Mobile Phone Text Messaging Intervention for Cervical Cancer Screening: Changes in Knowledge and Behavior Pre-Post Intervention

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Original Paper

Mobile Phone Text Messaging Intervention for Cervical Cancer Screening: Changes in Knowledge and Behavior Pre-Post Intervention

Hee Yun Lee1*, PhD;
Joseph S Koopmeiners2*, PhD;
Taeho Greg Rhee3*, AM;
Victoria H Raveis4*, PhD;
Jasjit S Ahluwalia5*, MD, MPH, MS

1School of Social Work and University of Minnesota Masonic Cancer Center, College of Education and Human Development, University of Minnesota, Twin Cities, St Paul, MN, United States
2Division of Biostatistics, School of Public Health, University of Minnesota, Twin Cities, Minneapolis, MN, United States
3Division of Health Policy and Management, School of Public Health, University of Minnesota, Twin Cities, Minneapolis, MN, United States
4Psychosocial Research Unit on Health, Aging, and the Community, College of Dentistry, New York University, New York, NY, United States
5Center for Health Equity and Department of Medicine, School of Medicine, University of Minnesota, Twin Cities, Minneapolis, MN, United States
*all authors contributed equally

Corresponding Author:
Hee Yun Lee, PhD

School of Social Work and University of Minnesota Masonic Cancer Center
College of Education and Human Development
University of Minnesota, Twin Cities
1404 Gortner Ave
St Paul, MN, 55108
United States
Phone: 1 612 624 3689
Fax: 1 612 624 3744

1]. While the Healthy People 2020 initiative states that 93% of women, aged 21-65 years, should have undergone a Pap test within the past 3 years [2], studies consistently report that, among women across US racial/ethnic groups, Korean American women have the lowest Pap test screening rates, ranging from 39% to 64% [3-8]. Given that early detection of cervical malignancies through this routine screening measure has been shown to significantly reduce cervical cancer mortality, Korean American women’s low screening rate indicates that efforts to increase their screening behavior would be very beneficial [1,9].

A variety of structural and cultural factors act as barriers to screening for Korean American women. Structural obstacles include health access due to inadequate health insurance [10-12], expense [1,13], time constraints [10,13], and language limitations [1,10,12-15]. Cultural barriers to cervical cancer screening encompass lack of knowledge regarding cervical cancer and cervical cancer screening [1,10,12,13,16], a wrongly held belief that screening is unnecessary in the absence of symptoms or at young ages [1,10,12,13,16,17], cultural modesty or embarrassment [10,13,16], lack of culturally appropriate health care providers [12,13], and fear of receiving negative screening results [10,16].

A limited number of interventions to address barriers and promote cervical cancer screening among Korean American women have been designed or implemented. These efforts have focused on peer-led workshops [18,19], dissemination of videos [18], and distribution of cancer education print materials [20,21]. There are a number of reasons why these approaches have been only partially effective in promoting cervical cancer screening in this population. Korean American women are a particularly hard-to-reach population [19,20]. Although earlier interventions have specifically targeted structural barriers to cancer screening (eg, providing low-cost or free Pap tests or in-language services), prominent cultural obstacles such as cultural modesty or misconceptions about screening were not addressed [19]. These previous intervention strategies also did not tailor the intervention to strategically target specific individual concerns about screening, despite evidence that there are multiple cultural reasons for Korean American women’s reservations about cervical cancer screening [20]. The restricted scope and lack of tailoring in these previous interventions may have contributed to their limited impact. Personalized interventions may be necessary to motivate a change in screening behavior with this difficult to reach population.

To address the multiple limitations that were present in prior interventions, we developed and tested a mobile phone text message-based cervical cancer Screening (mScreening) intervention that utilizes mobile health (mHealth) technology. mHealth is defined as the use of mobile and wireless devices as intervention tools to deliver health information or improve health outcomes, particularly using short message service (SMS or text) and/or multimedia message service (MMS, or images or pictures) [22]. mHealth is considered a promising tool for preventive care through promotion of behavioral change. mHealth is taking a primary place in a number of research initiatives related to the promotion of health behavior. For example, mHealth technology was successfully used in weight management [23], smoking cessation [24-28], youth sexual health [29], increased physical activity [30], self-care behaviors [27,28,31], and asthma monitoring and management programs [32].

Our study seeks to harness mobile phone technology to positively influence cancer screening behavior, taking preventive health care approaches to a new level [7,33]. Guided by the Fogg’s Behavior Model (FBM) [33], the mScreening intervention consists of three sequential components: (1) identifying barriers, (2) developing motivators, and (3) providing triggers (see Figure 1 for conceptual framework). With the FBM framework, we first identified specific structural and cultural barriers that prevent Korean American women from receiving a Pap test. This information guided our subsequent development and implementation of mobile tools (eg, SMS or MMS) to improve knowledge and provide the motivation for behavioral change. Triggers to act are employed in the form of reminder text messages (eg, “Make an appointment now!”) or electronic links (eg, “Click to talk to a Korean health navigator”) to prompt Korean American women to take immediate action to obtain a Pap test.

Our study had three primary aims: (1) to examine if the mScreening intervention increased research participants’ (a) knowledge of cervical cancer, relevant guidelines of cervical cancer screening, and cervical cancer risk factors, and (b) their intent to undergo screening; (2) to assess if the mScreening intervention contributed to a 20% increase in the receipt of the Pap test over the sample’s baseline rate; and (3) to examine the acceptability and satisfaction of the 7-day mScreening intervention program. Our study used evidence-based and theory-driven approaches to develop the mScreening intervention to concentrate on barriers (eg, cultural beliefs, perceived-risk, and limited health literacy) that prior work had not addressed, so as to increase Korean American women’s adherence to cervical cancer screening guidelines.

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