Cancer Control Interventions for Hispanics with Low Literacy Skills

Transcription

1 Cancer Control Interventions for Hispanics with Low Literacy Skills María E. Fernández, PhD Associate Professor of Health Promotion and Behavioral Sciences Associate Director, Center for Health Promotion and Prevention Research University of Texas, School of Public Health

2 Partnerships

3 Partnership, collaboration, energy, and commitment has led to. $$$ to do Cool Stuff!

4 Cultivando La Salud A Breast and Cervical Cancer Screening program for Farmworker Women

5 PROGRAM BACKGROUND NCFH received a grant from the CDC to develop, test, replicate and disseminate a breast & cervical cancer prevention program targeting Hispanic farmworker women. Goal - to increase breast and cervical cancer screening among Hispanic farmworker women 50 years of age and older.

6 IMPLEMENTING THE PROGRAM Used Promotora Model Door to door outreach Conducted educational sessions Made referrals to screening Follow-up

7 CLS TOOL KIT A COMPREHENSIVE HEALTH INTERVENTION Organizational Level - Manual for program adopters, e.g.: health center managers, promotora program coordinators, outreach directors. LHW Implementation Training - Curriculum to train promotoras how to implement CLS with farmworkers Community materials Teaching guide w/ detailed lesson plans Flipchart Video Breast model Pamphlets

8 SMALL MEDIA MATERIAL Flipchart & Video/DVD: Role model stories Testimonials Addressing misconceptions and barriers

9 EVALUATION

10 STUDY DESIGN Intervention Trial: Four matched sites randomly assigned to 2 Intervention sites (CA, TX) 2 Comparison sites (CA, NM) Target Population: Hispanic women aged 50 years

11

12 Table 3 Intervention Effect: Screening Completion by Study Group Intervention Comparison P value a Mammography with follow-up N=307 Pap test with follow-up N=170 53/130 (40.8%) 53/177 (29.9%).041* 32/81 (39.5%) 21/89 (23.6%).002* * P<.05 a Adjusted for site location and demographics (generalized linear mixed model) Fernandez ME, Gonzales A, Tortolero-Luna G, et al. Effectiveness of Cultivando La Salud: A breast and cervical cancer screening promotion program for low-income Hispanic women. Am J Public Health. 2009; 99 (5):

13 Ok, so it probably works, now what? 13

14 ADAPTATION IMPLEMENTATION OF CLS IN DIFFERENT SETTINGS Replication in Hays County Texas Adaptation of CLS for low-income Hispanic women in Houston Adaptation of CLS for Hispanic women in Puerto Rico

15 Cultivando La Salud (CLS) Houston, TX

16 Identify Screening Challenges in Houston for Hispanic Women Behavioral Level Health Literacy lacking Lack of trust in established services Environmental Level Great need for primary care Source: 2007 Community Health report

17 Adaptation focus on Environmental Factors & Matrices for Environmental Conditions in Houston Through the needs assessment we identified challenges related to access issues faced by lowincome Hispanic women in Houston. Identify what women need to do to obtain a screening exam - specific to the Hispanic population in Houston (e.g., qualifying for Gold Card) Develop new methods and materials related to accessing free/low cost providers

18 Comparison between Houston CLS and Original CLS Program Components To identify behavior and environmental conditions (and determinants) that were different between the original and CLS Program Reviewed how original education materials match the change objectives of adapted program matrices Adapted Training Program To identify areas for new promotora training modules Compared Houston CLS Training Performance Objectives to Original CLS Program s

19 CLS PROGRAM: TARGET POPULATION Original Mexican American Women (50 years +) Not adherent to screening guidelines Farmworker communities along the U.S.-Mexico border & in California (central valley) Low-income Houston Adapted Hispanic Not adherent to Pap Test screening (21+ years) or mammography screening (40+ years ) guidelines Residing in Houston, Gulfton, (and expanded to Greater Houston Area) Low income Intensive telephone-based navigation services offered until screening completed.

20 Target Population: Hispanic/Latina women in Houston: 40 years of age and older who have not had a mammogram in the past 2 years and/or 21 years of age and older who have not had a Pap test in the past 3 years Without a previous diagnosis of breast or cervical cancer Target Goal: 2,270 women Recruit 1,563 Hispanic Women into the evaluation part of the program. Administer educational material to an additional 707 women as a community service.

21 Community Outreach To ensure the program s successful outreach and to increase our reach and access to large numbers of eligible women for the program, we Developed an intensive recruitment strategy with our community partner ProSalud. Obtained active support from community-based organizations who refer women to our promotora-delivered program, and provide space for group sessions. Created recruitment packets to gain organization support and approval

22 Navigation A community-based navigation program protocol was developed to link women to cancer screening services in the Greater Houston Area The role of intensive navigator was also developed to systematically manage hard to reach participants and those with challenging barriers to cancer screening to provide ongoing assistance in overcoming the barriers.

23 Program Effectiveness with follow-up All (Intent-to-Treat) Intervention Controls Intervention Controls No. (%) No. (%) p-value No. (%) No. (%) p-value Mammography n=522 <0.000** n= * Screened 88 (38.4) 58 (19.8) 88 (21.7) 58 (14.4) Not Screened 141 (61.6) 235 (80.2) 318 (78.3) 346 (85.6) Pap n=297 <0.000** n= * Screened 71 (57.3) 48 (27.8) 71 (27.3) 48 (19.6) Not Screened 53 (42.7) 125 (72.3) 189 (72.7) 197 (80.4)

24 Cultivando La Salud (CLS) Minimal Adaptation for Puerto Rican Women

25 Adapting CLS to PR Research questions: Will CLS be effective in increasing screening tests for breast and cervical cancer among Puerto Rican women in the study? Will the minimally adapted CLS be acceptable to the Puerto Rican community?

26 CLS participants - PR Participants Women 21 years old Without cancer diagnosis Without hysterectomy Non pregnant Non-Adherent to Mammography Non-Adherent to Pap Test

27 Questions related to program fit: Are there different behaviors or sub-behavior relevant (or not relevant) for PR women? How do the factors influencing breast and cervical cancer screening in PR differ from those in other Hispanic groups targeted with the CLS program? Are materials, delivery channels and strategies used in the original program, feasible, acceptable, and effective in PR?

28 Adapting CLS using Intervention Mapping Conducted 7 focus groups/interviews (3 adherent + 4 non adherent) with women 40+ years on breast cancer and screening. Conducted 4 focus groups/interviews (1 adherent group + 3 non adherent) with women years on cervical cancer and screening. Results were compared to original CLS matrices and found to be very similar.

29 COMPARISONS OF DETERMINANTS INFLUENCING BREAST AND CERVICAL CANCER SCREENING Original Program- Cultivando la Salud- Mexican Origin women Low levels of Knowledge of breast and cervical cancer and screening guidelines Outcome Expectations Perceived Barriers and Benefits Attitude (fear of detection, fear of procedure and belief that cancer is incurable) Low Self-Efficacy Low Perceived Social Norms Availability and Accessibility Puerto Rico Low levels of Knowledge of breast and cervical cancer and screening guidelines (not as low) Low knowledge of availability Perception of risk (partly due to the confusion of thinking BSE was protective) Perceived Barriers and Benefits Attitude (fear of detection, fear of procedure) Low Self-Efficacy Environmental Factors differ considerably due to better access to care in PR Outreach Program

30 Minimal adaption of CLS for PR Element maintained: Training curriculum Materials: flipchart, delivery guides, tracking tools. Same recruitment and intervention protocols ElementsAdapted: No use of DVD Minor revision of specific Added information on HPV and HPV vaccine A list of local resources and screening centers was provided to participants Breast model with nodules is used in the intervention to deliver the message that BSE by itself is not a protective screening method

31 Cultivando la Salud Goal: 484 participants Targeting women 21 years old Canóvanas residents Survey includes section on Human Papillomavirus and the HPV vaccine Incidence Mortality Taller Salud

32 Cultivando La Salud ***Intervention Effect*** Intervention Group N (%) Comparison Group N (%) p value Mammography screening completion N=53 28 (19.7%) 25 (19.7%) Pap Test screening completion N=43 29 (24.4%) 14 (12.3%) 0.017

33 Por Nuestras Hijas For Our Daughters

34 Study Population and Timeframe Target population Hispanic parents of daughters (11-17 yrs) Daughters not vaccinated against HPV Spanish or English speaking Recruitment Site: Clinics & clinic waiting rooms Low-income areas in Houston, predominately Hispanic Clinic has free vaccine (Vaccine for Children s program) Timeframe Goal: Recruit 1,809 parents 6 month follow up after baseline with clinic record validation

35 Why Use Photonovels? Research* shows: People remember stories better than a set of facts Stories build selfconfidence Stories reinforce culture values and norms to promote healthy behaviors Stories can be used in creative ways to motivate and mpower people regardless of age or reading ability * Doak, et al. Teaching Patients with Low Literacy Skills, From: Pregnancy & Diabetes: Lucia s Story Published by Auger Communications, Inc.

36 For Our Daughters - Por Nuestras Hijas The Intervention: Fotonovela For Our Daughters fotonovela: available in English and Spanish addresses key determinants

37 Tailored Interactive Communications Approaches

38 Strategies for Achieving Tailoring Goals Personalization Feedback Content matching

39 For Our Daughters - Para Nuestras Hijas The Intervention: Tailored Interactive Program on ipad Moving video Stills with audio Graphics and Animation Data-based tailoring Self- Tailoring

40 Tailoring: Perceived Susceptibility & Vaccine Efficacy

41 Developed Training Programs LHW 2 ½ Day Training Developed & Implemented 1) Introduction, 2) Study Objectives, 3) Study Protocols, 4) HPV & Cervical Cancer, 5) HPV vaccine, 6) Study Design and LHWs Roles, 7) Overview of Intervention Materials, 8) Forms 9) ipad practice 10) Fotonovela practice 11) Q &A sessions

42 Evaluation Design Group Randomized Intervention Trial 1)Baseline: Data collectors recruit, consent & conduct face-to-face computer-assisted interviews with parents in clinic waiting rooms 2) LHWs deliver intervention in Intervention clinic sites] 3) Follow-up: Data collectors conduct 6 month follow-up by telephone plus clinc record validation

43 Preliminary Findings Comparison Odds Ratio (95% CI) p-value Control vs TIMI ( ) 0.004* Control vs Fotonovella ( ) 0.17 Fotonovella vs TIMI ( )

44 Click to edit Master title style Linking Callers to Cancer Control Services: A University of Texas CPCRN (LINCC) and TEXAS Collaboration

45 Improving ACCESS Texas Helpline is a nationally designated 3-digit telephone exchange connecting callers to health and social services within their community. It is operated by state and local systems, often in partnership with local public or private agencies. There are systems in 46 states and Washington, DC and Puerto Rico, covering over 80% of the U.S. population.

46 2-1-1Program callers call for Utilities, Medical, Food, and Shelter needs Call specialists administer risk assessment Eligible and consenting participants are placed into a navigation/control intervention

47 Telephone follow-up 1 and 4 months later - Did they contact referrals? - Did they obtain needed services?

48 Participant Demographics N % of total Sample Gender Male Female Median Age Male Age Female Age 46yrs old 38yrs old Race/Ethnicity Hispanic White Black Other Marital Status Divorced Living with someone Married Separated Single Widowed Highest Level Education Less than High School Diploma/GED Vocation/tech/Assoc degree Bachelors or Higher Income None 282 5

49 Cancer Risk Factors & Prevention Needs: Texas Callers: Houston, Weslaco, El Paso vs. Texas and U.S. (2013) Risk factor or preventive measure Respondents (n) Houston Weslaco El Paso TX** U.S.** No health insurance Had mammogram in the last 1-2 years Had Pap smear in the last 3 yrs Ever had a colonoscopy Received HPV vaccination (self) Received HPV vaccination (daughter) Current cigarette smoker All (n=6214) Women, 40+ (n=2585) Women, 18+ (n=5563) Men & women, 50+ (n=1642) Women, (n=984) Have daughters, 9-17 (n=1436) All (n=6214) 40% 71% 71% 30% 19% 57% 50% 60% 70% 76% 72% 84% 92% 79% 81% 45% 28% 44% 62% 65% 18% 12% 22% 15% 17% 44% 55% 55% 38 44% 23% 7% 7% 19%* 21%* **BRFSS 2010, *BRFSS 2011 median percentage

50 Navigator Responsibilities Navigators work with participants: Provide referrals Answer Questions Describe importance of and education on screenings Assist with setting up appointments for cancer screenings Identify and address barriers Arrange transportation to and from appointments Referrals and cancer screening services include: Breast Cervical Colorectal HPV vaccine for women, girls and boys Smoking Cessation Smoke-free Home Policies

51 Goal of Collaboration Community Outreach collaborates with call centers to: conduct a needs assessment implement an intervention to increase cancer screening and vaccination, and tobacco cessation Gulf Coast ~60,000 a month Tip of Texas ~ 5,000 a month Rio Grande ~ 7,200 calls a month

52 Linking Callers to Services Participating Call Centers: Houston Weslaco El Paso Number of Surveys Completed Risk Assessment n=over 4000 Intervention study n=1300

53 Implementation Challenges for Further Investigation Scientific research administration in a service oriented environment Competing responsibilities Commitment of collaborators Implementation practices Quality control Support & Continuity

54 Our Vision The potential of this work goes far beyond using as a recruitment venue for surveys and interventions to reach poor Americans The big payoff is helping an established service organization with broad reach in disparity population use EB cancer control strategically. Provides opportunities for advancing dissemination and implementation research.

55 Potential Public Health Impact Systems take an estimated 16 million calls annually With the potential of reaching 5 million smokers, 3.1 million women in need of Pap tests, 2.6 million women needing mammograms, 2.3 million women needing the HPV vaccination, 1.9 million with daughters in need of the HPV vaccination, 1.9 million in need of colonoscopies

56 Gracias