Problem Addressed

• 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.

Description of the Innovative Activity

• 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.

References/Related Articles

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Innovator Disclosures

Results

• 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?)

Context of the Innovation

Planning and Development Process

• 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.

Funding Sources

Tools and Other Resources

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.