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Cervical Cancer: Disparities and Models of Steps Toward a Solution

Cervical Cancer: Disparities and Models of Steps Toward a Solution. South Carolina Cancer Alliance Presentation May 11, 2007 Marvella E. Ford, PhD Associate Director for Cancer Disparities Associate Professor Medical University of South Carolina Hollings Cancer Center. Cervical Cancer.

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Cervical Cancer: Disparities and Models of Steps Toward a Solution

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  1. Cervical Cancer: Disparities and Models of Steps Toward a Solution South Carolina Cancer Alliance Presentation May 11, 2007 Marvella E. Ford, PhD Associate Director for Cancer Disparities Associate Professor Medical University of South Carolina Hollings Cancer Center

  2. Cervical Cancer • The human papillomavirus (HPV) has been identified as the primary factor related to development of cervical cancer • HPV can spread through skin contact during sexual activities

  3. Cervical Cancer • Over 100 types of HPV • 15 types are high risk • HPV vaccine Gardasil • Types 16 and 18 (high-risk; oncogenic) • Types 6 and 11 (low-risk; genital warts)

  4. Cervical Cancer • Some HPV types (16 and 18) cause abnormal cells to develop on the lining of the cervix that can develop into cancer • Some HPV types (6 and 11) cause genital warts • Typically bumpy, raised legions with a cauliflower shape

  5. Cervical Cancer • HPV can remain in the body for 9-12 months with no immune system response • HPV is the primary factor in the development of cervical cancer • The virus takes advantage when the body “concentrates” on something else • Immunosuppression: Pregnancy, HIV, chronic comorbidities, etc. Brandt et al. (2006) Cervical cancer disparities in South Carolina: An update of early detection, special programs, descriptive epidemiology, and emerging directions. The Journal of the South Carolina Medical Association, 102:223-230.

  6. Cervical Cancer • Primary risk factors for contracting HPV • Ethnicity - African Americans are at higher risk than Caucasians • Sex or sexual activity (more partners = greater risk) • Starting sexual activity at an early age

  7. Cervical Cancer • Primary risk factor for development of cervical cancer • Failure to receive/infrequent Pap tests • HPV infection • Cigarette smoking – accounts for approximately 1/3 of all cases of cervical cancer

  8. 15.1 9.4 6.3 2.5 http://scangis.dhec.sc.gov/scan/

  9. Cervical Cancer in South Carolina • The incidence of cervical cancer in SC is 24% higher than in the rest of the US • South Carolina ranks 9th in the nation for cervical cancer mortality rates SCCA 2006 Report Card

  10. Cervical Cancer Screening: Pap Tests • Pap Tests • All women should begin screening 3 years after sexual activity or by 21 years of age • Annual screening is conducted by smear-method Pap test OR every 2 years by liquid-based method • Women > 70 years with three or more normal Pap tests in a row can stop having screenings

  11. Cervical Cancer Screening: Pap Tests • BRFSS Survey Results for 2006 • Have you ever had a Pap test? http://www.scdhec.gov/hs/epidata/brfss_index.htm

  12. Cervical Cancer Screening Models • Two examples of approaches designed to reach underserved women with cervical cancer screening • The Deep South Network for Cancer Control, focusing on African Americans (Lisovicz et al. 2006) • Cervical Cancer Screening Program for Latinas: Project SAFe (Ell et al. 2002)

  13. The Deep South Network Project • Geographic location • Mississippi • Alabama

  14. The Deep South Network Project • Includes • A Community Health Advisor (CHA) model • An empowerment theory developed by Paulo Freire • Coalition-building strategies to develop partnerships within communities and on a statewide level

  15. The Deep South Network Project • Incorporates three models Community Health Advisors Coalition-Building Strategies Empowerment Eng, E. 1995; Eng, E. et al. 1994; Hinton, A. et al. 1992; Hinton, A. et al. 2005; Freire, P. 1970; Freire, P. 1983; Butterfoss, F.D. et al. 1993

  16. The Deep South Network Project • Methods • CHAs receive 8 weeks of training (2 hours per week) in breast and cervical cancer awareness information • After training, CHAs participate in monthly maintenance meetings • CHAs determine which cancer awareness methods are best suited for their communities

  17. The Deep South Network Project • Evaluation Methods • 20-item pre/posttest • Talking Circles

  18. The Deep South Network Project • Results • Participants • 883 CHA volunteers were trained • 857 (97%) - African American • 830 (94%) - female • 342 (38.7%) - from the rural Mississippi Delta • 113 (12.8%) - from the identified urban areas in Mississippi • 307 (34.8%) - from the Alabama Black Belt • 121 (13.7%) - from the identified urban areas of Alabama

  19. The Deep South Network Project • Results • CHAs participated in 740 training events over four years (2001-2004) • Church events • Health fairs • Health presentations • Parades • Relay for Life (ACS) • Other cancer awareness activities

  20. The Deep South Network Project • Results • In both Mississippi and Alabama, there was a significant positive difference in pre/posttest scores for many of the test items

  21. The Deep South Network Project • Results • The Deep South Network provided the information requested by the CHAs • Community presentations by program staff • Radio and television public serve announcements • Radio and television talk show appearances • Brochures and other printed materials • Breast models • Talking points about cancer and cancer awareness to assist the CHAs in their community cancer awareness activities

  22. The Deep South Network Project • Results • Coalition-building partners • The Deep South Network • ACS • The Department of Agriculture Cooperative Extension Services • Information and Quality Healthcare and the Alabama Quality Assurance Foundation • Medicare quality assurance organizations • State Departments of Public Health • National Black Church Family Council • Vision Ministries

  23. The Deep South Network Project • Results • Coalition-building activities • Cancer awareness walks • Town hall meetings • Fashion shows • Small workshops with cancer experts

  24. The Deep South Network Project • Results • Increased cervical cancer screening rates • Investigators report a 23% increase in cervical cancer screening via pap smear over the study period

  25. The Deep South Network Project • Lessons Learned • The need to collect community-level baseline evaluation data • The importance of careful selection, training, and support of staff • The importance of frequent communication with volunteers • The value of frequent meetings to build camaraderie among volunteers and staff

  26. The Deep South Network Project • Remaining Barriers • Inadequate funding • Transportation barriers • Public misconceptions and fears about cancer and cancer clinical trials • Limited outreach • Too few providers for screening and treatment Lisovicz, N., et al. (2006) The Deep South Network for Cancer Control: Building a Community Infrastructure to Reduce Cancer Health Disparities. Cancer. 107(8): 1971-1979.

  27. Cervical Cancer Screening Program for Latinas: Project SAFe • Project SAFe: Abnormal cervical screen follow-up among Latinas with low income • Rationale: • Cervical cancer incidence and mortality rates are higher among women with low income than in the general population • Ell, K., et al. (2002) Abnormal cervical screen follow-up among low-income Latinas: Project SAFe. Journal of women’s health & gender based medicine. 11(7):639-651.

  28. Cervical Cancer Screening Program for Latinas: Project SAFe • Design • Pilot study • Observational design • Structured case management program to intervene in response to personal and systems barriers to care

  29. Cervical Cancer Screening Program for Latinas: Project SAFe • Sample • 196 predominantly Latina women in Los Angeles, CA • Low income • Had either a low-grade or high-grade squamous intraepithelial lesion (LGSIL or HGSIL) abnormal Pap result

  30. Cervical Cancer Screening Program for Latinas: Project SAFe • Methods • SAFe materials were administered in Spanish with monolingual Spanish-speaking women • Intervention • Baseline 30-minute telephone call • Appointment reminder and follow-up calls • 6-month and 1-year calls to provide a reinforcing educational message about the value of follow-up and re-screening

  31. Cervical Cancer Screening Program for Latinas: Project SAFe • Results • 196/565 eligible women were enrolled between December 1998 and October 2000 • 81 (41%) had LGSIL • 115 (59%) had HGSIL

  32. Cervical Cancer Screening Program for Latinas: Project SAFe • Results • The majority (86%) were Latina • Most were young (129 (66%) were < 40 years) • 114 (58%) reported good or excellent health status • 75 (38%) reported moderate or high limitations in functional status • 94 (48%) reported having one or more health problems

  33. Cervical Cancer Screening Program for Latinas: Project SAFe • Results • One year post-enrollment: • 83% of women with LGSIL were adherent • 41% were fully adherent • 42% were partially adherent • 93% of women with HGSIL were adherent • 61% were fully adherent • 32% were partially adherent • In a comparison group of 369 non-enrollees: • 58% of women with LGSIL were adherent • 67% of women with HGSIL were adherent

  34. Presentation Summary • Suggestions for Cervical Cancer Screening Promotion • Use culturally competent outreach strategies • Include community members in outreach • Ask for community preferences in outreach activities

  35. Summary • Suggestions for Cervical Cancer Screening Promotion • Include men in cervical cancer awareness activities • Educate the community on the purpose of cervical cancer screening and the HPV vaccine • Clear the tension of sexual stigma

  36. Summary • Suggestions for Cervical Cancer Screening Promotion • Identify barriers to care • Seek more funding opportunities • Employ health advocates to navigate women through the healthcare system

  37. Cervical Cancer Screening Programs in SC • SCDHEC Family Planning Services http://www.scdhec.gov/health/mch/wcs/fp/index.htm • South Carolina Breast and Cervical Cancer Early Detection Program: Best Chance Network http://www.cancer.org • South Carolina Medicaid Breast and Cervical Cancer Program http://www.dhhs.state.sc.us • Cancer Health Initiative http://www.communitiesincharge.org/

  38. How Do We Improve Cervical Cancer Screening in SC? • Identify vulnerable communities • Recognize barriers to care • Limited medical access • Limited transportation • Limited income • Cultural barriers • Develop strategies to address these barriers

  39. References http://scangis.dhec.sc.gov/scan/ http://www.sccanceralliance.org http://www.scdhec.gov/health/mch/wcs/fp/index.htm Brandt, et al. (2006) Cervical cancer disparities in South Carolina: An update of early detection, special programs, descriptive epidemiology, and emerging directions. The Journal of the South Carolina Medical Association. 102:223-230. http://www.cancer.org http://www.dhhs.state.sc.us http://www.communitiesincharge.org/ Lisovicz, N., et al. (2006) The Deep South Network for Cancer Control: Building a Community Infrastructure to Reduce Cancer Health Disparities. Cancer. 107(8): 1971-1979. Eng, E. (1995) Partners for improved nutrition and health: Did the partnership make a difference? Final evaluation report. Chapel Hill, NC: University of North Carolina at Chapel Hill. Eng, E., et al. (1994) Measuring community competence in the Mississippi Delta: the interface between program evaluation and empowerment. Health Education Quarterly. 21:199-220.

  40. References Hinton, A, et al. (1992) Partners for improved nutrition and health – An innovative collaborative project. J Nutr Educ. 24:67-70 Hinton, A., et al. (2005) The community health advisor program and the deep South network for cancer control. Fam Community Health. 28:20-27. Freire, P. (1970) Pedagogy of the Oppressed. New York: Seabury Press. Freire, P. (1983) Education for Critical Consciousness. New York: Seabury Press. Butterfoss, F.D., et al. (1993) Community coalitions for health promotion and disease prevention. Health Educ Res. 8:315-330. Yancey, AK, et al. (1995) Increased cancer screening behavior in women of color by culturally sensitive video exposure. Preventive Medicine 24(2):142-8 Ell, K., et al. (2002) Abnormal cervical screen follow-up among low-income Latinas: Project SAFe. Journal of women’s health & gender based medicine. 11(7):639-651. Erwin, D.O., et al. (2007) A comparison of African American and Latina social networks as indicators for culturally tailoring a breast and cervical cancer education intervention. Cancer. 109(2): 368-377

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