Taking Care of Yourself and Your Risk for Breast Cancer (CUIDARSE): A Randomized Controlled Trial of a Health Communication Intervention for Latinas

Abstract

Latinas in the United States are more likely to be diagnosed with late-stage breast cancer (BC) compared to non-Latinas. Literacy-appropriate and culturally sensitive cancer communication interventions can help address existing racial/ethnic BC disparities. We formatively developed a new BC prevention brochure for Spanish-speaking Latinas (≥35 years). Eligible women (n = 240) from a large public hospital in California were randomly assigned to one of three study arms: Group 1 received the new brochure, Group 2 included a community health worker (CHW) who delivered the new brochure’s content, and a control group received a standard educational brochure. Participants completed three surveys (baseline, postintervention, 3-month follow-up) with a 100% completion rate for the first two surveys and 80.4% completion after 3 months. We assessed the difference in outcomes for BC risk knowledge, perceived BC susceptibility, and BC information self-efficacy between groups. Participant mean age was 52.3 years, and 82.1% reported low English proficiency. Mean knowledge scores increased and perceived BC susceptibility improved for all groups (p ≤ .05), yet treatment effects were not significant between groups for these outcomes. BC information self-efficacy also increased from baseline to postintervention for all groups to >80%. After 3 months, only Group 2 and the control group retained their increases and treatment effects were significant only for Group 2 compared to other groups in unadjusted and adjusted models. A CHW-delivered intervention may be more effective in improving BC information self-efficacy among Latinas compared to print material alone. More research is needed to examine the efficacy of CHW-delivered interventions.

Keywords

breast cancer community health worker health communication Latina/Hispanic randomized controlled trial

In the United States, breast cancer (BC) is the most commonly diagnosed cancer and leading cause of death among Latinas (American Cancer Society, 2015; Siegel et al., 2015). Despite numerous evidence-based risk reduction strategies, including mammography for early detection, Latinas are less likely to be diagnosed early (Chen & Li, 2015; Iqbal et al., 2015; Siegel et al., 2015), and those aged 40 to 65 years have lower odds of mammography utilization than non-Latinas (Ahmed et al., 2017).

Factors contributing to BC outcome disparities (American Cancer Society, 2015; Breen et al., 2011; Sabatino et al., 2015) include delays in receiving appropriate and timely treatment (Freedman et al., 2011; Karliner et al., 2019; Molina et al., 2013). Limited health care access (i.e., lack of health insurance or a usual source of care) and low socioeconomic status are also associated with fewer preventive BC behaviors (Abraido-Lanza et al., 2004; Graves et al., 2008; Greaney et al., 2014; Martínez-Donate et al., 2013; Miranda et al., 2012; Nuño, Castle, et al., 2011; Rauscher et al., 2012; Schueler et al., 2008; Selvin & Brett, 2003; Wells & Roetzheim, 2007). Lack of insurance coverage and a usual source of care are important barriers to cancer screening among immigrants (Adunlin et al., 2019). Furthermore, limited knowledge about cancer and screening also pose critical barriers among immigrants (Adunlin et al., 2019) and Latinas (Lawsin et al., 2011). BC knowledge is an important factor that is significantly associated with mammography screening among U.S. Latinas (Graves et al., 2008; A. G. Ramirez, Suarez et al., 2000).

Health communication interventions can reduce the cancer burden by increasing awareness and knowledge of effective cancer prevention and control behaviors (Hiatt & Rimer, 1999; Murphy et al., 2015). Developing and evaluating linguistically appropriate and culturally sensitive health communications (Betsch et al., 2016) can lead to effective efforts to reduce health inequities (Colon-Otero et al., 2014). The growth of the Latino population in the United States indicates a greater demand for such efforts (Elder et al., 2009). Linguistic barriers and low health literacy skills pose barriers for Spanish-speaking Latinos who seek to access cancer health information or treatment (Molina et al., 2013). Many Latino adults, particularly those who speak only Spanish, cannot access health materials and effectively accomplish health-related tasks (Kutner et al., 2006). Latinas with lower levels of acculturation (measured by language use) are at increased risk of not undergoing mammography (Graves et al., 2008). Few BC interventions have described the development of materials for Latinas with low health literacy or limited education (Molina et al., 2013).

We developed two health communication interventions with evidence-based messages on BC knowledge, risk, and preventive behavior for Spanish-speaking, low-income Latinas. The first intervention was a new educational brochure based on an integrated communication and health behavior model, evidence-based BC prevention and risk reduction guidelines, research and recommendations for developing cancer educational print materials for Latino populations, and feedback from multiple stakeholders. The second intervention used a community health worker (CHW) as the delivery mechanism for information in the new brochure. A CHW component was included in this study since many effective BC prevention strategies targeting Latinas have incorporated CHWs (Ayala et al., 2010; Corcoran et al., 2010; Fernandez et al., 2009; Hansen et al., 2005; Hunter et al., 2004; Livaudais et al., 2010; Luque et al., 2019; Martínez-Donate, 2009; Molina et al., 2013; Navarro et al., 1998; Nuño, Martinez, et al., 2011; Rhodes et al., 2007; Sauaia et al., 2007; Wells et al., 2011; White et al., 2012). We randomized eligible Latinas (n = 240) to one of three study arms, Group 1, Group 2, or a control group, and examined whether participants improved their BC knowledge, perceived BC susceptibility, and self-efficacy to seek BC information and advice.

Method

We conducted a randomized controlled trial (RCT) to assess the relative efficacy of a new Spanish educational brochure (Group 1) and a CHW-delivered intervention (Group 2) compared with a control group. The control group received a Spanish consumer guide on reducing the risk of BC published by the Agency for Healthcare Research and Quality (Eisenberg Center at Oregon Health & Science University, 2005). Outcomes consisted of BC risk knowledge, perceived BC susceptibility, and self-efficacy to seek BC information.

Recruitment and Data Collection

Bilingual and bicultural Latina research staff were trained to recruit and collect data for this study. Staff approached women to assess eligibility in outpatient clinic waiting rooms at a public hospital providing care for underserved populations in California. Eligible women were ≥35 years, were Spanish-speaking, were not pregnant (or desiring to be pregnant in the near future), and did not have a prior/current BC diagnosis or use of chemoprevention medications (Tamoxifen, Raloxifene, Tibolone, or Arimidex).

Eligible women answered questions about their risk for developing BC using the National Cancer Institute’s BC Risk Assessment Tool (Gail model) (Costantino et al., 1999; Gail et al., 1989; Rockhill et al., 2001). Questions asked about each woman’s reproductive, medical, and family BC history to estimate 5-year and lifetime risk of developing invasive BC compared to an average woman her age. Women with a 5-year score of >1.66% are considered high risk for BC.

Between 2012 and 2013, 240 eligible women were recruited (see Figure 1). Randomization was stratified by recruitment clinic and individual level of education (≥6 or <6 years of education) to prevent imbalanced group assignment due to possible confounders.

Figure 1.

Flowchart of participants in the CUIDARSE RCT.

All participants completed a baseline survey before being randomized to one of three study arms using sealed randomization envelopes. Data collectors were blind to the study condition up until this point. After opening the randomization envelope, they either handed the participant a brochure (Group 1 or the control group) or called the CHW to deliver the intervention (Group 2). Participants received a $25 gift card for their participation. RCT participants who completed the 3-month follow-up phone survey were mailed an additional $25 gift card. Study procedures and materials were approved by the RAND Human Subjects Protection Committee and Olive View-UCLA’s Institutional Review Board. All participants provided written informed consent.

Intervention Development

The conceptual framework used to guide development of the brochure integrated constructs from the McGuire input-output framework for constructing persuasive messages and the health belief model. McGuire’s (2015) framework, which postulates how to develop persuasive messages, suggests focusing on five input variables (source, message, channel, receiver, and destination) and related factors (Elder et al., 2009). We identified literature and evidence-based guidelines to inform our selection of the channel, receiver, and destination. We elicited feedback from experts and potential users to identify the source and messages. Key audience factors considered during development included language, literacy, and culture. Target behaviors included in the messages came from evidence-based BC prevention and reduction guidelines related to mammography and breast self-examination. Mediators of behavioral change and some message content were informed by the health belief model, which emphasizes the role of perceived barriers and benefits, perceived susceptibility, self-efficacy, and cues to action (Champion & Skinner, 2008).

We drafted the brochure prototype with messages about BC risk and preventive behaviors for a Spanish-speaking, low-literacy audience. Risk messages and storyboards were drafted in Spanish by bilingual research staff using the Checklist of Design Elements for the Development of Cancer Education Print Materials for Latina/o Audiences (Buki et al., 2008). Including these elements (e.g., use of loss-framed messages to appeal to individuals from a collectivist cultural background) can reduce disparities by increasing the effectiveness of a message (Betsch et al., 2016; Borrayo et al., 2017; Molina et al., 2013).

Multiple stakeholders provided feedback on the prototype, including a community advisory panel (CAP), patients, and medical experts. The CAP consisted of local and national organizations with expertise in health communication and/or health education materials for Latinos. We obtained feedback from 18 patients across four focus groups using a script covering BC knowledge, attitudes, beliefs, and prevention strategies. On average, focus group participants were 49 years old (range: 41–58), had lived in the United States for 22 years, and had completed 8 years of formal education. Discussions revealed that most participants lacked knowledge about BC risk factors and risk reduction strategies. Most expressed inaccurate BC risk estimates or were unaware of their risk. Half of those with a breast biopsy history (n = 9) did not recall the result.

To elicit input about the brochure’s visual cues and “catchy phrases,” we also presented storyboards with different graphical BC risk representations and fictional narratives of Latinas with varying BC risk levels. Participants preferred population diagrams to other risk representations and narratives to risk factor lists. Pictures were identified as highly desirable, especially among low-literacy women. Several women used the term cuidarse (taking care of oneself) as a euphemism for BC prevention, prompting us to name the new brochure CUIDARSE.

After drafting the brochure based on the collective input of the CAP and patients, we asked two medical experts to independently review the messages to ensure adherence to clinical guidelines. We worked with a professional graphic designer with experience designing Spanish health promotion material to finalize the design and images.

Intervention Description

Group 1 (CUIDARSE brochure) received the formatively developed Spanish-language breast health brochure featuring four fictional narratives from Latinas with varying BC risk levels. It included basic prevention and risk information illustrated in a narrative format. The brochure presented the advantages and disadvantages of prevention strategies and addressed common concerns and misconceptions. For example, it addressed the frequently mentioned belief that golpe (breast trauma) can cause BC (Borrayo & Jenkins, 2001; Hubbell et al., 1996). The brochure also presented modifiable risk factors including alcohol consumption, breastfeeding, smoking, diet, physical inactivity, adult weight gain, and high body mass index (postmenopausal only; Bhaskaran et al., 2014; Katzke et al., 2015), and nonmodifiable risk factors including family history and menarche age.

For Group 2 (CHW-delivered CUIDARSE brochure), a CHW verbally reviewed content from the CUIDARSE brochure in a 15- to 20-minute session. CHWs are defined as

lay members of communities who work either for pay or as volunteers in association with the local health care system in urban and rural environments and usually share ethnicity, language, socioeconomic status and life experiences with the community members they serve. (U.S. Department of Health and Human Services, 2007)

CHWs are also known as promotores de salud, lay health advisors, peer health advisors, educators, patient navigators, consejeras, and indigenous community leaders (Wells et al., 2011). We hired and trained two bilingual part-time Latina CHWs to deliver the CHW intervention, instructing them to review the brochure content without providing additional support or information. Minimum qualifications included fluency in English and Spanish, strong communication (oral, written, interpersonal) skills, basic word processing skills, reliability and part-time availability for the study duration, residence in the community where the study took place, and an interest in health education and women’s health. Each CHW underwent a 2-week training session with the aid of a 112-page CHW manual developed by the research team. Training included an overview of the study, BC risk and health education information, CITI (Collaborative Institutional Training Initiative program) human subjects research training, study recruitment and implementation procedures, and in-depth review of the CHW intervention (including several role-play scenarios with feedback).

The control group consisted of a staff member handing participants the Spanish version of the Agency for Healthcare Research and Quality’s consumer guide on reducing the risk of BC (Eisenberg Center at Oregon Health & Science University, 2005).

Measures

Participant age, education, household income, health insurance, marital status, country of birth, years living in the United States, English proficiency, self-reported data on prior mammography screening (only for those ≥40 years), and BC risk were assessed. Outcomes consisting of BC risk knowledge, perceived BC susceptibility, and self-efficacy to seek BC information were assessed at baseline, postintervention, and 3-month follow-up. The postintervention survey was administered immediately after respondents completed either an intervention or the control. The response rate was 100% at baseline and postintervention (n = 240) and decreased to 80.4% (n = 193) after 3 months.

We assessed BC risk knowledge using a 16-item response set with true/false response options with higher scores indicating accurate knowledge. The set included two items from McCance et al.’s (1990) BC knowledge test (breast self-examination and screening knowledge), two items from Stager’s (1993) BC knowledge test (breast trauma belief, being overweight as a risk factor), and an item on breastfeeding as a risk factor (Estape et al., 2003). The remaining 11 items were risk factors included in the CUIDARSE brochure.

Perceived BC susceptibility was assessed using a cancer susceptibility item from the National Cancer Institute’s 2012 Health Information National Trends Survey, adapted to be specific to BC. The item asked, “How likely are you to get BC in the future?” and was rated on a 5-point Likert-type response format (very likely to very unlikely).

Similarly, we assessed self-efficacy to access BC-related advice or information using an item adapted from a cancer confidence question in the 2012 Health Information National Trends Survey (National Cancer Institute, 2012). The item asked, “Overall, how confident are you that you could get advice or information about breast cancer if you needed it?” and was rated on a 5-point scale (completely confident to not confident at all).

Measures included scales and items from previously validated instruments. When necessary, English items were translated into Spanish and back-translated by a native Spanish speaker before use. After back-translation, translation discrepancies were reconciled by a bilingual committee composed of the principal investigator, project coordinator, and other bilingual and bicultural staff.

Statistical Methods

Unadjusted comparisons between the groups were conducted on baseline socio-demographic characteristics using analysis of variance, chi-square, and Fisher’s exact test, depending on the variable type. Statistical tests used an α = 0.05 threshold. Outcome comparisons between groups from baseline to postintervention and 3-month follow-up were assessed by testing for differences in the means between intervention arms across the three waves of data using two models: (1) ordinary least square regressions for BC risk factor knowledge items and (2) logistic models for binary outcomes, including self-efficacy to seek BC information (completely/very confident = 1, 0 otherwise), and perceived BC susceptibility (very low/somewhat low = 1, 0 otherwise).

General model : Y_{i t} = α + β_{1} (T_{i} * {Wave}_{t}) + β_{2} Y_{i (t - 1)} + ε_{i t},

where Y is one of the outcomes analyzed, T is the treatment arm, Wave is the survey (baseline, postintervention, and 3-month follow-up), and t is a point in time of the data collection.

Models controlled for the lagged outcome variable and were weighted to account for differences in attrition rates among the arms. We also conducted a sensitivity analysis of the outcomes using difference-in-differences models excluding the lagged outcome and adding the time point and the study arm (not shown). All analyses were performed using Stata software (Version 15; StataCorp, 2017).

Results

Study Population

Table 1 provides a comparison of baseline participant characteristics. The sample comprised 240 women with a mean age of 52.3 years (range 35–72 years). Nearly two thirds reported a minimum sixth-grade level of education (n = 154 or 64.2%). Nearly all (93.4%) were low-income, reporting an annual household income of less than $30,000. Four out of five reported having health insurance (79.6%). Nearly all (92.5%) reported being born in a Latin American country, yet 69.6% said they had lived in the United States for at least 15 years. Eighty-two percent reported low English proficiency (i.e., not well, almost none, or not at all).

Table 1.

Comparison of Baseline Characteristics Between RCT Study Participants (n = 240).

Characteristic	Total (n = 240), n (%)	Group 1 (n = 79), n (%)	Group 2 (n = 79), n (%)	Control (n = 82), n (%)	p
Age in years, M (SD)	52.3 (8.8)	52.3 (8.9)	52.3 (8.4)	52.3 (9.2)	.99
≥6th grade level of education	154 (64.2)	50 (63.3)	52 (65.8)	52 (63.4)	.93
<$30,000 annual household income	184 (93.4)	62 (95.4)	63 (94)	59 (90.8)	.55
Marital status					.20
Married	109 (46.8)	44 (56.4)	29 (38.2)	36 (45.6)	.06
Separated	71 (30.5)	19 (24.4)	29 (38.2)	23 (29.1)	.20
Single	53 (22.7)	15 (19.2)	18 (23.6)	20 (25.3)	.70
Has health insurance	191 (79.6)	65 (82.3)	59 (74.7)	67 (81.7)	.45
Country of birth					.12
Mexico	134 (55.8)	41 (51.9)	44 (55.7)	49 (59.8)	.62
El Salvador	54 (22.5)	20 (25.3)	23 (29.1)	11 (13.4)	.04^*
Guatemala	27 (11.3)	12 (15.2)	7 (8.9)	8 (9.8)	.43
Honduras	7 (2.9)	2 (2.5)	—	5 (6.1)	.08
United States	1 (0.4)	—	—	1 (1.2)	1.0
Other	17 (7.1)	4 (5.1)	5 (6.3)	8 (9.8)	.54
≥15 years in the United States	167 (69.6)	59 (74.7)	60 (75.9)	48 (58.5)	.03^*
English proficiency					.98
Very well	10 (4.2)	3 (3.8)	3 (3.8)	4 (4.9)	.99
Well	33 (13.8)	10 (12.7)	11 (13.9)	12 (14.6)	.97
Not well	75 (31.3)	27 (34.2)	25 (31.7)	23 (28)	.72
Almost none	68 (28.3)	24 (30.4)	20 (25.3)	24 (29.3)	.79
Not at all well	54 (22.5)	15 (18.9)	20 (25.3)	19 (23.2)	.64
Prior screening (≥40 years, n = 201)
Had a mammogram	201 (93.1)	66 (91.7)	68 (95.8)	67 (91.8)	.60
<2 years	182 (90.6)	58 (87.9)	64 (94.1)	60 (89.6)	.44
BC risk knowledge, M (SD)	8.33 (3.3)	8.65 (3.4)	8.16 (3.2)	8.17 (3.3)	.57
Perceived BC susceptibility					.87
Very/somewhat low	123 (53.9)	40 (52.6)	44 (57.9)	39 (51.3)	.70
Moderate	21 (9.2)	8 (10.5)	5 (6.6)	8 (10.5)	.66
Very/somewhat high	84 (36.8)	28 (36.8)	27 (35.5)	29 (38.2)	.99
BC information self-efficacy					.97
Completely/very confident	164 (69.5)	57 (72.2)	54 (71.1)	53 (65.4)	.61
Somewhat confident	50 (21.2)	15 (19.0)	15 (19.7)	20 (24.7)	.66
Slightly/not at all confident	22 (9.3)	7 (8.8)	7 (9.2)	8 (9.9)	.99

Note. RCT = randomized controlled trial; BC = breast cancer. Percentages are based on nonmissing values. Three participants did not report age, 43 did not report household income, 7 did not report marital status, 12 did not report perceived susceptibility, and 4 did not report self-efficacy.

p ≤ .05.

Surprisingly, the sample reported high levels of screening adherence at baseline. Among those 40 years or older, 93.1% reported a prior mammogram and 90.6% had a mammogram in the past 2 years. In terms of study outcomes, respondents had an average BC risk knowledge score of 8.33 (SD = 3.3). The average 5-year risk of developing BC (Gail score) was 0.71% and lifetime risk was 5.73%. About half perceived they had a low personal risk for developing BC (53.9%) whereas 36.8% believed their risk was either somewhat or very high. In actuality, average BC risk levels were low. About a third (30.5%) reported being only somewhat confident, slightly confident, or not confident at all in their ability to seek BC advice or information if they needed it.

Table 1 shows that randomization results were mostly balanced. Only two variables had statistically significant differences between groups. The control group had fewer participants born in El Salvador compared to Groups 1 and 2 (13.4% vs. 25.3% vs. 29.1%). The control group also had fewer participants with higher acculturation levels (≥15 years in the United States) compared to Groups 1 and 2 (58.5% vs. 74.7% vs. 75.9%).

Change in BC Risk Knowledge

At baseline, all three groups had mean BC risk knowledge score of ~8 points. Postintervention, all groups reported similar increases (+3) in mean knowledge scores. Increases in knowledge were not maintained after 3 months—scores decreased for all groups by approximately 1 point. However, mean knowledge scores remained higher than their respective baseline scores for all three groups (Figure 2). The results of the paired t test showed all changes between waves within the same group were significant (p ≤ .05). However, treatment effects showed no significant differences in the unadjusted or adjusted models (Table 2).

Figure 2.

RCT outcomes by study arm and data collection wave (baseline, immediate postintervention, 3-month follow-up).

Table 2.

Breast Cancer Risk Knowledge, Self-Efficacy, and Perceived Susceptibility Outcomes, Unadjusted and Adjusted Models (n = 240).

Variable	Group 1 vs. control						Group 2 vs. control						Group 2 vs. Group 1
	Baseline and postintervention		Baseline and 3-month		Postintervention and 3-month		Baseline and postintervention		Baseline and 3-month		Postintervention and 3-month		Baseline and postintervention		Baseline and 3-month		Postintervention and 3-month
	ME	p	ME	p	ME	p	ME	p	ME	p	ME	p	ME	p	ME	p	ME	p
Unadjusted models
Risk knowledge^a	−0.01	.98	−0.71	.10	−0.40	.37	0.06	.89	−0.48	.29	−0.53	.25	0.04	.92	0.19	.69	−0.17	.71
Perceived susceptibility^b	0.01	.93	0.02	.86	0.01	.88	0.13	.13	0.05	.56	0.03	.71	0.12	.15	0.04	.66	0.04	.69
Self-efficacy to access advice/information^b	0.05	.34	−0.10	.24	−0.09	.26	0.07	.17	0.14	.04*	0.13	.07	0.02	.75	0.24	.01*	0.21	.01*
Adjusted models
Risk knowledge^a	0.55	.16	−0.69	.12	−0.38	.39	0.42	.29	−0.43	.34	−0.47	.30	−0.15	.69	0.22	.64	−0.13	.78
Perceived susceptibility^b	0.01	.99	0.02	.84	0.01	.90	0.04	.69	0.06	.51	0.04	.68	0.03	.73	0.04	.63	0.04	.67
Self-efficacy to access advice/information^b	0.05	.34	−0.09	.30	−0.08	.32	0.04	.57	0.15	.04*	0.13	.08	−0.02	.68	0.24	.01*	0.20	.01*

Marginal effects (MEs) measure an estimated change in prevention knowledge scale associated with the treatment effect. ^bMarginal effects measure an estimated change in probability that the regressor of interest equals 1, associated with the treatment effect.

Marginal effects different from zero at the .05 level.

Change in Perceived BC Susceptibility

While the average 5-year risk of developing BC was low among the sample, only 50.6% of Group 1, 55.7% of Group 2, and 47.6% of the control reported their perceived BC susceptibility as being very or somewhat low at baseline. Knowledge of perceived BC susceptibility increased postintervention and increased further at the 3-month follow-up for Group 1 (54.6% to 65.1%), Group 2 (67.1% to 70.7%), and the control (53.3% to 62.5%; Figure 2). The results of the paired chi-squares test showed changes between waves within the same arm were significant (p ≤ .05) for all arms between baseline and postintervention. The change between the postintervention and 3-month follow-up was significant for the control group but not for Groups 1 or 2. Treatment effects were not significant for perceived BC susceptibility outcomes in the unadjusted or adjusted models (Table 2).

Change in BC Information Self-Efficacy

Self-efficacy related to seeking BC information or advice increased significantly from baseline to postintervention for Group 1 (72.2% to 87.3%), Group 2 (69.2% to 88.6%), and the control (64.6% to 80.3%). At the 3-month follow-up, participants in Group 2 and the control group retained their increases in self-efficacy, but the rate decreased in Group 1 (Figure 2).

Comparison of the baseline and 3-month data showed treatment effects for BC information self-efficacy were significant for Group 2 compared to the control and Group 1, respectively, in both the unadjusted and adjusted models (Table 2). In the adjusted models, baseline to 3-month follow-up BC information self-efficacy increased for Group 2 compared to the control (marginal effect [ME] = 0.15; p = .04). Group 2’s self-efficacy also increased relative to Group 1 when comparing the baseline and 3-month follow-up (ME = 0.24; p = .01) and the postintervention and 3-month follow-up data (ME = 0.20; p = .01).

In the sensitivity analysis of the outcomes, difference-in-differences without lagged term, no effects analyzed were significant and moved in the same direction as those from the main lagged model (not shown).

Discussion

The results contribute to the extant literature on BC prevention education and communication interventions for Latinas. The significant treatment effects for BC information self-efficacy for Group 2 suggest that CHW verbal review was more effective in increasing self-efficacy among Latinas than print material alone. Possible explanations include the persuasive element of having an interpersonal delivery mode, perhaps due to the provision of perceived social support (Hansen et al., 2005; Larkey et al., 2012; Livaudais et al., 2010) or participants identifying with or trusting the delivery source (Jandorf et al., 2014; Navarro et al., 1998). Isolating the effect of the interpersonal element of the CHW-delivered intervention on BC information self-efficacy is an important finding. Increasing self-efficacy among Latinas may contribute toward increasing resilience (Buki et al., 2008), improving behavioral intent (Deavenport et al., 2011), and overcoming structural inequalities contributing to cancer disparities.

Few prior studies have been explicit about the role of the CHW or used an RCT design to evaluate CHW interventions (Larkey et al., 2012; Swider, 2002). CHWs can serve a variety of functions (Rhodes et al., 2007; Wells et al., 2011), including addressing literacy gaps, facilitating access to resources, serving as health educators, or acting as “cultural brokers” bridging cultural and knowledge gaps between the health care system and patients (Fernandez et al., 2009; Hunter et al., 2004; Lara et al., 2009; Molina et al., 2013). CHWs in our study may have been perceived as health advisors, sources of information, or role models by participants. A possible reason for the increase in confidence may be due to empowerment associated with receiving information in an interpersonal context. Future CHW interventions can aim to understand the role of interpersonal factors and examine the most effective components of an intervention (Livaudais et al., 2010; Martínez-Donate, 2009; Rhodes et al., 2007). Furthermore, they should assess sociocultural factors that may mediate an intervention’s effectiveness (Hunter et al., 2004).

In our study, all participants received similar educational content—the differences consisted of the design/format and delivery mechanism. While all groups appear to have increased their BC knowledge, there was a slight decline after 3 months, and treatment effects were not statistically significant. A possible reason for a lack of statistically significant treatment effects may be the effectiveness of the interventions and control in providing basic BC risk information to Spanish-speaking Latinas. The slight decline in improvement in BC knowledge after a follow-up period is important, yet not unusual. A study on the effectiveness of a breast and cervical cancer screening promotion program (Cultivando La Salud) for low-income Latinas with a CHW intervention found no significant differences in BC knowledge between the intervention and control groups after 6 months (Fernandez et al., 2009). Another study that assessed the effects of group educational sessions for Latinas in North Carolina compared BC knowledge (risk factors, screening, signs and symptoms) at baseline, postintervention, and 3 months—the authors found the postintervention increases in BC risk factor knowledge were only somewhat sustained after 3 months (Laughman et al., 2017).

Another important finding is that rates of perceived BC susceptibility improved for all groups. Prior studies on BC risk perception and perceived susceptibility among Latinas have had mixed results—some found that Latinas underestimate their BC risk (Deavenport et al., 2011) while others report they have higher BC risk perceptions compared to White women (Kim et al., 2008). Perceived susceptibility, however, may not be as important toward motivating preventive BC behaviors as other factors. A study with predominantly Central and South American participants in the United States (n = 450) reported that 81% overestimated their BC risk. The same study found perceived risk, risk comprehension, and cancer worry were not associated with screening adherence, suggesting that providing general BC educational information (i.e., symptoms, early detection, risk factors) is more valuable than improving risk comprehension (Graves et al., 2008). Moreover, when low-income Hispanic women (n = 210) in California were randomized to receive targeted cancer prevention education (video and brochure) or a control group, findings showed that perceived susceptibility was not associated with mammography screening intentions (Deavenport et al., 2011). More research is needed to examine risk and related constructs (perceptions of absolute and objective risk, risk comprehension) in Latinas and the relationship between risk constructs, health behaviors, and health outcomes.

Strengths and Limitations

This study has several methodological strengths, including successful recruitment strategies, use of communication and health behavior theories and recommended design elements for print materials for Latino audiences (Buki et al., 2008), feedback from multiple stakeholders, and a rigorous study design to evaluate treatment effects. The success of the study, among other factors, required prepiloting alternative recruitment sites in a public hospital, as well as working with bilingual and bicultural staff to recruit participants, administer surveys, and obtain a high follow-up rate at 3 months. These strengths are particularly notable given the well-documented challenges associated with recruiting Latina women to studies, particularly about a topic with a history of limited engagement within the Latino community. Prior BC prevention interventions for Latinas have lacked these elements (Martínez-Donate, 2009; Nuño, Martinez, et al., 2011). Multiple safeguards were also employed to avoid contamination in randomization, such as blinding staff about assignments until after the baseline survey.

An important study limitation is selection bias in recruitment, which yielded a high percentage of women adherent to mammogram guidelines at baseline. We selected the setting expecting to identify a substantial number of patients without prior mammograms and with a greater prevalence of risk factors. However, more than 90% of the participants had a prior mammogram. Future studies should recruit Latinas who may face structural barriers impeding their access to health care from community settings including churches or community resource centers. Interventions addressing these types of structural barriers are needed to decrease BC disparities among Latinas (Corcoran et al., 2010; Deavenport et al., 2011; Luque et al., 2019), such as increasing awareness of free, locally available screening programs (Colon-Otero et al., 2014) or offering free mammograms (Skaer et al., 1996; White et al., 2012). Cancer education interventions are also needed for English-speaking Latinos who may have greater cancer risk knowledge deficits and more behavioral risk factors (A. S. Ramirez et al., 2013). The use of a single item to measure self-efficacy to access BC advice or information is also a limitation. A multi-item scale assessing confidence in one’s ability to seek BC advice or information would have been preferred to account for multiple sources or types of BC advice or information. Finally, the use of the Gail model has not been validated among Latinas (Costantino et al., 1999; Gail et al., 2007; Matsuno et al., 2011). Future studies should consider using an absolute risk model produced using data specific to Hispanic women by nativity (Banegas et al., 2017).

An important caveat of the study is that the brochure’s content included now-outdated BC screening guidelines. As of April 2019, the American College of Physicians released new BC screening guidelines, recommending that clinicians discuss whether to screen using mammography with average-risk women (40–49 years), offer biennial mammography for average-risk women (50–74 years), discontinue BC screening for average-risk women (75 years+ or ≤10 years life expectancy), and cease using clinical breast examinations for average risk women (Qaseem et al., 2019).

Conclusions

This study provides important evidence from an RCT on the effectiveness of a BC communication intervention to reach Latinas with low English proficiency and improve their BC risk knowledge, perceived BC susceptibility, and BC information self-efficacy. Overall, participants in all groups (including the control) appear to have mostly benefitted from the information provided regardless of delivery mechanism. However, the CHW-delivered intervention was more effective in improving BC information self-efficacy among Latinas compared to print material alone. This finding merits further exploration in other studies that use CHWs as a delivery mechanism for health information.

Footnotes

Acknowledgements

The authors are grateful to members of the study’s community advisory panel who represented the following organizations: Latinas Contra Cancer, Susan G. Komen for the Cure, Meeting Each Need With Dignity, National Council of La Raza–Institute for Hispanic Health, and Univision. They also thank the graphic designer (Andie Villafane), the research staff (Dunia Flores, Mary Lou Gilbert, Fabiola López, and Analia Lázaro), and the study participants.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant (R18HS019264) from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not represent the official views of the AHRQ.

ORCID iD

Denise D. Payán

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