¡Celebremos La Salud!¡Celebremos La Salud!: : A cancer prevention program for A cancer prevention program for Hispanic and non-Hispanic White Hispanic and non-Hispanic White
women living in a rural areawomen living in a rural area
Silvia Tejeda, MPHSilvia Tejeda, MPHDoctoral CandidateDoctoral Candidate
Department of Health ServicesDepartment of Health ServicesAnnual Spring Biobehavioral Cancer Fellows Day Annual Spring Biobehavioral Cancer Fellows Day
April 20, 2007April 20, 2007
BackgroundBackground
Breast cancer incidence (SEER)Breast cancer incidence (SEER) Hispanics have a lower incidence than non-Hispanic Hispanics have a lower incidence than non-Hispanic
White womenWhite women11..
DisparitiesDisparities Screening rates (NHIS)Screening rates (NHIS)
Hispanics are less likely to report ever having had a Hispanics are less likely to report ever having had a mammogram & having one within the past 2 years compared mammogram & having one within the past 2 years compared to White womento White women1,21,2. .
Stage at diagnosis (SEER)Stage at diagnosis (SEER) Hispanic women present with a more advanced breast Hispanic women present with a more advanced breast
cancer stage & poorer survival ratescancer stage & poorer survival rates33..
2(1. Howe et al 2006); (2. MMWR, 2005); (3. Li et al., 2003)
¡Celebremos La Salud!¡Celebremos La Salud!
AA community randomized trial of community randomized trial of Hispanic cancer prevention Hispanic cancer prevention
Outcome GoalsOutcome Goals Increase Increase
cancer screening behaviorscancer screening behaviors smoking cessationsmoking cessation healthy dietary changeshealthy dietary changes
Findings reported in Thompson Findings reported in Thompson et al (2006)et al (2006)11
Intervention effect: no differences Intervention effect: no differences between intervention & control between intervention & control communities in 3 outcome goalscommunities in 3 outcome goals
3(1. Thompson B et al, 2006)
Final Survey
Baseline Survey
InterventionN=10
Randomized
Communities Matched
ControlN=10
Lower Yakima ValleyLower Yakima Valley
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Research AimsResearch Aims To test whether mammography use was To test whether mammography use was
associated with individual level characteristics associated with individual level characteristics (barriers)(barriers)
To test whether having heard of or having To test whether having heard of or having participated in participated in Celebrating Health!Celebrating Health! program program activities were associated with mammography activities were associated with mammography useuse
To test potential modifiers of intervention on To test potential modifiers of intervention on the mammography outcomethe mammography outcome
5
MethodsMethods
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Study SampleStudy Sample
Follow-up survey participantsFollow-up survey participants
Hispanic women (N=202)Hispanic women (N=202)
non-Hispanic White women (N=389)non-Hispanic White women (N=389)
Age 40 and overAge 40 and over
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AnalysesAnalyses Mammography outcomesMammography outcomes
EverEver Recent (within the past 2 years)Recent (within the past 2 years)
Mixed Effects Mixed Effects Random effects: community level effects are Random effects: community level effects are
correlatedcorrelated Fixed effects: independent variablesFixed effects: independent variables
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ResultsResults
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Participant Characteristics at follow-upParticipant Characteristics at follow-up Compared to non-Hispanic White women, a Compared to non-Hispanic White women, a
greater percentage of Hispanic women weregreater percentage of Hispanic women were YoungerYounger Less educatedLess educated Less annual household incomeLess annual household income More likely not to have More likely not to have
health insurancehealth insurance a regular doctora regular doctor seen a doctor in the past yearseen a doctor in the past year
Hispanic womenHispanic women Mexican: 89%Mexican: 89% AcculturationAcculturation11: 60% Low, 40% High: 60% Low, 40% High
101 Coronado et al., 2005
Mammography percentages at follow-up, Mammography percentages at follow-up,
by group & ethnicityby group & ethnicity
Intervention N=285
Control N=306
Mammogram Total Hispanic NHW Total Hispanic NHW N(%) % % N(%) % % Ever 240(85) 75 91 263(87) 79 91 Within past 2 years
174(73) 66 75 192(73) 77 71
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Aim 1Aim 1 To test whether mammography use was To test whether mammography use was
associated with individual level characteristics associated with individual level characteristics (barriers) at follow-up(barriers) at follow-up
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Associations between mammography use & characteristicsAssociations between mammography use & characteristicsCharacteristic Ever Within Past 2 years OR1,2 OR1,2 Age 40-49 0.21* 0.96
50-69 1 1 70 and over
0.62 0.58*
Education (<HS) 0.33* 1.13 No Health Insurance 0.24* 0.45* No Regular Clinic 0.90 0.71 No Regular doctor 0.26* 0.60
Seen doctor in past year (no) 0.18* 0.22* Male Doctor 0.26* 0.36* 1 Models take into account dependence within community, by treating community as a random effect.2 Adjusted for age* Statistically significant at p<.05
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Associations between mammography Associations between mammography use & race/ethnicity & acculturationuse & race/ethnicity & acculturation
Characteristic Ever had a mammogram Within the past 2 years OR OR Model 1a,b Model 2a,c Model 3a,b Model 4a,c Race/Ethnicity Hispanic 0.41* 0.78 0.85 0.76 NHW (ref) Acculturation for Hispanic women
Low 0.39* 0.47 2.33* 2.33* High (ref)
a Models take into account dependence within community, by treating community as a random effect.b Adjusted for agec Adjusted for age + education + health insurance* Statistically significant at p<.05 14
Aim 2Aim 2
To test whether having heard of or having To test whether having heard of or having participated in participated in Celebrating Health!Celebrating Health! program program activities were associated with mammography activities were associated with mammography useuse
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Percentage of women having heard of Percentage of women having heard of
program activities by groupprogram activities by group
Heard of program activities Intervention
N=285 %
Control N=306
% Programs & activities about cancer prevention in community Health fairs or block parties 29 11 Presentations at schools 22 9 Someone coming to your door 26 5 Church events 17 8 Home health parties 17 4 Presentations at organizations 25 11 Display tables 26 16 Pledge programs 14 8 Community mailing
24 15
Programs in your community Wellness on Wheels 41 45 Celebrating Health 18 18 Topic Breast Cancer Screening 51 26
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Percentage of women having participated in Percentage of women having participated in
program activities by groupprogram activities by group
Participated in program activities Intervention
% Control
% Programs & activities about cancer prevention in community Health fairs or block parties 38 36 Presentations at schools 33 27 Someone coming to your door 66 62 Church events 52 30 Home health parties 50 15 Presentations at organizations 33 25 Display tables 56 43 Pledge programs 40 44 Community mailing
84 86
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Associations between recent mammogram & having heard of or Associations between recent mammogram & having heard of or participated in program activitiesparticipated in program activities
Mammogram within the past 2 years Heard Participated N(%) OR1,2 N(%) OR1,2 Programs & activities about cancer prevention in community
Health fairs or block parties
19 0.82 37 0.62
Presentations at schools
14 0.69 33 1.27
Someone coming to your door
15 0.84 64 0.61
Church events
13 1.53 48 0.97
Home health parties
8 0.47* 57 6.11*
Presentations at organizations
16 0.69 35 2.87
Display tables in grocery stores
21 1.03 51 1.25
Pledge programs
10 0.76 42 0.87
Community mailing
20 1.02 87 1.77
Programs in your community Wellness on Wheels 47 1.12 Celebrating Health
19 1.09
Topic Breast Cancer Screening 39 0.90 58(41) 1.44
1 Models take into account dependence within community, by treating community as a random effect.2 Adjusted for group (intervention/control), & race/ethnicity* Statistically significant at p<.05
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Aim 3Aim 3
To test potential modifiers of intervention on To test potential modifiers of intervention on the mammography outcomethe mammography outcome
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Effect modification of interventionEffect modification of intervention Ever had a mammogram__ __Mammogram within past 2 years__
Intervention N=280
Control N=301
Intervention N=239
Control N=262
Characteristic N (%) N (%) OR1,2 N (%) N (%) OR1,2 Education <HS 103(78) 120(82) 0.86 73(71) 92(77) 0.76 Race/Ethnicity Hispanic 74(75) 79(79) 0.73 49(66) 61(77) 0.6 Health Insurance No
19(63) 23(61) 1.09 8(42) 17(74) 0.26*
Regular Clinic No
55(89) 41(82) 1.78 37(67) 27(66) 1.12
Regular doctor No
22(61) 27(68) 0.78 11(50) 21(78) 0.31
1 Models take into account dependence within community pair, by treating community as a random effect.2 adjusted for baseline proportions of screening * Statistically significant at p<.05 20
ConclusionConclusion
Barriers related to SES and access to health care Barriers related to SES and access to health care were inversely associated with mammography usewere inversely associated with mammography use
Lower acculturation level: barrier & protective factor Lower acculturation level: barrier & protective factor
Further assessment of “home health parties” are Further assessment of “home health parties” are needed to determine effect on screening useneeded to determine effect on screening use
The “Wellness on Wheels” program may influence The “Wellness on Wheels” program may influence mammography use in communties mammography use in communties
Effect modification by health insuranceEffect modification by health insurance21
AcknowledgementsAcknowledgements
Research advisors: Research advisors: Beti Thompson, PhD (chair)Beti Thompson, PhD (chair) Gloria Coronado, PhDGloria Coronado, PhD Patrick Heagerty, PhDPatrick Heagerty, PhD Diane Martin, PhDDiane Martin, PhD
FundingFunding National Cancer Institute (CA-34827)National Cancer Institute (CA-34827) Biobehavioral Cancer Prevention & Control Training Biobehavioral Cancer Prevention & Control Training
ProgramProgram Research Assistantship from the UW SPHCMResearch Assistantship from the UW SPHCM
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