# Study Notes: Increasing Cervical Cancer Screening Among Hispanic Women Using the AMIGAS Intervention --- ## Overview of Cervical Cancer and Screening - **Cervical Cancer Trends**: - Incidence and mortality rates in the U.S. have decreased significantly since the introduction of the Pap test in the 1950s. - Despite this, disparities persist, particularly among Hispanic women, who face higher morbidity and mortality rates compared to non-Hispanic white women. - **Importance of Early Detection**: - Cervical cancer is curable if detected early. - The Pap test identifies premalignant lesions, preventing progression to cancer. - **Barriers to Screening**: - **Knowledge Gaps**: Limited awareness of screening guidelines. - **Access Issues**: Limited healthcare access and insurance coverage. - **Cultural Barriers**: Embarrassment, partner influence, and stigma. Behavioral interventions, such as one-on-one education and small-media materials, are effective strategies to increase screening rates. --- ## The AMIGAS Intervention ### What is AMIGAS? - **Full Name**: *Ayudando a las Mujeres con Información, Guía, y Amor para su Salud* (Helping Women with Information, Guidance, and Love for Their Health). - **Purpose**: Increase Pap test screening among women of Mexican origin. - **Delivery**: Conducted by trained lay health workers (*promotoras de salud*), either individually or in groups, in English or Spanish. ### Components of the Intervention 1. **Promotora Instruction Guide**: - Step-by-step instructions for delivering the intervention. 2. **Small-Media Materials**: - **Video**: Role models address common barriers and beliefs about cervical cancer and screening. - **Flip Chart**: Reinforces video content with additional details. - **Games and Handouts**: Interactive tools to reinforce key messages. 3. **"Mi Promesa" Contract**: - A personal commitment sheet where participants pledge to get screened or consider screening. For instance, a participant might write, "I promise to schedule my Pap test within the next month." 4. **Promotora Training**: - Bilingual and bicultural *promotoras* were trained through workshops and pilot sessions to ensure clarity and usability of materials. --- ## Study Design and Methods ### Eligibility Criteria - Women of self-reported Mexican origin, aged ≥21 years. - No history of cancer or hysterectomy. - No cervical cancer screening in the past 3 years. ### Study Sites 1. **El Paso, Texas** (US/Mexico border): Predominantly Hispanic population with high uninsured rates. 2. **Houston, Texas** (Urban): Large Hispanic population, primarily of Mexican origin, with significant healthcare access challenges. 3. **Yakima Valley, Washington** (Rural): Agricultural community with a high percentage of Mexican-origin residents. Each site faced unique challenges, such as recruitment difficulties in Houston and structural barriers in Yakima. ### Recruitment Strategies - Flyers and in-person recruitment at community locations (e.g., laundromats, beauty salons, schools). - Recruitment personnel included research assistants, *promotoras*, and project staff. ### Randomized Controlled Design - **Participants**: 613 women randomly assigned to one of four groups: 1. Full AMIGAS program (video + flip chart). 2. Video-only. 3. Flip chart-only. 4. Control group (usual care, no *promotora* education). - **Follow-Up**: Six months post-intervention, participants completed surveys on Pap test history and attitudes. --- ## Results ### Key Findings - **Screening Rates**: - Full AMIGAS: 52.3% (intent-to-treat), 61.7% (per-protocol). - Video-only: 41.3% (intent-to-treat), 56% (per-protocol). - Flip chart-only: 45.5% (intent-to-treat), 50.8% (per-protocol). - Control: 24.8% (intent-to-treat), 28.6% (per-protocol). $$ P < 0.0001 \text{ (statistically significant difference between intervention and control groups).} $$ - **Validated Results**: - Medical records confirmed Pap tests for 79% of women who self-reported screening. The full AMIGAS program showed the highest effectiveness, but all intervention arms significantly outperformed the control group. ### Site-Specific Observations - **El Paso and Yakima**: Statistically significant increases in screening rates across intervention groups. - **Houston**: Smaller increases, likely due to structural barriers (e.g., appointment availability, financial constraints). Assuming urban populations face fewer barriers can lead to underestimating challenges like clinic capacity and affordability. --- ## Discussion ### Effectiveness of AMIGAS - The intervention effectively increased Pap test screening among unscreened Hispanic women. - The full program (video + flip chart) provided the greatest benefit, but individual components (video or flip chart) were also effective. ### Practical Implications - **Flexibility**: The program can be adapted based on available resources (e.g., time, budget). - **Promotora Role**: Personal engagement by *promotoras* was a key factor in success. In focus groups, participants frequently mentioned the *promotora* visits as the most impactful part of the intervention. ### Limitations 1. **Self-Report Bias**: Reliance on self-reported data, though validated results aligned closely. 2. **Short-Term Focus**: The study did not assess long-term screening maintenance. 3. **Group Delivery**: Effectiveness in group settings was not evaluated. Future studies should explore long-term outcomes and cost-effectiveness of group versus individual delivery. --- ## Key Takeaways 1. **AMIGAS is Effective**: The intervention significantly increased cervical cancer screening rates among Hispanic women. 2. **Cultural Relevance Matters**: Tailored materials and bilingual *promotoras* were critical to success. 3. **Barriers Persist**: Structural and financial barriers remain challenges, particularly in urban settings like Houston. 4. **Flexibility in Delivery**: The program's modular design allows for adaptation to different community needs and resources. --- ## Practice Questions 1. **True or False**: The AMIGAS intervention was equally effective across all study sites. 2. **Short Answer**: What were the two main components of the AMIGAS intervention, and how did they contribute to its success? 3. **Multiple Choice**: Which of the following was NOT a barrier to cervical cancer screening identified in the study? - A) Lack of knowledge about guidelines - B) High cost of Pap tests - C) Overuse of screening services - D) Cultural stigma Review the results section to understand the differences in effectiveness across intervention arms and sites.