Changing Public

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Changing Public Patient Behavior Theory,
Evidence, PlanningTraining in Clinical
ResearchTranslating Evidence Into Practice
April 29, 2008

• Rena J. Pasick

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• Cancer screening disparities
• Intervention evidence
• Behavioral theory and culture
• Planning

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Trends in Early-Stage Female Breast Cancer
Incidence by Race/Ethnicity California, 1988-1999
Source Cancer in California, 1988-1999.
California Department of Health Services,
December 2001.
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Mammography Status in a Multiethnic
SampleAlameda County Women, 40-74Pathfinders
Baseline Survey, 1999-2000 (n1463)
Language n Mammography () Mammography () Mammography ()
Language n Recent Not recent Never
English 1016 60.2 29.3 10.4
Cantonese 171 50.3 26.3 23.4
Tagalog 56 48.2 33.9 17.9
Spanish 220 58.6 25.9 15.5
African American, Chinese, Filipina, Latina,
White women, Within 15 months of interview
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Cervical CancerAverage Annual Age-Adjusted
IncidenceUS, 1988 - 1992
SEER, 1996
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Research Background
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Research Background (cont)
Behavioral Constructs and Culture in Cancer Screening 2001-2007 NCI Filipina Latina Women Qualitative
Cross-Cultural Communication for Colorectal Screening 2002-2006 NCI African American, Chinese, and Latino primary care patients at Kaiser community clinics Formative study/pilot
Statewide Communication to Reach High-Risk Low-SES Women for Research and Prevention 2007-2012 NCI African American, Latino, Chinese, Vietnamese Korean women calling statewide Everywoman Counts toll-free line
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• Cancer screening disparities
• Intervention evidence
• Behavioral theory and culture
• Planning

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Interventions

• Promotion
• mass media
• small media
• small group education
• one on one education
• incentives
• reminders
• multi-component

• Access Enhancement
• laws
• non-clinical settings
• cost reduction
• eliminate structural barriers
• multi-component

Briss PA et al, Am J Prev Med 2000 Rimer BK et
al, Pub Hlth Rep 1993
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Cancer Screening Intervention Research

• Large body of research
• Extensive array of barriers identified
• Many effective interventions
• Extent to which interventions sustained
  disappointing
• Few interventions found effective are
  disseminated
• Multilevel theoretical and conceptual approaches
  are needed to understand the full context of
  cancer screening

Meissner H, 2004 Rakowski W, Breslau E. 2004
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Lesson 1 Virtually all major types of
community-based cancer screening interventions
have been found to be effective in some studies.
However, no interventions work for all people,
screening tests, or in all settings.
Pasick, Hiatt, Paskett. 2004
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Focal Point Framework
Intervention Strategies
Access enhancement laws non-clinical settings cost reduction eliminate structural barriers multi-component Promotion mass media small media small group education one on one education incentives reminders multi-component
Focal Point
Target population Setting Screening objective
Research
Fundamental research Intervention research
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Fundamental research(basic behavioral research)
Research
Fundamental research Intervention research

• Develop/refine the mechanisms that lead to
  intervention outcomes
• - theory measurement
• - messages
• - communication channels

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Intervention research

• Optimal intervention for the focal point is
  identified, implemented accurately, evaluated
  rigorously, and replicated.
• - formative evaluation
• - process evaluation
• - assessment of outcomes
• - including cost-effectiveness

Research
Fundamental research Intervention research
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Brilliant points of light..
Research
Fundamental research Intervention research
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punctuating vast empty spaces
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Fundamental research
Intervention research
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• Cancer screening disparities
• Intervention evidence
• Behavioral theory and culture
• Planning

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On the one hand..

• the reason for theory is to help guide the
  selection of important constructs thought to
  exert impact on health behavior

Crosby et al. 2002
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On the other hand
By targeting a specific range of theoretically
important constructs for examination or as a
foundation for designing health promotion
programs theory limits the breadth of
observations and investigations and the scope of
intervention
Crosby et al., 2002
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Limitations of Theoryfor Disparities Populations

• Origins of theory
• Measurement
• Decontextualization
• Focus on cognition

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Measurement
Theory
Interventions Messages
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Measurement

• Intention measurement includes action, target,
  time
• I intend to get a mammogram in the next 12
  months
  extremely unlikely ___1_____2_____3__
  ___4_____5_____6_____7__ extremely likely

• Pathfinders translation/adaptation for 5 race/
  ethnic and 4 language groups
• Do you plan to have a mammogram in the next 12
  mos? yes