REACH Lay Health Worker Intervention Program:A Community-Based Model to Promote Breast

Cancer Screening Among Vietnamese-American Women

Gem M. Le, MHS

Stephen J. McPhee, MD

Ginny Gildengorin, PhD

Ky Q. Lai, MD, MPH

Khanh Q. Le, MD, MPH

Tung T. Nguyen, MD

Thoa Nguyen

Vietnamese Community Health Promotion ProjectDivision of General Internal Medicine

University of California, San Francisco

Acknowledgements

• Funded by the Centers for Disease Control and Prevention’s REACH 2010 Program

Grant # U50/CCU 922156-05

• Supported by the Vietnamese REACH for Health Initiative Coalition, Santa Clara County, CA

• UCSF Vietnamese Community Health Promotion Project (VCHPP)

Background

There are disparities in breast cancer screening and early detection among Vietnamese American women

• Low breast cancer re-screening rates documented in Vietnamese

Lay health workers (LHWs) have been shown to be effective in promoting cancer screening

Our previous research has documented success in the use of LHWs in improving cervical cancer screening in Vietnamese

Lam TK, McPhee SJ, Mock J et al. “Encouraging Vietnamese-American Women to Obtain Pap Tests Through Lay Health Worker Outreach and Media Education,” Journal of General Internal Medicine, 2003;18(7):516-24.

Methods: Study Description Recruited 5 community-based organizations

(CBOs) in Santa Clara County, California

Trained 50 Lay Health Workers (LHWs) to conduct outreach activities to 1,100 Vietnamese women (age 40 or older) whom they recruited from their social networks

Controlled intervention trial: women randomized either to intervention or control groups

VCHPP Central Coordinating

Organization

1st LHW AGENCY

2nd LHW AGENCY

3rd LHW AGENCY

4th LHW AGENCY

5th LHW AGENCY

Community Collaboration

• UCSF Vietnamese Community Health Promotion Project (VCHPP) collaborated with 5 community-based agencies over 3 years

• Each agency recruited 10 LHWs

• Each LHW recruited 22 women who were randomized into intervention and control (delayed intervention) groups

Methods: Study Description

Intervention group women:

Received education regarding breast cancer, mammograms and clinical breast exams in 2 small group sessions led by LHWs using a standardized curriculum and flip chart

Control group women:

Received 1 LHW small group session after the post-intervention survey was completed

Methods: Study Design

EACH LHW AGENCY

(n=5)

LHWs (n=10)

Control Group (n=110)

Women (n=220)

Intervention Group (n=110)

RECRUIT

RECRUIT

INTERVENTION DELAYED

INTERVENTION

Total anticipated sample

Intervention: 550

Control: 550

Methods: Study Description

Mass media campaign regarding breast cancer occurred in Santa Clara County at the same time

Both intervention and control group women were exposed to this background media

Evaluation

Pre- and post-intervention telephone questionnaires completed by participants

Data analysis is now complete for 4 of the 5 agencies

Statistical tests used:• Matched-pair analysis

• McNemar’s chi-square test to detect the difference in the changes between intervention and control groups

CBO Lay Health Worker Agencies

First LHW Agency:Catholic Charities, John XXIII Multi-Service Center

Active period: 10/01/04 - 07/31/05

Second LHW Agency: Immigrant Resettlement and Cultural Center

Active period: 03/01/05 - 12/31/05

Third LHW Agency:Vietnamese Voluntary Foundation, Inc.

Active period: 08/01/05 - 05/31/06

Fourth LHW Agency: Asian Americans for Community Involvement

Active period: 12/01/05 - 10/01/06

Training Sessions for Lay Health Workers

Education about breast cancer, mammograms, and clinical breast exams

Methods for recruiting participants Methods for conducting small group

education sessions Role playing Each LHW received a total of 9 hours of

training

Characteristics of Lay Health Workers

Mean age (4 agencies): 57.3 years Range: 22-67 years Women were employed, housewives, or

students

Small Group Education Sessions

Setting: LHW agencies, participants’ homes, or LHWs’ homes

Size: 4 - 6 women per session Support: LHW Agency and Vietnamese

Community Health Promotion Project

Implementation

LHWs conducted 354 small group sessions for the first 4 agencies

During the intervention period, LHWs telephoned each participant ~5-6 times over the ~4 month period between the 2 sessions

Appreciation ceremony conducted following completion of intervention to get feedback from LHWs

Results: Participant Demographics

Control

(n=440)

Interven-tion

(n=440)

p-value

Age in years (mean) 57.3

57.2 0.81

Years in U.S. (mean) 13.8 13.2 0.24

% Poor English proficiency 96.8 97.5 0.69

% Less than high school education

58.0 57.6 0.95

% Unemployed 65.7 67.1 0.72

% Married 69.9 72.3 0.46

% Uninsured 18.8 20.9 0.79

Ever Heard of Breast Cancer? (% Yes)

91%87%

100%90%

0%

20%

40%

60%

80%

100%

Control (Media Only) Intervention* (LHW+Media)

PrePost

*p < 0.0001

% change**: 2.8% vs. 8.9% **p = 0.006

Ever Heard of Mammogram? (% Yes)

94%94%100%97%

0%

20%

40%

60%

80%

100%

Control Intervention*

PrePost

*p = <0.0001

% change: 2.2% vs. 5.4%

Ever Had Mammogram? (% Yes)

86%90%93%93%

0%

20%

40%

60%

80%

100%

Control^ Intervention*

PrePost

^p = 0.03 *p < 0.0001

% change: 2.7% vs. 6.7%

Had Last Mammogram WithinPast Year? (% Yes)

50%59%

73%

63%

0%

20%

40%

60%

80%

100%

Control^ Intervention*

PrePost

^p = 0.03 *p < 0.0001

% change**: 4.5% vs. 22.1% **p = 0.0004

Plan Mammogram Within 12 Months? (% Yes)

75%76%

96%

76%

0%

20%

40%

60%

80%

100%

Control Intervention*

PrePost

*p < 0.0001

% change**: 0.2% vs. 21.1% ** p < 0.0001

Ever Thought About Getting a Mammogram? (% Yes)

72%

44%

91%

56%

0%

20%

40%

60%

80%

100%

Control^ Intervention

PrePost

^p = 0.004 (n=25)

% change: 12.0% vs. 19.0%

Ever Heard of Clinical Breast Examination (CBE)?

(% Yes)

77%75%

99%86%

0%

20%

40%

60%

80%

100%

Control^ Intervention*

PrePost

% change**: 10.9% vs. 22.8% **p = 0.0003

^p < 0.0001 *p < 0.0001

Ever Had a CBE?(% Yes)

67%72%

87%

79%

0%

20%

40%

60%

80%

100%

Control^ Intervention*

PrePost

% change**: 7.3% vs. 19.8% **p = 0.0003

^p = 0.0005 *p < 0.0001

Had a CBE Within Past Year?(% Yes)

37%46%

65%

51%

0%

20%

40%

60%

80%

100%

Control^ Intervention*

PrePost

% change**: 5.1% vs. 27.8% **p < 0.0001

^p = 0.028 *p < 0.0001

Plan a CBE Within 12 Months?(% Yes)

70%75%

91%

73%

0%

20%

40%

60%

80%

100%

Control Intervention*

PrePost

% change**: -1.2% vs. 20.7% **p < 0.0001

*p < 0.0001

Thought of Getting a CBE?(% Yes)

48%48%

56%52%

0%

20%

40%

60%

80%

100%

Control^ Intervention*

PrePost

% change: 4.0% vs. 8.0%

^p < 0.0001 (n=25) *p < 0.0001 (n=32)

Age Women Should Start Mammograms?(% 40 Years)

27%30%

72%

31%

0%

20%

40%

60%

80%

100%

Control Intervention*

PrePost

% change**: 0.9% vs. 45.3% **p < 0.0001

*p < 0.0001

Age Women Should Start CBEs?(% 40 Years)

22%23%

68%

24%

0%

20%

40%

60%

80%

100%

Control Intervention*

PrePost

% change**: 0.9% vs. 45.9% **p < 0.0001

*p < 0.0001

Multiplier Effect: Participants’ Sharing of Information about Mammograms

437

1,215

1,640

0

500

1,000

1,500

2,000

Participants in theintervention

Family Friends

Num

ber

of p

eopl

e

Median number of people shared information per participant:

3.0 4.0

Multiplier Effect: Participants’ Sharing of Information about CBEs

437

1,215

1,644

0

500

1,000

1,500

2,000

Participants in theintervention

Family Friends

Num

ber

of p

eopl

e

Median number of people shared information per participant:

3.0 4.0

Implications

Researchers can work in partnership with community-based organizations to utilize lay health worker outreach effectively to reduce health disparities

LHWs can use their cultural knowledge, sensitivity, and social networks to reach out to underserved women in their communities

Conclusions Lay health worker outreach is feasible and

effective among Vietnamese American women in improving breast cancer:

• Awareness• Knowledge • Receipt of screening by mammography and

CBE Intervention produced a multiplier effect:

LHWs and participants told family members and friends about mammograms and CBEs

Future: Sustainability

Completion of current project will demonstrate the increased capacity of the Vietnamese community to promote and sustain lay health worker outreach education

Planned future projects (e.g., targeting colorectal cancer or cardiovascular risk factors) will include the 50 LHWs, who have developed new skills in effective lay health education