the lens of the RE-AIM framework. From a RE-AIM perspective, expanding current ESL health curricula to consider cultural health beliefs and barriers, and language learners’ social networks, could help to improve the reach of the intervention by opening up accessibility to multiple immigrant groups and affecting immigrant community members not attending the courses. Structured communicative exercises that practice language in the classroom and homework activities promoting discussion with learners’ social networks outside of the classroom could also improve adoption by ESL teachers because it fits with the content-based communicative approach currently widespread in ESL education [66]. In addition, a flexible curriculum that is accessible to the multicultural population of ESL classes and aligns with existing curricula frameworks and framework-based evaluations (i.e., evaluations against the competencies outlined in the Certificates of Spoken and Written English [CSWE]) could improve efficacy (of language skill acquisition), adoption, and implementation by ESL teachers and schools, as well as reach and maintenance by increasing the opportunity for the curriculum to be used over time with different ethnic mixes of language learners. Furthermore, developing and evaluating the curriculum within a theoretical base, and evaluating the spread of the health messages taught in the ESL classes through social network analysis methods, could provide evidence supporting the efficacy of this approach as a valid means to deliver health messages to a population at risk of missing out on mainstream public health initiatives. Outline for the development of pilot curriculum The following section describes the development and evaluation of a pilot curriculum focusing on health literacy relating to cancer prevention behaviors. The intervention is utilizing a health communication approach, aiming to increase functional and critical health literacy and so to improve health behaviors. We are incorporating a social network approach into this, with the aim to increase dissemination. To maximize the potential for translation, development is being informed by the RE-AIM framework. In Australia, new immigrants who are assessed as having less than a basic social proficiency of English can access the AMEP. The focus of the language instruction is on functional literacy designed to help them access a variety of services and employment. Immigrant English classes are generally well attended by adult ELLs who are motivated to learn [25], and in Australia classes are multicultural. The courses typically run in terms of up to 10 weeks, and the ethnic mix can be completely different in each course. The AMEP is nationwide and, although many teachers have autonomy regarding topics to teach and types of activity, they follow CSWE [67], a national graded competency framework of functional skills and grammar to be addressed at three different levels of language proficiency. Developing a program within this framework lends support to its potential for its scalability throughout the nation. We will now outline a curriculum that is currently being planned in accordance with these recommendations. The curriculum will focus on cancer prevention and if found to be efficacious can be used as a model to address education for immigrants with LEP regarding other chronic health conditions, and be applied to other languages and immigrant language programs internationally. ACCESS Development and efficacy testing of the Australian Curriculum of Cancer prevention Education for Speakers of other languageS (ACCESS) curriculum resource will expand on previous research in five key ways. It will (i) be theory driven in its development and evaluation, incorporating measures of knowledge acquisition and intentions to act in each lesson; (ii) encourage ELLs to share new knowledge with their wider social networks; (iii) be adaptable for use with ELLs from different countries of origin and different language course providers; (iv) address key cancer prevention factors and health service utilization for cancer prevention pertinent to Australia; and (v) focus on achievement of both functional and interactive English language and cancer prevention literacy as twin goals of the class. TRANSLATION FRAMEWORK AND THEORETICAL BASE Each stage of the development, trial, and evaluation of the curriculum will be guided by the RE-AIM framework to facilitate the development of a curriculum that optimizes translatability (by addressing both internal and external validity) and considers impacts at the individual, organizational, and community levels, hence enabling an estimation of the potential public health impact of the curriculum at the same time it addresses English language skills. Recommendations from the literature for incorporating RE-AIM into the planning stages of health interventions are summarized in the second column of Table 1. The third column describes how these recommendations could be applied to ESL health interventions. Table 1 Planning for implementation: RE-AIM dimensions and recommendations for designing and evaluating English as a second language (ESL) programs for migrants RE-AIM dimension + description Recommendations to optimize translation of health interventions, arising from the literature [63–65, 75], consistent with RE-AIM dimension Equivalent ESL health interventions, consistent with RE-AIM dimension; recommendations to optimize translation of ESL health interventionsa Reach Participant characteristics and representativeness to wider population • Design to reach and recruit representative portions of the community (e.g., ethnicity, age, gender, socioeconomic) and settings • Involve stakeholders in all research stages • Identify barriers and facilitators of participation • Involve stakeholders (ESL teachers and schools, community personnel, students) to identify potential barriers and facilitators to implementation123 • Design curriculum for multicultural classrooms12 • Prepare education materials to fit current national and local health, language guidelines2 • Prepare materials at different language proficiency levels2 • Address cultural health beliefs, taboos123 • Address language learners’ social networks123 Efficacy Evaluation of outcomes of interventions on participants • Use multiple outcome measures to examine intervention effect and replicate across homogeneous settings and populations • Use theory to explain behavior change, design intervention, underpin evaluation of outcome variables • Measure positive and negative intervention outcomes • Use appropriate theory/theories to inform and guide each aspect of curriculum design, trial, and evaluation23 • Use multiple outcome measures, including change in knowledge, beliefs, attitudes3 • Evaluate health-related outcomes, language skills3 • Conduct social network analyses3 Adoption Representativeness of staff and settings; barriers and facilitating factors affecting intervention delivery • Involve stakeholders in all research stages • Identify barriers and facilitators of participation by the settings and intervention agents • Identify requirements of staff and settings • Identify factors that could enhance feasibility and easy replication • Obtain feedback from all stakeholders, including ESL teachers and students when designing, implementing, and evaluating the curriculum1234 • Examine barriers and facilitators to uptake of the curriculum in different schools1234 • Align curriculum and materials with local and national language guidelines2 Implementation Estimation of how well the intervention is delivered as intended by staff and settings • Involve stakeholders in all research stages • Conduct formative evaluations to learn how the intervention will fit stakeholders’ responsibilities and environment, ask for suggestions • Measure extent of how the staff use/change resource • Conduct initial study investigating language schools’ implementation barriers and facilitators1 • Obtain feedback on the curriculum from teachers prior to, and after, trialing234 • Measure how curriculum was used in different settings, and extent of modifications34 Maintenance Long-term maintenance of behavior change in participants and usage of the intervention in a setting • Incorporate maintenance measurement phases in trials • Evaluate outcomes longer-term (at least 6 months to 1 year) with participants and stakeholders • Ask teachers about their use/adaptation/modification of other health resources used1 • Measure outcomes among language learners and extent of information sharing among their social networks over time34 • Measure use/adaptation/modification of the curriculum over time by teachers/schools34 RE-AIM dimension + description Recommendations to optimize translation of health interventions, arising from the literature [63–65, 75], consistent with RE-AIM dimension Equivalent ESL health interventions, consistent with RE-AIM dimension; recommendations to optimize translation of ESL health interventionsa Reach Participant characteristics and representativeness to wider population • Design to reach and recruit representative portions of the community (e.g., ethnicity, age, gender, socioeconomic) and settings • Involve stakeholders in all research stages • Identify barriers and facilitators of participation • Involve stakeholders (ESL teachers and schools, community personnel, students) to identify potential barriers and facilitators to implementation123 • Design curriculum for multicultural classrooms12 • Prepare education materials to fit current national and local health, language guidelines2 • Prepare materials at different language proficiency levels2 • Address cultural health beliefs, taboos123 • Address language learners’ social networks123 Efficacy Evaluation of outcomes of interventions on participants • Use multiple outcome measures to examine intervention effect and replicate across homogeneous settings and populations • Use theory to explain behavior change, design intervention, underpin evaluation of outcome variables • Measure positive and negative intervention outcomes • Use appropriate theory/theories to inform and guide each aspect of curriculum design, trial, and evaluation23 • Use multiple outcome measures, including change in knowledge, beliefs, attitudes3 • Evaluate health-related outcomes, language skills3 • Conduct social network analyses3 Adoption Representativeness of staff and settings; barriers and facilitating factors affecting intervention delivery • Involve stakeholders in all research stages • Identify barriers and facilitators of participation by the settings and intervention agents • Identify requirements of staff and settings • Identify factors that could enhance feasibility and easy replication • Obtain feedback from all stakeholders, including ESL teachers and students when designing, implementing, and evaluating the curriculum1234 • Examine barriers and facilitators to uptake of the curriculum in different schools1234 • Align curriculum and materials with local and national language guidelines2 Implementation Estimation of how well the intervention is delivered as intended by staff and settings • Involve stakeholders in all research stages • Conduct formative evaluations to learn how the intervention will fit stakeholders’ responsibilities and environment, ask for suggestions • Measure extent of how the staff use/change resource • Conduct initial study investigating language schools’ implementation barriers and facilitators1 • Obtain feedback on the curriculum from teachers prior to, and after, trialing234 • Measure how curriculum was used in different settings, and extent of modifications34 Maintenance Long-term maintenance of behavior change in participants and usage of the intervention in a setting • Incorporate maintenance measurement phases in trials • Evaluate outcomes longer-term (at least 6 months to 1 year) with participants and stakeholders • Ask teachers about their use/adaptation/modification of other health resources used1 • Measure outcomes among language learners and extent of information sharing among their social networks over time34 • Measure use/adaptation/modification of the curriculum over time by teachers/schools34 aSuperscript numbers represent stage that the item will be incorporated into Australian Curriculum of Cancer prevention Education for Speakers of other languages (ACCESS) curriculum development: 1Stage 1; 2Stage 2; 3Stage 3; 4Stage 4. View Large Table 1 Planning for implementation: RE-AIM dimensions and recommendations for designing and evaluating English as a second language (ESL) programs for migrants RE-AIM dimension + description Recommendations to optimize translation of health interventions, arising from the literature [63–65, 75], consistent with RE-AIM dimension Equivalent ESL health interventions, consistent with RE-AIM dimension; recommendations to optimize translation of ESL health interventionsa Reach Participant characteristics and representativeness to wider population • Design to reach and recruit representative portions of the community (e.g., ethnicity, age, gender, socioeconomic) and settings • Involve stakeholders in all research stages • Identify barriers and facilitators of participation • Involve stakeholders (ESL teachers and schools, community personnel, students) to identify potential barriers and facilitators to implementation123 • Design curriculum for multicultural classrooms12 • Prepare education materials to fit current national and local health, language guidelines2 • Prepare materials at different language proficiency levels2 • Address cultural health beliefs, taboos123 • Address language learners’ social networks123 Efficacy Evaluation of outcomes of interventions on participants • Use multiple outcome measures to examine intervention effect and replicate across homogeneous settings and populations • Use theory to explain behavior change, design intervention, underpin evaluation of outcome variables • Measure positive and negative intervention outcomes • Use appropriate theory/theories to inform and guide each aspect of curriculum design, trial, and evaluation23 • Use multiple outcome measures, including change in knowledge, beliefs, attitudes3 • Evaluate health-related outcomes, language skills3 • Conduct social network analyses3 Adoption Representativeness of staff and settings; barriers and facilitating factors affecting intervention delivery • Involve stakeholders in all research stages • Identify barriers and facilitators of participation by the settings and intervention agents • Identify requirements of staff and settings • Identify factors that could enhance feasibility and easy replication • Obtain feedback from all stakeholders, including ESL teachers and students when designing, implementing, and evaluating the curriculum1234 • Examine barriers and facilitators to uptake of the curriculum in different schools1234 • Align curriculum and materials with local and national language guidelines2 Implementation Estimation of how well the intervention is delivered as intended by staff and settings • Involve stakeholders in all research stages • Conduct formative evaluations to learn how the intervention will fit stakeholders’ responsibilities and environment, ask for suggestions • Measure extent of how the staff use/change resource • Conduct initial study investigating language schools’ implementation barriers and facilitators1 • Obtain feedback on the curriculum from teachers prior to, and after, trialing234 • Measure how curriculum was used in different settings, and extent of modifications34 Maintenance Long-term maintenance of behavior change in participants and usage of the intervention in a setting • Incorporate maintenance measurement phases in trials • Evaluate outcomes longer-term (at least 6 months to 1 year) with participants and stakeholders • Ask teachers about their use/adaptation/modification of other health resources used1 • Measure outcomes among language learners and extent of information sharing among their social networks over time34 • Measure use/adaptation/modification of the curriculum over time by teachers/schools34 RE-AIM dimension + description Recommendations to optimize translation of health interventions, arising from the literature [63–65, 75], consistent with RE-AIM dimension Equivalent ESL health interventions, consistent with RE-AIM dimension; recommendations to optimize translation of ESL health interventionsa Reach Participant characteristics and representativeness to wider population • Design to reach and recruit representative portions of the community (e.g., ethnicity, age, gender, socioeconomic) and settings • Involve stakeholders in all research stages • Identify barriers and facilitators of participation • Involve stakeholders (ESL teachers and schools, community personnel, students) to identify potential barriers and facilitators to implementation123 • Design curriculum for multicultural classrooms12 • Prepare education materials to fit current national and local health, language guidelines2 • Prepare materials at different language proficiency levels2 • Address cultural health beliefs, taboos123 • Address language learners’ social networks123 Efficacy Evaluation of outcomes of interventions on participants • Use multiple outcome measures to examine intervention effect and replicate across homogeneous settings and populations • Use theory to explain behavior change, design intervention, underpin evaluation of outcome variables • Measure positive and negative intervention outcomes • Use appropriate theory/theories to inform and guide each aspect of curriculum design, trial, and evaluation23 • Use multiple outcome measures, including change in knowledge, beliefs, attitudes3 • Evaluate health-related outcomes, language skills3 • Conduct social network analyses3 Adoption Representativeness of staff and settings; barriers and facilitating factors affecting intervention delivery • Involve stakeholders in all research stages • Identify barriers and facilitators of participation by the settings and intervention agents • Identify requirements of staff and settings • Identify factors that could enhance feasibility and easy replication • Obtain feedback from all stakeholders, including ESL teachers and students when designing, implementing, and evaluating the curriculum1234 • Examine barriers and facilitators to uptake of the curriculum in different schools1234 • Align curriculum and materials with local and national language guidelines2 Implementation Estimation of how well the intervention is delivered as intended by staff and settings • Involve stakeholders in all research stages • Conduct formative evaluations to learn how the intervention will fit stakeholders’ responsibilities and environment, ask for suggestions • Measure extent of how the staff use/change resource • Conduct initial study investigating language schools’ implementation barriers and facilitators1 • Obtain feedback on the curriculum from teachers prior to, and after, trialing234 • Measure how curriculum was used in different settings, and extent of modifications34 Maintenance Long-term maintenance of behavior change in participants and usage of the intervention in a setting • Incorporate maintenance measurement phases in trials • Evaluate outcomes longer-term (at least 6 months to 1 year) with participants and stakeholders • Ask teachers about their use/adaptation/modification of other health resources used1 • Measure outcomes among language learners and extent of information sharing among their social networks over time34 • Measure use/adaptation/modification of the curriculum over time by teachers/schools34 aSuperscript numbers represent stage that the item will be incorporated into Australian Curriculum of Cancer prevention Education for Speakers of other languages (ACCESS) curriculum development: 1Stage 1; 2Stage 2; 3Stage 3; 4Stage 4. View Large HBF [37] will provide the theoretical base for curriculum development and evaluation. This framework incorporates elements of several health behavior theories to account for the multifaceted nature of predictors of health behavior. These include domain knowledge, communication skills, cultural health beliefs, confidence in communication with health care providers, social normative influences, and social support [37]. For the development of ACCESS, the HBF will be expanded to include (i) attention to aspects of perceived self-efficacy for change and strategic planning for change (from the HAPA [30]), to help language learners identify and overcome potential barriers that may impact on turning behavioral intentions into action, and (ii) an investigation of health information–sharing practices within learners’ social networks and the impact of their networks on behavioral choices, to examine the potential of this approach to reach a wider number of immigrants than those actually taking the class. See Table 2 for examples of language activities to address different theoretical constructs. Table 2 Examples of health behavior theoretical constructs to be included in communicative activities in the curriculum HBF: individual variables Example activity in curriculum Knowledge 1. Pair work jigsaw reading/listening activity. Two forms (with blanked parts) of a reading about how to prevent skin cancer are given to pairs sitting back to back. ELLs must ask questions to be able to complete the information. 2. Using the Internet to find answers to questions about symptoms Communication with provider Role-play activity in small groups to practice going to a doctor to talk about symptoms Cultural factors and health beliefs Examples of different cultural health beliefs shown to ELLs (on video, readings) for ELLs to compare and contrast, followed by small group discussion of beliefs (either current or traditional) from their own cultural backgrounds Social norms Small group/whole class discussion of traditional cultural health practices compared with practices in Australia Social support Pair work. Role-cards of symptoms and practice of language of advice to encourage action Past health behaviors Student-led survey to create and then ask questions of others in class about health Barriers and supports Examples of barriers to attend screening to be modeled on the video (e.g., transport issues, cost, feeling nervous having blood taken), followed by small group brainstorming possible solutions Behavioral intentions Writing activity to identify health intentions and goals over the next 6–12 months HBF: provider and health care system variables Provider characteristics Using the Internet and responding to questions, ELLs identify and describe providers that they could access Health care setting Small groups use the Internet to respond to questions about different health care settings in Australia. They then prepare a PowerPoint slide and oral presentation to inform other members of the class Practice patterns ELLs read a brochure about attending for Pap smear testing and answer comprehension questions Structural factors Using the Internet or real brochures and responding to questions, ELLs research the health care system pertaining to the cancer topic at hand (e.g., how to attend for breast screening, to find out if they need to bring a health care card, or if payment is required) HAPA variables Action planning Writing exercise where ELLs plan when to self-check their skin for abnormalities, exercise, etc. Coping planning Small group exercise where ELLs brainstorm strategies for coping with feelings of not wanting to exercise. From this, each ELL writes down a coping plan that suits his/her own situation Social network variables ELLs identify significant members of their own social network, and, in small groups, practice informing someone about the health information that they have learned in class or how to go about acting on it HBF: individual variables Example activity in curriculum Knowledge 1. Pair work jigsaw reading/listening activity. Two forms (with blanked parts) of a reading about how to prevent skin cancer are given to pairs sitting back to back. ELLs must ask questions to be able to complete the information. 2. Using the Internet to find answers to questions about symptoms Communication with provider Role-play activity in small groups to practice going to a doctor to talk about symptoms Cultural factors and health beliefs Examples of different cultural health beliefs shown to ELLs (on video, readings) for ELLs to compare and contrast, followed by small group discussion of beliefs (either current or traditional) from their own cultural backgrounds Social norms Small group/whole class discussion of traditional cultural health practices compared with practices in Australia Social support Pair work. Role-cards of symptoms and practice of language of advice to encourage action Past health behaviors Student-led survey to create and then ask questions of others in class about health Barriers and supports Examples of barriers to attend screening to be modeled on the video (e.g., transport issues, cost, feeling nervous having blood taken), followed by small group brainstorming possible solutions Behavioral intentions Writing activity to identify health intentions and goals over the next 6–12 months HBF: provider and health care system variables Provider characteristics Using the Internet and responding to questions, ELLs identify and describe providers that they could access Health care setting Small groups use the Internet to respond to questions about different health care settings in Australia. They then prepare a PowerPoint slide and oral presentation to inform other members of the class Practice patterns ELLs read a brochure about attending for Pap smear testing and answer comprehension questions Structural factors Using the Internet or real brochures and responding to questions, ELLs research the health care system pertaining to the cancer topic at hand (e.g., how to attend for breast screening, to find out if they need to bring a health care card, or if payment is required) HAPA variables Action planning Writing exercise where ELLs plan when to self-check their skin for abnormalities, exercise, etc. Coping planning Small group exercise where ELLs brainstorm strategies for coping with feelings of not wanting to exercise. From this, each ELL writes down a coping plan that suits his/her own situation Social network variables ELLs identify significant members of their own social network, and, in small groups, practice informing someone about the health information that they have learned in class or how to go about acting on it ELL English language learner, HAPA Health Action Process Approach, HBF health behavior framework. View Large Table 2 Examples of health behavior theoretical constructs to be included in communicative activities in the curriculum HBF: individual variables Example activity in curriculum Knowledge 1. Pair work jigsaw reading/listening activity. Two forms (with blanked parts) of a reading about how to prevent skin cancer are given to pairs sitting back to back. ELLs must ask questions to be able to complete the information. 2. Using the Internet to find answers to questions about symptoms Communication with provider Role-play activity in small groups to practice going to a doctor to talk about symptoms Cultural factors and health beliefs Examples of different cultural health beliefs shown to ELLs (on video, readings) for ELLs to compare and contrast, followed by small group discussion of beliefs (either current or traditional) from their own cultural backgrounds Social norms Small group/whole class discussion of traditional cultural health practices compared with practices in Australia Social support Pair work. Role-cards of symptoms and practice of language of advice to encourage action Past health behaviors Student-led survey to create and then ask questions of others in class about health Barriers and supports Examples of barriers to attend screening to be modeled on the video (e.g., transport issues, cost, feeling nervous having blood taken), followed by small group brainstorming possible solutions Behavioral intentions Writing activity to identify health intentions and goals over the next 6–12 months HBF: provider and health care system variables Provider characteristics Using the Internet and responding to questions, ELLs identify and describe providers that they could access Health care setting Small groups use the Internet to respond to questions about different health care settings in Australia. They then prepare a PowerPoint slide and oral presentation to inform other members of the class Practice patterns ELLs read a brochure about attending for Pap smear testing and answer comprehension questions Structural factors Using the Internet or real brochures and responding to questions, ELLs research the health care system pertaining to the cancer topic at hand (e.g., how to attend for breast screening, to find out if they need to bring a health care card, or if payment is required) HAPA variables Action planning Writing exercise where ELLs plan when to self-check their skin for abnormalities, exercise, etc. Coping planning Small group exercise where ELLs brainstorm strategies for coping with feelings of not wanting to exercise. From this, each ELL writes down a coping plan that suits his/her own situation Social network variables ELLs identify significant members of their own social network, and, in small groups, practice informing someone about the health information that they have learned in class or how to go about acting on it HBF: individual variables Example activity in curriculum Knowledge 1. Pair work jigsaw reading/listening activity. Two forms (with blanked parts) of a reading about how to prevent skin cancer are given to pairs sitting back to back. ELLs must ask questions to be able to complete the information. 2. Using the Internet to find answers to questions about symptoms Communication with provider Role-play activity in small groups to practice going to a doctor to talk about symptoms Cultural factors and health beliefs Examples of different cultural health beliefs shown to ELLs (on video, readings) for ELLs to compare and contrast, followed by small group discussion of beliefs (either current or traditional) from their own cultural backgrounds Social norms Small group/whole class discussion of traditional cultural health practices compared with practices in Australia Social support Pair work. Role-cards of symptoms and practice of language of advice to encourage action Past health behaviors Student-led survey to create and then ask questions of others in class about health Barriers and supports Examples of barriers to attend screening to be modeled on the video (e.g., transport issues, cost, feeling nervous having blood taken), followed by small group brainstorming possible solutions Behavioral intentions Writing activity to identify health intentions and goals over the next 6–12 months HBF: provider and health care system variables Provider characteristics Using the Internet and responding to questions, ELLs identify and describe providers that they could access Health care setting Small groups use the Internet to respond to questions about different health care settings in Australia. They then prepare a PowerPoint slide and oral presentation to inform other members of the class Practice patterns ELLs read a brochure about attending for Pap smear testing and answer comprehension questions Structural factors Using the Internet or real brochures and responding to questions, ELLs research the health care system pertaining to the cancer topic at hand (e.g., how to attend for breast screening, to find out if they need to bring a health care card, or if payment is required) HAPA variables Action planning Writing exercise where ELLs plan when to self-check their skin for abnormalities, exercise, etc. Coping planning Small group exercise where ELLs brainstorm strategies for coping with feelings of not wanting to exercise. From this, each ELL writes down a coping plan that suits his/her own situation Social network variables ELLs identify significant members of their own social network, and, in small groups, practice informing someone about the health information that they have learned in class or how to go about acting on it ELL English language learner, HAPA Health Action Process Approach, HBF health behavior framework. View Large CURRICULUM CONTENT The curriculum will comprise lessons that can each stand alone as a separate topic, to aid in flexible delivery for ESL teachers. Each lesson will have a cancer prevention health objective that aligns with national guidelines. English language objectives will follow the functional language skill competencies outlined in the three-level CSWE [67] that align with the Australian Core Skills Framework that underpins Australian immigrant English programs. Each lesson will incorporate a variety of media, including video vignettes and accompanying print materials that will play a pivotal role in addressing the key cancer prevention health messages in each lesson. The material available for each lesson will also encompass a graded, functional language curriculum designed to support ELLs in the development of the communicative competence required to access available local resources (e.g., going to the doctor, screening services). Specific topics include (i) understanding what cancer is, and that many cancers are preventable or treatable if caught early; (ii) eating healthily; (iii) being physically active; (iv) reducing tobacco, alcohol, and sun exposure; and (v) accessing various vaccinations for cancer prevention and engaging in cancer-screening services, as appropriate for age and sex. It will be made clear that a pre-requisite for this course will be a basic understanding of the Australian health system (as taught in the survival settlement ESL course given to all ELL immigrants). Class format will be as follows. A video vignette will form the focal part of each lesson. A storyline using the same characters in each vignette will be used to introduce the health topic in a way that enables participants to learn about the specific cancer risk factor (e.g., in Australia there would be a focus on sun exposure risks for skin cancer) as well as learn and practice specific functional language. Accompanying printed materials, structured around the video content and characters, there will be a variety of graded speaking, reading, listening, and writing activities to improve literacy skills and practice new language. Adopting the principles of a content-based, communicative approach [66], there will be a focus on pair work, role-play, and group communicative activities to (i) practice key vocabulary and phrases for use outside the classroom, (ii) promote realistic discussion among ELLs about the similarities to their own culture and the differences they now encounter, and (iii) assist with access to online and print health materials. There will also be a focus on helping participants to apply planning strategies for healthy choices in Australia and an emphasis on sharing the new information throughout their social networks. CURRICULUM DEVELOPMENT The development of ACCESS will comprise four stages (see superscript numbers in the third column of Table 1). Stage 1 is a needs assessment stage with ESL teachers and immigrant community personnel with the aim to identify implementation barriers and facilitating factors. Focus groups and interviews will be held with these stakeholders and the focus group/interview schedule based on RE-AIM. Transcripts will be analyzed deductively using thematic framework analysis [68], driven by RE-AIM framework elements. The needs assessment phase is considered to be an important initial phase of any curriculum development process and said to be particularly important to ESL curricula due to the fact that ESL courses are taught to people from multinational backgrounds in a variety of settings throughout the world [69]. The needs assessment fits with the essence of using a translation framework such as RE-AIM, involving key stakeholders across the intervention process. In Stage 2, a draft curriculum of one lesson module will be developed based on theory, guided by the information obtained in Stage 1 and applying the content-based communicative approach used in second language curriculum development [39] and matching the competency skill requirements of the CSWE used in the AMEP. ESL teachers and students will be invited to provide their evaluation of a draft module by viewing the video vignettes and working through the module’s activities and assessments while completing an evaluation questionnaire. This quantitative questionnaire will comprise validated curriculum evaluation checklists [70, 71] as well as questions based on RE-AIM, inviting opinion ratings of any potential barriers of the module and its elements. A final draft will then be produced and final materials developed. A controlled efficacy and feasibility trial will be held in Stage 3 where knowledge, behavioral, and language outcomes will be formally assessed via validated questionnaires (e.g., pre- and post-assessment of health literacy, attitudes, and health beliefs and well as vocabulary and grammar), implementation factors examined (e.g., how much of the module was used as intended, and the nature of any adaptations/modifications), and opinion from teachers and ELL participants obtained. In Stage 4, a dissemination and implementation trial will be undertaken with the module trialed and evaluated across multiple settings, with Australian AMEP sites, staff and students being invited to participate. The trial evaluation, based on RE-AIM, will enable estimation of the potential public health impact of a cancer literacy ESL module by examining the proportion of ELLs (and their networks) reached, the degree to which the module and its elements are adopted by teachers and implemented into existing curricula as well as health literacy and English language outcomes for ELLs in class. The results of each of these stages will help tailor the most efficacious and effective combination of curriculum elements and activities which will then be applied to the development of the remaining modules in the ACCESS package. CONCLUSIONS In Australia, the development of culturally targeted health interventions to address health disparities by reducing cancer risk in vulnerable populations (encompassing LEP) is a key recommendation of national and state strategies [72, 73]. This is echoed abroad [74]. Current cancer prevention resources may not be accessible for the current immigration profiles due to language, literacy, and/or cultural barriers. A host country second language cancer literacy curriculum that is culturally sensitive and designed to improve knowledge of, and behaviors associated with, cancer prevention, as well as second language skills, provides a potentially feasible strategy to address these key national recommendations and deliver health messages to immigrants with LEP. With guidance from the RE-AIM framework, developing and testing a curriculum resource for efficacy as well as barriers and facilitators to implementation should greatly increase its effectiveness, because key issues to enhance program uptake at the individual, organizational, and community levels are considered, with stakeholder input from the beginning. RE-AIM, as a framework that addresses external as well as internal validity equally, has qualities that lend direction to all stages of the research process. If followed through, this framework can provide researchers and program planners with the best chance of achieving successful implementation and maintenance. ACCESS is a curriculum that will be developed in a manner consistent with the RE-AIM framework. If found to be efficacious in improving cancer prevention knowledge, health behaviors, intentions, and plans, as well as English language skills in immigrant ELLs and their wider networks in Australia, this novel health messaging approach could serve as a model to be applied to the development and implementation of other immigrant language health literacy programs, addressing other chronic health conditions, other languages and immigrant language programs abroad, and has the potential to help mitigate the health disparities experienced by some immigrant ethnic populations when they arrive to a new country. Acknowledgments: Funding: Not applicable. Compliance with Ethical Standards Conflict of Interest: The authors declare that they have no competing interests. Ethics Approval: Not applicable. Informed Consent: Not applicable. References 1. Czaika M , Haas H . The globalization of migration: Has the world become more migratory ? Int Migr Rev . 2014 ; 48 ( 2 ): 283 – 323 . Google Scholar CrossRef Search ADS 2. Australian Government Department of Immigration and Border Protection . Australia’s Humanitarian Programme—2013–2014 . Available at http://www.border.gov.au/ReportsandPublications/Documents/statistics/humanitarian-statistics-2013–14. Accessibility verified January 8, 2017 . 3. Australian Bureau of Statistics . Cultural Diversity in Australia 2017 . Available at http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2071.0~2016~Main%20Features~Cultural%20Diversity%20Data%20Summary~30. Accessibility verified January 8, 2018 . 4. AIHW . Cancer in Australia 2017 , Canberra, Australia ; 2017 . Available at https://www.aihw.gov.au/reports/cancer/cancer-in-australia-2017/contents/table-of-contents. Accessibility verified January 9, 2018 . 5. Anikeeva O , Bi P , Hiller JE , Ryan P , Roder D , Han GS . Trends in cancer mortality rates among migrants in Australia: 1981–2007 . Cancer Epidemiol . 2012 ; 36 ( 2 ): e74 – e82 . Google Scholar CrossRef Search ADS PubMed 6. Salant T , Lauderdale DS . Measuring culture: A critical review of acculturation and health in Asian immigrant populations . Soc Sci Med . 2003 ; 57 ( 1 ): 71 – 90 . Google Scholar CrossRef Search ADS PubMed 7. Singh M , de Looper M. Australian Health Inequalities: 1 Birthplace . Bulletin no. 2. AIHW Catalogue No. AUS 27. Canberra: AIHW; 2002 . 8. Weber MF , Banks E , Smith DP , O’Connell D , Sitas F . Cancer screening among migrants in an Australian cohort; cross-sectional analyses from the 45 and Up Study . bmc Public Health . 2009 ; 9 ( 1 ): 144 . Google Scholar CrossRef Search ADS PubMed 9. Oldach BR , Katz ML . Health literacy and cancer screening: A systematic review . Patient Educ Couns . 2014 ; 94 ( 2 ): 149 – 157 . Google Scholar CrossRef Search ADS PubMed 10. Nutbeam D , McGill B , Premkumar P . Improving health literacy in community populations: A review of progress . Health Promot Int . 2017 :1–11. doi:10.1093/heapro/dax015 11. Nutbeam D . Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century . Health Promot Int . 2000 ; 15 ( 3 ): 259 – 267 . Google Scholar CrossRef Search ADS 12. Shaw SJ , Huebner C , Armin J , Orzech K , Orzech K , Vivian J . The role of culture in health literacy and chronic disease screening and management . J Immigr Minor Health . 2009 ; 11 ( 6 ): 460 – 467 . Google Scholar CrossRef Search ADS PubMed 13. Federation of Ethnic Communities’ Council of Australia . Cancer and Culturally and Linguistically Diverse Communities . 2010 . Available at http://www.fecca.org.au/images/stories/pdfs/cancer_cald_communities_report2010. Accessibility verified January 8, 2017 . 14. Viswanath K , Nagler RH , Bigman-Galimore CA , McCauley MP , Jung M , Ramanadhan S . The communications revolution and health inequalities in the 21st century: Implications for cancer control . Cancer Epidemiol Biomarkers Prev . 2012 ; 21 ( 10 ): 1701 – 1708 . Google Scholar CrossRef Search ADS PubMed 15. Tsai TI , Lee SY . Health literacy as the missing link in the provision of immigrant health care: A qualitative study of Southeast Asian immigrant women in Taiwan . Int j Nurs Stud . 2016 ; 54 : 65 – 74 . doi:https://doi.org/10.1016/j.ijnurstu.2015.03.021 Google Scholar CrossRef Search ADS PubMed 16. Santos MG , Handley MA , Omark K , Schillinger D . ESL participation as a mechanism for advancing health literacy in immigrant communities . J Health Commun . 2014 ; 19 ( suppl 2 ): 89 – 105 . Google Scholar CrossRef Search ADS PubMed 17. Chen X , Goodson P , Acosta S . Blending health literacy with an English as a second language curriculum: A systematic literature review . J Health Commun . 2015 ; 20 ( suppl 2 ): 101 – 111 . Google Scholar CrossRef Search ADS PubMed 18. Coronado GD , Acorda E , Do HH , Taylor VM . Feasibility and acceptability of an English-as-a-second language curriculum on hepatitis B for older Chinese American immigrants . J Health Dispar Res Pract . 2008 ; 2 ( 3 ): 121 – 133 . Google Scholar PubMed 19. Taylor VM , Teh C , Lam W et al. Evaluation of a hepatitis B educational ESL curriculum for Chinese immigrants . Can J Public Health . 2009 ; 100 ( 6 ): 463 – 466 . Google Scholar PubMed 20. Taylor VM , Gregory Hislop T , Bajdik C et al. Hepatitis B ESL education for Asian immigrants . J Community Health . 2011 ; 36 ( 1 ): 35 – 41 . Google Scholar CrossRef Search ADS PubMed 21. Soto Mas F , Cordova C , Murrietta A , Jacobson HE , Ronquillo F , Helitzer D . A multisite community-based health literacy intervention for Spanish speakers . j Community Health . 2015 ; 40 ( 3 ): 431 – 438 . Google Scholar CrossRef Search ADS PubMed 22. Soto Mas F , Ji M , Fuentes BO , Tinajero J . The health literacy and ESL study: A community-based intervention for Spanish-speaking adults . J Health Commun . 2015 ; 20 ( 4 ): 369 – 376 . Google Scholar CrossRef Search ADS PubMed 23. Elder JP , Candelaria J , Woodruff SI et al. Initial results of “Language for Health”: Cardiovascular disease nutrition education for English-as-a-second-language students . Health Educ Res . 1998 ; 13 ( 4 ): 567 – 575 . Google Scholar CrossRef Search ADS PubMed 24. Elder JP , Candelaria JI , Woodruff SI , Criqui MH , Talavera GA , Rupp JW . Results of language for health: Cardiovascular disease nutrition education for Latino English-as-a-second-language students . Health Educ Behav . 2000 ; 27 ( 1 ): 50 – 63 . Google Scholar CrossRef Search ADS PubMed 25. Duncan LR , Martinez JL , Rivers SE et al. Healthy Eating for Life English as a second language curriculum: Primary outcomes from a nutrition education intervention targeting cancer risk reduction . J Health Psychol . 2013 ; 18 ( 7 ): 950 – 961 . Google Scholar CrossRef Search ADS PubMed 26. Coronado GD , Taylor V , Acorda E , Hoai Do H , Thompson B . Development of an English as a second language curriculum for hepatitis B virus testing in Chinese Americans . Cancer . 2005 ; 104 ( suppl 12 ): 2948 – 2951 . Google Scholar CrossRef Search ADS PubMed 27. Taylor VM , Coronado G , Acorda E et al. Development of an ESL curriculum to educate Chinese immigrants about hepatitis B . J Community Health . 2008 ; 33 ( 4 ): 217 – 224 . Google Scholar CrossRef Search ADS PubMed 28. Michie S , Abraham C . Interventions to change health behaviours: Evidence-based or evidence-inspired ? Psychol Health . 2004 ; 19 ( 1 ): 29 – 49 . Google Scholar CrossRef Search ADS 29. Davies P , Walker AE , Grimshaw JM . A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations . Implement Sci . 2010 ; 5 ( 1 ): 14 . Google Scholar CrossRef Search ADS PubMed 30. Schwarzer R . Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors . Appl Psychol . 2008 ; 57 ( 1 ): 1 – 29 . Google Scholar CrossRef Search ADS 31. Bandura A . Self-efficacy: Toward a unifying theory of behavioral change . Psychol Rev . 1977 ; 84 ( 2 ): 191 – 215 . Google Scholar CrossRef Search ADS PubMed 32. Berkman ND , Davis TC , McCormack L . Health literacy: What is it ? j Health Commun . 2010 ; 15 ( suppl 12 ): 9 – 19 . Google Scholar CrossRef Search ADS PubMed 33. Street B. Social Literacies: Critical Approaches to Literacy in Development, Education and Ethnography . London : Longman ; 1995 . 34. Rudd R. Health and Literacy in the New Millennium . Ottawa, Ontario, Canada : Canadian Public Health Conference ; 2000 . 35. Soto Mas F , Mein E , Fuentes B , Thatcher B , Balcázar H . Integrating health literacy and ESL: An interdisciplinary curriculum for Hispanic immigrants . Health Promot Pract . 2013 ; 14 ( 2 ): 263 – 273 . Google Scholar CrossRef Search ADS PubMed 36. Knowles M. The Adult Learner: A Neglected Species . Houston, TX: Gulf Publishing Company; 1973 . 37. Bastani R , Glenn BA , Taylor VM et al. Integrating theory into community interventions to reduce liver cancer disparities: The health behavior framework . Prev Med . 2010 ; 50 ( 1–2 ): 63 – 67 . Google Scholar CrossRef Search ADS PubMed 38. Glasgow RE , Marcus AC , Bull SS , Wilson KM . Disseminating effective cancer screening interventions . Cancer . 2004 ; 101 ( suppl 5 ): 1239 – 1250 . Google Scholar CrossRef Search ADS PubMed 39. Krashen SD , Terrell TD. The Natural Approach: Language Acquisition in the Classroom . San Francisco, CA: The Alemany Press; 1983 . 40. Edwards M , Wood F , Davies M , Edwards A . ‘Distributed health literacy’: Longitudinal qualitative analysis of the roles of health literacy mediators and social networks of people living with a long-term health condition . Health Expect . 2015 ; 18 ( 5 ): 1180 – 1193 . Google Scholar CrossRef Search ADS PubMed 41. Christakis NA , Fowler JH . The spread of obesity in a large social network over 32 years . n Engl J Med . 2007 ; 357 ( 4 ): 370 – 379 . Google Scholar CrossRef Search ADS PubMed 42. De La Haye K , Robins G , Mohr P , Wilson C . How physical activity shapes, and is shaped by, adolescent friendships . Soc Sci Med . 2011 ; 73 ( 5 ): 719 – 28 . Google Scholar CrossRef Search ADS PubMed 43. Koehly LM , Peterson SK , Watts BG , Kempf KK , Vernon SW , Gritz ER . A social network analysis of communication about hereditary nonpolyposis colorectal cancer genetic testing and family functioning . Cancer Epidemiol Biomarkers Prev . 2003 ; 12 ( 4 ): 304 – 313 . Google Scholar PubMed 44. Deri C . Social networks and health service utilization . J Health Econ . 2005 ; 24 ( 6 ): 1076 – 1107 . Google Scholar CrossRef Search ADS PubMed 45. Smith KP , Christakis NA . Social networks and health . Annu Rev Sociol . 2008 ; 34 : 405 – 429 . doi:10.1146/annurev.soc.34.040507.134601 Google Scholar CrossRef Search ADS 46. Campbell R , Starkey F , Holliday J et al. An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): A cluster randomised trial . Lancet . 2008 ; 371 ( 9624 ): 1595 – 1602 . Google Scholar CrossRef Search ADS PubMed 47. Molina Y , McKell MS , Mendoza N et al. Health volunteerism and improved cancer health for Latina and African American women and their social networks: Potential mechanisms . J Cancer Educ . 2018;33(1) :59. 48. Santos MG , McClelland J , Handley M . Language lessons on immigrant identity, food culture, and the search for home . TESOL J . 2011 ; 2 ( 2 ): 203 – 228 . Google Scholar CrossRef Search ADS 49. Wei C , Wilson C , Knott V . Roles of illness attributions and cultural views of cancer in determining participation in cancer-smart lifestyle among Chinese and Western youth in Australia . Asian Pac J Cancer Prev . 2013 ; 14 ( 5 ): 3293 – 3298 . Google Scholar CrossRef Search ADS PubMed 50. Wang JH , Mandelblatt JS , Liang W , Yi B , Ma IJ , Schwartz MD . Knowledge, cultural, and attitudinal barriers to mammography screening among nonadherent immigrant Chinese women: Ever versus never screened status . Cancer . 2009 ; 115 ( 20 ): 4828 – 4838 . Google Scholar CrossRef Search ADS PubMed 51. Huang Y , Shen F . Effects of cultural tailoring on persuasion in cancer communication: A meta‐analysis . J Commun . 2016 ; 66 ( 4 ): 694 – 715 . Google Scholar CrossRef Search ADS 52. Wang J , Burke A , Tsoh JY et al. Exploring a culturally relevant model of cancer prevention involving traditional Chinese medicine providers in a Chinese American community . Eur J Integr Med . 2014 ; 6 ( 1 ): 21 – 28 . Google Scholar CrossRef Search ADS PubMed 53. Burke NJ , Jackson JC , Thai HC et al. ‘Honoring tradition, accepting new ways’: Development of a hepatitis B control intervention for Vietnamese immigrants . Ethn Health . 2004 ; 9 ( 2 ): 153 – 169 . Google Scholar CrossRef Search ADS PubMed 54. Aarons GA , Green AE , Palinkas LA et al. Dynamic adaptation process to implement an evidence-based child maltreatment intervention . Implement Sci . 2012 ; 7 ( 1 ): 32 . Google Scholar CrossRef Search ADS PubMed 55. Glasgow RE , Vogt TM , Boles SM . Evaluating the public health impact of health promotion interventions: The RE-AIM framework . Am J Public Health . 1999 ; 89 ( 9 ): 1322 – 1327 . Google Scholar CrossRef Search ADS PubMed 56. Tabak RG , Khoong EC , Chambers DA , Brownson RC . Bridging research and practice: Models for dissemination and implementation research . Am J Prev Med . 2012 ; 43 ( 3 ): 337 – 350 . Google Scholar CrossRef Search ADS PubMed 57. Glasgow RE , Klesges LM , Dzewaltowski DA , Bull SS , Estabrooks P . The future of health behavior change research: What is needed to improve translation of research into health promotion practice ? Ann Behav Med . 2004 ; 27 ( 1 ): 3 – 12 . Google Scholar CrossRef Search ADS PubMed 58. National Institutes for Health . Toolkit Part 1: Implementation Science Methodologies and Frameworks . Fogarty International Center, Center for Global Health Studies . Available at https://www.fic.nih.gov/About/center-global-health-studies/neuroscience-implementation-toolkit/Pages/methodologies-frameworks.aspx. Accessibility verified December 4, 2017 . PubMed PubMed 59. Martinez JL , Duncan LR , Rivers SE , Bertoli MC , Latimer-Cheung AE , Salovey P . Healthy eating for life English as a second language curriculum: Applying the RE-AIM framework to evaluate a nutrition education intervention targeting cancer risk reduction . Transl Behav Med . 2017;7(4) :657–666. 60. Akers JD , Estabrooks PA , Davy BM . Translational research: Bridging the gap between long-term weight loss maintenance research and practice . J Am Diet Assoc . 2010 ; 110 ( 10 ): 1511 – 1522 . Google Scholar CrossRef Search ADS PubMed 61. Glasgow RE . eHealth evaluation and dissemination research . Am J Prev Med . 2007 ; 32 ( 5 ): S119 – S126 . Google Scholar CrossRef Search ADS PubMed 62. Dzewaltowski DA , Estabrooks PA , Klesges LM , Bull S , Glasgow RE . Behavior change intervention research in community settings: How generalizable are the results ? Health Promot Int . 2004 ; 19 ( 2 ): 235 – 245 . Google Scholar CrossRef Search ADS PubMed 63. Allen K , Zoellner J , Motley M , Estabrooks PA . Understanding the internal and external validity of health literacy interventions: A systematic literature review using the RE-AIM framework . J Health Commun . 2011 ; 16 ( suppl 3 ): 55 – 72 . Google Scholar CrossRef Search ADS PubMed 64. Klesges LM , Estabrooks PA , Dzewaltowski DA , Bull SS , Glasgow RE . Beginning with the application in mind: Designing and planning health behavior change interventions to enhance dissemination . Ann Behav Med . 2005 ; 29 ( 2 ): 66 – 75 . Google Scholar CrossRef Search ADS PubMed 65. Belza B , Toobert DJ , Glasgow RE. RE-AIM for Program Planning: Overview and Applications . Washington, DC : National Council on Aging ; 2007 . 66. Freeman YS , Freeman DE. ESL/EFL Teaching: Principles for Success . Portsmouth , NH : Heinemann ; 1998 . 67. Navitas English . Available at http://www.navitas-english.com.au/amep/amep-courses/cswe-courses/. Accessibility verified January 8, 2017 . 68. Srivastava A , Thomson SB . Framework analysis: A qualitative methodology for applied policy research . JOAAG . 2009 ; 4 ( 2 ): 72 – 79 . 69. Cullinan M . Critical review of ESL curriculum: Practical application to the UAE context . ICJI. 2016 ; 8 ( 1 ): 54 – 68 . 70. Badea M , Iridon C . Students’ evaluation of a Romanian language textbook . Procedia Soc Behav Sci . 2015 ; 203 : 303 – 309 . Google Scholar CrossRef Search ADS 71. Nimehchisalem V , Mukundan J . Refinement of the English language teaching textbook evaluation checklist . Pertanika J Soc Sci Hum . 2015 ; 23 ( 4 ):761–780. 72. National Health Priority Action Council . National Chronic Disease Strategy . Canberra, Australia: Australian Government Department of Health and Ageing ; 2006 . 73. Cancer Council of South Australia . Strategic Plan 2012–2015 . Adelaide, South Australia: Cancer Council of South Australia ; 2013 . 74. National Institutes for Health . Charting the Course: The Office of Disease Prevention Strategic Plan 2014–2018: NIH Office of Disease Prevention . 2014 ; Available at https://prevention.nih.gov/docs/about/ODP_StrategicPlan2014-2018.pdf. Accessibility verified April 26, 2017 . 75. RE-AIM website . Available at http://re-aim.org/. Accessibility verified January 8, 2017 . © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Translational Behavioral Medicine Oxford University Press

Can we address cancer disparities in immigrants by improving cancer literacy through English as a second language instruction?

Loading next page...
 
/lp/ou_press/can-we-address-cancer-disparities-in-immigrants-by-improving-cancer-k1uJ03OpUx
Copyright
© Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
ISSN
1869-6716
eISSN
1613-9860
D.O.I.
10.1093/tbm/iby030
Publisher site
See Article on Publisher Site

Abstract

Abstract In many Western countries, immigrants exhibit disparities in cancer incidence and mortality, and variable uptake of cancer prevention services. New immigrants may not be aware of cancer risks pertinent to their new country, or prevention resources. Traditional cancer prevention health messaging may not be accessible for cultural, language, or literacy reasons. New methods are needed. In North America, health message delivery via English classes for immigrants is showing potential as an efficacious and a feasible way to reach immigrants at the same time improving language skills. Interventions published to date are promising but limited in their ability to generalize or be adapted to a variety of populations and settings. This concept paper aims to synthesize previous findings and identify ways to improve and advance the translation potential of this approach. We propose that this could be achieved by (i) using a translation framework to guide intervention planning, development, implementation, and evaluation; (ii) encouraging and evaluating health message spread throughout language learners’ social networks; and (iii) incorporating cultural sensitivity into the curriculum. A pilot project following these recommendations is planned for Australia and will be discussed. These recommendations could serve as a framework to fit the requirements of immigrant language programs in other countries and other health topics. Implications Practice: Providers of English as a second language (ESL) instruction have the capacity to improve cancer outcomes among non–English-speaking immigrants by addressing cancer literacy through English language instruction, and the provision of a curriculum that can be readily implemented across diverse language instruction settings is a critical first step. Policy: Literacy service providers should work closely with health service providers to develop policy that incorporates education about important health messages within English language curricula. Research: Future research studies should be guided by a translation framework such as RE-AIM from the planning stage to identify potential barriers and facilitators to adoption and implementation within diverse migrant ESL providers. BACKGROUND Immigration trends are changing globally [1]. For example, Australia now hosts a cultural diversity not seen before; recent immigrants (people who come to a foreign country to live permanently) largely hail from China and India, but also from Middle Eastern, African, and Asian countries [2], many of which are developing nations. Currently, a third of Australia’s population were born abroad; a fifth of whom arrived since 2012. Twenty-one percent of the population speak one of over 300 languages other than English at home [3]. There are health implications associated with this current immigration pattern, particularly in relation to cancer incidence and mortality. Whilst the mortality rate is falling, cancer is still a major cause of illness in Australia and in 2011 was the leading cause of disease burden [4]. Although many immigrants from countries arrive to Australia and other “immigrant nations” with a lower risk of some cancers linked to lifestyle behaviors (known as the “healthy immigrant effect” [5]), this lower risk typically dissipates over time, and lifestyle-related cancer incidence tends to worsen as people adopt local lifestyle behaviors [6]. In addition, although some immigrants arrive with the knowledge and skills required to manage their health needs within a new society, many do not participate as readily as others in cancer prevention behaviors such as healthy eating and physical activity, or accessing health services that assist in reducing cancer prevalence such as screening [7]. For example, an Australian survey of adults aged over 45 found reduced mammography and bowel-screening rates in women from North African, Middle Eastern, and some Asian countries, and bowel screening in men from all parts of Asia compared with the rest of the population [8]. One reason underlying this observation is the likelihood of poorer health literacy within these communities [9]. Health literacy can be understood to be both task- and skills-based—the possession of adequate literacy (reading and writing) skills and the ability to utilize these literacy skills to be able to acquire, process, and apply health information to make informed health decisions and actions [10]. At a functional level, the skills enable individuals to obtain and apply basic health information (e.g., getting a prescription filled). More advanced interactive health literacy skills enable people to interact with and understand health professionals and communicative sources. Critical health literacy skills are still more advanced, enabling individuals to seek and critically analyze available health information to make greater health decisions for themselves and others [11]. Immigrants who have suffered reduced or disrupted education may not only have reduced literacy skills but also be challenged in the application of these skills at even the most basic functional level [9]. Low engagement in cancer-preventive behaviors and services may also be influenced by other factors such as cultural differences in beliefs about cancer, illness, and illness prevention [12] and/or resistance to use local health services due to mistrust or a perception that they are culturally inappropriate [13]. Furthermore, low functional English proficiency may limit awareness of available health services and materials, and the ability to comprehend and access public health information and services [9, 14]. Health information provided to new immigrants must therefore be understandable, culturally sensitive, and, for those with limited English proficiency (LEP), merge English literacy and health service literacy needs. Ideally, the information should also be made available soon after the immigrants’ arrival. Current resources for immigrants, such as translated cancer prevention fact sheets or professional interpreter use, may not achieve these aims for several reasons. For example, they may not be accessible to immigrants with reduced health literacy, reduced or disrupted education, and reduced literacy in their native language or those who speak a dialect, and they may not be culturally sensitive, especially if materials have been translated literally without cultural modification [15]. In addition, they do not equip individuals with the language to use health information to interact confidently within a potentially alien health care system. With the changing immigration environment, we need to consider different ways to deliver health messages so that all adults can feel confident to access available health resources and feel empowered to make their own, informed, health decisions. Immigrant English as a second language (ESL) instruction has been suggested as a possible vehicle to tackle health vulnerabilities of adult immigrants to English-speaking countries [16]. This may be a particularly useful mode of education in multicultural countries such as Australia, where new immigrants with LEP are offered around 510 hours of free government-sponsored language classes through the Adult Migrant English Program (AMEP) soon after arrival in the country. The aim of the language education, which can be accessed on a full- or part-time basis, is to facilitate settlement by equipping English language learner (ELL) immigrants with information about local services as well as English language skills to access these services. Settlement information provided to immigrants covers a wide range of topics including the Australian health care system and services. While many immigrants arrive with more pressing immediate needs such as securing employment, the classes address basic health service acquisition, and providing additional information and language regarding cancer prevention and available services could be a natural addition to the curriculum and a means to help improve timely uptake of available resources such as population-based cancer-screening programs. Although no studies have been completed in Australia, a recent systematic review conducted by Chen and colleagues [17] of 18 reports of curricula designed to blend health literacy with ESL highlighted four curricula that were subject to evaluation trials in North America. Results from these trials provide initial promising evidence of the efficacy and feasibility of this approach [17]. Three of these four curricula concentrated on physical outcomes and knowledge acquisition. Briefly, a significant increase in hepatitis B knowledge was found in a pretest–posttest trial (of a 3-hr session) of 56 Chinese immigrants aged over 50 [18], in a group-randomized trial assessed after 6 months among 298 adult Chinese immigrants [19], and among 218 Asian immigrants, also assessed 6 months after intervention [20]. Evaluations of an ESL cardiovascular health curriculum (designed to be taught over 6 weeks) reported significant improvements in functional health literacy in a pretest–posttest trial of 49 [21] and a randomized controlled trial of 155 adult ELLs [22]. A third curriculum, concentrating on nutrition for cardiovascular health, was evaluated in a multicenter cluster randomized parallel groups trial with 408 [23] and in a two-group repeated measures trial with 732 adult Latino ELLs [24]. Results indicated short-term (3 months) improvements in blood pressure and cholesterol readings and 6-month improvements in fat avoidance and nutrition knowledge [24]. The evaluation of a fourth curriculum extended beyond health knowledge and also assessed health behavior outcomes. This curriculum was evaluated via a 12-week pretest–posttest trial of 227 adult immigrants. Outcomes included English language fruit and vegetable vocabulary (scores on a U.S. statewide standardized reading and listening test), health knowledge, fruit and vegetable consumption, and action and coping planning skills in their evaluation of a cancer prevention healthy eating ESL curriculum Healthy Eating 4 Life (HE4L) [25]. The researchers found improvements in ELLs’ vocabulary of fruits and vegetables (reading scores as well as knowledge), self-reported intake of fruit and vegetables, and health-related planning skills following the intervention. This result is important because it highlights the potential of this blend of education to leverage health outcomes from achievement of the language aspirations of recently arrived immigrants with LEP. This additive success is likely to support sustainability, particularly where cancer literacy curricula are delivered in the context of English language instruction. In the conclusion of their systematic review, Chen et al. [17] recommended that future work consider both English and health outcomes, target more demographic groups, and include a greater variety of health topics [17]. With the exception of a hepatitis B intervention curriculum [26, 27], the cancer prevention topics covered to date tend to be general in nature, mainly targeting healthy eating and physical activity. In addition, the North American context and culture-specific nature of existing interventions could make translating them to another country difficult. In addition to Chen et al.’s recommendations [17], the following section identifies four further potential limitations that should be addressed to improve effectiveness and the translational potential of this approach. We outline these additional gaps and then sketch the components of a cancer prevention ESL curriculum being developed in Australia. LIMITATIONS IN CURRENT ESL HEALTH LITERACY INTERVENTIONS Limitation 1: theory has not been fully utilized to explain observed behavior change Interventions to change behavior will be more effectively understood if grounded in an appropriate theory and applied to program development and evaluation. Otherwise, it is difficult to identify the underlying psychological constructs that might explain observed behavioral changes, which has implications for successful replication in future interventions [28]. A systematic review of the use of theory to guide development and evaluation of dissemination and implementation interventions was conducted in 2010 by Davies and colleagues [29]. In this review, a study was classified to have “used theory” if the researchers cited a theory with references and explained how the theory was used to design a study or explain the change(s) observed in the study. In total, 235 health implementation intervention studies were reviewed. Davies and colleagues reported that less than a quarter (53/235, 22.5%) had openly used a theory of behavior or behavior change to guide the research process, and only 14 of these (14/53, 26.4%) used theory “explicitly,” meaning that a theory was explicitly described and one or more of the intervention’s research hypotheses tested constructs relating to that theory. The remaining 39 studies had some conceptual basis in theory, where theory was used to guide aspects of the research process but not tested [29]. Applying Davies et al.’s (2010) criteria [29] to the four curricula subject to review by Chen et al. [17], only one used theory explicitly. Both the curriculum development and a subsequent evaluation trial were based on the Health Action Process Approach (HAPA [30]), a stage model that attempts to bridge the gap between intentions and behavior by utilizing strategies targeting both motivational (e.g., self-efficacy) and volitional (e.g., planning) factors. In this study, ELLs were encouraged to plan their intended fruit and vegetable consumption, as well as plan what to do when faced with challenges. At 12 weeks, the researchers found improvements in self-reported fruit and vegetable intake as well as planning skills. Although longer-term outcomes were not reported, the theoretical basis of this study provides curriculum developers with an evidence-based rationale for including planning skills in future health curricula. These results support findings from other research in health behavior change which suggests that planning can lead to dietary and other health behavior changes [30] and provide evidence to encourage ESL curriculum writers to include planning activities in health topics. The other three curricula reviewed by Chen and colleagues [17] also reported using theory, but in a conceptual way, to inform aspects of the curriculum development, intervention or trial, but not tested explicitly. The theories used to inform aspects of these curricula and interventions varied. For example, Elder et al.’s nutrition curriculum [23, 24] was informed by social cognitive theory [31] that describes learning occurring in a social context (such as the ESL classroom) and health literacy and health behavior theory [32]. A health literacy curricula development trial conducted by Soto Mas and colleagues [21, 22] was reported as being informed by sociocultural approaches to literacy and communication [33], describing the communicative nature of the ESL classroom, health literacy [34], health behavior theory [31], and adult learning theory [35, 36]. Finally, the cancer prevention hepatitis B ESL course developed by Coronado et al. [26] was based on the health behavior framework (HBF [37]). While the elements of the HBF were explicitly described by the researchers clearly in the design of the curriculum, only knowledge was assessed in the curriculum’s evaluation [18, 19] or knowledge and self-reported screening behavior [20]. Aside from the one study by Duncan and colleagues [25], it is unclear whether the results reported in the other three ESL health literacy interventions discussed here [18–22, 24] were related to the psychological constructs underpinning the chosen theory(ies) because components of the theory were not fully evaluated. It is also worth noting that none of the ESL health evaluations to date included details of effect sizes, power analyses, or cost–benefit analyses, limiting conclusions about effectiveness and translation potential. Without attention to each of these areas, the possibility for replication in different settings or estimating likely public health impact is reduced [28]. In addition, as recommended by several authors [37, 38], behavior change interventions are more likely to have a greater public health impact if they simultaneously target and evaluate factors at the wider community and system levels as well as at the individual level. Furthermore, to evaluate the initial and long-term impact of these interventions and their likely translation capacity, it is important that an assessment of ELLs’ English language proficiency be included alongside health literacy as program outcomes. Explicit reference to theories of curriculum development or second language acquisition has not been made in the aforementioned health literacy ESL evaluations to date and could warrant attention. However, all of them were designed to exploit the content-based communicative methodological approach currently used in ESL teaching and curriculum design. This approach emphasizes the importance of creating realistic communicative opportunities in the classroom and arose from Krashen’s theory of second language acquisition [39]. It could be helpful to investigate this further and tease out the most useful aspects of this approach by evaluating the impact of different classroom activity types. Limitation 2: impacts on and from language learners’ wider social networks have not been evaluated We believe that the translation potential of this work to date can be further advanced by investigating and evaluating the nature and impact of learners’ social networks on the adoption and maintenance of health intentions and behaviors. The extent to which health messages learned in the classroom are shared with the ELLs’ family, friends, and community may also be important. In a recent study [40] that investigated the spread of health information within family groups, participants reported a strong dependence on their family and social networks for seeking, understanding, and using health information. Results from other studies have also demonstrated the interconnection between an individual’s health, health communication, and health-related behaviors and that of their familial and wider social networks [41–43]. For example, social network influences were found to be associated with the uptake (or not) of health prevention services among immigrants from a number of cultural backgrounds in the USA [44]. The mechanisms underlying the influence that social networks can have on health are suggested to be “social support, social influence, access to resources, social involvement, and person-to-person contagion” [45] (p. 417). Exploiting this influence, Campbell and colleagues [46] used social network methods to identify influential peer leaders at high schools and the leaders’ networks to successfully spread new nonsmoking behavioral norms among classmates. In addition, results from a recent study among 40 long-term health volunteers from Latino and African communities in the USA suggested that one individual can act as a key agent to feasibly disseminate health information to their wider community [47]. Within the ESL classroom, Santos and colleagues gave ELLs a post-lesson survey and found that about two-thirds of the class (n = 105,63.6%) anecdotally reported sharing some information from the diabetes lesson with their social networks [48]. Overall, these results highlight a potentially feasible opportunity to utilize existing immigrant English programs to activate the spread of cancer prevention health messages to new immigrant communities via a language learner in the position of agent of change. Limitation 3: cultural health beliefs and attitudes have not been adequately addressed There is evidence in the literature that cultural beliefs about health and illness affect engagement in chronic disease prevention behaviors [12]. For example, one recent study [49] found an association between traditional Chinese or Western cultural health beliefs and the degree to which university students engaged in physical activity, and another reported a link between cultural health beliefs and engagement in mammography [50]. Cultural differences in health beliefs and attitudes may contribute to difficulties with, and misunderstandings during, communication between health care provider and patient, and in the capacity of the immigrant to follow health care recommendations [12]. In the published ESL interventions, the potential of addressing cultural health beliefs and attributions in the curriculum has not yet been fully realized, although curricula have often been tailored for a particular cultural group. To date, in these programs, cultural tailoring could be considered to be “surface” level only [51], addressing language of delivery [22] or certain culturally linked health behaviors such as food choices [24]. In a recent meta-analysis of 36 studies investigating the persuasive impact of culturally tailored cancer messages [51], it was reported that incorporating “deeper tailoring,” such as embedding cultural norms, values, and religious beliefs into messaging, had a significantly stronger impact on persuasiveness. This suggests that efficacy may be best achieved when cultural influences, including barriers to uptake, are considered in content development. Some community health literacy interventions, not developed for the ESL classroom, have incorporated cultural norms, health beliefs, and values as an integral part of their curricula and have been well accepted within their intended immigrant audience. For example, Wang and colleagues [52], in conjunction with traditional Chinese medicine (TCM) practitioners, developed an educational resource flipchart to show, side-by-side, the relationship between TCM and biomedical views of colorectal cancer, its causes, risks, and prevention strategies. In another study [53], a Vietnamese-language video resource, entitled Honoring Tradition, Accepting New Ways, was developed to deliver health messages about hepatitis B for immigrants from Vietnam to the USA via a soap-opera. It depicted the lives of a three-generation family balancing and maintaining their cultural values, beliefs, and traditions while learning how to access the local health care system. Considering the predominantly multicultural enrolment character of many immigrant language programs in Western countries, the challenge now becomes how to best embed cultural sensitivity into an ESL cancer prevention literacy curriculum, so that its health messages will be accessible to ELLs from different countries. The development of strategies to achieve this requires comprehensive engagement at the development and planning stages of stakeholders of ESL education including teachers, students, and immigrant health providers, as well as the immigrant communities themselves. Limitation 4: current curricula are not easily generalizable The ESL health literacy interventions to date have been developed for specific groups and may not be readily applicable to other immigrant populations with LEP or other ESL settings [17]. In a multicultural country such as Australia, and in ESL classes that are multicultural, these interventions may therefore have limited uptake, not only by student groups, but by teachers as well. Developing a curriculum that can be generalizable to different language learners, as well as to different teachers and language schools, would improve the likelihood that it will be used and reused widely in the classroom, or used across different sites, and thus improving the public health impact. Its potential will be further enhanced by allowing flexibility within the curriculum for local customizations and adaptions to meet the requirements of ELLs or language providers or without losing the main tenets of the curriculum and its goals [54]. Addressing the limitations: a translational research framework An implementation science framework [55] used to guide aspects of health intervention could help address these limitations. One such framework is the RE-AIM evaluation framework, widely used and considered to be more operational than others [56]. This framework was developed by Glasgow and colleagues in 1999 [55] with the aim of improving the reporting of aspects of implementation and external validity of health research trials and is considered useful in this context due to its potential to be applied at all stages of the research process, from planning to evaluation. Briefly, RE-AIM is designed to encourage equal consideration of threats to external and internal validity; the latter of which is the benchmark by which most research is generally judged. The model requires that research testing intervention effectiveness (and ecological validity) report data on five dimensions: (i) reach to representative community populations, (ii) demonstrated efficacy (i.e., internal validity), (iii) adoption by settings and intervention agents, (iv) demonstrated effect on implementation in settings, and (v) demonstration of longer-term maintenance of individual and setting outcomes [57]. These five dimensions are spread across individual, organizational, and community levels to provide researchers with an estimation of the overall public health or policy impact of a health intervention [55, 58]. As an example of the utility of the RE-AIM framework, the HE4L ESL curriculum evaluation trial [25] was assessed using RE-AIM [59]. Through a combination of qualitative and quantitative methods, the researchers concluded that their curriculum had reached into their target population and provided a representative sample. In addition, they concluded that it had been efficacious at improving vocabulary, reading skills, fruit and vegetable intake, planning and coping skills at 3 months and in planning skills and knowledge at 6 months, and that it had been adopted by representative numbers of sites and locations for the US state of Connecticut. By tracking use of each curriculum component, the researchers concluded that they were able to assess which components were implemented as intended and which had been adapted. As it was a pilot study, there were no data for maintenance of the curriculum in settings and by staff over time. The RE-AIM framework has been used to evaluate translatability of other health literacy interventions focused on a wide variety of topics including weight loss [60], eHealth impact [61], and smoking [62]. It has also been used to guide investigation of health interventions via systematic reviews [38, 63]. The systematic reviews have highlighted that the RE-AIM factors of adoption, implementation, and maintenance, issues pertaining to external validity, have tended to be overlooked or poorly reported [63, 64]. To address this limitation, it has been recommended that RE-AIM be included at the planning stage of an intervention [63, 64]. An example of this approach is the study conducted by Belza and colleagues [65] who utilized RE-AIM from the planning stage to guide dissemination of an evidence-based physical activity program for older adults. They worked closely with key stakeholders to identify potential implementation challenges before they occurred and reported 12 months later that the stakeholders were still running the program with new groups of participants. Applying RE-AIM carefully from the outset to the planning of immigrant ESL health interventions could be instrumental in helping to develop an accessible education program relevant to the needs and requirements of learners, teachers, and education settings, and more likely to last. Maximizing translation of a curriculum using RE-AIM The aforementioned limitations within the health literacy ESL field could be addressed by looking through the lens of the RE-AIM framework. From a RE-AIM perspective, expanding current ESL health curricula to consider cultural health beliefs and barriers, and language learners’ social networks, could help to improve the reach of the intervention by opening up accessibility to multiple immigrant groups and affecting immigrant community members not attending the courses. Structured communicative exercises that practice language in the classroom and homework activities promoting discussion with learners’ social networks outside of the classroom could also improve adoption by ESL teachers because it fits with the content-based communicative approach currently widespread in ESL education [66]. In addition, a flexible curriculum that is accessible to the multicultural population of ESL classes and aligns with existing curricula frameworks and framework-based evaluations (i.e., evaluations against the competencies outlined in the Certificates of Spoken and Written English [CSWE]) could improve efficacy (of language skill acquisition), adoption, and implementation by ESL teachers and schools, as well as reach and maintenance by increasing the opportunity for the curriculum to be used over time with different ethnic mixes of language learners. Furthermore, developing and evaluating the curriculum within a theoretical base, and evaluating the spread of the health messages taught in the ESL classes through social network analysis methods, could provide evidence supporting the efficacy of this approach as a valid means to deliver health messages to a population at risk of missing out on mainstream public health initiatives. Outline for the development of pilot curriculum The following section describes the development and evaluation of a pilot curriculum focusing on health literacy relating to cancer prevention behaviors. The intervention is utilizing a health communication approach, aiming to increase functional and critical health literacy and so to improve health behaviors. We are incorporating a social network approach into this, with the aim to increase dissemination. To maximize the potential for translation, development is being informed by the RE-AIM framework. In Australia, new immigrants who are assessed as having less than a basic social proficiency of English can access the AMEP. The focus of the language instruction is on functional literacy designed to help them access a variety of services and employment. Immigrant English classes are generally well attended by adult ELLs who are motivated to learn [25], and in Australia classes are multicultural. The courses typically run in terms of up to 10 weeks, and the ethnic mix can be completely different in each course. The AMEP is nationwide and, although many teachers have autonomy regarding topics to teach and types of activity, they follow CSWE [67], a national graded competency framework of functional skills and grammar to be addressed at three different levels of language proficiency. Developing a program within this framework lends support to its potential for its scalability throughout the nation. We will now outline a curriculum that is currently being planned in accordance with these recommendations. The curriculum will focus on cancer prevention and if found to be efficacious can be used as a model to address education for immigrants with LEP regarding other chronic health conditions, and be applied to other languages and immigrant language programs internationally. ACCESS Development and efficacy testing of the Australian Curriculum of Cancer prevention Education for Speakers of other languageS (ACCESS) curriculum resource will expand on previous research in five key ways. It will (i) be theory driven in its development and evaluation, incorporating measures of knowledge acquisition and intentions to act in each lesson; (ii) encourage ELLs to share new knowledge with their wider social networks; (iii) be adaptable for use with ELLs from different countries of origin and different language course providers; (iv) address key cancer prevention factors and health service utilization for cancer prevention pertinent to Australia; and (v) focus on achievement of both functional and interactive English language and cancer prevention literacy as twin goals of the class. TRANSLATION FRAMEWORK AND THEORETICAL BASE Each stage of the development, trial, and evaluation of the curriculum will be guided by the RE-AIM framework to facilitate the development of a curriculum that optimizes translatability (by addressing both internal and external validity) and considers impacts at the individual, organizational, and community levels, hence enabling an estimation of the potential public health impact of the curriculum at the same time it addresses English language skills. Recommendations from the literature for incorporating RE-AIM into the planning stages of health interventions are summarized in the second column of Table 1. The third column describes how these recommendations could be applied to ESL health interventions. Table 1 Planning for implementation: RE-AIM dimensions and recommendations for designing and evaluating English as a second language (ESL) programs for migrants RE-AIM dimension + description Recommendations to optimize translation of health interventions, arising from the literature [63–65, 75], consistent with RE-AIM dimension Equivalent ESL health interventions, consistent with RE-AIM dimension; recommendations to optimize translation of ESL health interventionsa Reach Participant characteristics and representativeness to wider population • Design to reach and recruit representative portions of the community (e.g., ethnicity, age, gender, socioeconomic) and settings • Involve stakeholders in all research stages • Identify barriers and facilitators of participation • Involve stakeholders (ESL teachers and schools, community personnel, students) to identify potential barriers and facilitators to implementation123 • Design curriculum for multicultural classrooms12 • Prepare education materials to fit current national and local health, language guidelines2 • Prepare materials at different language proficiency levels2 • Address cultural health beliefs, taboos123 • Address language learners’ social networks123 Efficacy Evaluation of outcomes of interventions on participants • Use multiple outcome measures to examine intervention effect and replicate across homogeneous settings and populations • Use theory to explain behavior change, design intervention, underpin evaluation of outcome variables • Measure positive and negative intervention outcomes • Use appropriate theory/theories to inform and guide each aspect of curriculum design, trial, and evaluation23 • Use multiple outcome measures, including change in knowledge, beliefs, attitudes3 • Evaluate health-related outcomes, language skills3 • Conduct social network analyses3 Adoption Representativeness of staff and settings; barriers and facilitating factors affecting intervention delivery • Involve stakeholders in all research stages • Identify barriers and facilitators of participation by the settings and intervention agents • Identify requirements of staff and settings • Identify factors that could enhance feasibility and easy replication • Obtain feedback from all stakeholders, including ESL teachers and students when designing, implementing, and evaluating the curriculum1234 • Examine barriers and facilitators to uptake of the curriculum in different schools1234 • Align curriculum and materials with local and national language guidelines2 Implementation Estimation of how well the intervention is delivered as intended by staff and settings • Involve stakeholders in all research stages • Conduct formative evaluations to learn how the intervention will fit stakeholders’ responsibilities and environment, ask for suggestions • Measure extent of how the staff use/change resource • Conduct initial study investigating language schools’ implementation barriers and facilitators1 • Obtain feedback on the curriculum from teachers prior to, and after, trialing234 • Measure how curriculum was used in different settings, and extent of modifications34 Maintenance Long-term maintenance of behavior change in participants and usage of the intervention in a setting • Incorporate maintenance measurement phases in trials • Evaluate outcomes longer-term (at least 6 months to 1 year) with participants and stakeholders • Ask teachers about their use/adaptation/modification of other health resources used1 • Measure outcomes among language learners and extent of information sharing among their social networks over time34 • Measure use/adaptation/modification of the curriculum over time by teachers/schools34 RE-AIM dimension + description Recommendations to optimize translation of health interventions, arising from the literature [63–65, 75], consistent with RE-AIM dimension Equivalent ESL health interventions, consistent with RE-AIM dimension; recommendations to optimize translation of ESL health interventionsa Reach Participant characteristics and representativeness to wider population • Design to reach and recruit representative portions of the community (e.g., ethnicity, age, gender, socioeconomic) and settings • Involve stakeholders in all research stages • Identify barriers and facilitators of participation • Involve stakeholders (ESL teachers and schools, community personnel, students) to identify potential barriers and facilitators to implementation123 • Design curriculum for multicultural classrooms12 • Prepare education materials to fit current national and local health, language guidelines2 • Prepare materials at different language proficiency levels2 • Address cultural health beliefs, taboos123 • Address language learners’ social networks123 Efficacy Evaluation of outcomes of interventions on participants • Use multiple outcome measures to examine intervention effect and replicate across homogeneous settings and populations • Use theory to explain behavior change, design intervention, underpin evaluation of outcome variables • Measure positive and negative intervention outcomes • Use appropriate theory/theories to inform and guide each aspect of curriculum design, trial, and evaluation23 • Use multiple outcome measures, including change in knowledge, beliefs, attitudes3 • Evaluate health-related outcomes, language skills3 • Conduct social network analyses3 Adoption Representativeness of staff and settings; barriers and facilitating factors affecting intervention delivery • Involve stakeholders in all research stages • Identify barriers and facilitators of participation by the settings and intervention agents • Identify requirements of staff and settings • Identify factors that could enhance feasibility and easy replication • Obtain feedback from all stakeholders, including ESL teachers and students when designing, implementing, and evaluating the curriculum1234 • Examine barriers and facilitators to uptake of the curriculum in different schools1234 • Align curriculum and materials with local and national language guidelines2 Implementation Estimation of how well the intervention is delivered as intended by staff and settings • Involve stakeholders in all research stages • Conduct formative evaluations to learn how the intervention will fit stakeholders’ responsibilities and environment, ask for suggestions • Measure extent of how the staff use/change resource • Conduct initial study investigating language schools’ implementation barriers and facilitators1 • Obtain feedback on the curriculum from teachers prior to, and after, trialing234 • Measure how curriculum was used in different settings, and extent of modifications34 Maintenance Long-term maintenance of behavior change in participants and usage of the intervention in a setting • Incorporate maintenance measurement phases in trials • Evaluate outcomes longer-term (at least 6 months to 1 year) with participants and stakeholders • Ask teachers about their use/adaptation/modification of other health resources used1 • Measure outcomes among language learners and extent of information sharing among their social networks over time34 • Measure use/adaptation/modification of the curriculum over time by teachers/schools34 aSuperscript numbers represent stage that the item will be incorporated into Australian Curriculum of Cancer prevention Education for Speakers of other languages (ACCESS) curriculum development: 1Stage 1; 2Stage 2; 3Stage 3; 4Stage 4. View Large Table 1 Planning for implementation: RE-AIM dimensions and recommendations for designing and evaluating English as a second language (ESL) programs for migrants RE-AIM dimension + description Recommendations to optimize translation of health interventions, arising from the literature [63–65, 75], consistent with RE-AIM dimension Equivalent ESL health interventions, consistent with RE-AIM dimension; recommendations to optimize translation of ESL health interventionsa Reach Participant characteristics and representativeness to wider population • Design to reach and recruit representative portions of the community (e.g., ethnicity, age, gender, socioeconomic) and settings • Involve stakeholders in all research stages • Identify barriers and facilitators of participation • Involve stakeholders (ESL teachers and schools, community personnel, students) to identify potential barriers and facilitators to implementation123 • Design curriculum for multicultural classrooms12 • Prepare education materials to fit current national and local health, language guidelines2 • Prepare materials at different language proficiency levels2 • Address cultural health beliefs, taboos123 • Address language learners’ social networks123 Efficacy Evaluation of outcomes of interventions on participants • Use multiple outcome measures to examine intervention effect and replicate across homogeneous settings and populations • Use theory to explain behavior change, design intervention, underpin evaluation of outcome variables • Measure positive and negative intervention outcomes • Use appropriate theory/theories to inform and guide each aspect of curriculum design, trial, and evaluation23 • Use multiple outcome measures, including change in knowledge, beliefs, attitudes3 • Evaluate health-related outcomes, language skills3 • Conduct social network analyses3 Adoption Representativeness of staff and settings; barriers and facilitating factors affecting intervention delivery • Involve stakeholders in all research stages • Identify barriers and facilitators of participation by the settings and intervention agents • Identify requirements of staff and settings • Identify factors that could enhance feasibility and easy replication • Obtain feedback from all stakeholders, including ESL teachers and students when designing, implementing, and evaluating the curriculum1234 • Examine barriers and facilitators to uptake of the curriculum in different schools1234 • Align curriculum and materials with local and national language guidelines2 Implementation Estimation of how well the intervention is delivered as intended by staff and settings • Involve stakeholders in all research stages • Conduct formative evaluations to learn how the intervention will fit stakeholders’ responsibilities and environment, ask for suggestions • Measure extent of how the staff use/change resource • Conduct initial study investigating language schools’ implementation barriers and facilitators1 • Obtain feedback on the curriculum from teachers prior to, and after, trialing234 • Measure how curriculum was used in different settings, and extent of modifications34 Maintenance Long-term maintenance of behavior change in participants and usage of the intervention in a setting • Incorporate maintenance measurement phases in trials • Evaluate outcomes longer-term (at least 6 months to 1 year) with participants and stakeholders • Ask teachers about their use/adaptation/modification of other health resources used1 • Measure outcomes among language learners and extent of information sharing among their social networks over time34 • Measure use/adaptation/modification of the curriculum over time by teachers/schools34 RE-AIM dimension + description Recommendations to optimize translation of health interventions, arising from the literature [63–65, 75], consistent with RE-AIM dimension Equivalent ESL health interventions, consistent with RE-AIM dimension; recommendations to optimize translation of ESL health interventionsa Reach Participant characteristics and representativeness to wider population • Design to reach and recruit representative portions of the community (e.g., ethnicity, age, gender, socioeconomic) and settings • Involve stakeholders in all research stages • Identify barriers and facilitators of participation • Involve stakeholders (ESL teachers and schools, community personnel, students) to identify potential barriers and facilitators to implementation123 • Design curriculum for multicultural classrooms12 • Prepare education materials to fit current national and local health, language guidelines2 • Prepare materials at different language proficiency levels2 • Address cultural health beliefs, taboos123 • Address language learners’ social networks123 Efficacy Evaluation of outcomes of interventions on participants • Use multiple outcome measures to examine intervention effect and replicate across homogeneous settings and populations • Use theory to explain behavior change, design intervention, underpin evaluation of outcome variables • Measure positive and negative intervention outcomes • Use appropriate theory/theories to inform and guide each aspect of curriculum design, trial, and evaluation23 • Use multiple outcome measures, including change in knowledge, beliefs, attitudes3 • Evaluate health-related outcomes, language skills3 • Conduct social network analyses3 Adoption Representativeness of staff and settings; barriers and facilitating factors affecting intervention delivery • Involve stakeholders in all research stages • Identify barriers and facilitators of participation by the settings and intervention agents • Identify requirements of staff and settings • Identify factors that could enhance feasibility and easy replication • Obtain feedback from all stakeholders, including ESL teachers and students when designing, implementing, and evaluating the curriculum1234 • Examine barriers and facilitators to uptake of the curriculum in different schools1234 • Align curriculum and materials with local and national language guidelines2 Implementation Estimation of how well the intervention is delivered as intended by staff and settings • Involve stakeholders in all research stages • Conduct formative evaluations to learn how the intervention will fit stakeholders’ responsibilities and environment, ask for suggestions • Measure extent of how the staff use/change resource • Conduct initial study investigating language schools’ implementation barriers and facilitators1 • Obtain feedback on the curriculum from teachers prior to, and after, trialing234 • Measure how curriculum was used in different settings, and extent of modifications34 Maintenance Long-term maintenance of behavior change in participants and usage of the intervention in a setting • Incorporate maintenance measurement phases in trials • Evaluate outcomes longer-term (at least 6 months to 1 year) with participants and stakeholders • Ask teachers about their use/adaptation/modification of other health resources used1 • Measure outcomes among language learners and extent of information sharing among their social networks over time34 • Measure use/adaptation/modification of the curriculum over time by teachers/schools34 aSuperscript numbers represent stage that the item will be incorporated into Australian Curriculum of Cancer prevention Education for Speakers of other languages (ACCESS) curriculum development: 1Stage 1; 2Stage 2; 3Stage 3; 4Stage 4. View Large HBF [37] will provide the theoretical base for curriculum development and evaluation. This framework incorporates elements of several health behavior theories to account for the multifaceted nature of predictors of health behavior. These include domain knowledge, communication skills, cultural health beliefs, confidence in communication with health care providers, social normative influences, and social support [37]. For the development of ACCESS, the HBF will be expanded to include (i) attention to aspects of perceived self-efficacy for change and strategic planning for change (from the HAPA [30]), to help language learners identify and overcome potential barriers that may impact on turning behavioral intentions into action, and (ii) an investigation of health information–sharing practices within learners’ social networks and the impact of their networks on behavioral choices, to examine the potential of this approach to reach a wider number of immigrants than those actually taking the class. See Table 2 for examples of language activities to address different theoretical constructs. Table 2 Examples of health behavior theoretical constructs to be included in communicative activities in the curriculum HBF: individual variables Example activity in curriculum Knowledge 1. Pair work jigsaw reading/listening activity. Two forms (with blanked parts) of a reading about how to prevent skin cancer are given to pairs sitting back to back. ELLs must ask questions to be able to complete the information. 2. Using the Internet to find answers to questions about symptoms Communication with provider Role-play activity in small groups to practice going to a doctor to talk about symptoms Cultural factors and health beliefs Examples of different cultural health beliefs shown to ELLs (on video, readings) for ELLs to compare and contrast, followed by small group discussion of beliefs (either current or traditional) from their own cultural backgrounds Social norms Small group/whole class discussion of traditional cultural health practices compared with practices in Australia Social support Pair work. Role-cards of symptoms and practice of language of advice to encourage action Past health behaviors Student-led survey to create and then ask questions of others in class about health Barriers and supports Examples of barriers to attend screening to be modeled on the video (e.g., transport issues, cost, feeling nervous having blood taken), followed by small group brainstorming possible solutions Behavioral intentions Writing activity to identify health intentions and goals over the next 6–12 months HBF: provider and health care system variables Provider characteristics Using the Internet and responding to questions, ELLs identify and describe providers that they could access Health care setting Small groups use the Internet to respond to questions about different health care settings in Australia. They then prepare a PowerPoint slide and oral presentation to inform other members of the class Practice patterns ELLs read a brochure about attending for Pap smear testing and answer comprehension questions Structural factors Using the Internet or real brochures and responding to questions, ELLs research the health care system pertaining to the cancer topic at hand (e.g., how to attend for breast screening, to find out if they need to bring a health care card, or if payment is required) HAPA variables Action planning Writing exercise where ELLs plan when to self-check their skin for abnormalities, exercise, etc. Coping planning Small group exercise where ELLs brainstorm strategies for coping with feelings of not wanting to exercise. From this, each ELL writes down a coping plan that suits his/her own situation Social network variables ELLs identify significant members of their own social network, and, in small groups, practice informing someone about the health information that they have learned in class or how to go about acting on it HBF: individual variables Example activity in curriculum Knowledge 1. Pair work jigsaw reading/listening activity. Two forms (with blanked parts) of a reading about how to prevent skin cancer are given to pairs sitting back to back. ELLs must ask questions to be able to complete the information. 2. Using the Internet to find answers to questions about symptoms Communication with provider Role-play activity in small groups to practice going to a doctor to talk about symptoms Cultural factors and health beliefs Examples of different cultural health beliefs shown to ELLs (on video, readings) for ELLs to compare and contrast, followed by small group discussion of beliefs (either current or traditional) from their own cultural backgrounds Social norms Small group/whole class discussion of traditional cultural health practices compared with practices in Australia Social support Pair work. Role-cards of symptoms and practice of language of advice to encourage action Past health behaviors Student-led survey to create and then ask questions of others in class about health Barriers and supports Examples of barriers to attend screening to be modeled on the video (e.g., transport issues, cost, feeling nervous having blood taken), followed by small group brainstorming possible solutions Behavioral intentions Writing activity to identify health intentions and goals over the next 6–12 months HBF: provider and health care system variables Provider characteristics Using the Internet and responding to questions, ELLs identify and describe providers that they could access Health care setting Small groups use the Internet to respond to questions about different health care settings in Australia. They then prepare a PowerPoint slide and oral presentation to inform other members of the class Practice patterns ELLs read a brochure about attending for Pap smear testing and answer comprehension questions Structural factors Using the Internet or real brochures and responding to questions, ELLs research the health care system pertaining to the cancer topic at hand (e.g., how to attend for breast screening, to find out if they need to bring a health care card, or if payment is required) HAPA variables Action planning Writing exercise where ELLs plan when to self-check their skin for abnormalities, exercise, etc. Coping planning Small group exercise where ELLs brainstorm strategies for coping with feelings of not wanting to exercise. From this, each ELL writes down a coping plan that suits his/her own situation Social network variables ELLs identify significant members of their own social network, and, in small groups, practice informing someone about the health information that they have learned in class or how to go about acting on it ELL English language learner, HAPA Health Action Process Approach, HBF health behavior framework. View Large Table 2 Examples of health behavior theoretical constructs to be included in communicative activities in the curriculum HBF: individual variables Example activity in curriculum Knowledge 1. Pair work jigsaw reading/listening activity. Two forms (with blanked parts) of a reading about how to prevent skin cancer are given to pairs sitting back to back. ELLs must ask questions to be able to complete the information. 2. Using the Internet to find answers to questions about symptoms Communication with provider Role-play activity in small groups to practice going to a doctor to talk about symptoms Cultural factors and health beliefs Examples of different cultural health beliefs shown to ELLs (on video, readings) for ELLs to compare and contrast, followed by small group discussion of beliefs (either current or traditional) from their own cultural backgrounds Social norms Small group/whole class discussion of traditional cultural health practices compared with practices in Australia Social support Pair work. Role-cards of symptoms and practice of language of advice to encourage action Past health behaviors Student-led survey to create and then ask questions of others in class about health Barriers and supports Examples of barriers to attend screening to be modeled on the video (e.g., transport issues, cost, feeling nervous having blood taken), followed by small group brainstorming possible solutions Behavioral intentions Writing activity to identify health intentions and goals over the next 6–12 months HBF: provider and health care system variables Provider characteristics Using the Internet and responding to questions, ELLs identify and describe providers that they could access Health care setting Small groups use the Internet to respond to questions about different health care settings in Australia. They then prepare a PowerPoint slide and oral presentation to inform other members of the class Practice patterns ELLs read a brochure about attending for Pap smear testing and answer comprehension questions Structural factors Using the Internet or real brochures and responding to questions, ELLs research the health care system pertaining to the cancer topic at hand (e.g., how to attend for breast screening, to find out if they need to bring a health care card, or if payment is required) HAPA variables Action planning Writing exercise where ELLs plan when to self-check their skin for abnormalities, exercise, etc. Coping planning Small group exercise where ELLs brainstorm strategies for coping with feelings of not wanting to exercise. From this, each ELL writes down a coping plan that suits his/her own situation Social network variables ELLs identify significant members of their own social network, and, in small groups, practice informing someone about the health information that they have learned in class or how to go about acting on it HBF: individual variables Example activity in curriculum Knowledge 1. Pair work jigsaw reading/listening activity. Two forms (with blanked parts) of a reading about how to prevent skin cancer are given to pairs sitting back to back. ELLs must ask questions to be able to complete the information. 2. Using the Internet to find answers to questions about symptoms Communication with provider Role-play activity in small groups to practice going to a doctor to talk about symptoms Cultural factors and health beliefs Examples of different cultural health beliefs shown to ELLs (on video, readings) for ELLs to compare and contrast, followed by small group discussion of beliefs (either current or traditional) from their own cultural backgrounds Social norms Small group/whole class discussion of traditional cultural health practices compared with practices in Australia Social support Pair work. Role-cards of symptoms and practice of language of advice to encourage action Past health behaviors Student-led survey to create and then ask questions of others in class about health Barriers and supports Examples of barriers to attend screening to be modeled on the video (e.g., transport issues, cost, feeling nervous having blood taken), followed by small group brainstorming possible solutions Behavioral intentions Writing activity to identify health intentions and goals over the next 6–12 months HBF: provider and health care system variables Provider characteristics Using the Internet and responding to questions, ELLs identify and describe providers that they could access Health care setting Small groups use the Internet to respond to questions about different health care settings in Australia. They then prepare a PowerPoint slide and oral presentation to inform other members of the class Practice patterns ELLs read a brochure about attending for Pap smear testing and answer comprehension questions Structural factors Using the Internet or real brochures and responding to questions, ELLs research the health care system pertaining to the cancer topic at hand (e.g., how to attend for breast screening, to find out if they need to bring a health care card, or if payment is required) HAPA variables Action planning Writing exercise where ELLs plan when to self-check their skin for abnormalities, exercise, etc. Coping planning Small group exercise where ELLs brainstorm strategies for coping with feelings of not wanting to exercise. From this, each ELL writes down a coping plan that suits his/her own situation Social network variables ELLs identify significant members of their own social network, and, in small groups, practice informing someone about the health information that they have learned in class or how to go about acting on it ELL English language learner, HAPA Health Action Process Approach, HBF health behavior framework. View Large CURRICULUM CONTENT The curriculum will comprise lessons that can each stand alone as a separate topic, to aid in flexible delivery for ESL teachers. Each lesson will have a cancer prevention health objective that aligns with national guidelines. English language objectives will follow the functional language skill competencies outlined in the three-level CSWE [67] that align with the Australian Core Skills Framework that underpins Australian immigrant English programs. Each lesson will incorporate a variety of media, including video vignettes and accompanying print materials that will play a pivotal role in addressing the key cancer prevention health messages in each lesson. The material available for each lesson will also encompass a graded, functional language curriculum designed to support ELLs in the development of the communicative competence required to access available local resources (e.g., going to the doctor, screening services). Specific topics include (i) understanding what cancer is, and that many cancers are preventable or treatable if caught early; (ii) eating healthily; (iii) being physically active; (iv) reducing tobacco, alcohol, and sun exposure; and (v) accessing various vaccinations for cancer prevention and engaging in cancer-screening services, as appropriate for age and sex. It will be made clear that a pre-requisite for this course will be a basic understanding of the Australian health system (as taught in the survival settlement ESL course given to all ELL immigrants). Class format will be as follows. A video vignette will form the focal part of each lesson. A storyline using the same characters in each vignette will be used to introduce the health topic in a way that enables participants to learn about the specific cancer risk factor (e.g., in Australia there would be a focus on sun exposure risks for skin cancer) as well as learn and practice specific functional language. Accompanying printed materials, structured around the video content and characters, there will be a variety of graded speaking, reading, listening, and writing activities to improve literacy skills and practice new language. Adopting the principles of a content-based, communicative approach [66], there will be a focus on pair work, role-play, and group communicative activities to (i) practice key vocabulary and phrases for use outside the classroom, (ii) promote realistic discussion among ELLs about the similarities to their own culture and the differences they now encounter, and (iii) assist with access to online and print health materials. There will also be a focus on helping participants to apply planning strategies for healthy choices in Australia and an emphasis on sharing the new information throughout their social networks. CURRICULUM DEVELOPMENT The development of ACCESS will comprise four stages (see superscript numbers in the third column of Table 1). Stage 1 is a needs assessment stage with ESL teachers and immigrant community personnel with the aim to identify implementation barriers and facilitating factors. Focus groups and interviews will be held with these stakeholders and the focus group/interview schedule based on RE-AIM. Transcripts will be analyzed deductively using thematic framework analysis [68], driven by RE-AIM framework elements. The needs assessment phase is considered to be an important initial phase of any curriculum development process and said to be particularly important to ESL curricula due to the fact that ESL courses are taught to people from multinational backgrounds in a variety of settings throughout the world [69]. The needs assessment fits with the essence of using a translation framework such as RE-AIM, involving key stakeholders across the intervention process. In Stage 2, a draft curriculum of one lesson module will be developed based on theory, guided by the information obtained in Stage 1 and applying the content-based communicative approach used in second language curriculum development [39] and matching the competency skill requirements of the CSWE used in the AMEP. ESL teachers and students will be invited to provide their evaluation of a draft module by viewing the video vignettes and working through the module’s activities and assessments while completing an evaluation questionnaire. This quantitative questionnaire will comprise validated curriculum evaluation checklists [70, 71] as well as questions based on RE-AIM, inviting opinion ratings of any potential barriers of the module and its elements. A final draft will then be produced and final materials developed. A controlled efficacy and feasibility trial will be held in Stage 3 where knowledge, behavioral, and language outcomes will be formally assessed via validated questionnaires (e.g., pre- and post-assessment of health literacy, attitudes, and health beliefs and well as vocabulary and grammar), implementation factors examined (e.g., how much of the module was used as intended, and the nature of any adaptations/modifications), and opinion from teachers and ELL participants obtained. In Stage 4, a dissemination and implementation trial will be undertaken with the module trialed and evaluated across multiple settings, with Australian AMEP sites, staff and students being invited to participate. The trial evaluation, based on RE-AIM, will enable estimation of the potential public health impact of a cancer literacy ESL module by examining the proportion of ELLs (and their networks) reached, the degree to which the module and its elements are adopted by teachers and implemented into existing curricula as well as health literacy and English language outcomes for ELLs in class. The results of each of these stages will help tailor the most efficacious and effective combination of curriculum elements and activities which will then be applied to the development of the remaining modules in the ACCESS package. CONCLUSIONS In Australia, the development of culturally targeted health interventions to address health disparities by reducing cancer risk in vulnerable populations (encompassing LEP) is a key recommendation of national and state strategies [72, 73]. This is echoed abroad [74]. Current cancer prevention resources may not be accessible for the current immigration profiles due to language, literacy, and/or cultural barriers. A host country second language cancer literacy curriculum that is culturally sensitive and designed to improve knowledge of, and behaviors associated with, cancer prevention, as well as second language skills, provides a potentially feasible strategy to address these key national recommendations and deliver health messages to immigrants with LEP. With guidance from the RE-AIM framework, developing and testing a curriculum resource for efficacy as well as barriers and facilitators to implementation should greatly increase its effectiveness, because key issues to enhance program uptake at the individual, organizational, and community levels are considered, with stakeholder input from the beginning. RE-AIM, as a framework that addresses external as well as internal validity equally, has qualities that lend direction to all stages of the research process. If followed through, this framework can provide researchers and program planners with the best chance of achieving successful implementation and maintenance. ACCESS is a curriculum that will be developed in a manner consistent with the RE-AIM framework. If found to be efficacious in improving cancer prevention knowledge, health behaviors, intentions, and plans, as well as English language skills in immigrant ELLs and their wider networks in Australia, this novel health messaging approach could serve as a model to be applied to the development and implementation of other immigrant language health literacy programs, addressing other chronic health conditions, other languages and immigrant language programs abroad, and has the potential to help mitigate the health disparities experienced by some immigrant ethnic populations when they arrive to a new country. Acknowledgments: Funding: Not applicable. Compliance with Ethical Standards Conflict of Interest: The authors declare that they have no competing interests. Ethics Approval: Not applicable. Informed Consent: Not applicable. References 1. Czaika M , Haas H . The globalization of migration: Has the world become more migratory ? Int Migr Rev . 2014 ; 48 ( 2 ): 283 – 323 . Google Scholar CrossRef Search ADS 2. Australian Government Department of Immigration and Border Protection . Australia’s Humanitarian Programme—2013–2014 . Available at http://www.border.gov.au/ReportsandPublications/Documents/statistics/humanitarian-statistics-2013–14. Accessibility verified January 8, 2017 . 3. Australian Bureau of Statistics . Cultural Diversity in Australia 2017 . Available at http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2071.0~2016~Main%20Features~Cultural%20Diversity%20Data%20Summary~30. Accessibility verified January 8, 2018 . 4. AIHW . Cancer in Australia 2017 , Canberra, Australia ; 2017 . Available at https://www.aihw.gov.au/reports/cancer/cancer-in-australia-2017/contents/table-of-contents. Accessibility verified January 9, 2018 . 5. Anikeeva O , Bi P , Hiller JE , Ryan P , Roder D , Han GS . Trends in cancer mortality rates among migrants in Australia: 1981–2007 . Cancer Epidemiol . 2012 ; 36 ( 2 ): e74 – e82 . Google Scholar CrossRef Search ADS PubMed 6. Salant T , Lauderdale DS . Measuring culture: A critical review of acculturation and health in Asian immigrant populations . Soc Sci Med . 2003 ; 57 ( 1 ): 71 – 90 . Google Scholar CrossRef Search ADS PubMed 7. Singh M , de Looper M. Australian Health Inequalities: 1 Birthplace . Bulletin no. 2. AIHW Catalogue No. AUS 27. Canberra: AIHW; 2002 . 8. Weber MF , Banks E , Smith DP , O’Connell D , Sitas F . Cancer screening among migrants in an Australian cohort; cross-sectional analyses from the 45 and Up Study . bmc Public Health . 2009 ; 9 ( 1 ): 144 . Google Scholar CrossRef Search ADS PubMed 9. Oldach BR , Katz ML . Health literacy and cancer screening: A systematic review . Patient Educ Couns . 2014 ; 94 ( 2 ): 149 – 157 . Google Scholar CrossRef Search ADS PubMed 10. Nutbeam D , McGill B , Premkumar P . Improving health literacy in community populations: A review of progress . Health Promot Int . 2017 :1–11. doi:10.1093/heapro/dax015 11. Nutbeam D . Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century . Health Promot Int . 2000 ; 15 ( 3 ): 259 – 267 . Google Scholar CrossRef Search ADS 12. Shaw SJ , Huebner C , Armin J , Orzech K , Orzech K , Vivian J . The role of culture in health literacy and chronic disease screening and management . J Immigr Minor Health . 2009 ; 11 ( 6 ): 460 – 467 . Google Scholar CrossRef Search ADS PubMed 13. Federation of Ethnic Communities’ Council of Australia . Cancer and Culturally and Linguistically Diverse Communities . 2010 . Available at http://www.fecca.org.au/images/stories/pdfs/cancer_cald_communities_report2010. Accessibility verified January 8, 2017 . 14. Viswanath K , Nagler RH , Bigman-Galimore CA , McCauley MP , Jung M , Ramanadhan S . The communications revolution and health inequalities in the 21st century: Implications for cancer control . Cancer Epidemiol Biomarkers Prev . 2012 ; 21 ( 10 ): 1701 – 1708 . Google Scholar CrossRef Search ADS PubMed 15. Tsai TI , Lee SY . Health literacy as the missing link in the provision of immigrant health care: A qualitative study of Southeast Asian immigrant women in Taiwan . Int j Nurs Stud . 2016 ; 54 : 65 – 74 . doi:https://doi.org/10.1016/j.ijnurstu.2015.03.021 Google Scholar CrossRef Search ADS PubMed 16. Santos MG , Handley MA , Omark K , Schillinger D . ESL participation as a mechanism for advancing health literacy in immigrant communities . J Health Commun . 2014 ; 19 ( suppl 2 ): 89 – 105 . Google Scholar CrossRef Search ADS PubMed 17. Chen X , Goodson P , Acosta S . Blending health literacy with an English as a second language curriculum: A systematic literature review . J Health Commun . 2015 ; 20 ( suppl 2 ): 101 – 111 . Google Scholar CrossRef Search ADS PubMed 18. Coronado GD , Acorda E , Do HH , Taylor VM . Feasibility and acceptability of an English-as-a-second language curriculum on hepatitis B for older Chinese American immigrants . J Health Dispar Res Pract . 2008 ; 2 ( 3 ): 121 – 133 . Google Scholar PubMed 19. Taylor VM , Teh C , Lam W et al. Evaluation of a hepatitis B educational ESL curriculum for Chinese immigrants . Can J Public Health . 2009 ; 100 ( 6 ): 463 – 466 . Google Scholar PubMed 20. Taylor VM , Gregory Hislop T , Bajdik C et al. Hepatitis B ESL education for Asian immigrants . J Community Health . 2011 ; 36 ( 1 ): 35 – 41 . Google Scholar CrossRef Search ADS PubMed 21. Soto Mas F , Cordova C , Murrietta A , Jacobson HE , Ronquillo F , Helitzer D . A multisite community-based health literacy intervention for Spanish speakers . j Community Health . 2015 ; 40 ( 3 ): 431 – 438 . Google Scholar CrossRef Search ADS PubMed 22. Soto Mas F , Ji M , Fuentes BO , Tinajero J . The health literacy and ESL study: A community-based intervention for Spanish-speaking adults . J Health Commun . 2015 ; 20 ( 4 ): 369 – 376 . Google Scholar CrossRef Search ADS PubMed 23. Elder JP , Candelaria J , Woodruff SI et al. Initial results of “Language for Health”: Cardiovascular disease nutrition education for English-as-a-second-language students . Health Educ Res . 1998 ; 13 ( 4 ): 567 – 575 . Google Scholar CrossRef Search ADS PubMed 24. Elder JP , Candelaria JI , Woodruff SI , Criqui MH , Talavera GA , Rupp JW . Results of language for health: Cardiovascular disease nutrition education for Latino English-as-a-second-language students . Health Educ Behav . 2000 ; 27 ( 1 ): 50 – 63 . Google Scholar CrossRef Search ADS PubMed 25. Duncan LR , Martinez JL , Rivers SE et al. Healthy Eating for Life English as a second language curriculum: Primary outcomes from a nutrition education intervention targeting cancer risk reduction . J Health Psychol . 2013 ; 18 ( 7 ): 950 – 961 . Google Scholar CrossRef Search ADS PubMed 26. Coronado GD , Taylor V , Acorda E , Hoai Do H , Thompson B . Development of an English as a second language curriculum for hepatitis B virus testing in Chinese Americans . Cancer . 2005 ; 104 ( suppl 12 ): 2948 – 2951 . Google Scholar CrossRef Search ADS PubMed 27. Taylor VM , Coronado G , Acorda E et al. Development of an ESL curriculum to educate Chinese immigrants about hepatitis B . J Community Health . 2008 ; 33 ( 4 ): 217 – 224 . Google Scholar CrossRef Search ADS PubMed 28. Michie S , Abraham C . Interventions to change health behaviours: Evidence-based or evidence-inspired ? Psychol Health . 2004 ; 19 ( 1 ): 29 – 49 . Google Scholar CrossRef Search ADS 29. Davies P , Walker AE , Grimshaw JM . A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations . Implement Sci . 2010 ; 5 ( 1 ): 14 . Google Scholar CrossRef Search ADS PubMed 30. Schwarzer R . Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors . Appl Psychol . 2008 ; 57 ( 1 ): 1 – 29 . Google Scholar CrossRef Search ADS 31. Bandura A . Self-efficacy: Toward a unifying theory of behavioral change . Psychol Rev . 1977 ; 84 ( 2 ): 191 – 215 . Google Scholar CrossRef Search ADS PubMed 32. Berkman ND , Davis TC , McCormack L . Health literacy: What is it ? j Health Commun . 2010 ; 15 ( suppl 12 ): 9 – 19 . Google Scholar CrossRef Search ADS PubMed 33. Street B. Social Literacies: Critical Approaches to Literacy in Development, Education and Ethnography . London : Longman ; 1995 . 34. Rudd R. Health and Literacy in the New Millennium . Ottawa, Ontario, Canada : Canadian Public Health Conference ; 2000 . 35. Soto Mas F , Mein E , Fuentes B , Thatcher B , Balcázar H . Integrating health literacy and ESL: An interdisciplinary curriculum for Hispanic immigrants . Health Promot Pract . 2013 ; 14 ( 2 ): 263 – 273 . Google Scholar CrossRef Search ADS PubMed 36. Knowles M. The Adult Learner: A Neglected Species . Houston, TX: Gulf Publishing Company; 1973 . 37. Bastani R , Glenn BA , Taylor VM et al. Integrating theory into community interventions to reduce liver cancer disparities: The health behavior framework . Prev Med . 2010 ; 50 ( 1–2 ): 63 – 67 . Google Scholar CrossRef Search ADS PubMed 38. Glasgow RE , Marcus AC , Bull SS , Wilson KM . Disseminating effective cancer screening interventions . Cancer . 2004 ; 101 ( suppl 5 ): 1239 – 1250 . Google Scholar CrossRef Search ADS PubMed 39. Krashen SD , Terrell TD. The Natural Approach: Language Acquisition in the Classroom . San Francisco, CA: The Alemany Press; 1983 . 40. Edwards M , Wood F , Davies M , Edwards A . ‘Distributed health literacy’: Longitudinal qualitative analysis of the roles of health literacy mediators and social networks of people living with a long-term health condition . Health Expect . 2015 ; 18 ( 5 ): 1180 – 1193 . Google Scholar CrossRef Search ADS PubMed 41. Christakis NA , Fowler JH . The spread of obesity in a large social network over 32 years . n Engl J Med . 2007 ; 357 ( 4 ): 370 – 379 . Google Scholar CrossRef Search ADS PubMed 42. De La Haye K , Robins G , Mohr P , Wilson C . How physical activity shapes, and is shaped by, adolescent friendships . Soc Sci Med . 2011 ; 73 ( 5 ): 719 – 28 . Google Scholar CrossRef Search ADS PubMed 43. Koehly LM , Peterson SK , Watts BG , Kempf KK , Vernon SW , Gritz ER . A social network analysis of communication about hereditary nonpolyposis colorectal cancer genetic testing and family functioning . Cancer Epidemiol Biomarkers Prev . 2003 ; 12 ( 4 ): 304 – 313 . Google Scholar PubMed 44. Deri C . Social networks and health service utilization . J Health Econ . 2005 ; 24 ( 6 ): 1076 – 1107 . Google Scholar CrossRef Search ADS PubMed 45. Smith KP , Christakis NA . Social networks and health . Annu Rev Sociol . 2008 ; 34 : 405 – 429 . doi:10.1146/annurev.soc.34.040507.134601 Google Scholar CrossRef Search ADS 46. Campbell R , Starkey F , Holliday J et al. An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): A cluster randomised trial . Lancet . 2008 ; 371 ( 9624 ): 1595 – 1602 . Google Scholar CrossRef Search ADS PubMed 47. Molina Y , McKell MS , Mendoza N et al. Health volunteerism and improved cancer health for Latina and African American women and their social networks: Potential mechanisms . J Cancer Educ . 2018;33(1) :59. 48. Santos MG , McClelland J , Handley M . Language lessons on immigrant identity, food culture, and the search for home . TESOL J . 2011 ; 2 ( 2 ): 203 – 228 . Google Scholar CrossRef Search ADS 49. Wei C , Wilson C , Knott V . Roles of illness attributions and cultural views of cancer in determining participation in cancer-smart lifestyle among Chinese and Western youth in Australia . Asian Pac J Cancer Prev . 2013 ; 14 ( 5 ): 3293 – 3298 . Google Scholar CrossRef Search ADS PubMed 50. Wang JH , Mandelblatt JS , Liang W , Yi B , Ma IJ , Schwartz MD . Knowledge, cultural, and attitudinal barriers to mammography screening among nonadherent immigrant Chinese women: Ever versus never screened status . Cancer . 2009 ; 115 ( 20 ): 4828 – 4838 . Google Scholar CrossRef Search ADS PubMed 51. Huang Y , Shen F . Effects of cultural tailoring on persuasion in cancer communication: A meta‐analysis . J Commun . 2016 ; 66 ( 4 ): 694 – 715 . Google Scholar CrossRef Search ADS 52. Wang J , Burke A , Tsoh JY et al. Exploring a culturally relevant model of cancer prevention involving traditional Chinese medicine providers in a Chinese American community . Eur J Integr Med . 2014 ; 6 ( 1 ): 21 – 28 . Google Scholar CrossRef Search ADS PubMed 53. Burke NJ , Jackson JC , Thai HC et al. ‘Honoring tradition, accepting new ways’: Development of a hepatitis B control intervention for Vietnamese immigrants . Ethn Health . 2004 ; 9 ( 2 ): 153 – 169 . Google Scholar CrossRef Search ADS PubMed 54. Aarons GA , Green AE , Palinkas LA et al. Dynamic adaptation process to implement an evidence-based child maltreatment intervention . Implement Sci . 2012 ; 7 ( 1 ): 32 . Google Scholar CrossRef Search ADS PubMed 55. Glasgow RE , Vogt TM , Boles SM . Evaluating the public health impact of health promotion interventions: The RE-AIM framework . Am J Public Health . 1999 ; 89 ( 9 ): 1322 – 1327 . Google Scholar CrossRef Search ADS PubMed 56. Tabak RG , Khoong EC , Chambers DA , Brownson RC . Bridging research and practice: Models for dissemination and implementation research . Am J Prev Med . 2012 ; 43 ( 3 ): 337 – 350 . Google Scholar CrossRef Search ADS PubMed 57. Glasgow RE , Klesges LM , Dzewaltowski DA , Bull SS , Estabrooks P . The future of health behavior change research: What is needed to improve translation of research into health promotion practice ? Ann Behav Med . 2004 ; 27 ( 1 ): 3 – 12 . Google Scholar CrossRef Search ADS PubMed 58. National Institutes for Health . Toolkit Part 1: Implementation Science Methodologies and Frameworks . Fogarty International Center, Center for Global Health Studies . Available at https://www.fic.nih.gov/About/center-global-health-studies/neuroscience-implementation-toolkit/Pages/methodologies-frameworks.aspx. Accessibility verified December 4, 2017 . PubMed PubMed 59. Martinez JL , Duncan LR , Rivers SE , Bertoli MC , Latimer-Cheung AE , Salovey P . Healthy eating for life English as a second language curriculum: Applying the RE-AIM framework to evaluate a nutrition education intervention targeting cancer risk reduction . Transl Behav Med . 2017;7(4) :657–666. 60. Akers JD , Estabrooks PA , Davy BM . Translational research: Bridging the gap between long-term weight loss maintenance research and practice . J Am Diet Assoc . 2010 ; 110 ( 10 ): 1511 – 1522 . Google Scholar CrossRef Search ADS PubMed 61. Glasgow RE . eHealth evaluation and dissemination research . Am J Prev Med . 2007 ; 32 ( 5 ): S119 – S126 . Google Scholar CrossRef Search ADS PubMed 62. Dzewaltowski DA , Estabrooks PA , Klesges LM , Bull S , Glasgow RE . Behavior change intervention research in community settings: How generalizable are the results ? Health Promot Int . 2004 ; 19 ( 2 ): 235 – 245 . Google Scholar CrossRef Search ADS PubMed 63. Allen K , Zoellner J , Motley M , Estabrooks PA . Understanding the internal and external validity of health literacy interventions: A systematic literature review using the RE-AIM framework . J Health Commun . 2011 ; 16 ( suppl 3 ): 55 – 72 . Google Scholar CrossRef Search ADS PubMed 64. Klesges LM , Estabrooks PA , Dzewaltowski DA , Bull SS , Glasgow RE . Beginning with the application in mind: Designing and planning health behavior change interventions to enhance dissemination . Ann Behav Med . 2005 ; 29 ( 2 ): 66 – 75 . Google Scholar CrossRef Search ADS PubMed 65. Belza B , Toobert DJ , Glasgow RE. RE-AIM for Program Planning: Overview and Applications . Washington, DC : National Council on Aging ; 2007 . 66. Freeman YS , Freeman DE. ESL/EFL Teaching: Principles for Success . Portsmouth , NH : Heinemann ; 1998 . 67. Navitas English . Available at http://www.navitas-english.com.au/amep/amep-courses/cswe-courses/. Accessibility verified January 8, 2017 . 68. Srivastava A , Thomson SB . Framework analysis: A qualitative methodology for applied policy research . JOAAG . 2009 ; 4 ( 2 ): 72 – 79 . 69. Cullinan M . Critical review of ESL curriculum: Practical application to the UAE context . ICJI. 2016 ; 8 ( 1 ): 54 – 68 . 70. Badea M , Iridon C . Students’ evaluation of a Romanian language textbook . Procedia Soc Behav Sci . 2015 ; 203 : 303 – 309 . Google Scholar CrossRef Search ADS 71. Nimehchisalem V , Mukundan J . Refinement of the English language teaching textbook evaluation checklist . Pertanika J Soc Sci Hum . 2015 ; 23 ( 4 ):761–780. 72. National Health Priority Action Council . National Chronic Disease Strategy . Canberra, Australia: Australian Government Department of Health and Ageing ; 2006 . 73. Cancer Council of South Australia . Strategic Plan 2012–2015 . Adelaide, South Australia: Cancer Council of South Australia ; 2013 . 74. National Institutes for Health . Charting the Course: The Office of Disease Prevention Strategic Plan 2014–2018: NIH Office of Disease Prevention . 2014 ; Available at https://prevention.nih.gov/docs/about/ODP_StrategicPlan2014-2018.pdf. Accessibility verified April 26, 2017 . 75. RE-AIM website . Available at http://re-aim.org/. Accessibility verified January 8, 2017 . © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Journal

Translational Behavioral MedicineOxford University Press

Published: Mar 27, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off