1. 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 Project Division of General Internal Medicine University of California, San Francisco

2. 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)

3. 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.

4. 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

5. 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

6. 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

9. Methods: Study Design Total anticipated sample Intervention: 550 Control:550

10. 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

12. 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

13. 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

14. 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

15. Characteristics of Lay Health Workers  Mean age (4 agencies): 57.3 years  Range: 22-67 years  Women were employed, housewives, or students

17. 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

19. 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

20. Results: Participant Demographics

21. Ever Heard of Breast Cancer? (% Yes) *p < 0.0001 % change**: 2.8%vs. 8.9% **p = 0.006

22. Ever Heard of Mammogram? (% Yes) *p = <0.0001 % change: 2.2% vs.5.4%

23. Ever Had Mammogram? (% Yes) ^p = 0.03 *p < 0.0001 % change: 2.7% vs. 6.7%

24. Had Last Mammogram Within Past Year? (% Yes) ^p = 0.03 *p < 0.0001 % change**: 4.5% vs. 22.1% **p = 0.0004

25. Plan Mammogram Within 12 Months? (% Yes) *p < 0.0001 % change**: 0.2% vs. 21.1% ** p < 0.0001

26. Ever Thought About Getting a Mammogram? (% Yes) ^p = 0.004 (n=25) % change: 12.0% vs. 19.0%

27. Ever Heard of Clinical Breast Examination (CBE)? (% Yes) % change**: 10.9% vs. 22.8% **p = 0.0003 ^p < 0.0001 *p < 0.0001

28. Ever Had a CBE? (% Yes) % change**: 7.3% vs. 19.8% **p = 0.0003 ^p = 0.0005 *p < 0.0001

29. Had a CBE Within Past Year? (% Yes) % change**: 5.1% vs. 27.8% **p < 0.0001 ^p = 0.028*p < 0.0001

30. Plan a CBE Within 12 Months? (% Yes) % change**: -1.2% vs. 20.7% **p < 0.0001 *p < 0.0001

31. Thought of Getting a CBE? (% Yes) % change: 4.0% vs. 8.0% ^p < 0.0001 (n=25) *p < 0.0001 (n=32)

32. Age Women Should Start Mammograms? (% 40 Years) % change**: 0.9% vs. 45.3% **p < 0.0001 *p < 0.0001

33. Age Women Should Start CBEs? (% 40 Years) % change**: 0.9% vs. 45.9% **p < 0.0001 *p < 0.0001

34. Multiplier Effect: Participants’ Sharing of Information about Mammograms Median number of people shared information per participant: 3.0 4.0

35. Multiplier Effect: Participants’ Sharing of Information about CBEs Median number of people shared information per participant: 3.0 4.0

36. 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

37. 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

38. 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