Designed to increase cervical and breast cancer screening among Mexican American women, this community-based intervention promotes screening through mass media messages and community volunteers who act as role models in the media messages, reinforce those messages in face-to-face interactions, and distribute materials. The study showed an increase in Pap smear screening rates.
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Cancer is the second leading cause of death in the United States. Two of the most treatable cancers-- cervical and breast cancer-- disproportionately impact Latina women. The cervical cancer incidence rate for Latinas in the United States is twice that of Anglo women, but Latinas are less likely than Anglo women to participate in preventive cancer screening, and nearly 20 percent of Latinas over age 18 are non-compliant with Pap smear screening guidelines. Latinas have a lower breast cancer morbidity rate than Anglo women, but also a lower 5-year survival rate because detection frequently occurs in the late stages of the disease. Among Mexican American women specifically, mammogram screening rates have increased but remain lower compared with those of other women in the United States. Mexican American women are less likely than Anglo women to participate in breast cancer screening, particularly if they are recently immigrated, only speak Spanish, and are older. Community cancer prevention and education programs have included Latinos as a priority population, but only a handful have incorporated culturally relevant messages tailored to their needs.
A Su Salud en Acción is a 2-year community intervention consisting of a mass media and peer volunteer campaign to promote breast and cervical cancer screening among Mexican American women. The combination of media messages and community activities seeks to modify the target population's perception of cancer risk, screening barriers and benefits, self-efficacy, and outcome expectations. Media messages are provided in both English and Spanish via print, radio, and television. The intervention mobilizes a network of volunteers or "networkers" who are recruited from the community (e.g., from churches, community health clinics, and schools and/or through community outreach) and act as role models through media messages and in face-to-face interactions within the community. These individuals are early adopters with the same socioeconomic, ethnic, and cultural characteristics as the target audience, which may enhance the credibility of the cancer screening messages. In addition to being featured in the media messages, the community volunteers make personal contact with friends, relatives, co-workers, and neighbors to discuss the media messages and provide positive reinforcement for any health change effort. The volunteers distribute bilingual community bulletins at the beginning of each month in face-to-face interactions with members of their community. The bulletins include a calendar of upcoming television or radio features about positive role models (i.e., stories about women who are receiving Pap smears and mammograms), listing the channel, time, and program title; written stories and pictures about role models; and other information to encourage individuals to participate in screening, such as a list of clinical cancer-screening sites, fee schedules, phone numbers, and clinic times. Community volunteers also distribute a mid-month bilingual recipe flyer that typically promotes a traditional menu item (featuring foods low in fat and high in vitamins and fiber), accompanied by a picture of its author (either a volunteer or other community member).
Community Preventive Services Task Force Finding
A Su Salud en Acción is designed to be implemented over a minimum of a 2-year period, with weekly television and newspaper stories and monthly materials distribution. Although the time required to implement each aspect of the intervention may vary depending on community needs, screening goals, scope of activities, and resources available, a sample timeline is provided in the manual for the first year of implementation. Phase I, program planning and preparation, takes approximately 3-4 weeks. Phase II, which includes an analysis of the community and the local media and training of program staff, takes approximately 5-6 weeks.
The intervention is intended for low income Latinas in particular Mexican American women aged 18 years and older.
The intervention is intended for use in underserved, urban, predominantly Latino (i.e., Mexican American) communities.
Required resources for this program include the A Su Salud En Acción Manual, available in PDF or eBook versions, with accompanying video files.
For costs associated with this program, please contact the developer, Amelie Ramirez. (See products page on the EBCCP website for developer contact information.)
About the Study
The study was conducted in selected census tracts in two underserved, urban, predominantly Mexican American neighborhoods in Texas. San Antonio's West Side was selected to receive the program intervention, and Houston's Navigation area was selected as a comparison community. Women of Mexican origin who were 18 years or older and resided in the selected neighborhoods were eligible to participate in the study. Participants were selected randomly for baseline data collection. Pap smear and mammogram screening compliance were measured at baseline through in-person interviews. Prior to the baseline interview, participants were asked their preferred language (English or Spanish) to conduct the interview; language preference was also used in subgroup analyses. Approximately 2 years after the baseline interview, follow-up telephone interviews were conducted with those women who were non-compliant with the National Cancer Institute's cancer screening guidelines, as reported during the baseline interview. Women were selected for follow-up interviews if they had never had a Pap smear or had not completed a Pap smear in the 2 years prior to the baseline interview, or if they were older than 40 years of age and had never had a mammogram or had not completed a mammogram in the 2 years prior to the baseline interview. The second panel follow-up was conducted with non-compliant women over the phone 1 year later. A second follow-up telephone survey was conducted approximately 1 year after the first follow-up interview, following the conclusion of the intervention activities. Women were selected for this follow-up interview if they had never had a Pap smear or had not completed a Pap smear in the 12 months prior to the first interview, or if they were older than 40 years of age and had never had a mammogram or had not completed a mammogram in the 12 months prior to the first interview.
Pap smear screening compliance was measured by combining the answers to the following questions: "When did you have your most recent Pap smear?" and, if the respondent could not provide an exact date, "Was your Pap smear done less than a year ago, between 1 and 2 years ago, between 2 and 3 years ago, or more than 3 years ago?" The answers to these items were combined and coded as one dichotomous variable with two values: complied with cancer screening (had a Pap smear in the last 2 years) or did not comply with cancer screening (has never had a Pap Smear or had a Pap smear more than 2 years ago).
Mammogram screening compliance was measured using similar items: "When did you have your most recent mammogram?" If the respondent could not provide an exact date, then she was asked, "Was your mammogram done less than a year ago, between 1 and 2 years ago, between 2 and 3 years ago, or more than 3 years ago?" The questions about mammograms were asked only if the respondent was 40 years of age or older. The answers to these items were combined and coded in the same way as the items to assess Pap smear screening.
- Pap smear screening rates among women under the age of 40 were significantly higher in intervention neighborhoods than in comparison neighborhoods (p<.05).
Additional Findings From Reviewed Study
- For Pap smear screening, analyses of the first panel follow-up revealed a negative finding when results were analyzed by age subgroup. Women over 40 from comparison neighborhoods were significantly more likely to report a recent Pap smear compared with women in intervention neighborhoods (p<.05). At the second panel follow-up, there were no significant differences between the intervention and comparison neighborhoods in Pap smear screening rates, either for the entire sample or by subgroup.
- For mammogram screening, at both the first and second panel follow-ups, there were no significant differences between intervention and comparison neighborhoods, either for the entire sample or by language subgroup. (Age subgroup analyses were not conducted for this outcome.)
Additional Findings From a Maintenance Study Not Rated by EBCCP
The findings reported above are from a 2003 study that analyzed data collected more than 10 years ago. EBCCP accepted the study for review based on the existence of a more recent study of A Su Salud en Acción that reported significant findings. This maintenance study could not be rated because it did not utilize a quasi-experimental or experimental study design; however, key findings from this study are described below.
A 2011 study was conducted as a replication of A Su Salud en Acción in two Nevada community clinics serving a large Latino community. The intervention was designed for low-income Latinas aged 50-64 who were eligible for NBCCEDP (National Breast and Cervical Cancer Early Detection Program) screening funds. The intervention was implemented by trained lay public health workers. The evaluation used a single-group, pre-test/post-test design, with a pilot test at one clinic and a replication at the second clinic. Baseline and post-intervention screening data were estimated based on data collected retrospectively by the State contractor for the Women's Health Connection, which oversees all NBCCEDP funding sites in Nevada. A summary of grouped screening data was provided to the research team as annual rates per thousand women based on the 2000 Census age-eligible women for each site.
At both the pilot and replication sites, the program significantly increased screening mammogram rates (pilot: 58.7%, replication: 33.7%) and Pap smear rates (pilot: 51.8%, replication: 7.5%) from baseline to post-intervention.
Ramirez AG, Chalela P, Suarez L, Gallion KJ. (2011). A Su Salud En Accion: Replicating a Model to Increase Utilization of Cancer Screening among Low Income Latinas. Journal of Health Disparities Research and Practice, 5 (1), 65-79.
McAlister AL, Fernández-Esquer ME, Ramirez AG, Trevino F, Gallion KJ, Villarreal R, Pulley LV, Hu S, Torres I, Zhang Q. (1995). Community level cancer control in a Texas barrio: Part II--Base-line and preliminary outcome findings. Journal of the National Cancer Institute. Monographs, 18, 123-126. Bethesda, MD: National Cancer Institute.
Ramirez AG, McAlister A, Gallion KJ, Ramirez V, Garza IR, Stamm K, de la Torre J, Chalela P. (1995). Community level cancer control in a Texas barrio: Part I--Theoretical basis, implementation, and process evaluation. Journal of the National Cancer Institute. Monographs, 18, 117-122. Bethesda, MD: National Cancer Institute.