Intervention IP-081: De Casa en Casa: Cervical Cancer Screening in West and South Texas
Summary
The De Casa en Casa program is a theory-based, multicomponent, and culturally tailored cervical cancer screening intervention that addresses barriers to screening to increase screening rates among predominantly Latinix women along the US-Mexico border. The program provided bilingual health education, no-cost screening and diagnostic services, and navigation services for women 21 to 65 years old who are uninsured or underinsured. Study findings showed that culturally appropriate group education targeted to Hispanic women is as effective as individual education.
Overview
To improve cervical cancer screening uptake among Latinx women in West and South Texas and determine whether individual or group education was more effective at increasing screening rates
Research-Tested — Interventions with strong methodological rigor that have demonstrated short-term or long-term positive effects on one or more targeted health outcomes to improve minority health and/or health disparities through quantitative measures; Studies have a control or comparison group and are published in a peer-review journal; No pilot, demonstration or feasibility studies.
Intervention Details
Both Community and Academic/Clinical Researchers
Citations:
-
Shokar NK, Calderon-Mora J, Molokwu J, Byrd T, Alomari A, Mallawaarachchi I, Dwivedi A. Outcomes of a Multicomponent Culturally Tailored Cervical Cancer Screening Intervention Among Underserved Hispanic Women (De Casa en Casa). Health promotion practice. 2021 Jan;22(1):112-121. Epub 2019 Dec 24. PubMed
DOI
Relevance: Post-Intervention Outcomes, Main Intervention -
Calderón-Mora J, Byrd TL, Alomari A, Salaiz R, Dwivedi A, Mallawaarachchi I, Shokar N. Group Versus Individual Culturally Tailored and Theory-Based Education to Promote Cervical Cancer Screening Among the Underserved Hispanics: A Cluster Randomized Trial. American journal of health promotion : AJHP. 2020 Jan;34(1):15-24. Epub 2019 Aug 27. PubMed DOI
Relevance: Post-Intervention Outcomes -
Calderón-Mora J, Alomari A, Shokar N. Comparison of Narrative Video and Flipchart Presentation to Promote Cervical Cancer Screening Among Latinas Along the Border. Health education & behavior : the official publication of the Society for Public Health Education. 2022 Feb 3: 10901981221074918. Epub 2022 Feb 3. PubMed DOI
Relevance: Evaluations and Assessments
Yes
AMIGAS (Ayudando a Las Mujeres con Información, Guía y Amor para su Salud)
Theresa L. Byrd, DrPH, RN; Dean, School of Health Professions at University of Texas at Tyler
https://www.cdc.gov/cancer/cervical/amigas/index.htm
Citations:
-
Byrd TL, Wilson KM, Smith JL, Coronado G, Vernon SW, Fernandez-Esquer ME, Thompson B, Ortiz M, Lairson D, Fernandez ME. AMIGAS: a multicity, multicomponent cervical cancer prevention trial among Mexican American women. Cancer. 2013 Apr 1;119(7):1365-72. Epub 2012 Dec 21. PubMed PubMed Central DOI
-
Smith JL, Wilson KM, Orians CE, Byrd TL. AMIGAS: building a cervical cancer screening intervention for public health practice. Journal of women's health (2002). 2013 Sep;22(9):718-23. Epub 2013 Aug 9. PubMed PubMed Central DOI
-
Byrd TL, Wilson KM, Smith JL, Heckert A, Orians CE, Vernon SW, Fernandez-Esquer ME, Fernandez ME. Using intervention mapping as a participatory strategy: development of a cervical cancer screening intervention for Hispanic women. Health education & behavior : the official publication of the Society for Public Health Education. 2012 Oct;39(5):603-11. Epub 2012 Mar 1. PubMed DOI
No
The original program did not provide any clinical services. Therefore, only intention to be screened could be measured. In De Casa en Casa, we were able to measure actual completion of screening.
Contact Information
Jessica Calderon-Mora
The University of Texas at Austin Dell Medical School
https://ebccp.cancercontrol.cancer.gov/programDetails.do?programId=35029701
jessica.calderonmora@austin.utexas.edu
915-443-0272
Results
Improve minority health or the health of other populations with health disparities (e.g. rural populations, populations with low SES)
Cervical cancer screening
Attitudes and beliefs
We enrolled 300 women;150 in the group education (intervention) arm and 150 in the individual education (control) arm. Of all the participants, 85.7% completed the follow-up survey. Differences in screening rate at follow-up were analyzed by education type. Overall screening rate at follow-up was 73.2%; no significant difference by education type (individual: 77.6%, group: 68.9% P=.124). There were significant increases among group education at follow-up for knowledge (regression coefficient =0.79, P<.001), perceived susceptibility (regression coefficient =0.54, P<.001), perceived seriousness (regression coefficient =0.26, P<.001), and significant decrease for perceived benefits (regression coefficient =-0.63, P=.026).
Descriptive statistics were used to summarize demographic characteristics. Responses from items for each behavioral construct were summed and averaged to create a scale score. Change scores were calculated by subtracting the baseline score from the 4-month follow-up survey score. Relative risk (RR) regression analyses were conducted to assess the unadjusted and adjusted effects of group education on the uptake of screening compared to individual education.
The primary difference between the main intervention paper and the paper comparing group vs. individual education was that the main intervention paper utilized self-reported screening completion whereas the group vs. individual education paper utilized actual pathology results as the outcome. Self-reported data were used initially due to lack of EMR data being available at the time. Actual statistical analysis was similar for both papers; however, the primary outcome differed as described.
Evaluations and Assessments
No
Demographic and Implementation Description
Cervical Cancer
Hispanic or Latino, White
People with Lower Socioeconomic Status (SES), Racial and Ethnic Minority Populations, Underserved Rural Communities
Young Adults (18 - 39 years), Middle-Aged Adults (40 - 64 years)
Socio-demographics / Population Characteristics
Rural, Urban / Inner City, We included colonias within El Paso County Texas.
People with Low Education
Texas
Low SES
Minority Health and Health Disparities Research Framework
| Levels of Influence | |||||
|---|---|---|---|---|---|
| Individual | Interpersonal | Community | Societal | ||
| Determinant Types | Biological | ✔ | ✔ | ||
| Behavioral | ✔ | ✔ | ✔ | ||
| Physical / Built Environment | ✔ | ✔ | ✔ | ||
| Sociocultural Environment | ✔ | ✔ | ✔ | ✔ | |
| Health Care System | ✔ | ✔ | |||
Community Involvement
The community's role in different areas of the Intervention (Choices are "No Role", "Participation", and "Leadership"):
Participation
Participation
Participation
Participation
Participation
Participation
Participation
Participation
Characteristics and Implementation
Behavior Change
Secondary Prevention
Clinic / Health Care Facility, Home, Local Community (e.g. Barbershops, Beauty / Hair Salon, Laundromats, Food Markets, Community Centers), Parks and Recreation, Houses of Worship, Schools / Colleges
In-person
Community Health Worker/Promoters
Conceptual Framework
Health Belief Model, Social Cognitive / Social Learning Theory, Theory of Reasoned Action / Planned Behavior
Social Ecological Model
Implementation
Cluster Randomized Controlled Trial
300
257
2013
2016
Intervention Exposures
4-6 months
Once
1-2 Sessions
1-2 Hours
Group (e.g. Community leaders), Individual
Grade 6-7
Adaptations and Modifications
| Intervention Elements | Modified |
|---|---|
| Content |
Yes |
| Context |
Yes |
| Implementation |
Yes |
| Funding |
Yes |
| Organization |
Yes |
| Participants |
Yes |
| Providers |
No |
| Sociopolitical |
No |
| Stages of Occurrence | Yes |
Modification Details
| Explanation | |
|---|---|
| Content | |
|
Adding Elements, Tailoring, None |
For the De Casa en Casa program, we updated and revised the implementation guide used to train community health workers. We also adapted the AMIGAS flipchart presentation and narrative educational video to ensure it had updated cervical cancer screening guidelines, recent statistics, and included new infographics that were more interactive. We created shorter videos that were used as part of the education and adapted the flipchart presentation to a PowerPoint slide presentation. |
| Context | |
|
Format, None |
As a result of changing cervical cancer screening guidelines, we updated all guideline information to ensure it was current. We also updated statistics on incidence, mortality, and survival. Finally, we created new, modern, interactive infographics and narration that were included within the educational video. |
| Implementation | |
|
Delivery, Exposure, Study Design |
The implementation was essentially the same as was done for AMIGAS with enrollment and education conducted by a community health worker. For one of the research studies, we did randomize participants to group or one-on-one education based on recruitment site. Sessions were facilitated in an identical manner with the only difference being that groups were able to have interactive discussions. |
| Funding | |
|
State Government |
The AMIGAS program was funded through the Centers for Disease Control and Prevention, whereas the De Casa en Casa program was funded through Cancer Prevention and Research Institute of Texas. |
| Organization | |
|
Location |
The De Casa en Casa program recruited from community-based organizations, academic health centers, faith-based organizations, and community healthcare centers. |
| Participants | |
|
None |
The AMIGAS program was unable to provide screening services. Therefore, the De Casa en Casa program differed in that it prioritized women who were 21 to 65 years old, were uninsured and underinsured, and who had not had a Pap smear in the past 3 years. |
| Stages of Occurrence | |
|
Implementation, Planning/Pre-implementation/Pilot |
The intervention was modified for De Casa en Casa during the planning and pre-implementation stages through tailoring and development of the implementation guide, presentation, and educational video, as well as through the implementation phase where the video could be shown on a tablet or mobile device as it was available online. In the original AMIGAS program, it was shown in waiting rooms or dedicated community centers and was not available online. |
Impact, Lessons, Components
Yes
As a result of our findings, we recognized that participants could receive health education in a group setting. This allowed our program CHWs to provide health education to women needing cervical cancer screening in a group, rather than one-on-one. This was especially helpful during the pandemic when many Pap test appointments were canceled, but our CHWs would find groups of women at community events or health fairs and could provide a group presentation using our health educational materials.
Facilitation of the health education components by the CHW is critical for its success in immigrant, low socioeconomic status, and underserved populations. Our CHWs were hired from the very communities we served, therefore providing relatability and stronger rapport with participants.
As a result of our findings, we recognized that participants could receive health education in a group setting. This allowed our program CHWs to provide health education to women needing cervical cancer screening in a group, rather than one-on-one. This was especially helpful during the pandemic when many Pap test appointments were canceled, but our CHWs would find groups of women at community events or health fairs and could provide a group presentation using our health educational materials.
Lessons Learned
The most important takeaway is that group education is as effective as one-on-one education in increasing cervical cancer screening completion rates.
Insights Gained During Implementation
| Insight Category | Insight Description |
|---|---|
| Cost of Implementing or Sustaining | Although no formal cost-effective analysis was conducted, our findings indicated that any health educator or other staff providing health education would be able to deliver cervical cancer education in a group setting, rather than just one-on-one, which is practical and requires less staffing. |
| Logistics | We experienced loss to follow-up for the 4-month follow-up survey due to change in phone numbers, participants moving, or no answers or call-backs. This is not uncommon, however, it may be helpful to also obtain e-mail addresses from all participants so that a link to the survey can be e-mailed. |
| Administrative Resources | We learned that less staffing would be needed to facilitate the health education as we found that group education in groups no larger than 9 women were successful in increasing screening completion. It was also helpful for the CHWs to build a relationship with the staff of recruitment sites. |
| Equipment / Technologies | Through other related studies, we found that the video or flipchart could be shown online with no CHW facilitation and this method proved to also be successful in increasing screening completion. This could be via a YouTube link or link to the program website. |
| Training / Technical Assistance | Through this study and others, we learned that 2-3 days of training, role-playing, and shadowing of CHWs or other staff who would deliver the education would be sufficient to provide the appropriate message in a consistent manner. |
| Transportation | In further studies evaluating our health education materials, we found that providing a link to our narrative educational video was successful at increasing screening completion with no interaction with a CHW. Therefore, women would not have to travel to a site to receive the health education. |
| Staffing | e learned that less staffing would be needed to facilitate the health education as we found that group education in groups no larger than 9 women were successful in increasing screening completion. |
| Recruitment | Through this study, as well as through observation of our CHWs, we learned that building rapport with participants prior to introducing the study allowed for more successful enrollment outcomes. |
Intervention Components
Yes
No
Products, Materials, and Funding
| Used for Implementation | Needed for Sustainability | |
|---|---|---|
| Expertise | ||
|
Clinical Care |
Yes | Yes |
|
Health Education / Health Literacy |
Yes | Yes |
|
Key informants, Tribal leaders, Community gatekeepers |
Yes | Yes |
|
Patient Navigation |
Yes | Yes |
|
Research/Data science |
Yes | Yes |
|
Translation/linguistics |
Yes | Yes |
|
Community mobilization, community organization/coalition building |
Yes | Yes |
| Partnerships | ||
|
Universities |
Yes | Yes |
|
Community groups (e.g. faith-based organizations, barbershops, beauty-salons, laundromats, food markets, community centers, cultural associations, tribal groups) |
Yes | Yes |
|
Health care facilities (local clinics) |
Yes | Yes |
|
Media outlets (print/broadcast/social media) |
Yes | Yes |
|
School system (e.g. school administrators, health educators, daycares, preschools, private & public schools) |
Yes | Yes |
| Funding Sources | ||
|
Public funding (e.g., federal, state or local government) |
Yes | No |
Product/Material/Tools
| Tailored For Language | Language(s) if other than English | Material | |
|---|---|---|---|
| Outreach/Recruitment Tools | |||
|
Enrollment Packet [English]: Eligibility Form, Intake Form/Risk Factor Survey, Service Consent Form, Education Session Form, Screening Process Form, Promise Sheet, Promotional Flyer, Educational Leaflet, Resource List |
No |
Attachment available for request at the bottom of the page. |
|
|
Enrollment Packet [Spanish]: Eligibility Form, Intake Form/Risk Factor Survey, Service Consent Form, Education Session Form, Screening Process Form, Promise Sheet, Promotional Flyer, Educational Leaflet, Resource List |
Yes |
Spanish |
Attachment available for request at the bottom of the page. |
| Participant Educational Tools | |||
|
Videos |
No |
https://youtu.be/TCI-DbrMIR4
|
|
|
Videos |
Yes |
Spanish |
https://youtu.be/IDzXfmM4Z5c
|
|
Videos |
No |
https://youtu.be/intZwfwiF-Y
|
|
|
Videos |
Yes |
Spanish |
https://youtu.be/2CGdVlucg3U
|
|
Videos |
No |
https://youtu.be/xe0d96SRuGk
|
|
|
Videos |
Yes |
Spanish |
https://youtu.be/8__GS_46h30
|
|
Flipchart Presentation [English] |
No |
Attachment available for request at the bottom of the page. |
|
|
Flipchart Presentation [Spanish] |
Yes |
Spanish |
Attachment available for request at the bottom of the page. |
| Measurement Tools | |||
|
Standardized Instrument/Measures |
No |
Attachment available for request at the bottom of the page. |
|
|
Standardized Instrument/Measures |
Yes |
Spanish |
Attachment available for request at the bottom of the page. |
|
Standardized Instrument/Measures |
No |
Attachment available for request at the bottom of the page. |
|
|
Standardized Instrument/Measures |
Yes |
Spanish |
Attachment available for request at the bottom of the page. |
|
Standardized Instrument/Measures |
No |
Attachment available for request at the bottom of the page. |
|
|
Standardized Instrument/Measures |
Yes |
Spanish |
Attachment available for request at the bottom of the page. |
Implementation Materials and Products
| Material | |
|---|---|
| Implementation/Delivery Materials | |
|
Coordinator or Facilitator’s Guides |
Attachment available for request at the bottom of the page. |
| Implementation/Output Materials | |
|
Websites (include URL/link) |
https://ebccp.cancercontrol.cancer.gov/programDetails.do?programId=35029701
|
|
Social/traditional media publicity/news coverage |
https://www.facebook.com/CPEP.DeCasa/
|
|
Social/traditional media publicity/news coverage |
https://www.instagram.com/decasaencasa_ttuhscep/?hl=en
|
|
Websites (include URL/link) |
https://elpaso.ttuhsc.edu/som/family/CPP/de-casa-en-casa/default.aspx
|
Articles Related to Submitted Intervention
| Article | |
|---|---|
| Reports/Monographs | |
| No Reports/Monographs provided. | |
| Additional Articles | |
|
Evaluation, Cost-related |
Attachment available for request at the bottom of the page. |
|
Evaluation |
Attachment available for request at the bottom of the page. |
|
Qualitative findings |
https://pubmed.ncbi.nlm.nih.gov/33121254/
|
Materials Available for Request
- Recruitment Material [Eng.].pdf
- Recruitment Material [Span.].pdf
- FlipChart Presentation English [Promotora].pdf
- Cervical Cancer Awareness Month Presentation [Spanish].pdf
- De_Casa_Research_Survey_English_.pdf
- De_Casa_Research_Survey_Spanish.pdf
- De_Casa_Post_Immediate_and_4_month_follow_up_Survey_English.pdf
- De_Casa_Post_Immediate_and_4_month_follow_up_Survey_Spanish.pdf
- Post_education_DE_CASA_satisfaction_survey_English.pdf
- Post_education_DE_CASA_satisfaction_survey_Spanish.pdf
- Training Material.pdf
- De Casa - Grp. vs Ind. [2019].pdf
- De Casa Paper 2021.pdf