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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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FORMATIVE RESEARCHFORMATIVE RESEARCH
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 RESEARCH
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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Tailored Interactive Multimedia InterventionTailored Interactive Multimedia InterventionFlowchart
2020
Tailored Interactive Multimedia InterventionTailored Interactive Multimedia InterventionFlowchart
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
Tailored Interactive Multimedia InterventionTailored Interactive Multimedia Intervention
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
Screening validation
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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Tailored Interactive Multimedia InterventionTailored Interactive Multimedia Intervention
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