for our daughters training maria e. fernandez, phd ut health science center-houston school of public...
TRANSCRIPT
For Our Daughters
Training Maria E. Fernandez, PhD
UT Health Science Center-HoustonSchool of Public Health
Who We Are?
LINCC• Latinos in a Network for Cancer Control
(LINCC) is one 10 CPCRNs• Established in 2002 at the University of Texas,
School of Public Health, Center for Health Promotion and Prevention Research
• A Prevention Research Center Special Interest Project
• Currently LINCC represents a joint effort between the University of Texas, School of Public Health and MD Anderson Cancer Center
LINCC Partners Today
Staff Contact Information
• Leticia GatusResearch CoordinatorUniversity of Texas School of Public Health- [email protected]
• Lizette RangelGraduate Research AssistantUniversity of Texas School of Public Health- [email protected]
• Dr. Maria FernandezUniversity of Texas School of Public Health- [email protected]
Agenda
• Objectives of the training • Brief introduction of our program • The role of the promotora • Cervical Cancer• Human Papilloma Virus (HPV)• HPV vaccine • Role of the promotora in the For Our Daughters Study• Tailored Interactive Communications Approaches• HPV Implementation Project
Objectives of the Training
To familiarize yourself and learn about our study. To increase your knowledge about HPV, the vaccine against
HPV, and cervical cancer. To obtain the skills necessary to use the instruments of the
intervention- For Our Daughters website and the fotonovela.
“For Our Daughters Project”
Purpose of the Program: ◦ To decrease morbidity and mortality due to cervical
cancer among Hispanic women◦ To increase HPV vaccination among Hispanic girls,
adolescents, and young women◦ To increase parental knowledge about cervical
cancer and HPV, and knowledge, attitudes, and intentions about the HPV vaccine
“For Our Daughters” ProjectObjectives of the Problem:
• Use educational materials about cervical cancer, HPV, and the HPV vaccine to increase vaccination among adolescent Hispanic girls aged 9 to 26 years old How will the program be presented by the promotoras?
The program “ For Our Daughters” can be presented as an individual educational session with eligible parents.
The Role of the Promotora/Community Health Worker
Terminology used by the Promotoras
Promotoras
Community Health Counselor
Community Health Assistant
Community Health Worker
Health Education Assistant
Health Facilitator
Health Visitor
Home Visitor
Activity 1: What are some of the roles of a promotora?
Complete the spaces below with some of roles of a promotora
The Role of the Promotora
Emotional
Education
Community Outreach
Resources SUPPORT
The promotora helps form a connection between
Doctors or Health services
Promotora
Women
What does a promotora do?
What does a promotora do?
A Promotora:
• Develops a trusting relationship with the women she is working with.
• Does her work without prejudice and maintains strict confidentiality of her conversations with the women.
What are some characteristics of a Promotora?
Characteristics of a Promotora
• Has interest in health and community work.• Is humble and feels equal to others. • Is respected by the people.• Is confident with oneself. • Has the desire to learn. • Accepts new ideas. • Is a good leader and organizer.
Effectiveness of LHW programsReviews have demonstrated effectiveness for:• Increasing immunization uptake, promoting breastfeeding,
improving tuberculosis outcomes, and reducing morbidity and mortality from childhood illnesses (Lewin 2005 Cochrane; Lewin 2010 Cochrane)
• Improving health and behavioral outcomes in cardiovascular disease (Fleury 2009)
• Improved diabetes self-management and breastfeeding outcomes, as well as on general nutrition knowledge and dietary intake behaviors among Latinos (Perez-Escamilla 2010)
• Increasing use of cancer screening tests (Viswanathan 2010)
Individual Studies Showing Effectiveness of LHW Programs for Increasing Cancer Screening
• Cultivando La Salud: A Breast and Cervical Cancer Screening Promotion Program for Low-Income Hispanic Women (Fernandez, 2009)
• AMIGAS, a culturally-appropriate, theoretically sound intervention for Hispanic women living along the Texas-Mexico border (Byrd, et al. 2013)
• Lay Health Worker Outreach and Media-Based Education for Promoting Cervical Cancer Screening Among Vietnamese American Women (Mock 2007)
Like a Promotora• The main objective of the promotora is to deliver these
intervention approaches to the individuals in an effective way. • Being well informed of the methods of intervention is
essential for the effectiveness of their delivery.• Therefore, adequate training
will ensure that each promotora has the knowledge needed to deliver the intervention.
During your meeting with a participant,
• Use simple language and define new terms.
• Speak clearly and with short phases.
• Look at non-verbal signals for understanding in women.
• Be an active listener.
• Try to keep the interaction entertaining and lively.
Keys to being a good promotora
Keys to being a good promotora
After the meeting, • Encourage women to ask their doctor about any
questions they may still have. • Ask women to repeat back to you what they have
learned.
Keys to being a good promotora
REMEMBERIf the women feels like you are interested in their health, the intervention will be more effective.
◦ Use techniques to listen actively during the entire session.
◦ Always make the participant feel comfortable.
Things that the promotoras should AVOID
Promotoras should avoid:Giving incorrect information Making decisions for the
community Putting themselves in harms way Violating trust or confidentiality
Things that the promotoras should AVOID
Promotoras should avoid:Giving their own opinions or advice
to others about health. Talking about diseases or topics of
health which they do not have training.
Activity 2: Female Reproductive System
What are the parts of the female reproductive system?
List of words Fallopian tubes Ovaries Endometrium Vagina Uterus Cervix Collar of the Uterus Labia
Activity 2: Female Reproductive System
What are the parts of the female reproductive system?
List of words Fallopian tubes Ovaries Endometrium Vagina Uterus Cervix Collar of the Uterus Labia
Fallopian tubes
Ovary
Ovary
Uterus
Vagina
Labia
What is Cervical Cancer?
Occurs when abnormal cells grow in the cervix.
If these abnormal cells
are not treated, they
can become cancer.
Source: http://www.cdc.gov/cancer/cervical/statistics/
Cervical Cancer Statistics
• In the United States, cervical cancer used to be the leading cause of death by cancer in women.
• In 2011, (the most recent year for which data is available):
• 12,109 women in the United States received a diagnosis of cervical cancer.*
• 4,092 women in the United States died of cervical cancer.
Source: http://www.cdc.gov/cancer/cervical/statistics/
Why are there still differences among the population?
Why are there still differences among the population?
• Limited access to health services
• Health Beliefs• Lack of Knowledge• Attitudes and Fears• Income Disparities• Cultural Competency
Cervical Cancer Disparities
Cervical Cancer Screening Disparities
Barriers to screening
National HPV Vaccination RatesNational HPV vaccination rates: the National Immunization Survey 20131
• at least 1 dose: 57.3%
• 3 doses: 37.6%
• BRFSS showed rates ranged widely among the states, from 20.6% in Texas to 50.4% in New York
• NHIS showed that 15% of 11-12 year old girls and 25% of 13-17 year olds had received at least one dose; only 6% and 11% respectively received all three doses3
1MMWR (2013) 62 (29). Human Papillomavirus Vaccination Coverage Among Adolescent Girls, 2007–2012, and Postlicensure Vaccine Safety Monitoring, 2006–2013 — United States; 22010 National STD Prevention Conference, March 2010; 3Pruitt and Shootman, Am J Prev Med 2010;38(5):525–533)
Behavioral Factors:
Reduction in HPV-related
disease
Environmental Factors:
Organizational Recommendations made by national immunization
programs and professional organizations Infrastructure for implementation of adolescent
vaccination (schools, other organizations) Office procedures to maximize vaccination Clinic policies or protocols
Interpersonal Clinician recommendation
Community/Societal Health insurance, Medicaid, or access to VFC Availability (community access-eg. mobile vans) Immunization registries Social capital/community context Policy Cost of the vaccine/ Insurance coverage/Subsidies Pharmaceutical marketing
Willingness/Intention to vaccinate self (Adolescents and young women)
Willingness/Intention to vaccinate one’s daughter (Parents)
Factors influencing willingness to vaccinate daughter Perceived barriers to vaccination Belief about acceptable age for vaccination Perceived adverse behavioral consequences
Factors influencing willingness to vaccinate oneself Perceived feelings of parents -subjective norms Belief in the health benefits
Factors impacting clinician recommendation for vaccination Perceived value of recommendations made by national immunization programs and professional organizations/ Belief that influential organizations endorse vaccine HPV knowledge Perceived risk of patient to HPV and HPV-related diseases Concern about the need to discuss sexuality when recommending HPV vaccine Perceived severity of HPV infection Belief in importance of vaccinating prior to sexual initiation Barriers and benefits to vaccination Belief in mandated vaccination Academic vs non-academic practice
HPV Vaccination Factors influencing willingness/intention to vaccinate
one’s daughter or oneself Knowledge of HPV and its relation to cancer Perceived vaccine safety, effectiveness, and side effects Perceived severity to HPV & HPV related disease Perceived susceptibility to HPV Perceived social norms
a
Subjective norms b
Perceived provider endorsement General attitudes about vaccines Perceived benefits
Figure 1: Logic Model of Factors Influencing HPV Vaccination
Fernandez ME, Allen JD, Mistry R, Kahn JA, Integrating Clinical, Community, and Policy Perspectives on HPV Vaccination. Annual Reviews of Public Health. 2010; 31: 235-252.
Integrating Clinical, Community, and Policy Perspectives on HPV Vaccination
:Behavioral Factors
Willingness/Intention to vaccinate self (Adolescents
and young women)
Willingness/Intention to vaccinate one’s daughter
(Parents)
Factors influencing willingness to vaccinate daughter• Perceived barriers to vaccination • Belief about acceptable age for vaccination• Perceived adverse behavioral
consequences
Factors influencing willingness to vaccinate oneselfPerceived feelings of parents -subjective normsBelief in the health benefits
HPV Vaccination
Factors influencing willingness/intention to vaccinate one’s daughter or oneselfKnowledge of HPV and its relation to cancerPerceived vaccine safety, effectiveness, and side effectsPerceived severity to HPV & HPV related diseasePerceived susceptibility to HPVPerceived social norms Subjective norms
Perceived provider endorsementGeneral attitudes about vaccinesPerceived benefits
Environmental Factors:
Organizational• Recommendations made by national
immunization programs and professional organizations
• Infrastructure for implementation of adolescent vaccination (schools, other organizations)
• Office procedures to maximize vaccination• Clinic policies or protocols
Interpersonal· Clinician recommendation
Community/Societal• Health insurance, Medicaid, or access to
VFC
• Availability (community access-eg. mobile vans)
• Immunization registries• Social capital/community context• Policy• Cost of the vaccine/ Insurance
coverage/Subsidies• Pharmaceutical marketing
Factors impacting clinician recommendation for vaccination
Perceived value of recommendations made by national immunization programs and professional organizations/ Belief that influential organizations endorse vaccine
HPV knowledge
Perceived risk of patient to HPV and HPV-related diseases
Concern about the need to discuss sexuality when recommending HPV vaccine
Perceived severity of HPV infection
Belief in importance of vaccinating prior to sexual initiation
Barriers and benefits to vaccination
Belief in mandated vaccination
Academic vs non-academic practice
Interventions Cervical Cancer
Client Reminders Recommended
Client Incentives Insufficient Evidence
Small media Recommended
Mass media Insufficient Evidence
Group education Insufficient Evidence
One on One education Recommended
Reducing structural barriers Insufficient Evidence
Reducing out of pocket costs Insufficient Evidence
Recommendation Approaches: Community Guide
Recommended approaches for Vaccination
Activity 3: Risk Factors for Cervical Cancer
• We will go around the room and each person will mention a risk factor for cervical cancer.
• If you can’t think of one, don’t worry, we will continue with the next person.
• When we have finished with our list, we can discuss these factors that increase the risk of cervical cancer.
Discussion: Risk Factors for Cervical Cancer
Infection with a sexually transmitted disease, especially with the human papilloma virus (HPV)*
Initiation of sexual intercourse at an early age Having more than one partner, or have a partner who has multiple
partnersSmokingMultiple births
* Most Important Risk Factor
Human Papilloma Virus (HPV)
Human Papillomavirus (HPV)• The virus is usually transmitted through sexual contact. • About 79 million Americans are currently infected with HPV
and about 14 million Americans will become newly infected this year. (CDC, 2014).
• Several types of HPV: The majority of HPV infections have no symptoms and the body gets rid of them, but some types of high-risk HPV can persist and cause cervical cancer.
CDC (2014). Genital HPV infection-Fact Sheet. Retrieved from http://www.cdc.gov/std/HPV/STDFact-HPV.htm
Human Papillomavirus (HPV)
HPV is the most common sexually transmitted infection.
HPV can be eliminated from the body, but in some cases it can develop into cervical cancer.
Hispanic women have a higher rate of cervical cancer associated with HPV compared to other races.
Other cancers related to HPV
• Besides cervical cancer, Human papillomavirus (HPV) has been found to be associated with several types of cancer such as:
- Vulvar- Vaginal- Penile- Anal
• Oropharyngeal (back of the throat, including the base of the tongue and tonsils).
• Each year, more than 20,000 HPV-associated cancers occur in women
• About 12,000 HPV-associated cancers occur each year in men
HPV-Associated Cancers (Genital HPV Infection)• Cancers that develop in cells infected with HPV develop in areas
involved with sexual activity
• Caused by high-risk HPV types • Most cases caused by types 16 and 18
• HPV is associated with 25,000 cases of cancer / yr:• The following are the percentage of each type of cancer associated
with genital HPV infection: • Cervical – 99%• Anal – 90%• Vulva, vagina, penile – 40%• Mouth – 25%• Throat – 35%
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Genital HPV Infection in Men
• Is as common in men as it is in women
• Increases a man’s risk of getting cancers around the genitals, although not common• For example, anal and penile cancers
• Risk of anal cancer is: • 17 times higher in sexually active gay and bisexual men than in men who
only have sex with women• Higher in men with HIV
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Low-risk HPV Types (Signs and Symptoms of Genital HPV Infection)
• Does not always have visible symptoms• Appearance of warts or lesions on skin surface
• In or around the genital area• Vagina, cervix, anus, penis, scrotum
• In mouth or throat• Warts may appear years after contracting the virus
• If warts appear, the person should seek medical attention immediately
50
High-risk HPV Types (Signs and Symptoms of Genital HPV Infection)• Rarely has visible symptoms• Abnormal Pap test (presence of dysplasia or abnormal cells)
• For Women: Cervical Cancer• Usually no symptoms
• Are usually only sensed once it has become more severe• Unusual vaginal bleeding or discharge• Bleeding or pain after sexual intercourse• Pelvic pain
• For Men: Penile Cancer• Changes in color, skin thickening, or a build-up of tissue on the penis• A growth or sore on the penis, usually painless• In some cases, sore may be painful and bleed
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Types of HPV
Over 100 HPV Types
Non-sexual Transmission
- About 70 types- Cause skin warts
Sexual Transmission - About 30 types
High-Risk Types-Types 16 and 18
- Cause dysplasia, leads to cancer
Low-Risk Types-Types 6 and 11- Non-cancerous
- Cause genital warts
Activity 4: How much do we know about HPV?
• Instructions: Using the sheet provided, please select the statements that you believe are correct regarding the HPV vaccine.
• If you are not sure, don’t worry. We are here to learn together. After a few minutes, we will discuss the information as a group.
The HPV vaccine• Cervarix and Gardasil, are two
vaccines available to protect women against the types of HPV that cause most cervical cancers (CDC, 2011).
• Gardasil* and Cervarix are vaccines that have been approved for girls and women 9 to 26 years of age to help protect against the following diseases cause by HPV(FDA, 2009):• Cervical Cancer• Genital warts • Cervical precancerous lesions
* Gardasil has also been approved for boys and young men from 9 to 26 years of age to prevent cancers of the penis and anus, and genital warts.
CDC. (2011, August 8). Reports of health concerns following hpv vaccination. Retrieved from http://www.cdc.gov/vaccinesafety/vaccines/hpv/gardasil.html
CDC. (2011, September 15). Hpv vaccine information. Retrieved from http://www.cdc.gov/std/hpv/stdfact-hpv-vaccine-young-women.htm
History of HPV and HPV Vaccine
1983Discover that HPV can cause Cervical Cancer
2000-2006The vaccine is tested in more than 21,000 women around the world
May 2010Around 80 million doses of the HPV vaccine are distributed around the world
1991Scientists begin to study the HPV vaccine
June 2006FDA approve vaccineCDC recommends
Who should be vaccinated and when they should do so?
The American Cancer Society recommends that:
11 to 12 year-old girls should be vaccinated against HPV. It consists of a series of three injections in 6 months (1st dose- Now, 2nd dose- 1 or 2 months after 1st dose, 3rd dose- 6 months after 1st dose).
The vaccine may be given to girls starting at age 9. Young people aged 13 to 18 years can also be
vaccinated. These young people can complete any dose they need.
Women aged 19 to 26 years need to consult with their doctors whether they need to be vaccinated.
Do the young people who were vaccinated also need to have a Pap test?
Yes, the HPV vaccine does not protect against all types of HPV that can cause cervical cancer.
HPV mass media campaigns in US:Merck’s ONE LESS Campaign
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• Uses risk message frames • Emphasizes messages of loss :
“Get vaccinated or risk HPV and cervical cancer”
https://www.youtube.com/watch?v=hJ8x3KR75fA
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HPV mass media campaigns:“Armed for Life” Campaign
• Gain framed message• Protection • Caused substantial
controversy
Role of the promotora in the For Our Daughters Study
Role of the promotora in the study:
Population of our Intervention:Hispanic parents with daughters who are 11-17 years of
age. Parents who have not vaccinated their daughters against
HPV. Parents and their daughters that live in Houston.
Clinics and clinic waiting rooms in: Areas with low incomeAreas that are predominantly Hispanic Clinics that offer the HPV vaccine
Role of the promotora in the study:
• Study Period:• 8 months to complete the initial interview and intervention.
• 6-month follow up interview after the initial interview.
• Goal: 1,809 parents
• 1,206 parents will receive the intervention.
• 151 intervention per month, 30 intervention per promotora (5).
• About 7 to 8 participants per week, per interviewer.
Study Design: 27 Clinics *N= 1,809 Eligible Parents
Random Distribution of Clinics
9 Clinics Control (n=67 Parents)
9 Clinics with Promotoras + TIMI (n=67 Parents)
9 Clinics with Promotoras + Fotonovela(n=67 Parents)
80% Follow up (n=1,512 Parents) at 6 months
Lost to Follow Up n= 297 Parents (20%) at 6 months
Data Analysis n=1809ts
* We will have a total of 33 clinics where 6 of them are clinics that will replace others in case any clinics stop participating at some point during the study.
Map of Houston—Clinics
Approach • There will be two different approaches: a fotonovela or an interactive
video. • These interventions have been created based on an earlier study called
Living without Cancer. • Focus groups with the parents also verified the appropriateness of these
interventions.
The Fotonovela
• Fotonovelas are brief stories with images and dialogues that accompany the images.
• Fotonovelas are popular in Hispanic societies and are used for describing and educating the Latino audience about health issues.
Why Use Photonovels?
Research* shows: • People remember stories
better than a set of facts• Stories build self-
confidence• Stories reinforce culture
values and norms to promote healthy
behaviors• Stories can be used in creative ways to motivate
and mpower people regardless of age or
reading ability
* Doak, et al. Teaching Patients with Low Literacy Skills, 1996.
From: Pregnancy & Diabetes: Lucia’s Story Published by Auger Communications, Inc.
The Interactive Video
The interactive program includes a video, still images with audio and animation to communicate information.
Messages will be adapted to the person, so each participant receives information geared to their individual concerns.
Get into groups of two, one of you will be the promotora and one will be the mother of a child eligible for the HPV vaccine. How would you (the promotora) explain to the mother about HPV and the vaccine?
We will take turns so more can participate.
Activity 5: Role Play
Tailored Interactive Communications Approaches
Tailoring• ‘Tailoring’ refers to any of a number of methods for creating
communications individualized for their receivers, with the expectation that this individualization will lead to larger intended effects of these communications.
Hawkins, et al. 2009 Understanding tailoring in communicating about health Health Education research Vol.23 no.3 2008 Pages 454–466
Strategies for Achieving Tailoring Goals
• Personalization• Feedback• Content matching
For Our Daughters - Para Nuestras Hijas
Moving video Stills with audio Graphics and
Animation Data-based tailoring Self- Tailoring
Intervention: Interactive ProgramTailored Portions Description of prgram
contentRationale
Language Parents choose either English or Spanish version
Anticipating majority of parents will only speak Spanish but do not want to exclude English speakers
Perceived Susceptibility
Slideshow illustrating importance of HPV vaccine in preventing cervical cancer; demonstrates susceptibility
Protection Motivation Theory
Perceived Vaccine Efficacy
Virtual promotora explains that the vaccine is effective (reinforced later in the program by the doctor)
Protection Motivation Theory Block & Keller (1995)-increase belief in efficacy of the vaccine
General Concerns/Barriers to Vaccination
Provide set of common concerns addressed with additional information
Increase belief in efficacy of the vaccineAddress concerns (Social Cognitive Theory, Theory of Planned Behavior)
Skill-Related Barriers to Vaccine Completion
Present common skill-related barriers to completing vaccine series and ways to overcome them.
Stress importance of completing vaccine series and provide information to do so
Self- Efficacy Testimonials of mothers who have vaccinated their daughters
Those low in self-efficacy hear from parents who encountered barriers to vaccination but were able to overcome them
Activity 6: Teach with Stories Method
• The Teach-With-Stories Method used with photonovels is a patient (or learner) centered educational approach designed to:
•Build 3 Kinds of Power• Power-with-Others• Power-from-Within• Power-as-Mastery
•Honor Latino Cultural Values & Norms
•Foster Critical Thinking and Behavior Change
•Create a Safe Space to Discuss Social Determinants of Health
HPV Implementation Project
Individual Session Tracking
Thank You!
QUESTIONS?