Ellen Eidem, M.S. Acting Director Ricardo Contreras, M.P.H. Research Analyst September 2004

1. CERVICAL CANCER PREVENTION AND EDUCATION INITIATIVE (CCPEI): A Multicultural, Multimedia Marketing and Outreach Campaign in Los Angeles CountyOFFICE OF WOMEN’S HEALTHLOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES Ellen Eidem, M.S. Acting Director Ricardo Contreras, M.P.H. Research Analyst September 2004

2. The Need for CervicalCancer Prevention • January 2002, Office of Women’s Health launched The Cervical Cancer Prevention and Education Initiative (CCPEI) because of the exceptionally high rates among women of color for a disease that is preventable • Women of color and recent immigrants have cervical cancer incidence rates nearly twice that of white women.

3. The Need for Cervical Cancer Prevention • The cervical cancer incidence rate for women in the U.S. is 8.7 per 100,000. The 1996-2000 incidence rates among women of color in Los Angeles County were: • Latinas: 18.3 per 100,000 rate compared to 8.1 per 100,000 among white women in the County • Korean women: 15.7 per 100,000 rate • Black non-Latina women: 11.7 per 100,000 rate • Asian & Pacific Islander women: 11.2 per 100,000 rate

4. Goals and Objectives • Goal: to reduce cervical cancer morbidity & mortality in women of color (especially below 200% FPL) in Los Angeles County. • Increase awareness that cervical cancer is preventable with a routine Pap test • Increase the number of women screened, especially women who have not tested recently (last 3yrs) • Increase access to screening, follow-up and treatment by addressing barriers to care • Decrease the stage at diagnosis

5. Methods • CCPEI: Two year multi-cultural, multi-media and grassroots campaign • Three pronged approach: 1) multi-cultural, multi-media campaign in local ethnic and general media outlets 2) multi-lingual 1-800 hotline through which eligible women could schedule no-cost cervical cancer screening and breast health appointments with local providers 3) community-based outreach activities

6. CCPEI Campaign Components • Created and maintained multi-lingual 1-800 hotline to schedule appointments and provide information • 7 languages: Spanish, English, Mandarin, Cantonese, Korean, Vietnamese and Armenian) • Tracking system and database for appointments, health, demographics, reminder letters, maps to local clinics, and Pap results • Developed & distributed multi-lingual promotional and educational materials at health fairs, community events and through community partners • Additional languages: Cambodian and Tagalog • Hired an independent evaluator to assist with the evaluation component of the campaign

7. CCPEI Campaign Components: Key Partners • Network of 300 community partners • 166 clinical providers offering free Pap tests and breast health screenings to qualified women • 21 community based organizations to conduct grassroots efforts on prevention • Spokespersons for each campaign

8. CCPEI Campaign Components: Partners in Media • Hired four marketing agencies to design and implement a comprehensive communications plan (TV, radio, print and grassroots efforts) that utilized both paid and unpaid media: • Each agency had a specific ethnic focus to conduct media and grassroots campaigns to reach low-income women: • Latinas, African American Women, Asian women (Korean, Chinese, Vietnamese, Filipina & Cambodian Women), Armenian Women

9. CCPEI Campaign Components: Mobile Health Clinic • Brings no cost comprehensive health screenings to low-income women at various locations such as health fairs, community centers, adult schools, churches, and Latin American Consulates • Hypertension screenings • Cholesterol screenings • Diabetes screenings • Cervical Cancer screenings • Clinical Breast exams • Gynecological exams (including Pap test) • Link to mammography services for women 40 years of age and older • Follow up appointments are made for all abnormal results

10. Results • The CCPEI Media and Outreach campaign successfully reached women in low income, linguistically isolated communities throughout LA County • Over 30,000 calls were answered, including appointment rescheduling, calls for information, other services, and calls from outside LA County (due to the media reach) • 14,000 women received cervical cancer and breast exam/mammography appointments • 750,000 multi-lingual educational and promotional materials were developed and distributed

11. Results Data represents January 2002 through August 2003 Appointments • Over 98% of women were at or below 200% of the Federal Poverty Level • 96% women of color • 75% preferred a language other than English • 28% had not had a Pap test in over 3 yrs or had never been tested • 60% appointments to Latinas, 27% to Asian women, and over 6% to African-American women

12. Results Data represents January 2002 through August 2003 Appointments • Number of appointments were almost twice as high during months when paid media campaigns were running as when they were not • Three woman were found to have Cervical Cancer and 300 had Abnormal Pap tests. All were sent for follow-up testing and treatment

15. Average CCPEI “Show” Rate = 65.2%

17. CCPEI Cost Effectiveness • Approximately $1.6 Million was estimated to be saved in future costs associated with high grade cervical lesions or invasive cancers from CCPEI clients screened between January 2002 and August 2003 • The savings were derived by applying cost data associated with each stage of cervical cancer abnormality to the estimated percentage of each stage that progresses to a high grade lesion or invasive cancer • By screening, diagnosing and treating all precursors of cervical cancer early, both the State of California and the County of Los Angeles saved future health care costs associated with high grade lesions and cervical cancer • Since 1997 is the most current federal cost data available, and given the inflationary rate of health care costs, the actual savings to the health care system for early detection would actually be substantially higher

18. Campaign Highlights • Chinese and Korean women were the least likely to have been screened recently, were the most likely to attend their appointment, and had the highest abnormal Pap test result rate of all CCPEI clients • Although the cervical cancer incidence rate is the highest among LA County Latinas, the CCPEI abnormal rate for Latinas was actually the lowest rate. • African American women reached through the campaign were the most likely to be screened recently. 58.2% of African American women had been screened in the last 2 years, leaving 41.8% that were overdue for screening.

19. Campaign Highlights • Women who had never been screened or who had not been screened in the last 3 years had a higher than average rate of abnormal results, supporting the importance of a multi-lingual campaign in bringing “at-risk” women into service. • The hotline was utilized as a source of follow-up care, bringing women back into service • Women who were recently screened had the lowest appointment attendance rate, yet had the highest abnormal Pap test rate (nearly 20%).

20. Lessons Learned • Success can be achieved by combining and linking a mass media campaign with an effective community-based outreach effort. • Conducting a multi-lingual and multi-cultural media campaign showed that racial/ethnic groups respond differently to various media sources • CCPEI clients used the hotline for services other than cervical cancer screening and mammography (e.g., referrals for women’s and general health services, cancer services, etc.)

21. Lessons Learned • Should set up all systems/ clarify all expectations with community partners prior to implementation • CCPEI and County funding leveraged to launch highly effective women’s health mobile clinic • Solicit future funding from year one of the campaign to ensure that program will be sustained • Constant evaluation to reach those women that are most in need of the service

22. Overcoming Barriers • Necessity for substantial investment of initial-start up financing to create successful infrastructure and staffing • budget crisis, difficulty of securing large grants for countywide program • Possible ways to overcome barriers • streamlining programs, multiple smaller grants, more conservative undertakings, in-kind services, leveraging other monies, County contributions

23. Public Health Implications • When implementing multi-lingual, multi-cultural media campaign, collaborate with community stakeholders familiar with target communities • Public private partnership very effective way to reach communities of color not likely to be established with health care system • Chose campaign within overall burden of disease for women • How to expand a program with categorical funding (cervical and breast cancer screening) to a larger campaign on PREVENTION

24. Conclusion • The CCPEI multi-cultural media, outreach, and education campaign was successful in reaching high-risk, low income women of color from traditionally underserved LA communities that have not received regular cervical cancer screenings. • Different populations are at higher risk for developing cervical cancer due to differences in culture, screening frequency, and limited access to the health care system

25. Prevent Cervical Cancer Get Tested Now PREVENTION MATTERS