Effectiveness of a health belief model intervention using a lay health advisor strategy on mouth self-examination and cancer screening in remote aboriginal communities: A randomized controlled trial

Highlights

• Lay health advisors decrease barriers to oral cancer screening in aboriginals.

• Lay health advisors increase self-efficacy of oral cancer screening in aboriginals.

• Lay health advisors increase self-efficacy of mouth self-examination in aboriginals.

• Lay health advisors improve mouth self-examination in aboriginals.

Abstract

Objective

Oral cancers caused by chewing betel nuts have a poor prognosis. Using a lay health advisor (LHA) can increase access to health care among underprivileged populations. This study evaluated a health belief model (HBM) intervention using LHAs for oral cancer screening (OCS) and mouth self-examination (MSE) in remote aboriginal communities.

Methods

The participants were randomly assigned to intervention (IG; n = 171) and control groups (CG; n = 176). In the IG, participants received a three-chapter one-on-one teaching course from LHAs, whereas those in the CG received only a leaflet.

Results

The IG participants were 2.04 times more likely to conduct a monthly MSE than those in the CG (95% confidence interval: 1.31–3.17) and showed significantly higher self-efficacy levels toward OSC and MSE (β = 0.53 and 0.44, effect size = 0.33 and 0.25, respectively) and a lower barrier level for OSC (β = −1.81, effect size = −0.24).

Conclusion

The LHA intervention had a significantly positive effect on MSE, strengthening self-efficacy and reducing barriers to OCS among aboriginal populations.

Practice Implications

The effectiveness of the clinical treatment of underprivileged group can be improved through early diagnosis, which can be achieved using LHAs to reduce barriers to OSC.

Introduction

In Taiwan, mortality from and the incidence of oral cancer are both higher in the aboriginal population than in the general population. Furthermore, the mortality and incidence of oropharyngeal cancer are both higher among aboriginal communities with high prevalence of betel quid chewing than among those with a low prevalence [1]. The indigenous people who originally lived in Taiwan are referred to as aborigines and comprise 16 independent aboriginal groups, accounting for 2% of the total population of Taiwan [2]. Each aboriginal group has a unique cultural background that renders it unique from other aboriginal groups and the main culture of Taiwan. Areas in which the original culture of aboriginal communities remain are in the remote mountain areas of eastern Taiwan and southern Taiwan [2]. Aboriginal communities that inhabit remote areas in Taiwan traditionally chew betel quid and have a high proportion of betel quid chewers [3]. Studies have shown that aboriginal betel quid chewers often develop severe oral lesions [4] and periodontal alveolar bone loss [5]. A recent study on aboriginal women with betel quid chewing habits found a significant effect of betel quid exposure during pregnancy on birth outcomes [6].

Data from Taiwan’s nationwide cancer registration system from 2009 to 2014 showed that oral cancer is the fifth leading cause of all cancer deaths and the fourth leading cause of cancer deaths among men [7,8]. The major risk factors for oral cancer in Taiwan are betel quid chewing with or without tobacco, alcohol consumption, and cigarette smoking [[9], [10], [11]], with the highest incidence among individuals who habitually chew betel quid and smoke cigarettes [12]. Therefore, the Taiwanese government has enforced health education and cessation classes for quitting betel quid chewing and cigarette smoking in high-risk populations. However, 70% of current betel quid users in Taiwan have already developed a betel quid use disorder, and a higher frequency or longer history of betel quid use are key factors correlated with an enhanced risk of an oral potentially malignant disorder [13]. Furthermore, aboriginal betel quid chewers are less likely to quit betel quid chewing because of peer pressure and withdrawal symptoms [3,14].

Implementation of community-based cancer screening programs has several benefits, including cost-effectiveness and early identification of high-risk populations [15]. However, aboriginal communities in remote areas lack sufficient resources and personnel for health promotion. In addition, each aboriginal community has a unique cultural background [3]; cultural differences and insufficient resources are major barriers to cancer screening.

A lay health advisor (LHA) is a natural helper who communicates health information between a local health department and community residents. Using the LHA strategy helps local health departments to save on staffing costs and to breakdown cross-cultural barriers. In the United States, using LHA interventions has increased the screening rates for several cancers, including colorectal cancer, breast cancer, and cervical cancer [[16], [17], [18], [19], [20], [21]].

The health belief model (HBM) was developed in the 1950s by Hochbaum (1958) and subsequently modified by Rosenstock (1974, 1991) and Hochbaum (1992) as a model for health educators. Use of the HBM has resulted in the development of effective programs in which individuals have undergone changes in beliefs that have led to increases in healthy behaviors. The HBM is based on the concepts of perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action [22,23]. Studies have found the HBM valuable in predicting health behaviors and designing intervention programs, especially for cancer screenings, such as screenings for cervical, colorectal, prostate, and breast cancers [[24], [25], [26], [27], [28], [29]].

A 2 year intervention program using the LHA strategy to promote oral cancer screening was conducted in remote aboriginal communities in southern and eastern Taiwan. Therefore, we evaluated the effectiveness of the HBM-based intervention program with LHA strategy on oral cancer screening and self-examination among aboriginal communities in Taiwan.