Transcript Slide 1

Development of a Tailored
Interactive Multimedia Intervention
to increase Colorectal Cancer
Screening among Hispanics along
Texas-Mexico Border
María E. Fernández, Ph.D.
The University of Texas, School of Public Health
RESEARCH TEAM
Houston:
Maria Fernandez, Ph.D (P.I.)
Sally Vernon, Ph.D.
Evelyn Chan, M.D.
Pam Diamond, Ph.D.
Dave Lairson, Ph.D.
Brownsville:
Maureen Sanderson, Ph.D.
El Paso:
Theresa Byrd, Dr.P.H.
Staff
Rosario Wippold, M.P.H.
Janet Williams, M.P.H.
Jicela Longoria
CDC
Steven S. Coughlin, Ph.D.
Katherine M. Wilson, Ph.D.
National Center for Farmworker
Health:
Sylvia Partida, MA
Alicia Gonzales, MSW
Monica Saavedra
Consultants:
Amelie Ramirez, Dr.P.H.
Armado Valdez, Ph.D.
Karen Emmons, Ph.D. (Havard)
Jeff Harris (UW), Deb Bowan
This project is supported by Cooperative Agreement Number U48 DP000057 from the Centers for Disease Control and
Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the2
Centers for Disease Control and Prevention
OVERVIEW
•Formative Research
•Intervention Planning using
Intervention Mapping
•Brief Description of Program
•Evaluation
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STUDY SETTING
• The study sites are colonias along the Texas-Mexico border: the
formative work was conducted in El Paso County, (El Paso), Cameron
County (Brownsville), and Webb County (Laredo); the intervention
trial will be carried out in the LRGV.
• Colonias are unincorporated, un-zoned, semi-rural communities often
without access to public drinking water or wastewater systems.
• Individuals living in colonias have high rates of poverty,
unemployment, and low education levels.
FORMATIVE RESEARCH
Qualitative Study
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12 Focus Groups: 5 with men, 6 with women, 1 with promotoras
Colonias of the El Paso, Laredo, & Brownsville regions
Interview guide question categories- Knowledge, Experience, CRCS behavior
Eligibility: Hispanic/Latino, 50+, No prior/current cancer diagnosis
Recruitment: Flyers, Word of mouth, Local colonia churches, Promotoras
Audio-taped sessions were transcribed, translated, and back-translated
Qualitative analysis using Atlas.ti
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FORMATIVE RESEARCH
Survey
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•
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Face to face interviews with 544 men and women
Colonias of the El Paso, Laredo, & Brownsville
Eligibility: Hispanic/Latino, 50+, no prior/current cancer diagnosis
Recruitment: Flyers, Word of mouth, Local colonia churches, Promotoras
• The survey was conducted in Spanish included items assessing:
demographics, colorectal cancer screening behaviors, Knowledge,
Perceived Susceptibility/Risk, Intentions, Self Efficacy, Decisional
Balance, Subject Norms, Social Norms, Fatalism, Acculturation
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FORMATIVE RESEARCH
Themes and subthemes related to colorectal cancer screening
Themes
Subthemes
Healthcare utilization
Comparison of perceptions of U.S. and Mexico
Health behaviors
Seeking preventive healthcare
Colorectal cancer screening behaviors
Internal factors influencing colorectal cancer
screening
“If the doctor
would tell me to
do it, the yes…
(I would get
tested)”
“
External factors influencing colorectal cancer
screening
Knowledge
Attitudes
Beliefs about cancer and colorectal cancer
screening
Pain
“It is because of
Cancer death
ignorance….one does
not ask to be screened
Curability
because she does not
Fatalism
know
that she should do
Spirituality and religious
beliefs
it, because one does not
Beliefs about causes and
symptoms of cancer
know the importance of
and colorectal cancer being screened.”
Emotions
System level barriers
Lack of access to health services
Interpersonal
Provider behavior
Language barriers
FORMATIVE RESEARCH
Themes and sub-themes related to colorectal cancer screening
Themes
Healthcare utilization
Health behaviors
Colorectal cancer screening behaviors
“No, what I tell you is
Internal
factors influencing colorectal cancer
that cancer is a bad
screening
disease, very ugly for
the people who have it,
almost always there is
no cure. It is very rare
to hear that one has
been saved from
cancer… it is a terrible
disease.”
External factors influencing colorectal cancer
screening
Sub-themes
“If of
it is
outside
the
Comparison of perceptions
U.S.
and Mexico
skin, I think it can be
Seeking preventive healthcare
cured.”
“..there are two types
of cancer, but the one
Knowledge
that you cannot feel or
Attitudes
detect, “the silent
is thecancer
one that
Beliefs about cancer and one,”
colorectal
kills you quickly “
screening
Pain
Cancer death
Curability
Fatalism
Spirituality and religious beliefs
Beliefs about causes and symptoms of cancer and
colorectal cancer
Emotions
System level barriers
Lack of access to health services
Interpersonal
Provider behavior
Language barriers
FORMATIVE RESEARCH
Sample Characteristic (N=544)
Age group
50-59
48.9
266
60-69
27.2
148
70 and over
23.7
129
Male
73.0
397
Female
27.0
147
None
9.6
50
1-5
41.3
215
6-11
40.0
208
12 and over
9.0
47
Born in U.S.
22.1
118
Born in Mexico, <10 years in US
11.3
60
Born in Mexico, over 10 years in US
66.6
355
< $10,000
71.8
303
$10,000 - $19,999
22.7
96
$20,000 - $29,999
5.2
22
None
50.2
269
Any
49.8
267
Gender
Education (years)
Birth Status & Years in the US
Income
Insurance
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FORMATIVE RESEARCH
Brownsville El Paso
(N=265)
(N=82)
Laredo
(N=198)
All Sites
(N=544)
Variable
%
N
%
N
%
N
%
N
Ever Heard
of Test (Yes)
FOBT
Sigmoidoscopy
Colonoscopy
Barium Enema
35.5
28.7
30.6
22.3
167
67
81
59
45.7
28.4
34.6
30.9
37
23
28
25
43.9
28.8
34.3
29.3
87
57
68
58
40.1
28.7
32.5
26.1
218
156
177
142
Ever Had CRCS
(Yes)
FOBT
Sigmoidoscopy
Colonoscopy
Barium Enema
22.3
10.2
11.7
10.6
59
27
31
28
30.9
8.6
13.6
23.5
25
7
11
19
14.6
7.1
9.1
6.1
29
14
18
12
20.8
8.8
11.0
10.8
113
48
60
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FORMATIVE RESEARCH
Findings- CRCS Behavior (Survey findings)
Have You Ever Had Colorectal Cancer
Screening Test? (N=544)
COLONOSCOPY
(32%)
NO
(66%)
SIGMOIDOSCOPY
(32%)
YES
(34%)
FOBT
(61%)
BARIUM ENEMA
(25%)
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FORMATIVE RESEARCH
Survey Findings- Determinants of CRCS Behavior
Multivariate Logistic Model Predicting CRCS Behavior
Odds Ratio
C.I
60-69
.80
(.489, 1.309)
70 and over
.52
(.297. 912)
Any
4.04
(2.556, 6.385)
Self Efficacy
1.41
(1.154, 1.722)
Decisional Balance
1.35
(1.000, 1.834)
Age group
Referent: 50-59
Insurance
Referent: None
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INTERVENTION MAPPING
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INTERVENTION MAPPING
Matrix of Change Objectives
BEHAVIOR: Move to contemplation (start thinking about CRCS)
PRECONTEMPLATION: Unaware of CRCS tests (never heard of); has heard about but does not intend to have one; has had CRCS in the past but does not
intend to have again
INTERNAL DETERMINANTS
PO
PO1. Seek
information
about
CRC/CRCS
KNOWLEDGE
1. About CRC
2. About CRCS
3. About insurance
PERCEIVED
RISK
DECISIONAL
BALANCE
OUTCOME
EXPECTATIONS
SELF
EFFICACY/SKILLS
PK1.States that
local clinic,
doctor, or
promotora can
provide you
information
about
CRC/CRCS
PPR1.Perc
eives that
getting
info. Will
decrease
risk of
getting
CRC
PDB1.a.State the
advantages of
obtaining info about
CRC/CRCS .
PDB1.b.Describe the
barriers to obtaining
info Re. CRC/CRCS
(lack of literacy,
lack of skills to
obtain info)
POE1.a.Expects
that will be able
to find
information about
CRC/CRCS .
POE1b.Expects
that seeking
information from
different sources
will clarify
misconceptions
about
CRC/CRCS.
POE1c. Expects
that getting
information will
get a better
understanding of
CRC/CRCS
PSE1.Expresses
confidence and
demonstrate skills in
seeking information
about CRC/CRCS
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INTERVENTION MAPPING
Methods and Strategies
Learning
Objectives
Method
Strategy
Program Component
PK1, PK2a., PK2b,
PK2c,PK2d, PK2e,
PK3a,CK1a, CK1b,
CK1c, CK2a,
CK2b, CK2c,
CK3a, CK3b,
CK3c, CK3d,
CK3e, CK3f,
CK4a, CK4b, CK5,
PPR1, PPR2,
CPR1, CPR2,
CPR3, CPR6,
CPR7, CPR8,
PRPR6
PDB1a, PDB1b,
PDB2a,
PDB2b,PDB3a,
PDB3b.CDB1a,
CDB1b, CDB2,
CDB3,CDB5a,
CDB5b, CDB6a,
CDB6b, CDB7,
Discussion
Active Learning
Tailoring
Images
Information
Demonstrations, workbook,
group sessions
Flipchart
Video
TIMI
Information about
personal risk,
consciousness raising,
fear arousal, dramatic
relief.
Self-reevaluation
Environmental
evaluation
Modeling
Discussions and homework,
Video clip with testimonial
Flipchart
Video
TIMI
Discussions in groups
Flipchart
Discussion
TIMI
Video-tape vignettes
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INTERVENTION DEVELOPMENT
Target
Tailored
•
Intended to reach a specific
population sub-group which is
homogeneous in some
particular way.
•
Intended to reach one specific
individual
•
Doesn’t distinguish between
members of the sub-group
•
Based on characteristics unique to
that person
•
Cannot address variations
between individuals
•
Takes into account the needs and
interests of each person
•
Not Individualized
•
Based on individual assessment
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Tailored Interactive Multimedia Intervention
Why TIMI ?
• Engages user in active learning
• Individualized, user his/her own pace
• Audio and Video facilitate learning in low literacy populations
• Little training required
• Reduces promotora burden
• Easy to Disseminate
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Tailored Interactive Multimedia Intervention
Flowchart
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Tailored Interactive Multimedia Intervention
Flowchart
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Tailored Interactive Multimedia Intervention
Flowchart
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Tailored Interactive Multimedia Intervention
Intervention with moving video (novela type story and testimonials),
audio, graphics, animation, stills, and interactive educational segments.
Targeted for:
• Hispanics
• Low literacy level
• Low education
Tailored to:
• Gender
• Language preference
•Awareness of CRCS
• Individual Stage of Change
• Attitudes about screening
•Knowledge
• Specific barriers
Interactive:
• Allows participants to choose topics of interest
• Allows participant to follow own learning pace
• Gives individualized feedback
• Provides decision support
Tailored Interactive Multimedia Intervention
Vale La Pena…..Prevenir
Vale La Pena…..Prevenir
‘Telenovela’ Style
Vale La Pena…..Prevenir
Interactive Segment
REASONS TO GET TESTED FOR
COLORECTAL CANCER
Colorectal cancer
can be cured!
To prevent treatments
and feeling ill
Vale La Pena…..Prevenir
Study Design
Colorectal Cancer Screening Among Hispanic Women Living in the
Lower Rio Grande Valley of Texas
To increase comparability of
study groups, we will use
MAUM to assign a score for
each site on a single
composite blocking factor.
This blocking factor will be
used to take into account
colonia age and size.
Randomize 24 Colonias
No Intervention
N=8 colonias
Intervention
N=8 colonias
Intervention
N=8 colonias
(Group 1)
(Group 2)
(Group 3)
Randomly select households
in colonias and recruit 20
participants per colonia Based on colonia maps
Recruitment of study participants
Baseline
interview
Baseline
interview
Implement
Intervention 1
Promotora-delivered
n= 160
small media print and
linear video
(usual practice)
n=160
Baseline
interview
Implement
Intervention 2
Promotora-delivered
Interactive Multimedia
n=160
Followup Interview
Followup Interview
Followup Interview
(6 mos following baseline)
(6 mos following baseline)
(6 mos following baseline)
Screening
validation
Screening
validation
Screening
validation
Two promotora groups will
be delivering the
interventions
Tailored Interactive Multimedia Intervention
Intervention Delivery
• Lay Health Worker
• Laptop Computer with Stylus
• Home Visit
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Planned Activities
Completion of Program Materials and Intervention Trial
•Cognitive testing
•TIMI and Small Media Interventions Pilot testing
A. Promotora training
B. Focus groups
•Baseline data collection
•TIMI and Small Media implementation
•Follow-up
•Validation of self-reported CRCS
•Data analysis
•Assessment of Cost-Effectiveness of Intervention