1. Contributions to research Theresa Byrd, Dr.PH Associate Dean and Chair Department of Public Health TTUHSC

2.  Community-based participatory research is a form of research that includes the community in every aspect of the research  Community Health Workers (CHWs; Promotores) can help us connect with communities, and encourage communities to be involved in research  They can also assure that we are true to the community, keeping our word, and serving the needs of the people

4.  AMIGAS (Ayudando a las Mujeres con Información, Guía, y Amor para su Salud) is a theory-based intervention developed with the participation of the community, aimed at increasing cervical cancer screening in women of Mexican origin.

5.  In the US in 2015 there will be an estimated 12,900 cases of invasive cervical cancer and 4,100 women will die of cervical cancer.  Rate of invasive cancer is almost twice as high in Hispanic women when compared to non-Hispanic white women 12.7/100,000 vs 7.3/100,000.

6.  Like colorectal cancer, cervical cancer can be prevented through screening  In addition, early detection of cervical cancer leads to better outcomes

7.  Infection with HPV  Early age at first intercourse  Multiple sex partners (or partner with multiple partners)  Smoking  Low SES

8.  Testing should begin at age 21  Women between 21 and 29 should have a Pap test every three years  Women between 30 and 65 should have a Pap test and an HPV test every 5 years, or Pap alone every three years

9.  There is evidence that Hispanic women are less likely to use screening services  Several barriers have been suggested, including access, attitudes, and lack of knowledge  Year 2020 objective--93% of women 21-65 will have Pap tests according to the current guidelines (baseline is 84%)

10.  Phase 1 ◦ A pilot study with 18-25 year old women ◦ A larger study of over 500 women in El Paso ◦ Using the data, we developed an intervention together with community members ◦ The product was pilot tested

11.  During phase one, community health workers were involved in several ways: 1. They helped us clarify the items on the survey. 2. They helped us during the development of the educational strategies. 3. They reviewed and edited the video script. 4. They were actors in the video.

12.  Phase 2 ◦ AMIGAS was “renovated” by a team including:  Theresa Byrd, DrPH  CDC researchers  Battelle  Lay Community Advisory Group ◦ Material updated to include new guidelines, English added, activities and games added

13.  During Phase two, we had promotoras on the team that revised AMIGAS.  They also tested the revised intervention in small groups and suggested changes.  They approved the final version.

19. It is embarrassing. “Many of us feel embarrassed about getting a Pap test. The test does not take very long. The clinic staff are professionals and they see women’s bodies every day.” It is embarrassing.

20. I will die faster if I know. “Some women think they will die faster if they know about cervical cancer. In fact, we may die faster if we do not get a Pap test. The Pap test can find cervical cancer early so it can be treated.” I will die faster if I know.

21.  Allowed the woman to make a promise to herself  In focus group interviews, many women talked about the “mi promesa” as a helpful tool

22.  Clinical trial to test the effectiveness of the intervention

23.  Aim 1: To assess the efficacy of AMIGAS for increasing compliance with cervical cancer screening guidelines among Urban, Rural, and Border women of Mexican origin  Aim 2: To characterize the relative effectiveness of the major components of the intervention in increasing compliance

24.  Aim 3: To conduct a process evaluation to ensure appropriate delivery of the intervention and to describe processes that enhance optimal program implementation  Aim 4: To conduct a cost-effectiveness analysis of the intervention incremental gain in compliance compared to the incremental cost of moving from usual care to successively more intensive and costly intervention strategies.

25.  The intervention was delivered in the community by the promotoras. They assisted with recruitment and provided the education to the women. They kept us apprised of any problems or issues that developed during the trial.

26.  Trial was conducted in: ◦ Houston (Urban) ◦ El Paso (Border) ◦ Yakima Valley (rural)

27. Intervention Groups Full AMIGAS Movie + Flipchart + Other components AMIGAS Movie Movie + Other components AMIGAS Flipchart Flipchart + Other components Control No intervention

28. Flip ChartMovieOverallEl PasoHoustonYakima Control28.6 a (133)28.0 a (50)23.3 (43)35.0 a (40) Yes 61.7 b (128)62.5 b ( 48)45.4 (44)80.6 b (36) NoYes56.0 b (125)47.9 b (48)47.5 (40)75.7 b (37) YesNo50.8 b (128)50.0 b (46)38.5 (39)62.8 b (43) P-value: comparison of the four arms. <0.00010.00700.08430.0001 P-value: comparison of the 3 non- control arms. 0.21690.3276No test.0.1970

29.  Last year we developed an administrator’s guide  In November the CDC made AMIGAS materials available to the public on their website  The administrator’s guide included a discussion of the role of community health workers and how to recruit them

30.  Se are currently finishing a project in Washington, comparing materials alone and with a promotora. Data are collected—being analyzed now.