Effectiveness of Cultivando La Salud: A Breast and Cervical Cancer Screening Promotion Program for Low-Income Hispanic Women

María E. Fernández, PhD; Alicia Gonzales, MSW; Guillermo Tortolero-Luna, MD, PhD; Janet Williams, MPH; Monica Saavedra-Embesi, MPH; Wenyaw Chan, PhD; Sally W. Vernon, PhD


Am J Public Health. 2009;99(5):936-943. 

In This Article

Abstract and Introduction


Objectives: We tested the effectiveness of a lay health worker intervention to increase breast and cervical cancer screening among low-income Hispanic women.
Methods: Participants were women 50 years and older who were nonadherent to mammography (n=464) or Papanicolaou (Pap) test (n=243) screening guidelines. After the collection of baseline data, lay health workers implemented the Cultivando la Salud (CLS; Cultivating Health) intervention. Data collectors then interviewed the participants 6 months later.
Results: At follow-up, screening completion was higher among women in the intervention group than in the control group for both mammography (40.8% vs 29.9%; P<.05) and Pap test (39.5% vs 23.6%; P<.05) screening. In an intent-to-treat analysis, these differences remained but were not significant. The intervention increased mammography self-efficacy, perceived susceptibility, perceived survivability, perceived benefits of mammography, subjective norms, and processes of change. The intervention also significantly increased Pap test self-efficacy, perceived benefits of having a Pap test, subjective norms, and perceived survivability of cancer. It did not change Pap test knowledge, perceived susceptibility, or perceptions about negative aspects of Pap test screening.
Conclusions: Our results add to the evidence concerning the effectiveness of lay health worker interventions for increasing Pap test screening and mammography. Future research should explore the effectiveness of CLS in other Hispanic groups, the mechanisms through which interpersonal communication influences decisions about screening, and how effective interventions such as CLS can best be adopted and implemented in community-based organizations or other settings.


Although incidence and mortality rates for breast cancer are lower among Hispanic women than among non-Hispanic women, Hispanic women are more likely to be diagnosed at a later stage of the disease and have lower survival rates.[1,2,3,4,5,6] Cervical cancer incidence and mortality rates are nearly twice as high for Hispanic women as they are for non-Hispanic White women; in addition, Hispanic women are diagnosed at later stages and have poorer survival rates.[1,6]

Lower levels of cancer screening among Hispanic women are the result of psychosocial factors including fear of cancer, invasive procedures, and pain; lack of knowledge about cancer and its screening methods; attitudes of fatalism; religious or spiritual beliefs; concerns over confidentiality; language barriers and perceived discrimination; embarrassment; and partner disapproval.[1,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24] External factors also influence screening, such as a lack of health insurance, regular sources of health care, and physician referral; transportation barriers; cost; and restrictive work policies.[7,8,9,10,11,12,14,15,25,26,27,28,29,30,31,32,33,34,35,36,37,38]

Successful cancer-control programs for Hispanic women have used (1) Spanish-language media; (2) role models appearing in mass media (newspapers, television) with social reinforcement by community volunteers; (3) "small media," such as videos delivered in group settings or kiosks; (4) multimethod approaches; and (5) lay health workers or promotoras.[38,39,40,41,42,43,44,45,46,47] The lay health worker or promotora model, which was first developed in Latin America, is a peer health education model whereby respected community members educate peers in a culturally appropriate manner.[48,49]

A recent Cochrane review documented the effectiveness of lay health worker programs for increasing immunization uptake, promoting breastfeeding, improving tuberculosis outcomes, and reducing morbidity and mortality as the result of childhood illnesses.[50,51] In another systematic review, the US Preventive Services Task Force identified 1-on-1 education as an effective strategy for increasing both breast and cervical cancer screening.[52] The task force was unable to make a recommendation about the use of lay health worker programs specifically because there were insufficient numbers of published studies evaluating their effectiveness.

Although evidence suggests that lay health worker programs can improve some health behaviors, the effectiveness of this model for increasing cancer screening has yet to be fully explored. To fill this gap in the literature, we implemented and evaluated Cultivando la Salud (Cultivating Health), a lay health worker-delivered educational intervention for breast and cervical cancer screening. We expected the intervention would increase mammography and Papanicolaou (Pap) test screening among low-income Hispanic farmworker women who did not adhere to recommended screening guidelines.