Partnership to Reduce Cancer Disparities in Spanish Speakers

Institution: University of California, San Francisco
Investigator(s): Rena Pasick, DrPH - Maximiliana Ruiz, Psycho-Oncology Therapy - Molly Bergstrom,  - Peggy McGuire,  -
Award Cycle: 2005 (Cycle 11) Grant #: 11AB-1800 Award: $55,502
Award Type: CRC Pilot Award
Research Priorities
Community Impact of Breast Cancer>Disparities: eliminating the unequal burden of breast cancer

This is a collaboration with: 11AB-1801 -

Initial Award Abstract (2005)
Latina women often do not have access to the breast cancer education and support available in more affluent communities. Lay Health Workers (LHWs) are widely used in community clinics as a valuable link between the health care system and the Latino community. For breast cancer control, LHWs provide general education, outreach for screening, navigation for follow-up of abnormal tests and for cancer treatment, and outreach for cancer support. Our study seeks to design optimal LHW models to reduce breast cancer disparities for limited English proficiency Latina women by identifying and evaluating best practices in all aspects of breast cancer outreach, education and support.

We propose an 18-month project in Alameda County to prepare for a three-year evaluation trial. The pilot study will answer these questions: for Latina women, what makes LHW breast cancer programs successful? how do LHW programs vary? what are the bases for these variations? what are the strengths and limitations of each? what are the most promising, important, and relevant strategies for Latina women? What are the key differences in need across the spectrum of breast cancer control (outreach for screening, navigation of abnormals/treatment), that affect the design of LHW interventions? What criteria should be applied in designing LHW interventions?

In this pilot phase, we will identify the most promising LHW approaches in order to test them in a full CRC trial. We will interview the people who know the most about LHWs: directors of organizations who use LHWs, managers who supervise LHWs, LHWs themselves, and women from the community - both those who have and have not been served by LHWs. These interviews and analyses of the information that results will be conducted in accordance with qualitative research methods. Members of the Alameda Cty Latino Cancer Coalition will be trained to conduct interviews by UCSF researchers, and analyses will be conducted jointly. This systematic identification of key issues related to our research questions is called "formative research" and precedes an intervention trial.

Even though LHWs often play a central role in interventions to reduce breast cancer disparities, no one has studied them the way most other human service practices are evaluated, breaking them down into their component parts and testing alternative approaches. In addition, most LHW studies only look at main outcomes - for example, did screening or abnormal follow-up increase? We will also look at the impact on the organizations that use LHW models to determine which approaches are optimal for them (and thus more likely to be sustained). Lastly, we seek to increase the capacity of the organizations based in and trusted by the Latino community since they are best positioned to reduce the breast cancer burden in their community.

The community is involved in three ways in this project. First, the community partners include representatives of all the clinics that serve Latinos in Alameda County (La Clinica de la Raza, Tiburcio Vasquez Health Center, Inc., Alta Bates/Summit Medical Center, Alameda County Medical Center) and other programs that provide breast cancer support and education to the Latino community (Women's Cancer Resource Center and the ACS). The impetus for the study came from this group. Second, we will convene and include in an expert panel representatives of other relevant organizations and community members; and third, we will interview LHWs and women from the community.

Final Report (2008)
Many community agencies utilize lay health worker models to conduct outreach and provide services to Latina women. However, these models vary significantly, and there is little research that identifies common challenges and synthesizes their solutions. The primary aim of our pilot study was to conduct an 18-month project based in Alameda County to prepare for a 3-year evaluation trial. The specific aims were to: 1)Identify the variable components of LHW models in theory, and in practice locally; 2) From the perspective of all relevant stakeholders, assess the strengths and limitations of each component specific to breast cancer education, screening, abnormal follow-up, and cancer patient support among Spanish-speaking women. 3) Create a research plan to test and compare for effectiveness and cost-effectiveness alternative LHW components. Secondary aims were: a) To build the research and organizational capacity of the ACLCC; b) To inform the development of a model for Comprehensive Cancer Center-community based organizations partnerships; c) To explore another common interest, the cultivation of advocacy among Latina breast cancer survivors.

We used qualitative methods to achieve our primary aims, including 6 key informant interviews with directors of agencies that have lay health worker programs, 2 focus groups with lay health worker managers, and 3 focus groups with lay health workers. To achieve our secondary aims, UCSF researchers trained ACLCC members in qualitative research methods including conducting interviews and focus groups, and coding and analyzing qualitative data. The ACLCC and UCSF-CCC jointly created the guides for each interview and focus group, jointly conducted the interviews and focus groups and collaborated on the analysis of the data. We found that promotora programs operate on multiple levels: 1) to empower promotoras as individuals and community members; 2) to increase awareness of specific health issues and access to health through informal social networks and formal planned events, and 3) to foster social change through these activities. Because neither of the two primary Latino clinics in Alameda County had a promotora program addressing breast cancer during our research, we were unable fully address Aim 2; however, we attempted to overcame this barrier by developing a Full CBCRP proposal which would involve the development, implementation and evaluation of breast cancer promotora programs at each of the two primary clinics in Alameda serving Latinos.

In addition to submission of a full proposal, other major accomplishments include the identification of variable components of LHW programs, successful collaboration of UCSF & ACLCC, enhanced research capacity of ACLCC, presentation of findings at a community forum, and development of a manuscript outline for publication in a public health journal. Based on these successes, we now plan (as discussed in our full proposal) to develop two breast cancer education and outreach programs in order, for the first time, to develop a prospective understanding of how and why program objectives are accomplished. The overall goal will be to develop theory that predicts and explains effectiveness of promotora breast cancer outreach and education programs by elucidating the processes involved in all phases of development and implementation of two programs, and the influence of these processes on impacts and outcomes.