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
1
Sponsor: Cheng Ching Hospital, Taichung, Taiwan
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
2
Specific Aims
1. Pilot Study
-
To develop and validate study instruments
To assess factors that influence Pap screening
behavior among women in Taiwan
2. Develop and implement a theory and evidence
based intervention using Intervention Mapping
3. Evaluate the effectiveness of the program
intervention
3
© Su-I Hou, DrPH, RN, CHES
Outcomes
Primary Outcome Measures
Pap screening rate
Secondary Outcome Measures
Perceived pros, perceived cons
Susceptibility, perceived norms
Knowledge of cervical cancer & Pap
Covariates
Demographics
4
© Su-I Hou, DrPH, RN, CHES
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
5
© Su-I Hou, DrPH, RN, CHES
Risk Factors 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)
6
© Su-I Hou, DrPH, RN, CHES
Pap Screening Behavior
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
7
 Factors Influencing Pap Screening Behavior
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)
8
© Su-I Hou, DrPH, RN, CHES
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
9
© Su-I Hou, DrPH, RN, CHES
 Pilot Study and Instrument Validation
Method
Sample:
Female family members of patients admitted to ChengChing 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
10
© Su-I Hou, DrPH, RN, CHES
 Pilot Study and Instrument Validation (con’t)
Results
Sample Characteristics (N=125)
mean age:
38
Married:
90%*
Work full time:
62%
> College education: 32%
Scale Reliability
Perceived pros:
Perceived cons:
Perceived norms:
Susceptibility:
Knowledge:
(p=.03)
Chronbach 
0.88 (11 items)
0.68 ( 9 items)
0.72 ( 4 items)
0.68 ( 2 items)
0.70 (16 items)
Items with low CITC (corrected-item-total corr.) were re-evaluate
for their appropriateness
11
© Su-I Hou, DrPH, RN, CHES
 Pilot Study and Instrument Validation (con’t)
Logistic regression Analysis
Adjusted for Marital Status
Scales
Odds Ratio
95% CI
P-Value
Pros
1.08
(1.00, 1.16)
0.04*
Cons
0.87
(0.80, 0.95)
0.00*
Norms
1.25
(1.04, 1.50)
0.02*
Knowledge
1.14
(1.01, 1.30)
0.03*
12
© Su-I Hou, DrPH, RN, CHES
 Pilot Study and Instrument Validation (con’t)
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
13
screening behavior.
 Intervention Development
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
14
 Intervention Development (con’t)
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:
External determinants:
© Su-I Hou, DrPH, RN, CHES
knowledge; outcome expectations
reward / compensation
15
 Intervention Development (con’t)
IM Step 2: Methods and Strategies
Learning
Objectives
Methods
Knowledge
determinate LO
Information Direct mail
Brochure
transmission communication Fact Sheet
Intention, perceived
Modeling
pros/cons; perceived
norms; & susceptibility Persuasion
determinate LO
Cue to action /
Facilitation
availability of
alternative service
© Su-I Hou, DrPH, RN, CHES
Strategies
Testimonial
descriptions
Persuasive
communication
Enabling
services
Reminders
Increase
availability
Components
Role model
stories
Quotes from
women
Phone calls
Reminding letter
Screening
service
16
 Intervention Development (con’t)
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
17
18
© Su-I Hou, DrPH, RN, CHES
 Intervention Development (con’t)
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
19
© Su-I Hou, DrPH, RN, CHES
 Intervention Development (con’t)
IM Step 5: Generating an Evaluation Plan
Pretest - Posttest Control Group
R
R
O1
O1
X
O2 (3 mon. after O1)
O2 (3 mon. after O1)
where
R= random assignment
==============================================
post-test (O2)
pre-test (O1)
Demographics
Previous screening experience Screening behavior
Beliefs
Beliefs
Knowledge
Knowledge
Intervention components
20
© Su-I Hou, DrPH, RN, CHES
 Intervention Development (con’t)
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
21
well.
 Program Intervention Evaluation
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
22
 Program Intervention Evaluation (con’t)
Results (N=424)
Sample Characteristics & Group Comparisons (Baseline)
mean age:
Married:
Work full time:
> College education:
34
89%
40%
28%
P=.227
p=.532
p=.777
p=.195
Prior screening (ever)
Intention
58% p=.168
63% p=.422
Women in the study were randomly assigned to each group very 23well.
© Su-I Hou, DrPH, RN, CHES
 Program Intervention Evaluation (con’t)
Comparisons of Scale Means (Baseline)
Scales
Knowledge
(16 items)
Pros
(13 items)
Cons
(13 items)
Norms
(4 items)
Susceptibility
(3 items)
Intervention Comparison
All
(N=212)
(N=212)
(N=424)
P-Value
(T-test)
0.77
0.74
0.76
0.103
4.17
4.17
4.17
0.978
2.77
2.79
2.78
0.748
3.90
3.95
3.92
0.320
2.81
2.84
2.83
0.678
24
© Su-I Hou, DrPH, RN, CHES
 Program Intervention Evaluation (con’t)
Pap Completion Rate
Intervention Group:
Comparison Group:
0%
0%
51%
32%
P=0.002*
89%
93%
btw groups
P=0.310
Pap Intention (Pre-contemplators)
Intervention Group:
Comparison Group:
0%
0%
within groups P=0.000*
Pap Intention (Contemplators)
Intervention Group: 62% obtain a Pap
Comparison Group: 38% obtain a Pap
P=0.008*
25
© Su-I Hou, DrPH, RN, CHES
 Program Intervention Evaluation (con’t)
Comparisons of Scale Means (Follow-up)
Scales
Intervention
(N=123)
Comparison
(N=124)
P-Value
(Adjusted)
Knowledge
0.82
0.79
0.305
Pros
4.26
4.16
0.031*
Cons
2.65
2.75
0.059
Norms
3.88
3.90
0.880
Susceptibility
2.96
2.92
0.447
Linear reg. were used for the follow-up group comparisons to
26
adjust pretest scale and intervention effects
© Su-I Hou, DrPH, RN, CHES
 Program Intervention Evaluation (con’t)
Changes in Scales Within Groups Over Time (pre- & post-test)
Scales
Intervention
 Mean
Knowledge
0.04
P-value Comparison
(paired-t)
 Mean
0.016*
0.03
P-value
(paired-t)
0.020*
Pros
0.09
0.008*
-0.01
0.838
Cons
-0.08
0.076
0.03
0.472
Norms
0.00
0.961
-0.03
0.470
Susceptibility
0.13
0.011*
0.08
0.101
27
© Su-I Hou, DrPH, RN, CHES
 Program Intervention Evaluation (con’t)
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
28
Pilot Study Publications related to this project

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.
29
30
Su-I Hou (sweet)