Development of a Tailored Interactive Multimedia Intervention to increase Colorectal Cancer...

Development of a Tailored Development of a Tailored Interactive Multimedia Intervention Interactive Multimedia Intervention

to increase Colorectal Cancer to increase Colorectal Cancer Screening among Hispanics along Screening among Hispanics along

Texas-Mexico BorderTexas-Mexico Border

María E. FernándezMaría E. Fernández,, Ph.D. Ph.D.The University of Texas, School of Public HealthThe University of Texas, School of Public Health

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RESEARCH TEAMRESEARCH 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.

StaffRosario 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, MAAlicia 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 the Centers for Disease Control and Prevention

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OVERVIEWOVERVIEW

•Formative ResearchFormative Research

•Intervention Planning using Intervention Planning using Intervention MappingIntervention Mapping

•Brief Description of ProgramBrief Description of Program

•EvaluationEvaluation

STUDY SETTINGSTUDY SETTING• The study sites are The study sites are coloniascolonias along the Texas-Mexico border: the along the Texas-Mexico border: the

formative work was conducted in El Paso County, (El Paso), Cameron formative work was conducted in El Paso County, (El Paso), Cameron County (Brownsville), and Webb County (Laredo); the intervention County (Brownsville), and Webb County (Laredo); the intervention trial will be carried out in the LRGV. trial will be carried out in the LRGV.

• Colonias are unincorporated, un-zoned, semi-rural communities often Colonias are unincorporated, un-zoned, semi-rural communities often without access to public drinking water or wastewater systems.without access to public drinking water or wastewater systems.

• Individuals living in colonias have high rates of poverty, Individuals living in colonias have high rates of poverty, unemployment, and low education levels.unemployment, and low education levels.

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FORMATIVE RESEARCHFORMATIVE RESEARCH

Qualitative StudyQualitative Study • 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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SurveySurvey • 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

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

Knowledge AttitudesBeliefs about cancer and colorectal cancer screeningPainCancer deathCurabilityFatalismSpirituality and religious beliefsBeliefs about causes and symptoms of cancer and colorectal cancerEmotions

External factors influencing colorectal cancer screening

System level barriersLack of access to health servicesInterpersonalProvider behaviorLanguage barriers

“It is because of ignorance….one does not ask to be screened because she does not know that she should do it, because one does not know the importance of being screened.”

“If the doctor would tell me to do it, the yes…

(I would get tested)”“


FORMATIVE RESEARCHFORMATIVE RESEARCHThemes and sub-themes related to colorectal cancer screening

Themes Sub-themes

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

Knowledge AttitudesBeliefs about cancer and colorectal cancer screeningPainCancer deathCurabilityFatalismSpirituality and religious beliefsBeliefs about causes and symptoms of cancer and colorectal cancerEmotions

External factors influencing colorectal cancer screening

System level barriersLack of access to health servicesInterpersonalProvider behaviorLanguage barriers

“No, what I tell you is that cancer is a bad 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.”

“If it is outside the skin, I think it can be cured.”

“..there are two types of cancer, but the one that you cannot feel or detect, “the silent one,” is the one that kills you quickly “ “

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FORMATIVE RESEARCHFORMATIVE RESEARCHSample Characteristic (N=544)

Age group 50-59

48.9 266

60-69 27.2 148

70 and over 23.7 129

Gender

Male 73.0 397

Female 27.0 147

Education (years)

None 9.6 50

1-5 41.3 215

6-11 40.0 208

12 and over 9.0 47

Birth Status & Years in the US

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

Income < $10,000

71.8 303

$10,000 - $19,999 22.7 96

$20,000 - $29,999 5.2 22

Insurance

None 50.2 269

Any 49.8 267

FORMATIVE RESEARCHFORMATIVE RESEARCHBrownsville

(N=265)

El Paso

(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

156177

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

59

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FORMATIVE RESEARCHFORMATIVE RESEARCH Findings- CRCS Behavior (Survey findings)

Have You Ever Had Colorectal Cancer Screening Test? (N=544)

BARIUM ENEMA (25%)

SIGMOIDOSCOPY(32%)

COLONOSCOPY (32%)

FOBT(61%)

NO(66%)

YES(34%)

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FORMATIVE RESEARCHFORMATIVE RESEARCH Survey Findings- Determinants of CRCS Behavior

Multivariate Logistic Model Predicting CRCS Behavior

Odds Ratio

C.I

Age group

Referent: 50-59

60-69 .80 (.489, 1.309)

70 and over .52 (.297. 912)

Insurance

Referent: None

Any 4.04 (2.556, 6.385)

Self Efficacy 1.41 (1.154, 1.722)

Decisional Balance 1.35 (1.000, 1.834)

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INTERVENTION MAPPINGINTERVENTION MAPPING

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INTERVENTION MAPPINGINTERVENTION MAPPING

Matrix of Change ObjectivesMatrix 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

KNOWLEDGE 1. About CRC 2. About CRCS 3. About insurance

PERCEIVED RISK

DECISIONAL BALANCE

OUTCOME EXPECTATIONS

SELF EFFICACY/SKILLS

PO1. Seek information about CRC/CRCS

PK1.States that local clinic, doctor, or promotora can provide you information about CRC/CRCS

PPR1.Perceives 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 MAPPINGINTERVENTION MAPPINGMethods and StrategiesMethods 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,

Discussion Active Learning Tailoring Images Information

Demonstrations, workbook, group sessions

Flipchart Video TIMI

PPR1, PPR2, CPR1, CPR2, CPR3, CPR6, CPR7, CPR8, PRPR6

Information about personal risk, consciousness raising, fear arousal, dramatic relief.

Discussions and homework, Video clip with testimonial

Flipchart Video TIMI

PDB1a, PDB1b, PDB2a, PDB2b,PDB3a, PDB3b.CDB1a, CDB1b, CDB2, CDB3,CDB5a, CDB5b, CDB6a, CDB6b, CDB7,

Self-reevaluation Environmental evaluation Modeling

Discussions in groups Video-tape vignettes

Flipchart Discussion TIMI

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INTERVENTION DEVELOPMENTINTERVENTION 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

Tailored Interactive Multimedia InterventionTailored 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 InterventionTailored Interactive Multimedia InterventionFlowchart

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2020


Tailored Interactive Multimedia Tailored Interactive Multimedia InterventionIntervention

Intervention with moving video (Intervention with moving video (novelanovela type story and type story and testimonials), audio, graphics, animation, stills, and interactive testimonials), audio, graphics, animation, stills, and interactive educational segments.educational segments. Targeted for:Targeted for:

• Hispanics Hispanics • Low literacy levelLow literacy level• Low educationLow education

Tailored to:Tailored to:• GenderGender• Language preferenceLanguage preference•Awareness of CRCSAwareness of CRCS• Individual Stage of ChangeIndividual Stage of Change• Attitudes about screeningAttitudes about screening•KnowledgeKnowledge• Specific barriersSpecific barriers

Interactive:Interactive:• Allows participants to choose topics of interestAllows participants to choose topics of interest• Allows participant to follow own learning paceAllows participant to follow own learning pace• Gives individualized feedback Gives individualized feedback • Provides decision supportProvides decision support


Vale La Pena…..Prevenir

Vale La Pena…..PrevenirVale La Pena…..Prevenir‘‘Telenovela’ Style

Vale La Pena…..PrevenirVale La Pena…..PrevenirInteractive Segment

To live a long lifeTo live a long life

To prevent cancerTo prevent cancer

Colorectal cancer Colorectal cancer can be cured!can be cured! For my familyFor my family

To prevent treatments To prevent treatments and feeling illand feeling ill

To do things I’ve To do things I’ve plannedplanned

REASONS TO GET TESTED FOR REASONS TO GET TESTED FOR COLORECTAL CANCERCOLORECTAL CANCER

Vale La Pena…..PrevenirVale La Pena…..Prevenir

No InterventionN=8 colonias

(Group 1)

Intervention N=8 colonias

(Group 2)

Intervention N=8 colonias

(Group 3)

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

Baseline interview

Two promotora groups will be delivering the

interventions

Colorectal Cancer Screening Among Hispanic Women Living in theLower Rio Grande Valley of Texas

Randomly select households in colonias and recruit 20 participants per colonia - Based on colonia maps

Baseline interview

Baseline interview

Recruitment of study participants

Implement Intervention 2

Promotora-delivered

Interactive Multimedia

n=160

Followup Interview

(6 mos following baseline)

Screening validation



Followup Interview

(6 mos following baseline) Followup Interview

(6 mos following baseline)

n= 160

Implement Intervention 1

Promotora-delivered

small media print and linear video

(usual practice)

n=160

Study DesignStudy Design

• Lay Health Worker

• Laptop Computer with Stylus

• Home Visit

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Intervention Delivery

Planned ActivitiesPlanned 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

Development of a Tailored Interactive Multimedia Intervention to increase Colorectal Cancer...

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