Cancer Control Interventions for

Hispanics with Low Literacy Skills

María E. Fernández, PhD Associate Professor of Health Promotion and Behavioral Sciences

Associate Director, Center for Health Promotion and Prevention Research

University of Texas, School of Public Health

Partnerships

Partnership, collaboration, energy, and

commitment has led to…. $$$ to do

Cool Stuff!

Cultivando La Salud A Breast and Cervical Cancer Screening program

for Farmworker Women

PROGRAM BACKGROUND

• NCFH received a grant from the CDC to develop, test, replicate and disseminate a breast & cervical cancer prevention program targeting Hispanic farmworker women.

• Goal - to increase breast and cervical cancer screening among Hispanic farmworker women 50 years of age and older.

• Used Promotora Model

• Door to door outreach

• Conducted educational sessions

• Made referrals to screening

• Follow-up

IMPLEMENTING THE PROGRAM

CLS TOOL KIT – A COMPREHENSIVE

HEALTH INTERVENTION

• Organizational Level - Manual for program adopters, e.g.: health center managers, promotora program coordinators, outreach directors.

• LHW Implementation Training - Curriculum to train promotoras how to implement CLS with farmworkers

• Community materials

Teaching guide w/ detailed lesson plans

Flipchart

Video

Breast model

Pamphlets

“SMALL MEDIA” MATERIAL

Flipchart & Video/DVD: • Role model stories

• Testimonials

• Addressing misconceptions and barriers

EVALUATION

STUDY DESIGN

• Intervention Trial:

Four matched sites randomly assigned to

2 Intervention sites (CA, TX)

2 Comparison sites (CA, NM)

• Target Population:

Hispanic women aged 50 years

Table 3—Intervention Effect: Screening Completion

by Study Group

Intervention Comparison P value a

Mammography

with follow-up

N=307

53/130 (40.8%)

53/177 (29.9%)

.041*

Pap test with

follow-up

N=170

32/81 (39.5%)

21/89 (23.6%)

.002*

* P<.05 a Adjusted for site location and demographics (generalized linear mixed model)

Fernandez ME, Gonzales A, Tortolero-Luna G, et al. Effectiveness of Cultivando La Salud: A breast and cervical

cancer screening promotion program for low-income Hispanic women. Am J Public Health. 2009; 99 (5): 936—943.

Ok, so it probably works,

now what?

13

ADAPTATION IMPLEMENTATION OF

CLS IN DIFFERENT SETTINGS

• Replication in Hays County Texas

• Adaptation of CLS for low-income

Hispanic women in Houston

• Adaptation of CLS for Hispanic women in

Puerto Rico

Cultivando La Salud (CLS) Houston, TX

Identify Screening Challenges in

Houston for Hispanic Women

Behavioral Level

• Health Literacy lacking

• Lack of trust in established services

Environmental Level

• Great need for primary care

Source: 2007 Community Health report

Adaptation focus on Environmental Factors & Matrices for Environmental Conditions in Houston

• Through the needs assessment we identified

challenges related to access issues faced by low-

income Hispanic women in Houston.

• Identify what women need to do to obtain a

screening exam - specific to the Hispanic

population in Houston (e.g., qualifying for Gold

Card)

• Develop new methods and materials related to

accessing free/low cost providers

Comparison between Houston CLS and Original

CLS Program Components

• To identify behavior and environmental conditions (and

determinants) that were different between the original and

CLS Program

• Reviewed how original education materials match the change

objectives of adapted program matrices

Adapted Training Program

• To identify areas for new promotora training modules

• Compared Houston CLS Training Performance Objectives to

Original CLS Program’s

CLS PROGRAM: TARGET POPULATION

Original Houston Adapted

• Mexican American

• Women (50 years +)

• Not adherent to screening

guidelines

• Farmworker communities along

the U.S.-Mexico border & in

California (central valley)

• Low-income

• Hispanic

• Not adherent to Pap Test

screening (21+ years) or

mammography screening (40+

years ) guidelines

• Residing in Houston, Gulfton,

(and expanded to Greater

Houston Area)

• Low income

• Intensive telephone-based

navigation services offered until

screening completed.

Target Population: • Hispanic/Latina women in Houston:

• 40 years of age and older who have not had a

mammogram in the past 2 years and/or

• 21 years of age and older who have not had a Pap test in

the past 3 years

• Without a previous diagnosis of breast or cervical cancer

Target Goal: 2,270 women • Recruit 1,563 Hispanic Women into the evaluation part of

the program.

• Administer educational material to an additional 707 women

as a community service.

Community Outreach

To ensure the program’s successful outreach and to increase our

reach and access to large numbers of eligible women for the

program, we

Developed an intensive recruitment strategy with our

community partner ProSalud.

Obtained active support from community-based organizations

who refer women to our promotora-delivered program, and

provide space for group sessions.

Created recruitment packets to gain organization support and

approval

Navigation

A community-based navigation program protocol was

developed to link women to cancer screening services in

the Greater Houston Area

The role of intensive navigator was also developed to

systematically manage hard to reach participants and those

with challenging barriers to cancer screening to provide

ongoing assistance in overcoming the barriers.

with follow-up All (Intent-to-Treat)

Intervention Controls Intervention Controls

No. (%) No. (%) p-value No. (%) No. (%) p-value

Mammography n=522 <0.000** n=810 0.007*

Screened 88 (38.4) 58 (19.8) 88 (21.7) 58 (14.4)

Not Screened 141 (61.6) 235 (80.2) 318 (78.3) 346 (85.6)

Pap n=297 <0.000** n=505 0.041*

Screened 71 (57.3) 48 (27.8) 71 (27.3) 48 (19.6)

Not Screened 53 (42.7) 125 (72.3) 189 (72.7) 197 (80.4)

Program Effectiveness

Cultivando La Salud (CLS) Minimal Adaptation for Puerto

Rican Women

Adapting CLS to PR

Research questions:

• Will CLS be effective in increasing

screening tests for breast and cervical

cancer among Puerto Rican women in the

study?

• Will the minimally adapted CLS be

acceptable to the Puerto Rican community?

CLS participants - PR

• Participants – Women ≥ 21 years old

• Without cancer diagnosis

• Without hysterectomy

• Non pregnant

– Non-Adherent to

Mammography

– Non-Adherent to Pap Test

Questions related to program fit:

• Are there different behaviors or sub-behavior

relevant (or not relevant) for PR women?

• How do the factors influencing breast and cervical

cancer screening in PR differ from those in other

Hispanic groups targeted with the CLS program?

• Are materials, delivery channels and strategies

used in the original program, feasible, acceptable,

and effective in PR?

Adapting CLS using Intervention Mapping

• Conducted 7 focus groups/interviews (3 adherent

+ 4 non adherent) with women 40+ years on breast

cancer and screening.

• Conducted 4 focus groups/interviews (1 adherent

group + 3 non adherent) with women 26-39 years

on cervical cancer and screening.

• Results were compared to original CLS matrices

and found to be very similar.

COMPARISONS OF DETERMINANTS INFLUENCING BREAST AND

CERVICAL CANCER SCREENING

Original Program- Cultivando la

Salud- Mexican Origin women

Low levels of

• Knowledge of breast and cervical

cancer and screening guidelines

• Outcome Expectations

• Perceived Barriers and Benefits

• Attitude (fear of detection, fear of

procedure and belief that cancer is

incurable)

• Low Self-Efficacy

• Low Perceived Social Norms

• Availability and Accessibility

Puerto Rico

Low levels of

• Knowledge of breast and cervical cancer and screening guidelines (not as low)

• Low knowledge of availability

• Perception of risk (partly due to the confusion of thinking BSE was protective)

• Perceived Barriers and Benefits

• Attitude (fear of detection, fear of procedure)

• Low Self-Efficacy

Outreach Program

Environmental Factors differ

considerably due to better access to

care in PR

Minimal adaption of CLS for PR

Element maintained: • Training curriculum

• Materials: flipchart,

delivery guides, tracking

tools.

• Same recruitment and

intervention protocols

ElementsAdapted: No use of DVD

Minor revision of specific

Added information on HPV and

HPV vaccine

A list of local resources and

screening centers was provided to

participants

Breast model with nodules is used in

the intervention to deliver the

message that BSE by itself is not a

protective screening method

Cultivando la Salud

– Goal: 484 participants

– Targeting women ≥ 21 years old

– Canóvanas residents

– Survey includes section on Human

Papillomavirus and the HPV vaccine

Incidence

Mortality

Taller Salud

Cultivando La Salud

***Intervention Effect***

Intervention

Group

N (%)

Comparison

Group

N (%)

p value

Mammography

screening

completion N=53

28 (19.7%)

25 (19.7%)

0.995

Pap Test

screening

completion N=43

29 (24.4%)

14 (12.3%)

0.017

Por Nuestras Hijas For Our Daughters

Study Population and Timeframe Target population

Hispanic parents of daughters (11-17 yrs)

Daughters not vaccinated against HPV

Spanish or English speaking

Recruitment Site: Clinics & clinic waiting rooms

Low-income areas in Houston, predominately Hispanic

Clinic has free vaccine (Vaccine for Children’s program)

Timeframe

Goal: Recruit 1,809 parents

6 month follow up after baseline with clinic record

validation

Why Use Photonovels?

Research* shows:

• People remember stories

better than a set of facts

• Stories build self-

confidence

• Stories reinforce culture

values and norms to

promote healthy behaviors

• Stories can be used in

creative ways to motivate

and mpower people

regardless of age or

reading ability

* Doak, et al. Teaching Patients with Low Literacy Skills, 1996.

From: Pregnancy & Diabetes: Lucia’s Story

Published by Auger Communications, Inc.

For Our Daughters - Por Nuestras Hijas The Intervention: Fotonovela

For Our Daughters fotonovela:

available in English and Spanish

addresses key determinants

Tailored Interactive Communications

Approaches

Strategies for Achieving Tailoring Goals

• Personalization

• Feedback

• Content matching

For Our Daughters - Para Nuestras Hijas

The Intervention: Tailored Interactive Program on iPad

Moving video

Stills with audio

Graphics and Animation

Data-based tailoring

Self- Tailoring

Tailoring: Perceived Susceptibility & Vaccine Efficacy

Developed Training Programs

LHW 2 ½ Day Training Developed &

Implemented

1) Introduction,

2) Study Objectives,

3) Study Protocols,

4) HPV & Cervical Cancer,

5) HPV vaccine,

6) Study Design and LHWs’ Roles,

7) Overview of Intervention Materials,

8) Forms

9) iPad practice

10) Fotonovela practice

11) Q &A sessions

Evaluation Design

Group Randomized Intervention Trial

1)Baseline: Data collectors

recruit, consent & conduct

face-to-face computer-assisted

interviews with parents

in clinic waiting rooms

2) LHWs deliver intervention in

Intervention clinic sites]

3) Follow-up: Data collectors

conduct 6 month follow-up by

telephone plus clinc record

validation

Preliminary Findings

Comparison Odds Ratio (95% CI) p-value

Control vs TIMI 1.979 (1.238-3.164) 0.004*

Control vs Fotonovella 1.325 (0.884-1.985) 0.17

Fotonovella vs TIMI 1.494 (0.973-2.294) 0.0665

Click to edit Master title style

Linking Callers to Cancer Control Services:

A University of Texas CPCRN (LINCC) and

TEXAS 2-1-1 Collaboration

Improving ACCESS

2-1-1 Texas Helpline

• 2-1-1 is a nationally designated 3-digit

telephone exchange connecting callers to

health and social services within their

community.

• It is operated by state and local systems, often

in partnership with local public or private

agencies.

• There are 209 2-1-1 systems in 46 states and

Washington, DC and Puerto Rico, covering

over 80% of the U.S. population.

2-1-1Program

• 2-1-1 callers call for

Utilities, Medical, Food,

and Shelter needs

• Call specialists

administer risk

assessment

• Eligible and consenting

participants are placed

into a navigation/control

intervention

Telephone follow-up 1 and 4 months later

- Did they contact referrals?

- Did they obtain needed services?

Participant Demographics N % of total Sample

Gender Male

Female

514

5596

8

92 Median Age Male Age

Female Age 46yrs old

38yrs old --

-- Race/Ethnicity Hispanic

White

Black

Other

2937

393

2586

142

47

6

42

2 Marital Status Divorced

Living with someone

Married

Separated

Single

Widowed

637

331

1576

826

2380

290

10

5

25

13

38

5

Highest Level Education Less than High School

Diploma/GED

Vocation/tech/Assoc

degree

Bachelors or Higher

1179

2898

1674

295

19

47

27

Income None

<10k

10-20k

20-30k

30-40k

40+

282

2267

2038

777

204

157

5

36

32

12

3

3

Cancer Risk Factors & Prevention Needs: 2-1-1 Texas Callers:

Houston, Weslaco, El Paso vs. Texas and U.S. (2013)

Risk factor or preventive measure Respondents (n) 2-1-1

Houston

2-1-1

Weslaco

2-1-1

El Paso TX** U.S.**

No health insurance All (n=6214) 40% 71%

71%

30% 19%

Had mammogram in the last 1-2 years Women, 40+ (n=2585) 57% 50%

60%

70% 76%

Had Pap smear in the last 3 yrs Women, 18+ (n=5563) 72% 84% 92% 79% 81%

Ever had a colonoscopy Men & women, 50+

(n=1642)

45% 28% 44% 62% 65%

Received HPV vaccination (self) Women, 18-26 (n=984) 18% 12% 22% 15% 17%

Received HPV vaccination (daughter) Have daughters, 9-17

(n=1436)

44% 55% 55% 38 44%

Current cigarette smoker All (n=6214) 23% 7% 7% 19%* 21%*

**BRFSS 2010, *BRFSS 2011 median percentage

Navigator Responsibilities • Navigators work with 2-1-1 participants:

– Provide referrals

– Answer Questions

– Describe importance of and education on screenings

– Assist with setting up appointments for cancer screenings

– Identify and address barriers

– Arrange transportation to and from appointments

• Referrals and cancer screening services include: – Breast

– Cervical

– Colorectal

– HPV vaccine for women, girls and boys

– Smoking Cessation

– Smoke-free Home Policies

Goal of 2-1-1 Collaboration • Community Outreach collaborates with

2-1-1 call centers to:

– conduct a needs assessment

– implement an intervention to increase

cancer screening and vaccination, and

tobacco cessation

Gulf Coast 2-1-1

~60,000 a month

Rio Grande 2-1-1

~ 7,200 calls a month

Tip of Texas 2-1-1

~ 5,000 a month

Linking Callers to Services

• Participating Call Centers:

– Houston

– Weslaco

– El Paso

• Number of Surveys

Completed

– Risk Assessment n=over 4000

– Intervention study n=1300

Implementation Challenges for

Further Investigation

• Scientific research administration in

a service oriented environment

• 2-1-1 Competing responsibilities

• Commitment of collaborators

• Implementation practices

• Quality control

• Support & Continuity

Our Vision

• The potential of this work goes far beyond using 2-

1-1 as a recruitment venue for surveys and

interventions to reach poor Americans…

• The big payoff is helping an established service

organization with broad reach in disparity

population use EB cancer control strategically.

• Provides opportunities for advancing

dissemination and implementation research.

Potential Public Health Impact

2-1-1 Systems take an estimated 16 million calls annually

With the potential of reaching 5 million smokers,

3.1 million women in need of Pap tests,

2.6 million women needing mammograms,

2.3 million women needing the HPV vaccination,

1.9 million with daughters in need of the HPV vaccination,

1.9 million in need of colonoscopies

Gracias