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Promotoras for cancer prevention

Female cancer survivors turned lay health educators offer personal approach to screening among their own trusted circles of friends
Pap test
Studies show Hispanic women have about twice the risk of developing invasive cervical cancer compared to non-Hispanic women. By encouraging Pap tests and other forms of cancer screening, promotoras may impact cure rates. Photo by Todd McNaught

Hispanic female cancer survivors who are trained as lay health educators can increase cancer-screening rates among their network of family members and friends, according to a pilot study by researchers in the Public Health Sciences Division.

Drs. Carol Moinpour, Donna Pauler and Polly Feigl of the Southwest Oncology Group (SWOG) Statistical Center helped design a pilot study to evaluate the feasibility of using promotoras — lay health educators — to convey cancer information and encourage cervical- and breast-cancer screenings in the under-tested Hispanic community. Since the study was conducted, Pauler began work at another research center, and Feigl retired. Lisa Hansen, a nurse-researcher at the Columbia River Community Clinic Oncology Program (CCOP) directed the single-institution study through SWOG. Findings were published in the January-February 2005 issue of the journal Cancer Nursing.

Increasing screening rates could have a major impact on cancer-cure rates in the Hispanic community. Hispanic women have about twice the risk of developing invasive cervical cancer compared to non-Hispanic women. While regular screening for cervical cancer with Pap smears can detect the disease at an early, curable stage, Hispanic women are less likely to get regular Pap tests. Just 44 percent of recent Hispanic immigrants seek cervical-cancer screenings.

Breast-cancer screening is also low in this population. Among foreign-born Hispanic women over 40 years old, 62 percent have never had a mammogram.

Barriers to screening

A number of cultural issues, access barriers and misconceptions about cancer contribute to the low screening rates, said Moinpour, a behavioral scientist for the SWOG Statistical Center. "Language can be a problem, as can lack of medical insurance or access to medical care," she said. "There are also false beliefs that cancer is always fatal, and you can't do anything about it. The intervention was designed to address these issues."

While the idea of training community members to convey health messages to their peers is not a new one, this study was the first at the time to use cancer survivors in the role. The study also represented a first attempt to implement the promotora concept in a cooperative group setting.

SWOG is one of the largest organizations in the world sponsoring clinical trials of cancer in adults. It is supported as one of the cooperative groups funded by the National Cancer Institute and is a network of almost 4,000 physicians at 283 institutions throughout the United States and Canada. SWOG serves as a research base for its membership by designing and implementing cancer clinical trials and reporting the results of its studies. CCOPs allow patients with cancer to be treated in their own communities; the program also involves community oncology clinics in clinical research and delivers research-based treatment to patients nationwide.

The pilot study was conducted at the San Antonio Minority-Based CCOP for 18 months. About 56 percent of San Antonio's residents are Hispanic. Promotoras were recruited from a private oncologist's office in the community. The five bilingual Hispanic women attended a 12-week training course, which focused on cancer information and treatment, teaching skills and screening facts. All of the promotoras volunteered their time.

From conversations to care

Using contact logs to document their activities, the promotoras shared breast- and cervical-cancer screening information with friends, relatives and community members. Over a 13-month period, 141 women were contacted by the promotoras. Women without medical insurance or an established relationship with a health-care provider were offered free or reduced-fee screening at community health clinics. Just over 35 percent of the contacts obtained a mammogram and/or Pap smear during the study period. Mammograms were sought by 29 of the women, and 43 received a Pap smear. Screenings were noted by postcards returned by medical offices and by review of the community health clinic records.

"It was interesting to note how many of the conversations took place in homes," Moinpour said. "That shows the level of intimacy, reflective of the promotora's personal network. The educators were dealing with people they knew, and they were able to contact a large number of people."

Other PHS researchers have led studies that relied on the use of lay educators in Hispanic and other minority communities. "It is a feasible approach for cancer prevention and control studies," Moinpour said.

"It just makes sense to use the promotora approach," she said. "A woman who is not as knowledgeable about diseases would most trust someone she knows, and therefore could be more likely to engage in a particular screening behavior. The educators are not only family members or friends but women who have had cancer; therefore, they are speaking from experience."

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