The Chinese Women's Health Project

The United States 2000 Census counted ethnic Chinese at 2.4 million, and the Chinese are now the largest Asian subgroup in both Canada and the United States. Recent Chinese immigrants have been identified as an underserved group requiring special attention from public health professionals because of low acculturation levels, low English proficiency, and relative cultural isolation. Several studies have suggested that women of Chinese ethnicity have higher invasive cervical cancer rates than the general North American population because of poor compliance with cervical cancer screening guidelines. The incidence rates of invasive cervical cancer among Chinese and White women living in Los Angeles are 12.3 and 7.2 per 100,000, respectively. An ethnically focused behavioral risk factor survey conducted in Oakland, California, from 1989 to 1990 found that 45% of women of Chinese ethnicity had never been screened for cervical cancer, and only 37% of respondents to a 1994 San Francisco survey were routinely obtaining Pap testing. To address lack of familiarity with minority health concepts and practices, health educators are increasingly integrating qualitative approaches into the development of diverse types of intervention and screening programs targeting immigrant groups. 

The Chinese Women's Health Project aims to decrease the incidence of invasive cervical cancer among women of Chinese ethnicity by increasing the frequency and regularity of Pap testing. Outreach workers visit women of Chinese ethnicity at home, acting as role models, providing social support, and serving as cultural mediators between women and health care facilities. The outreach workers use visual aids, including an education-entertainment video, motivational pamphlet, fact sheets, and an educational brochure. The outreach workers provide tailored responses to each woman's individual barriers to cervical cancer screening, and also offer assistance as necessary with clinic referral and appointment scheduling, interpreter services, and transportation assistance.

Time required for the home visit varies depending on the degree of interaction between the outreach worker and the woman, ranging from 15 to 45 minutes. For instance, if the woman wanted to watch the video with the outreach worker, an additional 20 minutes would be required. Outreach workers also need enough time to address problems around the woman's identified barriers to cervical cancer screening and to provide assistance with such logistics as clinical referrals, appointment scheduling, translation, and transportation.

 The intended audience is adult women of Chinese ethnicity.

 The intervention is suitable for implementation in the home.

Required resources include:

• "The Chinese Women's Health Project, Outreach Worker Manual", a manual with information to assist the outreach worker
• Brochures written in Chinese and English regarding Pap testing: "Prevention of Cervical Cancer: The Pap Test" and "Pap Testing: A New Step on the Path to Women's Health"
• Sample pap testing fact sheets, written in Chinese and English, listing clinic locations
• "A New Pathway to Women's Health", an educational-entertainment video, available in Cantonese and Mandarin with English subtitles
  Bicultural, trilingual (Cantonese, Mandarin, and English), female outreach workers of Chinese ethnicity are necessary to conduct the home visits.

The estimated cost of the outreach worker-based intervention is $73.06 per participant, which includes both personnel and nonpersonnel costs. Personnel costs include staff training and project meetings, assembling an initial mailing, and home visits (contacts, tracking, travel, parking, time spent at the home, assisting with appointment scheduling). Nonpersonnel costs include the production of handbooks and manuals, mailing supplies, VCR equipment, the video, a Pap test kit, a speculum, and the three motivational and educational brochures.

A randomized controlled trial was conducted to evaluate the impact of two culturally and linguistically appropriate cervical cancer control educational interventions: a "high intensity" outreach worker-based intervention where the intervention was delivered by outreach workers at participants' homes, and a "low intensity" direct mail intervention where all intervention materials were sent to participants in the mail. Control group participants received usual care at local clinics and doctors' offices. The sample was composed of 402 women of Chinese ethnicity living in either Seattle, Washington, (45%) or Vancouver, British Columbia, (55%) between the ages of 20 and 69 (20-44: 42%; 45-69: 58%).

Women in the experimental groups received the appropriate intervention within 1 month of random assignment. Six months following randomization, participants completed a follow-up survey where they were asked if they had received Pap testing in the last 2 years and whether they planned to be screened in the next 2 years.

Cost data to determine the cost-effectiveness of the intervention were collected using four methods: (1) a modified Delphi technique where staff estimated a priori how much each activity was likely to cost and how much time it would take to complete tasks; (2) accounting records used to record the purchase of supplies, materials, and other goods; payroll reports; and capital expenditures; (3) sampling of staff time logs, kept for 1 month midway through the project, in 15-minute increments; and (4) modeling of miscellaneous and overhead costs based on historical accounting data for miscellaneous costs. Effectiveness of the intervention was measured as the proportion of women in each intervention arm who reported receiving a Pap test since the trial began. 

Effect of Chinese Women's Health Project on Pap Testing

• Of the women in the outreach worker condition, 39% reported Pap testing in the 6 months between randomization and follow-up survey completion, compared with 25% and 15% in the direct mail and control conditions, respectively (outreach versus direct mail: p=.02; outreach versus control: p<.001; direct mail versus control: p=.03).

•  Seventy-two percent of the outreach worker group, 59% of the direct mail group, and 48% of the control group indicated they were planning to get Pap testing in the next 2 years (outreach versus direct mail: p=.03; outreach versus control: p<.001: direct mail versus control: p=.05).

Cost-Effectiveness of Chinese Women's Health Project

• The outreach worker intervention, though more expensive overall, was more cost-effective than the mailing intervention. The intent-to-treat cost for each additional woman to be screened for a Pap test was $415 in the outreach arm and $676 for the direct mailing arm.