J Canc Educ (2014) 29:62–68 DOI 10.1007/s13187-013-0544-3
Increasing Cervical Cancer Screening for a Multiethnic Population of Women in South Texas Laura B. Fornos & Kathleen A. Urbansky & Roberto Villarreal
Published online: 31 October 2013 # Springer Science+Business Media New York 2013
Abstract Cervical cancer is a preventable disease. Precancers can be identified and treated through cervical screenings. The HPV vaccine prevents precancers from becoming cancers. The aim of the A Su Salud Cervical Cancer Prevention Program was to apply well-understood health promotion techniques and increase the rate of cervical cancer screening among a high-risk, multiethnic, low-income population in South Texas. Qualitative research was used to identify uptake barriers and tailor media messaging. Using existing resources, we applied evidence-based strategies in novel ways that changed personal behaviors, leading to cancer screening, risk reduction, and early detection. We created a database to track a cohort of 32,807 women and measured cervical cancer screenings over 3 years. Our analysis revealed an increase in cervical cancer screenings after use of highly targeted automated telephone reminders and media dissemination on multiple platforms. Those women at low risk for cervical cancer obtained the highest proportion of Pap tests. This innovative, theory-based program increased overall Pap tests up to 9 % among women enrolled in a safety net hospital financial assistance plan. This study fills a gap in research on Pap test L. B. Fornos (*) Health Informatics Research, University Health System, Corporate Square, MS 45-2, 4801 NW Loop 410, Suite 200, San Antonio, TX 78229, USA e-mail: [email protected] K. A. Urbansky Office of Chief Medical Information Officers, University Health System, 5835 Callaghan Rd., Ste. 503, San Antonio, TX 78228, USA e-mail: [email protected] R. Villarreal Research and Information Management, University Health System, Corporate Square, MS 45-2, 4801 NW Loop 410, Suite 200, San Antonio, TX 78229, USA e-mail: [email protected]
compliance in uninsured, mostly Hispanic women by building on cultural strengths and tailored messaging. Keywords Hispanic Americans . Women . Medically uninsured . Cervical cancer . Papanicolaou test . Early medical intervention . Cultural competency By 2050, Hispanics will rise from 14 % of the US population in 2005 to 29 % [17] and to over 37 % in Texas [23]. This significant growth reaffirms the need for current, credible information on Hispanics and their prominence in the national healthcare system. Understanding their growing diversity and expanding upon well-documented socioeconomic inequalities they face will provide unique and cultural insights [15]. Lowwage, low-status minority workers (especially Hispanics) and workers who are employed in small firms are least likely to have employee benefits and most likely to be uninsured [11]. Although Hispanics have lower incidence rates for all cancers compared to Whites, they have higher rates of cervical cancer [1], are more likely to be diagnosed with cervical cancer at later stages [6], and have incidence and mortality rates twofold higher than non-Hispanic Whites [2]. The proportion of women aged 18 or over at risk for cervical cancer in the USA is 18.7 % [7]. For Texas, it was 20.6 % and for the San Antonio Metropolitan Statistical Area 26.1 % [5]. Overall, the rate of women in Texas having had a Pap test in the last 3 years is about 80 % [22]; this leaves a gap of 20 % of women who need screening services [2]. In San Antonio, this gap is much larger (60 %) for a subpopulation of predominantly Hispanic women [1]. They were the focus of the A Su Salud Cervical Cancer Prevention program. A Su Salud (To Your Health) Cervical Cancer Prevention Program was conducted from 2010 to 2012 at University Health System (UHS) in San Antonio, Texas, with support from the Cancer Prevention and Research Institute of Texas. UHS is a
J Canc Educ (2014) 29:62–68
large, urban safety net health system serving San Antonio and 22 counties south of San Antonio. In Texas, care of the indigent including the uninsured is fundamentally a county responsibility. UHS operates CareLink, a financial assistance program for uninsured citizens of the city of San Antonio and the surrounding area of Bexar County. In Texas, care of the indigent including the uninsured is fundamentally a county responsibility. UHS operates CareLink, a financial assistance program for uninsured citizens of the city of San Antonio and the surrounding area of Bexar County. Our target population was a high-risk subpopulation of women enrolled in CareLink. At the end of 2009, approximately 33,000 (67 %) women enrolled in CareLink were neither current for Pap tests nor actively obtaining Pap test appointments. Pathology results showed 80 % of CareLink women had some level of abnormal cytology, e.g., inflammation, ablation. We developed and delivered a culturally competent, evidence-based community education program for secondary prevention of cervical cancer. A Su Salud has been proven effective in Hispanic groups from diverse national origins and is based on Social Cognitive Theory [3]. Our mass media component influenced behavior change through social modeling, and a community organization component influenced behavior change through informal encouragement and social reinforcement. We integrated the Health Belief Model (HBM) [14] and the Transtheoretical Model (TTM) [18] to create targeted, tailored media messages from focus group data. The HBM attempts to explain and predict health-related behaviors from patterns of belief about recommended health behavior and health problems the behavior was intended to prevent or control. The TTM Model of Behavior Change assesses an individual’s readiness to act on new healthier behaviors and provides strategies or processes to guide the individual through stages of change to take action and maintain the new behavior. Messages were disseminated through community networking, print and mass media including motivational interviewing, tailored telephone reminders, text messaging, and a virtual telephone navigator to reach over 30,000 women. Online social networks also played an important role in achieving positive health outcomes and influencing behavioral changes.
63
recommendations for cervical cancer screenings. Our aim was to learn how barriers and other factors influenced perspectives about cervical cancer and screening. Recruitment flyers were distributed at the front desk of CareLink’s central enrollment office for current members and members waiting to enroll. Members had an opportunity to ask questions about the study. CareLink Member Services Representatives informed members they were free not to take part in the study; they could stop taking part at any time, and refusing to take part would not affect their medical care with UHS or their membership status with CareLink. If members were interested in the focus group interview, they called a telephone number on the flyer. Study team members then verified eligibility and scheduled the interview. Participants were provided with a $25 gift card incentive. Five focus group interviews were conducted with 20 women, three in English and two in Spanish. Each focus group was composed of six to eight women 18 and older. Data collected from focus groups were translated, transcribed, and entered into ATLAS.ti© a qualitative data analysis program. Message Development We developed health promotion messages using results from focus groups. Constructs of the HBM and the TTM guided message content. Pap test status determined dose and frequency of messaging. Using primary themes from focus groups, we created a matrix juxtaposing perceived vulnerabilities against stages of change. These messages were applied to small and mass media, social networking, client reminders, motivational interviewing, and community outreach. Pap test data was abstracted for a cohort of 32,800 CareLink women in July 2009. Female CareLink members, age 18 or older, were selected. Women were stratified into three groups based on date of their most recent Pap test: low risk if her last Pap test was within 3 years, average risk if last Pap test was between 3 and 5 years, and high risk if her last Pap test was more than 5 years. HPV status was not measured.
Program Component Development Small Media
Methods Activities were reviewed and approved by the Institutional Review Board of the University of Texas Health Science Center at San Antonio. Formative Data Collection A qualitative research design served as the basis for tailored, cultural messaging for women out of compliance with
Media and program coordinators created monthly, bilingual newsletters. Each contained a different health promotion message that reinforced positive behavior and provided indications for, benefits of, and ways to overcome barriers to cervical cancer screening. Newsletters were two pages long (200 words or less) and written at a sixth grade or lower reading level. Newsletters were printed monthly until the funding period ended. Newsletters were distributed to UHS ambulatory clinics, in CareLink enrollment offices, and at preventive
64
health clinics by a community outreach specialist and community volunteers. Mass Media Mass media, including televised segments and public service announcements (PSAs) posted on the Internet, were used to communicate education and motivation information to the larger community. A Su Salud television segments aired on local Spanish language Univision , every Tuesday during the 5:00 pm newscast. Currently, the fifth largest network in the USA, Univision, serves a broad and diverse audience composed of a vast Spanish-speaking population from many ethnic origins and cultures and has been in partnership with UHS for over 20 years. Women in these 12 televised segments dialogued with health experts who articulated indications for and benefits of a Pap test. We also created five, 30-s PSAs in English and Spanish. The target audience was directed to these PSAs through postings on our UHS Facebook page and on the Internet http:// www.youtube.com/asusaludsanantonio. Facebook comments were posted at least three times a week and included visual media, links to local resources, or events and requests for personal input. Client Reminders We developed printed and telephone messages as client reminders encouraging women, friends, and families who may be due or late for cervical cancer screening to get a Pap test. For those who agreed to accept calls, messages encouraged women to schedule their Pap test and provided information about how and where they could obtain an appointment. Women at highest risk of cervical cancer were selected for high-priority reminders. We sent text messages to CareLink members to remind them about Pap testing. Members were sent a preliminary message asking them to opt in, or accept, cell phone data from UHS. They were also given the choice to receive messages in English or Spanish. We also inserted reminder messages in CareLink billing statements. Unlike phone reminders, the content of billing inserts was not tailored to women but extended to personal networks of friends or family members. Community Outreach Community volunteers are the backbone of the outreach component. These workers are members of the target community recruited as volunteers. Their primary functions are to distribute health promotion messages and serve as role models. A community outreach specialist organizes meetings with local leadership in high-risk neighborhoods. She recruits additional volunteers and establishes and maintains professional and social networks.
J Canc Educ (2014) 29:62–68
Newsletters, PSAs, automated client reminders, and billing inserts asked women to call “Claudia,” a recognizable, bilingual contact person. Multiple program staff members responded as Claudia and navigated women through the health system. Claudia embodied the Mexican American cultural value of personalized social communication, or personalismo, that is, the value of interpersonal relations and social interactions where people deal with one another as considerate, kind persons rather than simply distant participants of specific roles.
Program Results Focus Groups This activity was critical to message development. We uncovered three domains: education, lack of empowerment, and male support. We developed our small and mass media components to highlight these domains. Domain 1: Education Across all groups, women understood they should visit their doctor yearly. Although these women were compliant, many did not know why they were being tested. One woman said, “I know I have to get it because the doctors tell me I should.” When asked, the women responded that the test was given to check for cysts, diseases, and infections. When asked, what have you heard about cervical cancer? One respondent replied, “That it’s bad. But, nothing can be done about it.” We probed further to ask what caused cervical cancer. Many answers reflected myths and misconceptions, from wearing out the cervix through childbirth, poor anemia, a poor thyroid, or too much sexual activity. Only a few women knew Pap testing identified and prevented cervical cancer. Domain 2: Lack of Empowerment Many women expressed concern that their health-care providers did not discuss Pap tests and, therefore, felt less empowered to ask questions. Physician encounters where the doctor is seen as an authority figure sometimes generate feelings of conflict in female patients. A second-generation Mexican American woman explained It’s our culture; the way we were raised. We feel it is indecent that other man sees your body. One time a young doctor said that the test was no problem at all because women nowadays feel no shame. I do feel it, but I know that if I get sick it will be worse because more people will have to see me. I know it is necessary and that is why I come. You do feel ashamed. Domain 3: Male Support When the women were asked how important it was to have support from their partner for cervical cancer screenings, their responses revealed contradictions between Spanish speakers and English speakers. Spanish
J Canc Educ (2014) 29:62–68
65
speakers, however, described incidents of partner coercion against taking gynecological exams: Some husbands don’t let their wives go to the doctor. One of my sisters-in-law, her husband hits her if she goes to the doctor for anything. He says she wants the doctor to touch her. English speakers claimed they received not only support from their husbands, but also encouragement, saying, “He’d rather have me in good health than being sick.”
Process Results The program was evaluated by tracking reach and coverage. To promote the importance of male support, we produced segments titled: Cervical cancer and male support. What you can do? These segments highlighted the importance of social support from spouses and significant others to motivate women to obtain a Pap test and protect themselves from cervical cancer. This is particularly important in Spanish-speaking families where males have a large influence in the household.
businesses. Between UHS and the San Antonio community, these newsletters reached an estimated 2,500 to 6,500 people. Each month, the average number of newsletters distributed was 3,490. Mass Media Twelve television segments were aired on a widespread, local Spanish television network, Univision. PSAs were considered free content and picked up by 75 television stations outside of San Antonio and 5 television stations outside Texas. As of 2012, 639 unique viewers accessed the PSAs through the Internet. Because some women did not know what caused cervical cancer, we introduced the link between HPV and cervical cancer in two PSAs titled Cervical Testimonial and Sex, HPV, Cancer. Client Reminders
Between 2010 and 2012, 13,964 newsletters were distributed to our five community health-care clinics, ten preventive health clinics, and five CareLink offices. Community volunteers distributed newsletters to approximately 100 community
We attempted more than 20,000 telephone calls on five separate occasions. On average, 30 % of women listened to the entire message. Although 103 people agreed to receive text messaging, many telephone numbers were blocked, did not answer, or were landlines. Therefore, only 46 English calls were attempted, and one successful text message was made. We attempted 25 Spanish calls, but only one text message was received. During another attempt, we sent out 7,628 English texts; only three were received. We sent 4,251 Spanish texts; only three were successfully received.
Table 1 Cohort descriptive characteristics
Variables
N
Low risk
Average risk
High risk
Total Percent of total Age, mean (SD) Marital status (%) Not married Married Race/ethnicity (%) Hispanic White African American Other/multiracial/no answer
32,807 43.7 (13)
10,847 33 % 43.5 (12)
3,073 9% 47.12 (12)
18,887 58 % 43.2 (14)
20,779 (63) 12,028 (37)
5,762 (53) 5,085 (47)
1,657 (54) 1,416 (46)
13,360 (71) 5,527 (29)
23,125 (71) 4,413 (13) 1,638 (5) 3,631 (11)
8,580 (79) 1,227 (11) 495 (5) 545 (5)
2,439 (79) 307 (10) 126 (4) 201 (7)
12,106 (65) 2,879 (15) 1,017 (5) 2,885 (15)
28,580 (87) 4,147 (12) 80 (
Increasing Cervical Cancer Screening for a Multiethnic Population of Women in South Texas Laura B. Fornos & Kathleen A. Urbansky & Roberto Villarreal
Published online: 31 October 2013 # Springer Science+Business Media New York 2013
Abstract Cervical cancer is a preventable disease. Precancers can be identified and treated through cervical screenings. The HPV vaccine prevents precancers from becoming cancers. The aim of the A Su Salud Cervical Cancer Prevention Program was to apply well-understood health promotion techniques and increase the rate of cervical cancer screening among a high-risk, multiethnic, low-income population in South Texas. Qualitative research was used to identify uptake barriers and tailor media messaging. Using existing resources, we applied evidence-based strategies in novel ways that changed personal behaviors, leading to cancer screening, risk reduction, and early detection. We created a database to track a cohort of 32,807 women and measured cervical cancer screenings over 3 years. Our analysis revealed an increase in cervical cancer screenings after use of highly targeted automated telephone reminders and media dissemination on multiple platforms. Those women at low risk for cervical cancer obtained the highest proportion of Pap tests. This innovative, theory-based program increased overall Pap tests up to 9 % among women enrolled in a safety net hospital financial assistance plan. This study fills a gap in research on Pap test L. B. Fornos (*) Health Informatics Research, University Health System, Corporate Square, MS 45-2, 4801 NW Loop 410, Suite 200, San Antonio, TX 78229, USA e-mail: [email protected] K. A. Urbansky Office of Chief Medical Information Officers, University Health System, 5835 Callaghan Rd., Ste. 503, San Antonio, TX 78228, USA e-mail: [email protected] R. Villarreal Research and Information Management, University Health System, Corporate Square, MS 45-2, 4801 NW Loop 410, Suite 200, San Antonio, TX 78229, USA e-mail: [email protected]
compliance in uninsured, mostly Hispanic women by building on cultural strengths and tailored messaging. Keywords Hispanic Americans . Women . Medically uninsured . Cervical cancer . Papanicolaou test . Early medical intervention . Cultural competency By 2050, Hispanics will rise from 14 % of the US population in 2005 to 29 % [17] and to over 37 % in Texas [23]. This significant growth reaffirms the need for current, credible information on Hispanics and their prominence in the national healthcare system. Understanding their growing diversity and expanding upon well-documented socioeconomic inequalities they face will provide unique and cultural insights [15]. Lowwage, low-status minority workers (especially Hispanics) and workers who are employed in small firms are least likely to have employee benefits and most likely to be uninsured [11]. Although Hispanics have lower incidence rates for all cancers compared to Whites, they have higher rates of cervical cancer [1], are more likely to be diagnosed with cervical cancer at later stages [6], and have incidence and mortality rates twofold higher than non-Hispanic Whites [2]. The proportion of women aged 18 or over at risk for cervical cancer in the USA is 18.7 % [7]. For Texas, it was 20.6 % and for the San Antonio Metropolitan Statistical Area 26.1 % [5]. Overall, the rate of women in Texas having had a Pap test in the last 3 years is about 80 % [22]; this leaves a gap of 20 % of women who need screening services [2]. In San Antonio, this gap is much larger (60 %) for a subpopulation of predominantly Hispanic women [1]. They were the focus of the A Su Salud Cervical Cancer Prevention program. A Su Salud (To Your Health) Cervical Cancer Prevention Program was conducted from 2010 to 2012 at University Health System (UHS) in San Antonio, Texas, with support from the Cancer Prevention and Research Institute of Texas. UHS is a
J Canc Educ (2014) 29:62–68
large, urban safety net health system serving San Antonio and 22 counties south of San Antonio. In Texas, care of the indigent including the uninsured is fundamentally a county responsibility. UHS operates CareLink, a financial assistance program for uninsured citizens of the city of San Antonio and the surrounding area of Bexar County. In Texas, care of the indigent including the uninsured is fundamentally a county responsibility. UHS operates CareLink, a financial assistance program for uninsured citizens of the city of San Antonio and the surrounding area of Bexar County. Our target population was a high-risk subpopulation of women enrolled in CareLink. At the end of 2009, approximately 33,000 (67 %) women enrolled in CareLink were neither current for Pap tests nor actively obtaining Pap test appointments. Pathology results showed 80 % of CareLink women had some level of abnormal cytology, e.g., inflammation, ablation. We developed and delivered a culturally competent, evidence-based community education program for secondary prevention of cervical cancer. A Su Salud has been proven effective in Hispanic groups from diverse national origins and is based on Social Cognitive Theory [3]. Our mass media component influenced behavior change through social modeling, and a community organization component influenced behavior change through informal encouragement and social reinforcement. We integrated the Health Belief Model (HBM) [14] and the Transtheoretical Model (TTM) [18] to create targeted, tailored media messages from focus group data. The HBM attempts to explain and predict health-related behaviors from patterns of belief about recommended health behavior and health problems the behavior was intended to prevent or control. The TTM Model of Behavior Change assesses an individual’s readiness to act on new healthier behaviors and provides strategies or processes to guide the individual through stages of change to take action and maintain the new behavior. Messages were disseminated through community networking, print and mass media including motivational interviewing, tailored telephone reminders, text messaging, and a virtual telephone navigator to reach over 30,000 women. Online social networks also played an important role in achieving positive health outcomes and influencing behavioral changes.
63
recommendations for cervical cancer screenings. Our aim was to learn how barriers and other factors influenced perspectives about cervical cancer and screening. Recruitment flyers were distributed at the front desk of CareLink’s central enrollment office for current members and members waiting to enroll. Members had an opportunity to ask questions about the study. CareLink Member Services Representatives informed members they were free not to take part in the study; they could stop taking part at any time, and refusing to take part would not affect their medical care with UHS or their membership status with CareLink. If members were interested in the focus group interview, they called a telephone number on the flyer. Study team members then verified eligibility and scheduled the interview. Participants were provided with a $25 gift card incentive. Five focus group interviews were conducted with 20 women, three in English and two in Spanish. Each focus group was composed of six to eight women 18 and older. Data collected from focus groups were translated, transcribed, and entered into ATLAS.ti© a qualitative data analysis program. Message Development We developed health promotion messages using results from focus groups. Constructs of the HBM and the TTM guided message content. Pap test status determined dose and frequency of messaging. Using primary themes from focus groups, we created a matrix juxtaposing perceived vulnerabilities against stages of change. These messages were applied to small and mass media, social networking, client reminders, motivational interviewing, and community outreach. Pap test data was abstracted for a cohort of 32,800 CareLink women in July 2009. Female CareLink members, age 18 or older, were selected. Women were stratified into three groups based on date of their most recent Pap test: low risk if her last Pap test was within 3 years, average risk if last Pap test was between 3 and 5 years, and high risk if her last Pap test was more than 5 years. HPV status was not measured.
Program Component Development Small Media
Methods Activities were reviewed and approved by the Institutional Review Board of the University of Texas Health Science Center at San Antonio. Formative Data Collection A qualitative research design served as the basis for tailored, cultural messaging for women out of compliance with
Media and program coordinators created monthly, bilingual newsletters. Each contained a different health promotion message that reinforced positive behavior and provided indications for, benefits of, and ways to overcome barriers to cervical cancer screening. Newsletters were two pages long (200 words or less) and written at a sixth grade or lower reading level. Newsletters were printed monthly until the funding period ended. Newsletters were distributed to UHS ambulatory clinics, in CareLink enrollment offices, and at preventive
64
health clinics by a community outreach specialist and community volunteers. Mass Media Mass media, including televised segments and public service announcements (PSAs) posted on the Internet, were used to communicate education and motivation information to the larger community. A Su Salud television segments aired on local Spanish language Univision , every Tuesday during the 5:00 pm newscast. Currently, the fifth largest network in the USA, Univision, serves a broad and diverse audience composed of a vast Spanish-speaking population from many ethnic origins and cultures and has been in partnership with UHS for over 20 years. Women in these 12 televised segments dialogued with health experts who articulated indications for and benefits of a Pap test. We also created five, 30-s PSAs in English and Spanish. The target audience was directed to these PSAs through postings on our UHS Facebook page and on the Internet http:// www.youtube.com/asusaludsanantonio. Facebook comments were posted at least three times a week and included visual media, links to local resources, or events and requests for personal input. Client Reminders We developed printed and telephone messages as client reminders encouraging women, friends, and families who may be due or late for cervical cancer screening to get a Pap test. For those who agreed to accept calls, messages encouraged women to schedule their Pap test and provided information about how and where they could obtain an appointment. Women at highest risk of cervical cancer were selected for high-priority reminders. We sent text messages to CareLink members to remind them about Pap testing. Members were sent a preliminary message asking them to opt in, or accept, cell phone data from UHS. They were also given the choice to receive messages in English or Spanish. We also inserted reminder messages in CareLink billing statements. Unlike phone reminders, the content of billing inserts was not tailored to women but extended to personal networks of friends or family members. Community Outreach Community volunteers are the backbone of the outreach component. These workers are members of the target community recruited as volunteers. Their primary functions are to distribute health promotion messages and serve as role models. A community outreach specialist organizes meetings with local leadership in high-risk neighborhoods. She recruits additional volunteers and establishes and maintains professional and social networks.
J Canc Educ (2014) 29:62–68
Newsletters, PSAs, automated client reminders, and billing inserts asked women to call “Claudia,” a recognizable, bilingual contact person. Multiple program staff members responded as Claudia and navigated women through the health system. Claudia embodied the Mexican American cultural value of personalized social communication, or personalismo, that is, the value of interpersonal relations and social interactions where people deal with one another as considerate, kind persons rather than simply distant participants of specific roles.
Program Results Focus Groups This activity was critical to message development. We uncovered three domains: education, lack of empowerment, and male support. We developed our small and mass media components to highlight these domains. Domain 1: Education Across all groups, women understood they should visit their doctor yearly. Although these women were compliant, many did not know why they were being tested. One woman said, “I know I have to get it because the doctors tell me I should.” When asked, the women responded that the test was given to check for cysts, diseases, and infections. When asked, what have you heard about cervical cancer? One respondent replied, “That it’s bad. But, nothing can be done about it.” We probed further to ask what caused cervical cancer. Many answers reflected myths and misconceptions, from wearing out the cervix through childbirth, poor anemia, a poor thyroid, or too much sexual activity. Only a few women knew Pap testing identified and prevented cervical cancer. Domain 2: Lack of Empowerment Many women expressed concern that their health-care providers did not discuss Pap tests and, therefore, felt less empowered to ask questions. Physician encounters where the doctor is seen as an authority figure sometimes generate feelings of conflict in female patients. A second-generation Mexican American woman explained It’s our culture; the way we were raised. We feel it is indecent that other man sees your body. One time a young doctor said that the test was no problem at all because women nowadays feel no shame. I do feel it, but I know that if I get sick it will be worse because more people will have to see me. I know it is necessary and that is why I come. You do feel ashamed. Domain 3: Male Support When the women were asked how important it was to have support from their partner for cervical cancer screenings, their responses revealed contradictions between Spanish speakers and English speakers. Spanish
J Canc Educ (2014) 29:62–68
65
speakers, however, described incidents of partner coercion against taking gynecological exams: Some husbands don’t let their wives go to the doctor. One of my sisters-in-law, her husband hits her if she goes to the doctor for anything. He says she wants the doctor to touch her. English speakers claimed they received not only support from their husbands, but also encouragement, saying, “He’d rather have me in good health than being sick.”
Process Results The program was evaluated by tracking reach and coverage. To promote the importance of male support, we produced segments titled: Cervical cancer and male support. What you can do? These segments highlighted the importance of social support from spouses and significant others to motivate women to obtain a Pap test and protect themselves from cervical cancer. This is particularly important in Spanish-speaking families where males have a large influence in the household.
businesses. Between UHS and the San Antonio community, these newsletters reached an estimated 2,500 to 6,500 people. Each month, the average number of newsletters distributed was 3,490. Mass Media Twelve television segments were aired on a widespread, local Spanish television network, Univision. PSAs were considered free content and picked up by 75 television stations outside of San Antonio and 5 television stations outside Texas. As of 2012, 639 unique viewers accessed the PSAs through the Internet. Because some women did not know what caused cervical cancer, we introduced the link between HPV and cervical cancer in two PSAs titled Cervical Testimonial and Sex, HPV, Cancer. Client Reminders
Between 2010 and 2012, 13,964 newsletters were distributed to our five community health-care clinics, ten preventive health clinics, and five CareLink offices. Community volunteers distributed newsletters to approximately 100 community
We attempted more than 20,000 telephone calls on five separate occasions. On average, 30 % of women listened to the entire message. Although 103 people agreed to receive text messaging, many telephone numbers were blocked, did not answer, or were landlines. Therefore, only 46 English calls were attempted, and one successful text message was made. We attempted 25 Spanish calls, but only one text message was received. During another attempt, we sent out 7,628 English texts; only three were received. We sent 4,251 Spanish texts; only three were successfully received.
Table 1 Cohort descriptive characteristics
Variables
N
Low risk
Average risk
High risk
Total Percent of total Age, mean (SD) Marital status (%) Not married Married Race/ethnicity (%) Hispanic White African American Other/multiracial/no answer
32,807 43.7 (13)
10,847 33 % 43.5 (12)
3,073 9% 47.12 (12)
18,887 58 % 43.2 (14)
20,779 (63) 12,028 (37)
5,762 (53) 5,085 (47)
1,657 (54) 1,416 (46)
13,360 (71) 5,527 (29)
23,125 (71) 4,413 (13) 1,638 (5) 3,631 (11)
8,580 (79) 1,227 (11) 495 (5) 545 (5)
2,439 (79) 307 (10) 126 (4) 201 (7)
12,106 (65) 2,879 (15) 1,017 (5) 2,885 (15)
28,580 (87) 4,147 (12) 80 (
