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Cervical Cancer Screening Among Chinese Women

Cervical Cancer Screening Among Chinese Women. Su-I Hou, DrPH, MPH, RN, CHES Assistant Professor, Health Promotion & Behavior, University of Georgia, Athens, GA Email: shou@uga.edu. UT-Houston, School of Public Health Health Promotion / Health Education.

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Cervical Cancer Screening Among Chinese Women

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  1. Cervical Cancer Screening Among Chinese Women Su-I Hou, DrPH, MPH, RN, CHES Assistant Professor, Health Promotion & Behavior, University of Georgia, Athens, GA Email: shou@uga.edu UT-Houston, School of Public Health Health Promotion / Health Education Sponsor: Cheng Ching Hospital, Taichung, Taiwan

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

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

  4. 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, DrPH, RN, CHES

  5. Introduction • Cervical Cancer 2nd most common cancer among women worldwide 1st 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 cervical cancer © Su-I Hou, DrPH, RN, CHES

  6. RiskFactors 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, DrPH, RN, CHES

  7. Pap Screening Behavior Hiatt RA & Pasick R, 1995 (Bay area, SF) Prevalence of ever had a Pap: White/Black -- 98%; Latino -- 97%; Chinese -- 56% 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 / 615) © Su-I Hou, DrPH, RN, CHES

  8. Factors Influencing Pap Screening Behavior Personal Factors Knowledge (Harlan ‘91; Jian ‘92; Kelly ‘96) Perceived susceptibility (Seow ‘95, Neilson ‘98) Perceived pros/cons (Pham ‘92; Seow ‘95; Yu ‘98, etc.) Perceived norms (Gotay ‘98) Demographics (Yi ‘94; Wang ‘96) External Factors Availability/Accessibility/Affordability (Wilcox ‘93) Social support (Li ‘91; Suarez ‘94; Burnett ‘95) Doctor-patient relationships (Pham ‘92; Yi ‘94) © Su-I Hou, DrPH, RN, CHES

  9. Significance • Data for Chinese women are limited • National Health Insurance Plan provides women aged 30 and older to have an annual Pap test • The significance of cervical cancer in Taiwan • Few intervention programs targeting Chinese women and none were developed based on theory or evaluated properly © Su-I Hou, DrPH, RN, CHES

  10. 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-participants; Chi-square test; log regression analysis © Su-I Hou, DrPH, RN, CHES

  11. Pilot Study and Instrument Validation (con’t) Results Sample Characteristics (N=125) mean age: 38 Married: 90%* (p=.03) Work full time: 62% > College education: 32% Scale Reliability Chronbach  Perceived pros: 0.88 (11 items) Perceived cons: 0.68 ( 9 items) Perceived norms: 0.72 ( 4 items) Susceptibility: 0.68 ( 2 items) Knowledge: 0.70 (16 items) Items with low CITC (corrected-item-total corr.) were re-evaluate for their appropriateness © Su-I Hou, DrPH, RN, CHES

  12. Pilot Study and Instrument Validation (con’t) Logistic regression Analysis © Su-I Hou, DrPH, RN, CHES

  13. Pilot Study and Instrument Validation (con’t) 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 examine the relationships of these potential influencing factors and screening behavior.

  14. Intervention Development Methods 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 IM Step 5: Generating an Evaluation Plan Needs Assessment Quantitative results from pilot study Qualitative data from focus groups Existing social and behavior science theories Findings from previous studies © Su-I Hou, DrPH, RN, CHES

  15. Intervention Development (con’t) IM Step 1: Proximal Program Objectives Behavior - Non-compliant women will obtain a Pap after the intervention PO1: schedule a Pap test PO2: obtain a Pap test Personal determinants: intention; knowledge; perceived pros/cons; perceived norms; susceptibility External determinants: cues to action Environments - Increased availability of alternative service by female doctors PO1: hospital administrators approve provision of service PO2: female Drs. sign up to perform Pap exams in the community Personal determinants: knowledge; outcome expectations External determinants: reward / compensation © Su-I Hou, DrPH, RN, CHES

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

  17. 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: 1st month - personalized welcome letter cervical cancer/Pap brochure quotes of other women’s experience screening schedule w/ doctors information 2nd month - personalized screening invitation letter screening service provided by female doctor role model stories knowledge-based fact sheet updated screening schedule 3rd month - phone intervention (reminder calls) reminding letters © Su-I Hou, DrPH, RN, CHES

  18. © Su-I Hou, DrPH, RN, CHES

  19. Intervention Development (con’t) IM Step 4: Adoption and Implementation Plans PO1: program sponsor approves the intervention program PO2: obtain a list of non-compliant women PO3: schedule and mail the intervention materials to women PO4: co-ordinate community screening services with female doctors PO5: conduct screening reminding calls Personal determinants: behavior capability; outcome expectations External determinants: reward / compensation Training sessions: recruiting and identifying non-compliant women schedule and send program materials conducting screening reminding calls © Su-I Hou, DrPH, RN, CHES

  20. Intervention Development (con’t) IM Step 5: Generating an Evaluation Plan Pretest - Posttest Control Group R O1 O2 (3 mon. after O1) R O1 X O2 (3 mon. after O1) where R= random assignment ============================================== post-test (O2) Screening behavior Beliefs Knowledge Intervention components pre-test (O1) Demographics Previous screening experience Beliefs Knowledge © Su-I Hou, DrPH, RN, CHES

  21. 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, or using other methods/strategies can be developed with this IM process as well.

  22. Program Intervention Evaluation Method Sample: Female family members of patients who admitted 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 hysterectomy, not pregnant Analysis: Compare study outcomes between women in intervention and comparison groups pre- & post- changes within groups © Su-I Hou, DrPH, RN, CHES

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

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

  25. Pap Completion Rate Intervention Group: 0% 51% Comparison Group: 0% 32% P=0.002* Pap Intention (Pre-contemplators) Intervention Group: 0% 89% Comparison Group: 0% 93% btw groups P=0.310 Pap Intention (Contemplators) Intervention Group: 62% obtain a Pap Comparison Group: 38% obtain a Pap P=0.008* • Program Intervention Evaluation (con’t) within groups P=0.000* © Su-I Hou, DrPH, RN, CHES

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

  27. Program Intervention Evaluation (con’t) Changes in Scales Within Groups Over Time (pre- & post-test) © Su-I Hou, DrPH, RN, CHES

  28. 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 role of pros/cons on influencing cancer screening behavior

  29. Publications related to this project Pilot Study • 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 • 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 • 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 • Hou, S., Luh, W., & Chen, P. (in press). Psychometric properties of the Cervical Smear Belief Inventory for Chinese women. International Journal of Behavior Medicine.

  30. The End Su-I Hou (sweet)

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