Cervical Cancer Screening Among Chinese Women SuI Hou

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Cervical Cancer Screening Among Chinese Women Su-I Hou, Dr. PH, MPH, RN, CHES Assistant

Cervical Cancer Screening Among Chinese Women Su-I Hou, Dr. PH, MPH, RN, CHES Assistant Professor, Health Promotion & Behavior, University of Georgia, Athens, GA Email: [email protected] edu UT-Houston, School of Public Health Promotion / Health Educatio 1 Sponsor: Cheng Ching Hospital, Taichung, Ta

Outline of the Presentation X Specific Aims X Introduction X Significance X Pilot Study

Outline of the Presentation X Specific Aims X Introduction X Significance X Pilot Study and Instrument Validation Methods/Results/Summary X Intervention Development Methods/Results/Summary X Program Intervention Evaluation 2 © Su-I Hou, Dr. PH, RN, CHES Methods/Results/Summary

Specific Aims 1. Pilot Study To develop and validate study instruments To assess factors

Specific Aims 1. Pilot Study To develop and validate study instruments To assess factors that influence Pap screening behavior among women in. Develop and implement a theory and evidence Taiwan - based intervention using Intervention Mappin 3. Evaluate the effectiveness of the program intervention © Su-I Hou, Dr. PH, RN, CHES 3

Outcomes Primary Outcome Measures Pap screening rate Secondary Outcome Measures Perceived pros, perceived cons

Outcomes Primary Outcome Measures Pap screening rate Secondary Outcome Measures Perceived pros, perceived cons Susceptibility, perceived norms Knowledge of cervical cancer & Pap Covariates Demographics © Su-I Hou, Dr. PH, RN, CHES 4

Introduction X Cervical Cancer 2 nd most common cancer among women worldwide 1 st

Introduction X Cervical Cancer 2 nd most common cancer among women worldwide 1 st most common cancer among women in Taiwan Incidence rate: 32. 49/10, 000 40% of the female deaths in Taiwan due to cancer 10% of these cancer deaths were due to 5 © Su-I Hou, Dr. PH, RN, CHES

X Risk Factors for Cervical Cancer Sexual activity before the age of 20 (Zhang

X Risk Factors for Cervical Cancer Sexual activity before the age of 20 (Zhang & Chen, 1986) Multiple sexual partners (Cuzick et al, 1989 ; Parazzini et al, 1992) History of HPV / STDs (Kjaer et al, 1996) Smoking (Coker, 1992; Simons et al, 1993) History of abnormal Pap (Zhang & Chen, 1986) © Su-I Hou, Dr. PH, RN, CHES 6

X Pap Screening Behavior Hiatt RA & Pasick R, 1995 (Bay area, SF) Prevalence

X Pap Screening Behavior Hiatt RA & Pasick R, 1995 (Bay area, SF) Prevalence of ever had a Pap: White/Black -- 98%; Latino -- 97%; Chinese -Wang PD & Lin RS, 1996 (Taipei, Taiwan) About 40+% of the women never had a Pap 86% had not had one in the past year Li CF & Zhou BS, 1997 (Kimen, Taiwan) Pap test prevalence: 62% (615 / 990) Annual Pap test compliance: 45% (274 / 7615) © Su-I Hou, Dr. PH, RN, CHES

X Factors Influencing Pap Screening Behavi Personal Factors Knowledge (Harlan ‘ 91; Jian ‘

X Factors Influencing Pap Screening Behavi Personal Factors Knowledge (Harlan ‘ 91; Jian ‘ 92; Kelly ‘ 96) Perceived susceptibility (Seow ‘ 95, Neilson ‘ 98) Perceived pros/cons (Pham ‘ 92; Seow ‘ 95; Yu ‘ 9 Perceived norms (Gotay ‘ 98) Demographics (Yi ‘ 94; Wang ‘ 96) External Factors Availability/Accessibility/Affordability (Wilcox ‘ Social support (Li ‘ 91; Suarez ‘ 94; Burnett ‘ 95) Doctor-patient relationships (Pham ‘ 92; Yi ‘ 94) © Su-I Hou, Dr. PH, RN, CHES 8

Significan ce X Data for Chinese women are limited X National Health Insurance Plan

Significan ce X Data for Chinese women are limited X National Health Insurance Plan provides women aged 30 and older to have an annual Pap test X The significance of cervical cancer in Taiwan X Few intervention programs targeting Chinese women and none were © Su-I Hou, Dr. PH, RN, CHES 9

X Pilot Study and Instrument Validation Method Sample: Female family members of patients admitted

X Pilot Study and Instrument Validation Method Sample: Female family members of patients admitted to Cheng-Ching Hospital (CCH) during Feb. ~ Mar. 1999 Measurement: Self administered questionnaire (prior screening experience; perceived pros/cons; perceived norms; susceptibility; knowledge; and demographics) Analysis: Compare screening participants v. s. non-partici Chi-square test; log regression analysis © Su-I Hou, Dr. PH, RN, CHES 10

X Pilot Study and Instrument Validation (con Results Sample Characteristics (N=125) mean age: 38

X Pilot Study and Instrument Validation (con Results Sample Characteristics (N=125) mean age: 38 Married: 90%* (p=. 03) Work full time: 62% > College education: 32% Scale Reliability Perceived pros: Perceived cons: Perceived norms: Susceptibility: Knowledge: Chronbach 0. 88 (11 items) 0. 68 ( 9 items) 0. 72 ( 4 items) 0. 68 ( 2 items) 0. 70 (16 items) Items with low CITC (corrected-item-total corr. ) were re-ev for their appropriateness 11 © Su-I Hou, Dr. PH, RN, CHES

X Pilot Study and Instrument Validation (con Logistic regression Analysis © Su-I Hou, Dr.

X Pilot Study and Instrument Validation (con Logistic regression Analysis © Su-I Hou, Dr. PH, RN, CHES 12

X Pilot Study and Instrument Validation (con Summary & Limitations It provided a basis

X Pilot Study and Instrument Validation (con Summary & Limitations It provided a basis for measuring factors associated with Pap screening behavior among Chinese women. The pilot study helped define the approach of further needs assessment and intervention development. Larger studies are required to further 13

X Intervention Methods Development Intervention Development Process IM Step 1: Proximal Program Objectives IM

X Intervention Methods Development Intervention Development Process IM Step 1: Proximal Program Objectives IM Step 2: Methods and Strategies IM Step 3: Designing and Organizing Programs IM Step 4: Adoption and Implementation Plans Assessment Needs IMQuantitative Step 5: Generating an Evaluation Plan results from pilot study Qualitative data from focus groups Existing social and behavior science theories 14 Findings from previous studies © Su-I Hou, Dr. PH, RN, CHES

X Intervention Development IM (con’t) Step 1: Proximal Program Objectives Behavior - Non-compliant women

X Intervention Development IM (con’t) Step 1: Proximal Program Objectives Behavior - Non-compliant women will obtain a Pap after the in PO 1: schedule a Pap test PO 2: obtain a Pap test Personal determinants: intention; knowledge; perceived pros perceived norms; susceptibility External determinants: cues to action Environments - Increased availability of alternative service by female doctors PO 1: hospital administrators approve provision of service PO 2: female Drs. sign up to perform Pap exams in the comm Personal determinants: knowledge; outcome expectations External determinants: reward / compensation © Su-I Hou, Dr. PH, RN, CHES 15

X Intervention Development (con’t) IM Step 2: Methods and Strategies © Su-I Hou, Dr.

X Intervention Development (con’t) IM Step 2: Methods and Strategies © Su-I Hou, Dr. PH, RN, CHES 16

X Intervention Development (con’t) IM Step 3: Designing and Organizing Programs Program Theme: “Love

X Intervention Development (con’t) IM Step 3: Designing and Organizing Programs Program Theme: “Love yourself before you take care of your family Scope and Sequence of the program: 1 st month personalized welcome letter cervical cancer/Pap brochure quotes of other women’s experience screening schedule w/ doctors information 2 nd month personalized screening invitation lett screening service provided by female docto role model stories knowledge-based fact sheet updated screening schedule 3 rd month (reminder calls) © Su-I Hou, Dr. PH, RN, CHES phone intervention 17

© Su-I Hou, Dr. PH, RN, CHES 18

© Su-I Hou, Dr. PH, RN, CHES 18

X Intervention Development IM Step 4: Adoption and Implementation Plans (con’t) PO 1: program

X Intervention Development IM Step 4: Adoption and Implementation Plans (con’t) PO 1: program sponsor approves the intervention program PO 2: obtain a list of non-compliant women PO 3: schedule and mail the intervention materials to wome PO 4: co-ordinate community screening services with femal PO 5: conduct screening reminding calls Personal determinants: behavior capability; outcome expectations External determinants: reward / compensation Training sessions: recruiting and identifying non-compliant w schedule and send program materials conducting screening reminding calls © Su-I Hou, Dr. PH, RN, CHES 19

X Intervention Development (con’t) IM Step 5: Generating an Evaluation Plan Pretest - Posttest

X Intervention Development (con’t) IM Step 5: Generating an Evaluation Plan Pretest - Posttest Control Group R O 1 O 2 (3 mon. after O 1) R O 1 X O 2 (3 mon. after O 1) where R= random assignment =================== post-test (O 2) pre-test (O 1) Demographics Previous screening Screening behavior experience Beliefs Knowledge Intervention components © Su-I Hou, Dr. PH, RN, CHES 20

X Intervention Development (con’t) Summary & Future Directions By using the IM process, we

X Intervention Development (con’t) Summary & Future Directions By using the IM process, we were able to systematically incorporate empirical and new data, as well as utilize theories to guide the intervention design. The needs assessment provided an important foundation of the program. IM helped us ensure addressing factors associated with screening behavior in the program development. The framework also helped us in developing the evaluation questions. Programs targeting other health related behavior, 21 or

X Program Intervention Evaluation Method Sample: Female family members of patients who admit in

X Program Intervention Evaluation Method Sample: Female family members of patients who admit in the CCH during Aug. ~Sep. 1999 (N=424) Inclusion Criteria: Married women or aged 30+, non-compliant to Pap screening (no Pap in the past 12 months), no Analysis: hysterectomy, not pregnant Compare study outcomes between women in intervention and comparison groups 22 pre- & post- changes within groups © Su-I Hou, Dr. PH, RN, CHES

X Program Intervention Evaluation (con’t) Results (N=424) Sample Characteristics & Group Comparisons (Base mean

X Program Intervention Evaluation (con’t) Results (N=424) Sample Characteristics & Group Comparisons (Base mean age: Married: Work full time: > College education: 34 P=. 227 89% p=. 532 40% p=. 777 28% p=. 195 Prior screening (ever) 58% p=. 168 Intention 63%p=. 422 omen in the study were randomly assigned to each group 23 very w © Su-I Hou, Dr. PH, RN, CHES

X Program Intervention Evaluation (con’t) Comparisons of Scale Means (Baseline) © Su-I Hou, Dr.

X Program Intervention Evaluation (con’t) Comparisons of Scale Means (Baseline) © Su-I Hou, Dr. PH, RN, CHES 24

X Program Intervention Evaluation (con’t) Pap Completion Rate Intervention Group: Comparison Group: 0% 0%

X Program Intervention Evaluation (con’t) Pap Completion Rate Intervention Group: Comparison Group: 0% 0% 51% P=0. 002* 32% Pap Intention (Pre-contemplators) Intervention Group: Comparison Group: 0% 0% btw groups 89% P=0. 310 93% within groups P=0. 000* Pap Intention (Contemplators) Intervention Group: 62% obtain a Pap P=0. 008* Comparison Group: 38% obtain a Pap © Su-I Hou, Dr. PH, RN, CHES 25

X Program Intervention Evaluation (con’t) Comparisons of Scale Means (Follow-up) Linear reg. were used

X Program Intervention Evaluation (con’t) Comparisons of Scale Means (Follow-up) Linear reg. were used for the follow-up group comparison 26 adjust pretest scale and intervention effects © Su-I Hou, Dr. PH, RN, CHES

X Program Intervention Evaluation (con’t) Changes in Scales Within Groups Over Time (pre- &

X Program Intervention Evaluation (con’t) Changes in Scales Within Groups Over Time (pre- & p © Su-I Hou, Dr. PH, RN, CHES 27

X Program Intervention Evaluation (con’t) Limitations & Future Directions Limitations: The generalization of the

X Program Intervention Evaluation (con’t) Limitations & Future Directions Limitations: The generalization of the results Future Directions: Program designed to address factors associated with screening behavior can result an effective intervention for the specific population Future program can consider similar strategies for reaching at-risk population Future studies should further investigate the 28 role of pros/cons on influencing cancer

Pilot Study Publications related to this project l Hou, S. , Fernandez, M. ,

Pilot Study Publications related to this project l Hou, S. , Fernandez, M. , Baumler, E. , Parcel, G, & Chen P. (2003). Correlates of cervical cancer screening among women in Taiwan. Health Care for Women International, 24 (5), 384 -398. Intervention Development l Hou, S. , Fernandez, M. , & Parcel, G. (2004). Development of a cervical cancer educational program for Chinese women using Intervention Mapping. Health Promotion Practice, 5(1), 80 -87. Evaluation Study l Hou, S. , Fernandez, M. , Baumler, E. , & Parcel G. (2002). Effectiveness of an intervention to increase Pap test screening among Chinese women in Taiwan. Journal of Community Health, 27(4), 277 -290. Instrument Development l Hou, S. , Luh, W. , & Chen, P. (in press). Psychometric properties of the Cervical Smear Belief Inventory for Chinese women. International Journal of Behavior Medicine. 29

Su-I Hou (sweet) 30

Su-I Hou (sweet) 30