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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

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


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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


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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


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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


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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


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  • 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


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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


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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


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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


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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


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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


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Logistic regression Analysis

© Su-I Hou, DrPH, RN, CHES


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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.


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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


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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


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IM Step 2: Methods and Strategies

© Su-I Hou, DrPH, RN, CHES


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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


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© Su-I Hou, DrPH, RN, CHES


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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


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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


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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.


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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


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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


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Comparisons of Scale Means (Baseline)

© Su-I Hou, DrPH, RN, CHES


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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


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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


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Changes in Scales Within Groups Over Time (pre- & post-test)

© Su-I Hou, DrPH, RN, CHES


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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


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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.


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The End

Su-I Hou (sweet)