Rena J. Pasick

1. Changing Public & Patient Behavior: Theory, Evidence, PlanningTraining in Clinical ResearchTranslating Evidence Into PracticeApril 29, 2008 Rena J. Pasick

2. Cancer screening disparities • Intervention evidence • Behavioral theory and culture • Planning

3. Trends in Early-Stage Female Breast Cancer Incidence by Race/Ethnicity California, 1988-1999 Source: Cancer in California, 1988-1999. California Department of Health Services, December 2001.

4. Mammography Status in a Multiethnic* SampleAlameda CountyWomen, 40-74Pathfinders Baseline Survey, 1999-2000 (n=1463) *African American, Chinese, Filipina, Latina, White women, ** Within 15 months of interview

5. Cervical CancerAverage Annual Age-Adjusted IncidenceUS, 1988 - 1992 SEER, 1996

6. Research Background

7. Research Background (con’t)

8. Cancer screening disparities • Intervention evidence • Behavioral theory and culture • Planning

9. Access Enhancement laws non-clinical settings cost reduction eliminate structural barriers multi-component Promotion mass media small media small group education one on one education incentives reminders multi-component Interventions Briss PA et al, Am J Prev Med 2000 Rimer BK et al, Pub Hlth Rep 1993

10. Cancer Screening Intervention Research • Large body of research • Extensive array of barriers identified • Many effective interventions • Extent to which interventions sustained “disappointing” • Few interventions found effective are disseminated • Multilevel theoretical and conceptual approaches are needed to understand the full context of cancer screening Meissner H, 2004; Rakowski W, Breslau E. 2004

11. Lesson 1 Virtually all major types of community-based cancer screening interventions have been found to be effective in some studies. However, no interventions work for all people, screening tests, or in all settings. Pasick, Hiatt, Paskett. 2004

12. “Focal Point” Framework

13. Fundamental research(basic behavioral research) • Develop/refine the mechanisms that lead to intervention outcomes • - theory & measurement • - messages • - communication channels

14. Intervention research • Optimal intervention for the “focal point” is identified, implemented accurately, evaluated rigorously, and replicated. • - formative evaluation • - process evaluation • - assessment of outcomes - including cost-effectiveness

15. Brilliant points of light…..

16. …punctuating vast empty spaces

18. Cancer screening disparities • Intervention evidence • Behavioral theory and culture • Planning

19. On the one hand….. • the reason for theory is to help guide the selection of important constructs thought to exert impact on health behavior Crosby et al. 2002

20. On the other hand… By targeting a specific range of theoretically important constructs for examination or as a foundation for designing health promotion programs… theory limits the breadth of observations and investigations and the scope of intervention Crosby et al., 2002

21. Limitations of Theoryfor Disparities Populations • Origins of theory • Measurement • Decontextualization • Focus on cognition

22. Measurement Theory Interventions & Messages

23. Measurement • Intention measurement includes action, target, time: • I intend to get a mammogram in the next 12 months extremely unlikely :___1__:___2__:___3__:___4__:___5__:___6__:___7__: extremely likely • Pathfinders translation/adaptation for 5 race/ ethnic and 4 language groups: Do you plan to have a mammogram in the next 12 mos? yes  no 

24. Perceived Benefits of Mammographyin a Multiethnic, Multilingual Sample (n=1463)

25. Perceived Benefits &Regular Mammographyin a Multiethnic, Multilingual Sample (n=1463)

27. Summary: 3Cs Quantitative FindingsPathfinders Baseline & Final Surveys* • performed as expected • self-efficacy predicted recent screening longitudinally across ethnic groups • subjective norms was associated with mammography cross-sectionally • differential predictive strength by ethnicity • intention • perceived benefits • no evidence of association • perceived susceptibility * 5 Race/ethnic and 4 language groups Stewart SL. Behavioral Constructs and Mammography in Five Ethnic Groups (in progress)

28. Data Quality in Multiethnic Health Surveys • A study to assess the validity and comparability of survey questions across cultures and languages • Mixed methods to explain findings and understand more complex meaning • Survey instruments & quantitative data from 3 multi-lingual breast & cervical screening intervention studies • Data from 3 studies (6760 interviews) Pasick, RJ, Stewart SL, Bird JA, D’Onofrio CN. 2001 Data Quality in Multiethnic Health Surveys - Public Health Reports 116: 223-243,

29. Data Quality in Multiethnic Health Surveys • Quality of multi-ethnic, multi-lingual data should be regarded as questionable • Measurement is affected by complex factors not readily observed or understood through standard tests • Objective items present fewer problems than attitudinal items • All are subject to translation difficulties & lack of cross-cultural comparability

30. MeasurementTheoryCommunication CULTURE

31. Understanding Culture Images Stated values & beliefs Ways of communicating

32. Culture • a system of knowledge that allows us to know how to communicate with others and how to interpret their behaviors (Gudykunst, 1998)

33. High Context Communication Associated more with collectivist cultures* Very little information is in coded, explicit, transmitted part of the message** Low Context Communication Associated more with individualistic cultures* Explicit, direct, precise messages * Gudykunst & Ting-Toomey, 1988 ** Hall, 1976

34. * G Gao, S Ting-Toomey 1998 - Sage Publications Hypothetical Vignette based onCommunicating Effectively with the Chinese* Scene: Anglo MD recommending CRC screening to Chinese patientMD prescribes med for presenting GI complaint…

35. MD:“You’re now 51. At this age your risk of CRC cancer goes up. I’d like you to start doing yearly stool tests and to have a test called a sigmoidoscopy every 5 years. Here’s a booklet that describes this. Stop at the lab for the test kit and call the nurse if you have any questions.” Patient is silent, thinking:She thinks I have cancer Explanation - In high-context cultures, people read between the lines, expecting to find more meaning in what is not said than in what is verbalized Anglo MD & Chinese patient(con’t)

36. MD:“Do you have any questions?” Patient:“No” Explanation - In some cultures, it is considered impolite & disrespectful for a lay person to question an MD; one accepts authority without question. Anglo MD & Chinese patient (con’t)

37. Understanding Culture Images Stated values & beliefs Ways of communicating Socio-Cultural Context

38. Culture is… • the tools that group members use to make sense of the chaos around them, putting the abstract ideas of worldview into tangible beliefs and behaviors Kagawa-Singer M. 1997 a system of knowledge that allows us to know how to communicate with others and how to interpret their behaviorsGudykunst WB. 1998 a system whose whole pattern (most of which is not conscious at any particular time) is required to understand the meanings that people attach to specific facts and observations Bourdieu P. 1990

39. Behavioral Theory: Like a Compass on Mars Mars groups who suffer cancer disparities Compass behavioral research theory & methods

40. The Problem • Behavioral theory constructs • Developed with mainstream populations • Used as universal • Underlying concepts • Not tested for cultural appropriateness • Focus is cognition, not context • Measures • Not validated for cross-cultural comparability or validity

41. The Problem • Behavioral theory constructs • Developed with mainstream populations • Used as universal • Underlying concepts • Not tested for cultural appropriateness • Focus is cognition, not context • Measures • Not validated for cross-cultural comparability or validity

42. Behavioral Constructs & Culturein Cancer Screening(3Cs)funded by the NCI 2001-2006 • Methodological study to assess the cultural appropriateness of 5 behavioral theory constructs • Mixed methods • multi-lingual survey • in-depth interviews • key informant “scholars” • community gatekeepers • women in community Self efficacy IntentionPerceived BenefitPerceived Susceptibility Subjective Norms

43. 3Cs Research Team • Investigators Consultants • Rena Pasick • Nancy Burke Bill Rakowski • Susan Stewart Melissa Clark • Judith Barker • Joyce Bird • Regina Otero-Sabogal • Noe Tuason • Galen Joseph • Anthropology * Behavioral Science * Biostatistics * Health Psychology * Public Health * Sociology

44. The Problem • Behavioral theory constructs • Developed with mainstream populations • Used as universal • Underlying concepts • Not tested for cultural appropriateness • Focus is cognition, not context • Measures • Not validated for cross-cultural comparability or validity

45. Is Intention Comparable in Meaning & Measurement Across Cultures?

46. Self efficacyIntention Perceived BenefitPerceived SusceptibilitySubjective Norms • intention– the determination to perform certain activities (e.g., mammography) or to bring about a certain future state of affairs; the likelihood of doing something (Theory of Planned Behavior) • mechanisms • cognitive representation of future outcome • goal setting and self-evaluation • assumptions • behavior is volitional • people are rational

47. Theory of Planned Behavior OR…… Beliefs + Beliefs + Beliefs > Intention > Behavior

48. 3Cs Qualitative Methods • Key informant (KI) interviews • Scholars from the ethnic group of interest • Community gatekeeper (GK) interviews • CBO directors/managers, public health nurses, religious leaders • Ethnographic interviews with women • Latina and Filipina women in the community • Transcription (and translation) • Collaborative coding • Identification of themes

49. Qualitative Methods in Health Research vs the Anthropological Approach Pasick R, Burke N (2007) A Critical Review of Theory in Breast Cancer Screening Promotion across Cultures. Ann Rev Pub Hlth

50. Themes with relevance to intention