Salud es Vida: Development of a Cervical Cancer Education Curriculum for Promotora Outreach With Latina Farmworkers in Rural Southern Georgia

Abstract

We developed and evaluated a lay health worker curriculum intended to educate Hispanic farmworker women on cervical cancer, human papillomavirus (HPV), and the HPV vaccine. We pilot tested the curriculum in 2010 with 7 volunteer promotoras for readability, attractiveness, content, comprehension, cultural appropriateness, persuasion, structure and organization of lessons, balance between didactic and participatory activities, and ease of diffusion to community members. Peer-led cervical cancer prevention education is a practical option for low-income, Hispanic farmworker women in newer immigrant-receiving areas of the United States with fewer Spanish-speaking health professionals.

Hispanics represent the largest racial/ethnic minority group in the United States. Cervical cancer is characterized by health disparities in incidence and mortality, disproportionately affecting Hispanic women compared with White women in the United States.¹ Hispanic women have the highest incidence rate of cervical cancer (11.5/100 000) of any ethnic group in the United States.² Efforts to improve cervical cancer prevention among Mexican immigrants, the largest Hispanic subgroup, will have a significant public health impact.³ The aim of this study was to develop and evaluate a lay health worker (promotora) curriculum intended to educate Hispanic farmworker women on cervical cancer, human papillomavirus (HPV), and the HPV vaccine in rural southern Georgia. The curriculum comprised 2 learning modules that were designed and conceptualized by a multidisciplinary, bilingual team with expertise in cancer prevention and control, health communications and literacy, and design of lay health worker programs.

METHODS

In partnership with a Hispanic-serving nonprofit agency in southern Georgia, the study team developed 2 cervical cancer education modules, guided by previously developed curricula for diverse audiences, and earlier ethnographic research with Hispanic farmworker women in Florida.^4–6 We employed a theory matrix, coding health behavior constructs in appropriate sections of the curriculum.⁷ We pilot tested the draft curriculum with 7 volunteer promotoras (Table 1) who completed a 2-session, 6-hour training during a 2-week period in August 2010. The promotoras evaluated the curriculum for readability, attractiveness, content, comprehension, cultural appropriateness, persuasion, structure and organization of lessons, balance between didactic and participatory activities, and ease of diffusion to community members. Training sessions were held in the classroom of our collaborating community partner, a site familiar and convenient to the promotoras.

TABLE 1.

Demographic Characteristics of Promotora Cervical Cancer Education Training Participants, Rural Southern Georgia

Characteristic (n = 7)	Mean (Range) or No. (%)
Age, years	41 (29–48)
Years of schooling	9 (6–12)
Years in United States	15 (9–23)
Household income per week,a $	250 (0–850)
Marital status
Married or living together	2 (29)
Single or other	5 (71)
Currently employed	2 (29)
Regular health care provider	5 (71)

^aData reported represent median income values with categorical range.

The curriculum comprised 2 modules: module 1 covered female anatomy, cancer, and cervical cancer, and module 2 covered cervical cancer screening, HPV, HPV vaccine, and community health resources. The curriculum included accompanying slide presentations, vocabulary cards, problem cards for discussion, and a resource list to facilitate access to cervical cancer screening. The curriculum was designed with a popular education framework and coded throughout with cues for listening, dialogue, and action, and with constructs from social cognitive theory (Table 2).^8,9 Each module began with an icebreaker exercise and included interactive activities to facilitate colearning. Promotoras received a $75 stipend for their participation, and the study was approved by the Georgia Southern University institutional review board.

TABLE 2.

Theory Matrix Used to Code Curriculum for Promotora Cervical Cancer Education Training Participants, Rural Southern Georgia

Components	Participant Definition	Content Output	Learner Outcomes
Social cognitive theory8
Environment	Factors physically external to the person	Instructor provides resource list and contact information for Vaccine for Children (VFC) providers	Promotoras can state locations of local OB/GYNs, primary care, and VFC providers
Situational	Person's perception of environment	Instructor provides information on free or low-cost health care options and human papillomavirus (HPV) vaccination	Promotoras relate cost barriers to screening and common misperceptions about HPV vaccination
Behavioral capability	Knowledge and skills to perform a behavior	Instructor shares with promotoras how screening and HPV vaccination reduces cervical cancer risk	Promotoras state how screening and HPV vaccination can reduce risk for cervical cancer
Expectations	Anticipatory outcomes of a behavior	Instructor relates to promotoras the health benefits of regular Papanicolaou tests	Promotoras state benefits of Papanicolaou tests and getting screened regularly
Self-control	Personal regulation of goal-directed behavior	Instructor shows how to maintain a calendar for medical scheduling	Promotoras relate the importance of scheduling doctor's visits in advance
Observational learning	Behavioral acquisition after watching outcomes of others’ behavior	Instructor explains the Papanicolaou test procedure, shows video, and explains how to interpret results	Promotoras are able to explain the Papanicolaou test procedure and how to interpret results
Reinforcements	Responses to a person's behavior that increases or decreases the likelihood of recurrence	Instructor provides opportunity for promotoras to record and discuss ideas for client reminders	Promotoras develop reminder systems to help clients remember Papanicolaou tests and discuss ideas
Self-efficacy	Person's confidence to perform a behavior	Instructor guides discussion of “excuses” and ideas for coping and screening	Promotoras acknowledge the number of possible reasons for individuals not getting screened
Emotional coping responses	Strategies used by a person to deal with emotional stimuli	Instructor guides discussion of challenges and solutions to challenges	Promotoras are able to think of challenges related to regular screening
Reciprocal determinism	The dynamic interaction of the person, the behavior, and environment in which the behavior is performed	Instructor guides discussion of common reasons for delayed screening and offers ideas to deal with “excuses” for not getting regular screening	Promotoras are able to address individual's reasons for delayed screening and offer suggestions
Empowerment theory9
Listening	Understand community's issues	Instructor shares with promotoras statistics on cervical cancer	Promotoras state the health disparities with cervical cancer in their community
Dialogue	Investigating issues using problem posing	Open discussion between instructor and promotoras	Promotoras discuss how cancer affects their community
Action	Positive changes that people envision	Instructor provides resource list and guides activities to increase access	Promotoras obtain information on resources, insurance access

We evaluated the curriculum content and delivery quantitatively through a 20-item pretest–posttest instrument and qualitatively through a posttraining focus group, posttraining reports from the educator or trainer, written session evaluations, and telephone exit interviews (a copy of the complete instrument is available as a supplement to the online version of this article at http://www.ajph.org). We used the Wilcoxon sign rank test to analyze the pretest–posttest scores. We used qualitative data analysis to analyze the written evaluations, focus group, and exit interviews to identify codes and themes.

RESULTS

We found a significant increase in posttraining cervical cancer knowledge based on an average pretest score of 66.4% (SD = 9.9), and an average posttest score of 80.0% (SD = 10.0; z = −1.9; P < .05). The promotoras indicated that what they liked most about the training included participating in the poster-making exercise, watching a tailored cancer screening educational video,¹⁰ engaging in icebreaker exercises, and learning about the HPV vaccine. The single drawback expressed was not having more time for some activities.

The focus group highlighted cultural barriers for cervical cancer screening that the promotoras had heard expressed by friends, primarily regarding feelings of embarrassment, but also fear of the procedure and not having permission from their husbands to go to the clinic. These barriers were also repeated during the individual exit interviews, as well as monetary costs, transportation, language, lack of motivation, and time constraints. Promotoras indicated their willingness to share the information they learned, assuage fears that others might have about the examination, and inform others about preferred health care providers and services. During individual exit interviews, all promotoras expressed positive self-efficacy to receive regular Papanicolaou tests in the future and to promote screening behavior to their fellow community members.

DISCUSSION

Peer-led education on cervical cancer screening and the benefits of the HPV vaccine is a practical option for educating low-income, Hispanic farmworker women in newer immigrant-receiving areas of the United States where there are fewer Spanish-speaking health professionals to connect women to health services. This study shows that development of a cervical cancer curriculum can be highly informed by the involvement of community partners and promotoras. The piloted modules were attentive to culture and literacy issues, but they will be further refined (e.g., modify the flipcharts) for greater adoption by other promotora programs based on their input.

A positive study outcome was the increase in community collaboration in research, by involving our community partner in the design of the curriculum. Importantly, our community partner valued the program, and the promotoras are now being incorporated into regular migrant health education and outreach activities. Increasing awareness and access to screening and the HPV vaccine through peer education is critical to reducing the cervical cancer burden in medically underserved Hispanic communities.