Effectiveness of a Community Health Worker-Delivered Intervention to Increase Breast and Cervical Cancer Screening Among Medically Underserved Hispanics
Authors: Savas L.S. , Heredia N.I. , Coan S.P. , Fernandez M.E. 
Published: September 2018

Background: Underutilization of preventive breast and cervical cancer screenings contributes to later stage breast cancer diagnoses and lower survival rates, as well as higher cervical cancer incidence and mortality among Hispanics compared with non-Hispanic whites. To increase screening among medically underserved Hispanic women in urban settings, we adapted an evidence-based community health worker (CHW)-delivered screening education and referral intervention ( Cultivando la Salud) developed and evaluated among rural Mexican American migrant farmworkers. CHWs delivered the adapted intervention for Hispanics residing in Houston, Texas. The adaptation focused on intervention and implementation strategies, resulting in modifications, such as group education rather than one-on-one education and an expanded cancer prevention coaching and navigation intervention to remove barriers and facilitate access to care. Aim: We examined the effect of the adapted intervention on increasing Pap and mammography screenings. Methods: To assess effectiveness, we conducted a randomized controlled trial among nonadherent women based on American Cancer Society screening guidelines. CHWs recruited women in community settings using structured eligibility forms, and bilingual data collectors confirmed eligibility, consented women, and conducted telephone-based baseline and 6-month follow-up surveys. We conducted both intent-to-treat and per-protocol analyses using logistic regression to evaluate intervention effect on mammogram and Pap completion. Covariates significant in univariate analyses ( P < 0.20) were included in the final models, and time to follow-up was adjusted in per protocol analyses. Results: We enrolled 1,025 women and randomized women to intervention and control (delayed intervention) groups. Among women followed-up, 39.9% received a mammogram in the intervention group compared with 20.3% in the control group ( P = 0.001) and 55.8% received a Pap screening in the intervention group compared with 27.4% in the control group ( P = 0.001). Women in the breast cancer screening intervention group had 2.02 increased odds of receiving a mammogram compared with women in the control group, based on the adjusted intent-to-treat analysis (adjusted OR=2.02, 95% CI: 1.42-2.87) and 2.17 time greater screening odds in the adjusted per protocol analysis (adjusted OR=2.17, 95% CI: 1.48-3.18). Women in the Pap screening intervention group had 1.84 increased odds of completing a Pap screening based on the adjusted intent-to-treat analysis (adjusted OR=1.85, 95% CI: 1.22-2.80) and 3.09 increased odds based on the adjusted per protocol analysis (adjusted OR=3.09, 95% CI: 1.88-5.08). Conclusion: This RCT intervention trial provides evidence that the adapted intervention effectively increased breast and cervical cancer screenings among underserved Hispanic women. Future intervention and implementation research to further strengthen the intervention effect is needed.