Our findings indicate that lay health worker interventions for Vietnamese women are acceptable to the community, feasible to implement, and can positively impact levels of Pap testing use among women who have previously been screened for cervical cancer (but are non-adherent with guidelines for interval screening). Specifically, 84% of the 106 women that our lay health workers were able to contact completed a home visit. Additionally, we demonstrated an intervention effect among previously screened women using a conservative approach which assumed that all women without follow-up data were unscreened, as well as that failure to retrieve a Pap testing medical record always meant that the woman was truly unscreened.
A previous California study randomized Vietnamese women to lay health worker group education plus media-based education (combined intervention) or media-based education alone (media only intervention). Women provided information about their Pap testing history four months after randomization. The combined intervention was more effective than the media only intervention in increasing the rate of previous Pap testing receipt (66% to 82% versus 70% to 76%, p<0.001). Among those who had never been screened, significantly more women in the combined intervention group (46%) than in the media only group (27%) obtained Pap tests (p<0.001) (13
). It is possible that the California intervention was more effective for previously unscreened women than our intervention because of differences in the intervention intensity and/or components. Specifically, the California intervention included two face-to-face educational sessions with lay health workers (rather than one face-to-face educational session) and use of a flipchart (rather than a DVD).
In our study, 33% of experimental group women with follow-up data and 18% of control group women with follow-up data reported Pap testing (p=0.02). Previous studies have evaluated lay health worker interventions for women who are non-adherent to Pap testing guidelines among other racial/ethnic minority groups with similar results. Another Washington State study focused on Chinese American women. Six months after randomization, 37% of the experimental group and 22% of the control group reported Pap testing (p=0.07) (14
). A Texas study focused on low-income Hispanic women. Pap testing completion was significantly higher in the experimental group (40%) than the control group (24%) when women were interviewed after an interval of six months (15
Our study strengths include a randomized controlled design, as well as use of both self-report and medical records data for end-point ascertainment. Several studies have found that the accuracy of screening test self-reports among Asian American women is relatively low, compared to the accuracy among non-Latina white women (16
). For example, one study was able to verify Pap smear self-report for 85% of non-Latina white women, but only 68% of Chinese women and 67% of Filipina women (16
). We were able to request medical records for 41 (93%) of the 44 women who reported Pap testing following randomization, and were able to verify Pap testing for 24 (63%) of these 41 women. Asian naming systems may result in misfiling of test results and difficulty finding medical records. It is possible, therefore, that at least some of the women whose self-reported recent Pap testing could not be verified had, in fact, received a recent Pap smear.
Our study has several limitations that should be recognized. First, we recruited individuals living in one geographic area of the US, and the results may not be applicable to all Vietnamese American women. Second, only individuals who agreed to complete a baseline survey were eligible for participation in the trial, and survey responders may be more receptive to health education programs than survey non-responders. Third, although we requested the medical records of all individuals who reported Pap testing since randomization, we made no attempt to verify the accuracy of self-reports among women who reported they had not been tested. It is possible that some of these individuals received a Pap test, without their knowledge, during a gynecologic exam for a health problem. Finally, our follow-up interval was only six months and some trial participants may have received Pap testing after their follow-up survey.
Our results add to the evidence concerning the effectiveness of lay health worker approaches to cervical cancer control in Vietnamese and other Asian immigrant communities (13
). Future research should evaluate the effectiveness of lay health education for other racial/ethnic minority and limited English proficient groups, as well as other screening modalities (e.g., fecal occult blood testing and colonoscopy). It will also be important for researchers to conduct dissemination studies focusing on the adaptation and implementation of cervical cancer control lay health worker interventions in community health center and other community-based organization settings (15