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Service Delivery Innovation Profile

Culturally Competent Outreach Programs Increase Cervical Cancer Screening Among Chinese Women


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Snapshot

Summary

The Chinese Women's Health Project consisted of two interventions to promote cervical cancer screening among Chinese American and Canadian women. The "low-intensity" intervention involved mailing Chinese language audiovisual and print materials to women, while the "high-intensity" intervention involved home visits by bicultural, trilingual outreach workers to educate women and encourage screening. Both interventions significantly increased screening rates among women as compared with a control group, with the high-intensity intervention being the more effective.

Evidence Rating (What is this?)

Strong: The evidence consists of post-implementation data comparing self-reported screening rates among three randomly assigned groups—two intervention groups and a control group. Additional analyses evaluated the potential impact of confounding variables and attempted to adjust for potential problems with self-reported data; these analyses confirmed the initial findings.
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Developing Organizations

British Columbia Cancer Agency; Fred Hutchinson Cancer Research Center; Harborview Medical Center
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Date First Implemented

2000
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Patient Population

Race and Ethnicity > Asian; Gender > Female; Vulnerable Populations > Immigrants; Non-english speaking/limited english proficiency; Womenend pp

Problem Addressed

Studies suggest that Chinese women have lower screening rates with the Papanicolaou (Pap) smear test than do the general population of women in North America.1 In addition, the health needs of Chinese women and other Asians living in North America are not well understood.
  • Lower screening rates: California Health Interview Survey data from 2003 provide the most recent direct comparisons of cervical cancer screening rates among Chinese and other racial/ethnic groups. This survey found that 68 percent of Chinese women aged 18 years and older reported Pap testing in the previous 3 years, compared with 84 percent of white, 87 percent of black, and 85 percent of Hispanic women.2
  • Lack of knowledge on this population: The preventive health care needs of Chinese women and other Asians living in North America are not well understood, with little information having been published on effective interventions targeting these minority populations.

What They Did

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Description of the Innovative Activity

The Chinese Women's Health Project consisted of culturally and linguistically competent interventions to increase cervical cancer screening among Chinese women in Seattle, WA; and Vancouver, British Columbia. The project sponsored two such interventions at each site: a "low-intensity" direct mail intervention and a "high-intensity" outreach worker intervention, both of which used Chinese language materials to educate women and motivate them to seek Pap testing. Key elements of the interventions are described below:
  • Recruitment and baseline survey: The program identified Chinese households in both cities by matching common Chinese names to local telephone directories and through commercially available listings provided by a marketing company. Each household received a letter in both English and Chinese introducing the project and requesting participation. Female Chinese interviewers speaking Cantonese, Mandarin, and English surveyed women in these households about Pap testing.
  • Participant eligibility: The program used the baseline survey to determine which women were eligible for the interventions. Women were eligible for participation if they were between 20 and 69 years of age; able to speak Cantonese, Mandarin, or English; had no history of invasive cervical cancer; had never received a hysterectomy; and were noncompliant with cervical cancer screening guidelines. For the initial trial, project leaders randomly assigned eligible participants to one of the two interventions or a control group.
  • Direct mail intervention: The "low-intensity" intervention consisted of mailing eligible women a packet of culturally and linguistically competent materials, which are described below. All of the written materials included both Chinese and English text.
    • Education-entertainment video: A video, available in Cantonese and Mandarin with English subtitles, educates participants about cancer using a soap opera format. The video provides cultural context by referring to traditional Chinese health practices, recognizing the importance of events in Chinese culture, and including footage of familiar scenes, such as a traditional herbalist store. The video also addresses barriers to cervical cancer screening identified in previous research, such as beliefs questioning the necessity of Pap testing for asymptomatic, sexually inactive, and postmenopausal women.
    • Motivational pamphlet: The packet included a motivational pamphlet to enhance the effectiveness of the video. The pamphlet, which features drawings of women by a Chinese artist, addresses barriers to screening through testimonials from Chinese women. It also includes a question and answer section.
    • Fact sheets: The packet included fact sheets addressing linguistic and financial barriers to health care. The sheets were tailored to the Chinese communities in Seattle and Vancouver, providing information about clinics with Chinese language interpreter services and coverage of cervical cancer screening by public and private insurers serving the areas.
    • Educational brochure: An educational brochure covering basic facts about cervical cancer and Pap testing was also included in the packet; the Federation of Chinese American and Canadian Medical Societies developed this brochure.
  • Outreach worker intervention: The "high-intensity" intervention consisted of home visits conducted by bicultural, trilingual outreach workers. Outreach workers acted as role models, provided social support, and served as cultural mediators between women and health care facilities. All of the educational materials described above were used by the outreach workers.
    • Home visits: Women targeted for this intervention received Chinese and English versions of an introductory letter. Within 3 weeks of receiving the letter, they received a visit by a female Chinese outreach worker who spoke Cantonese, Mandarin, and English. Ten attempts were made to visit each woman, and those who were contacted but refused home visits were offered the educational materials.
    • Educational materials: Outreach workers used visual aids, such as a speculum and Pap testing kit, and provided tailored responses to each woman's barriers to cervical cancer screening. During the home visit, outreach workers asked participants if they were willing to watch the video together. If the participant preferred, outreach workers left a copy of the video at the house for her to watch later. Participants also received all of the printed educational materials used in the direct mail intervention.
    • Logistical assistance: Outreach workers offered several types of logistical assistance to participants, as necessary. They referred participants to clinics, assisted in scheduling appointments, arranged transportation to and from appointments, and provided medical interpreter services during visits for Pap testing.
    • Followup contact: Approximately 1 month after the initial home visit, an outreach worker contacted each participant via telephone to see if Pap testing had been completed and to offer any further assistance that was needed.

Context of the Innovation

The Chinese Women's Health Project was a program of the Fred Hutchinson Cancer Research Center, a nonprofit, Seattle-based research institution dedicated to the elimination of cancer and related diseases, in partnership with the British Columbia Cancer Agency, a comprehensive cancer control program in Vancouver, and Harborview Medical Center, a leading teaching hospital for the University of Washington School of Medicine.

Did It Work?

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Results

Followup survey data showed that both interventions were effective in increasing Pap testing, as compared with a control group.3 The outreach worker intervention was more effective.
  • Increased screening rates: Of the 402 women who responded to a followup survey (out of 482 total participants in the study), 39 percent of those in the outreach worker intervention and 25 percent of those in the direct mail intervention reported having a Pap test in the time period between being enrolled in the program and followup data collection. Both of these figures were well above the 15 percent screening rate among women in the control group, and all three pair-wise comparisons were statistically significant.
  • Further analysis does not alter results: A multivariate analysis conducted to control for the effects of potential confounding variables, such as age and education, did not significantly alter these findings. In addition, women who reported cervical cancer screening were asked to sign a medical release form giving project staff permission to verify their self-reported Pap tests. Even if more conservative assumptions are used (i.e., that women who did not sign the release form were not actually tested), both interventions still led to increased screening rates.

Evidence Rating (What is this?)

Strong: The evidence consists of post-implementation data comparing self-reported screening rates among three randomly assigned groups—two intervention groups and a control group. Additional analyses evaluated the potential impact of confounding variables and attempted to adjust for potential problems with self-reported data; these analyses confirmed the initial findings.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Development of educational and training materials: Project leaders conducted inperson interviews and focus groups to understand some of the barriers to seeking health care in the target communities. The qualitative data collected from these interviews informed the development of the educational materials and a training manual for outreach workers. The program developed the video in partnership with a television company based in Vancouver; the company helped to make the educational content more entertaining to (and thus, more likely to be remembered by) viewers.
  • Development of baseline questionnaire: Project leaders developed the baseline questionnaire in English, translated it into Chinese, and then back-translated it to English to ensure that the two versions were equivalent.
  • Recruitment and training of outreach workers: The program identified bicultural, trilingual outreach workers through word of mouth and the assistance of community coalitions in Seattle and Vancouver. The program selected some outreach workers from the pool of baseline survey interviewers. The two outreach workers from each site attended day-long training session led by a general internist with a background in anthropology. During the training, outreach workers learned how to use the visual aids during home visits and how to act as role models, provide social support, and serve as cultural mediators between women and health care facilities.

Resources Used and Skills Needed

  • Staffing: The program employed four part-time bicultural, trilingual outreach workers, who together covered 161 participants. In addition, each site had a project coordinator to supervise the outreach workers on a day-to-day basis.
  • Costs: Personnel costs included time spent training staff, intervention-related meetings, mail-merging, assembling packets, contacting participants, home visits, and logistical assistance. Nonpersonnel costs included production of handbooks, manuals, and educational materials, VCR equipment, a Pap test kit, and a speculum. The average cost of the direct mail intervention was $48.54 per participant, and the average cost of the outreach worker intervention was $73.06 per participant.
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Funding Sources

National Cancer Institute
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Tools and Other Resources

National Cancer Institute. The Chinese Women's Health Project: Products [Web site]. Available at: http://rtips.cancer.gov/rtips/productDownloads.do?programId=155735&topicId=102264.

Adoption Considerations

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Getting Started with This Innovation

  • Secure financial resources: This program is relatively resource intensive, and obtaining initial funding often represents the biggest challenge to getting it off the ground.
  • Select effective outreach workers: Culturally and linguistically competent outreach workers are crucial to the success of the "high-intensity" intervention.
  • Obtain input from the target community: Project staff solicited advice from community coalitions about recruiting outreach workers and the appropriate content for educational materials.

More Information

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Contact the Innovator

Victoria M. Taylor, MD, MPH
Fred Hutchinson Cancer Research Center
1100 Fairview Ave North (MP-702)
Seattle, WA 98105
Phone: (206) 667-5114
Fax: (206) 667-5977
E-mail: vtaylor@fhcrc.org

Innovator Disclosures

Dr. Taylor reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

Thompson B, Thompson LA, Chan NL, et al. Cost effectiveness of cervical cancer screening among Chinese women in North America. Asian Pac J Cancer Prev. 2007;8(2):287-93. [PubMed]

Footnotes

1 Lee-Lin F, Menon U. Breast and cervical cancer screening practices and inventions among Chinese, Japanese, and Vietnamese Americans. Oncol Nurs Forum. 2005;32(5):995-1003. [PubMed]
2 California Health Interview Survey. Health of California's adults, adolescents, and children: findings from the CHIS 2003 and CHIS 2001. Available at: http://escholarship.org/uc/item/0043g9t1.
3 Taylor VM, Hislop TG, Jackson JC, et al. A randomized controlled trial of interventions to promote cervical cancer screening among Chinese women in North America. J Natl Cancer Inst. 2002;94(9):670-7. [PubMed]
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Original publication: October 13, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 06, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.