¡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

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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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