Interventions to Reduce Cervical Cancer Risk in Appalachia Ohio

Electra D. Paskett, Ph.D.

Ohio State University

Supported by NCI Grant Number P50 CA105632

National Cancer Institute

Cervical Cancer

6

8

10

Appalachia Non-Appalachia

80%

100%

Appalachia Non-Appalachia

73.7%82.7%

9.6

7.7

Incidence(2001-2005)

0

2

4

6

Mortality(2001-2005)

0%

20%

40%

60%

Pap Test in past 3 years

(18+ yrs, intact cervix, 2007)

Ohio BRFSS

73.7%82.7%

3.12.3

Ohio Cancer Incidence Surveillance System

Cells to Society: Overcoming Health Disparities

http://cancercontrol.cancer.gov/populationhealthcenters/cphhd/index.html

Centers for Population Health and Health Disparities

DETROIT

CHICAGOPHILADELPHIA

BOSTON

SANTA MONICA

GALVESTON

WASHINGTONAPPALACHIA

Mission

� Integrate the basic, population, and clinical sciences.

� Develop innovative transdisciplinary methods.

Create linkages with the community.� Create linkages with the community.

� Translate research to change policy and practice.

� Train the next generation of investigators.

One of the Few NCI Initiatives that Spans Basic Biology to the Population“From Cells to Society”

Clinical Translation,

Physical Environment

Genetics, Biology

Behavior& Individual Risk Factors

Socio-Cultural

Context & Relationships

Translation, Community,Institutions,

Neighborhood,& Policy

Upstream Factors

Model for Analysis of Population Health and Health Disparities

Social and

FundamentalCauses

Disparate Health

Social Conditions and PoliciesCulture, Norms, Racism, Sexism

Discrimination, Public Policies, Poverty

InstitutionsHealth Care System, Families, Churches, Community-based organizations, Legal

System, Media, Political System

Social/Physical ContextCollective Efficacy, Social Capital,

Access to Resources, Social Cohesion, Segregation, Neighborhood Disadvantage,

Neighborhood Stability

Upstream Factors

Individual Risk FactorsAge, SES, Education, Obesity, Tobacco Use, Acculturation,

Diet, Race

Downstream Factors

Biologic/Genetic PathwaysAllostatic Load, Metabolic Processes,

Physiological Pathways, Genetic Mechanisms

Warnecke et al., AJPH 2008

Social and Physical Context

Individual Demographic and Risk Factors

Biologic Responses and Pathways

Disparate Health Outcomes

Social RelationshipsSocial Networks, Social Support

Social Influences, Social Engagement

Neighborhood Stability

Downstream Factors

Research Teams of the Future

MULTIDISCIPLINARYMULTIDISCIPLINARY

�� SeparateSeparate bodies of bodies of knowledgeknowledge

�� DifferentDifferent“languages”“languages”

MULTIDISCIPLINARYMULTIDISCIPLINARY INTERDISCIPLINARYINTERDISCIPLINARY

Research Teams of the Future

�� SeparateSeparate bodies of bodies of knowledgeknowledge

�� DifferentDifferent“languages”“languages”

�� SharedShared bodies of bodies of knowledgeknowledge

�� SharedShared“vocabulary”“vocabulary”

Research Teams of the Future

MULTIDISCIPLINARYMULTIDISCIPLINARY INTERDISCIPLINARYINTERDISCIPLINARY TRANSDISCIPLINARYTRANSDISCIPLINARY

�� SeparateSeparate bodies of bodies of knowledgeknowledge

�� DifferentDifferent“languages”“languages”

�� SharedShared bodies of bodies of knowledgeknowledge

�� SharedShared“vocabulary”“vocabulary”

�� Shared languageShared language

�� PooledPooled bodies of bodies of knowledge and knowledge and theorytheory

�� JointlyJointly--developeddevelopednew methodsnew methods

Neighborhood/Community Context

Community Engagement

Preclinical Impact on Biomarker

CPHHD Transdisciplinary Research Framework:

Emerging Cross-Center Themes

Preclinical and Clinical Studies

Impact on Patient and Community

Biomarker & Animal Model Studies

Genetics, Biological Basis of Disparities, Biomarkers for

Risk Assessment and Screening

Etiology, Screening, Treatment

Dissemination of Research, Quality of Life, Access to Care,

Policy

Goal

To understand why Appalachian

OSU Center For Population Health

And Health Disparities

To understand why Appalachian Ohio women have high

incidence and mortality rates for cervical cancer.

Theoretical Framework:Social Determinants Of Health

PsychologicalMotivationKnowledge/ Risk

WorkOccupationRegulations

Social EnvironmentSocial capitalSocial cohesionSocial networkNeighborhood disadvantage

Social StructureEducationHealth Care Delivery

Material FactorsIncomeTransportation

CultureAppalachian Norms

Knowledge/ RiskBrainStressDepressionNicotine dependence

Morbidity/MortalityHealth Status/Outcomes

General HealthCervical Health

Pathophysiological Changes

HPVCINCarcinogenesis

Health BehaviorCervical screening

Tobacco Use

Sexual activity

Contraception

Alcohol use

Diet

Early life

Genes

Marmot and Wilkinson, 2001

ScreeningRisky Behaviors

- HPV

- Pap Smear

Cervical Cancer

Follow-upOf Abnormalities

- HPV

- Smoking

14 Clinics

Observational Study

N=571Multi-level factors associated with tobacco use and Pap testing

Project 1

N=286

Project 2

N=302N=286

Pap smear use:

•Risk appropriate guidelines

•Barriers counseling

N=302

Smoking cessation:

•Biochemical validation

•Pharma-based intervention with

behavioral component

RCT testing LHA vs. usual care

Project 3 N=1360

Case-control study

•HPV testing, Pap smear, EBV titers, Cotinine

•TGF-Beta receptor

MONROE

MORGAN

NOBLEPERRY

SON

CARROLL

COLUMBIANA

BELMONT

COSHOCTON

GUERNSEY

HARRISON

HOLMESJEFFER

Regions 1-4

MUSKINGHAM

2

3

4

56

7

81

TUSCARAWAS

ADAMS

ATHENS

BROWNGALLIA

HIGHLAND

HOCKING

JACKSON

LAWRENCE

MEIGS

MORGAN

PIKE

ROSS

SCIOTO

VINTON

WASHINGTON

CLERMONT

Region 1

Region 2

Region 3

Region 4

12

9

10

11

13

1415

16

Clinic locations

What have we What have we learned so learned so learned so learned so

far?far?

Cervical Cancer Risk

� High rate of Abnormal Pap Smears – 12% vs. 3-5% in U.S.

� High rate of smoking – 28% vs. 21% in U.S.

Rate of HPV positivity - 13% vs. 4% in U.S. � Rate of HPV positivity - 13% vs. 4% in U.S.

� High rate of smoking among women with abnormal Pap tests – 69%

� High rate of depressive symptoms - 31%

� Most women were at high risk of developing cervical cancer - 79%

(Paskett et. al.; Wewers et. al.; Ruffin et. al.)

Social Factors� Women with few social contacts more

likely to smoke

� Women reported feeling “stressed” and isolatedand isolated

� Women do not trust health care providers nor do they feel respected by them

� Access to care is influenced by geographic barriers, cost, and transportation

� Providers reported women felt “hopeless”

(Wewers, et al., under review; Katz, et al., under review; McAlerney, et al., under review)

Cervical Cancer

Healthcare accessHealthcare provider trust

Abnormal Pap test ratesSmoking prevalenceHPV rates

Appalachian Culture

HPV ratesPovertyRisky sex behaviorsDepression

Lay Health Advisor Lay Health Advisor Intervention to Intervention to

Improve Pap Smear Improve Pap Smear Utilization among Ohio Utilization among Ohio Appalachian WomenAppalachian WomenAppalachian WomenAppalachian Women

Electra D. Paskett, PhD, Mira Katz, PhD, Electra D. Paskett, PhD, Mira Katz, PhD, Paul Reiter, PhD, Jill M. Oliveri, MPH, DrPH, Paul Reiter, PhD, Jill M. Oliveri, MPH, DrPH, Amy Lehman, MS, Stan Lemeshow, PhD, Amy Lehman, MS, Stan Lemeshow, PhD, Douglas Post, PhD and Mack Ruffin, MDDouglas Post, PhD and Mack Ruffin, MD

Eligibility CriteriaEligibility Criteria

�� Age 18 and olderAge 18 and older

�� No history of cervical cancerNo history of cervical cancer

�� English speakingEnglish speaking

�� Not pregnantNot pregnant�� Not pregnantNot pregnant

�� Randomly selected from clinic Randomly selected from clinic populationpopulation

�� In need of a Pap smearIn need of a Pap smear

�� Agree to participateAgree to participate

Screened At Least Annually

Women At Higher Risk(engage in risky sexual behaviors, smoke,

or have HPV)

Screened At Least Every 3 Years

Women At Normal Risk

Components of the Intervention

�� Two inTwo in--person visits by a LHAperson visits by a LHA

�� Mailed materials based on Stages of Mailed materials based on Stages of ChangeChange

�� Phone callsPhone calls

LHA assessed cervical cancer risk, LHA assessed cervical cancer risk, �� LHA assessed cervical cancer risk, LHA assessed cervical cancer risk, addressed barriers to receiving a Pap test, addressed barriers to receiving a Pap test, and provided educational materials. and provided educational materials.

�� Usual Care received a letter from their Usual Care received a letter from their doctor and brochure about Pap testsdoctor and brochure about Pap tests

�� Women were in program for 10 monthsWomen were in program for 10 months

Preliminary ResultsResults

N=271

Participant Demographics (N=271)

Variable Level Control

N (%)

Interv

N (%)

Total

N (%)

p-value

Age (yrs)

18-30 27 (19) 42 (29) 69 (24) NS

31-50 66 (47) 59 (40) 125 (44)

51+ 47 (34) 45 (31) 92 (32)

Educ <HS 10 (7) 10 (7) 20 (7) NS

HS grad 56 (40) 61 (42) 117 (41)

College 74 (53) 75 (51) 149 (52)

Race White 134 (96) 139 (95) 273 (96) NS

Non-wh 6 (4) 7 (5) 13 (5)

Participant Demographics (N=271)

Variable Level Control

N (%)

Interv

N (%)

Total

N (%)

p-value

Income <$20K<$20K 49 (38)49 (38) 50 (37)50 (37) 99 (37)99 (37) NSNS

$20$20--50K50K 45 (35)45 (35) 55 (40)55 (40) 100 (38)100 (38)

>$50K>$50K 35 (27)35 (27) 32 (23)32 (23) 67 (25)67 (25)>$50K>$50K 35 (27)35 (27) 32 (23)32 (23) 67 (25)67 (25)

MS NeverNever 16 (12)16 (12) 15 (10)15 (10) 31 (11)31 (11) NSNS

MarriedMarried 82 (59)82 (59) 99 (68)99 (68) 181 (64)181 (64)

Div/WidDiv/Wid 41 (30)41 (30) 32 (22)32 (22) 73 (26)73 (26)

Hlth Ins PrivatePrivate 83 (59)83 (59) 83 (57)83 (57) 166 (58)166 (58) NSNS

Gov’tGov’t 36 (26)36 (26) 31 (21)31 (21) 67 (24)67 (24)

NoneNone 21 (15)21 (15) 31 (21)31 (21) 52 (18)52 (18)

Calculation of Primary Outcome

�� For every participant, the 12 month For every participant, the 12 month followfollow--up date was calculated as the up date was calculated as the minimumminimum of:of:

�� One year after the control materials One year after the control materials �� One year after the control materials One year after the control materials were mailed (control group) or the first were mailed (control group) or the first intervention visit (intervention group), intervention visit (intervention group), oror

�� 14 months after the baseline interview 14 months after the baseline interview (both control and intervention) (both control and intervention)

Summary of Pap Status (N=271)

Treatment Arm

Pap date checked and not within last 12 months

Pap date checked and within last 12 months

Total

Control 92 (71%) 38 (29%) 130 Control 92 (71%) 38 (29%) 130

Intervention 87 (62%) 54 (38%) 141

Total 179 (66%) 92 (34%) 271

Crude Odds Ratio =1.50; p= 0.1162

Predictors of Pap Smear Use-Multivariate Model*

�� Age: 30 < age ≤ 50 vs. Age ≤ Age: 30 < age ≤ 50 vs. Age ≤ 30 yrs30 yrs

OR = 0.44 (p=.05) OR = 0.44 (p=.05) �� OR = 0.44 (p=.05) OR = 0.44 (p=.05)

�� Previous Abnormal Pap Test: Previous Abnormal Pap Test: Yes vs NoYes vs No

�� OR = 1.89 (p=.05)OR = 1.89 (p=.05)

*Adjusted for all variables and clinic included as a random effect in the model

Upstream Factors

Model for Analysis of Population Health and Health Disparities

Social and

FundamentalCauses

Disparate Health

Social Conditions and PoliciesCulture, Norms, Racism, Sexism

Discrimination, Public Policies, Poverty

InstitutionsHealth Care System, Families, Churches, Community-based organizations, Legal

System, Media, Political System

Social/Physical ContextCollective Efficacy, Social Capital,

Access to Resources, Social Cohesion,Segregation, Neighborhood Disadvantage,

Neighborhood Stability

Upstream Factors

Individual Risk FactorsAge, SES, Education, Obesity, Tobacco Use, Acculturation,

Diet, Race

Downstream Factors

Biologic/Genetic PathwaysAllostatic Load, Metabolic Processes,

Physiological Pathways, Genetic Mechanisms

Warnecke et al., AJPH 2008

Social and Physical Context

Individual Demographic and Risk Factors

Biologic Responses and Pathways

Disparate Health Outcomes

Social RelationshipsSocial Networks, Social Support

Social Influences, Social Engagement

Neighborhood Stability

Downstream Factors

SmokingPap Test

What We Knew About Cervical Cancer In 2002

HPV

Pap Test

Individual Behaviors

� 3 factors

� Research focus was one level

New Model

Abnormal Cervical CellsCervical Cancer Cells

Social Networks SES

Marital Status

TobaccoSexual

Behaviors

HPVIntroduced

Appalachian Culture

Access To Care

Trust Physicians

Health Policy

GeneticsEnvironmental

Exposures

TGFB

Exercise Diet

Immune System

Built Environment

Comprehensive Cancer CenterCathy TatumCecilia DeGraffinreidMelissa HicksDarla Fickle Jill Oliveri

College of Nursing

Center For Population Health And Health Disparities“Reducing Cervical Cancer In Appalachia”

College of Public HealthElectra PaskettMary Ellen WewersStanley LemeshowMira KatzAmy FerketichAnn McAlearney

Center For BiostatisticsAmy LehmanErinn HadeBryan BallDale Rhoda

University of MichiganMack RuffinPaula Lantz

College of NursingKaren AhijevychJudy HarnessPamela Salsberry

Medicine and Family MedicineDouglas PostDavid Cohn

ConsultantsBeti ThompsonElizabeth Unger

Department of EconomicsPatricia Reagan

Department of PathologyScott Jewell

Dale Rhoda

THANK YOU TO OUR FIELD STAFF AND PARTICPANTS!!!!