Taking Care of Ourselves and Each Other: African American Breast Cancer Screening Project targets African American women over age 40. The goal of the project is to increase the mammogram screening rate of African American women in King and Pierce Counties, Washington State via the following objectives:
Train 20 outreach educators in education program methods.
Reach 800 African American women with program.
Increase by 20% (100 additional) the number of African American women who receive mammogram.
Ensure 100% of women referred for mammogram receive follow-up.
Train 100 health care providers to improve access to services, increase cultural competency skills, and increase customer satisfaction for African American women.
Evaluate the effectiveness of education programs.
African American women have a lower incidence rate of breast cancer and a higher mortality rate in King and Pierce Counties, Washington State. During outreach for the Washington Breast and Cervical Health Program staff found a sub-group of African American women eligible for free mammograms who decided not to have a mammogram. Staff reviewed the literature and found no research that involved speaking with women who were offered, but refused a mammogram. Staff reviewed the county mammogram screening, breast cancer incidence and mortality rates for African American women. The significantly higher death rate was identified as the key relevant issue. While the causes are many (higher incidence of more aggressive tumors, higher incidence of breast cancer at a younger age) the solution does include assuring access to regular mammogram screening. The goal of the project was to increase mammogram screening among all African American women by developing new communication messages and tools that would effectively engage women in discussions about breast cancer and mammograms, address their concerns and provide both motivation and support for screening actions.
The literature review and our program data revealed extensive information about barriers to screening for women who decided to be screened. But there were no published studies and program staff had not contacted the group of women reached through program outreach who declined to have a mammogram. The program used PATCH during its initial planning phase in 1994. Once priority populations were identified (those with higher incidence of breast cancer or lower screening rates), outreach was planned for each group. Basic program messages were tailored for language, culture, degree of acculturation with Western medicine, age, length of time in the US and so forth. This approach worked well with a large number of women in the priority populations as many thousands of women were recruited and screened. The innovation of this project comes from discovering the group of women who received this tailored and refined outreach and still decided not to have a mammogram; implementing a research study to find out the reasons; and developing a new communication plan specifically designed to address those reasons.
Agency Community RolesProgram staff were co-principle investigators with the research project. Actvities included: assisting with the grant application, developing and maintaining the database, assisting in recruiting and training interviewers, recruiting and staffing the community advisory group, analyzing data and writing papers. For the education program development, public health staff were the principal investigators on the 3 grants, coordinated the entire project, recruited and trained speakers, compiled results, wrote and published the curriculum kit. An advisory committee for the research project reviewed the research questions, assisted with many processes used in attempts to reach women on the population database, reviewed research findings and recommendations from the study.
For the education project program staff held community focus groups with African American women and recruited a group to review and advise during the entire production of the films, development and testing of the curricula and final review of the curriculum kit. This group had veto power during the program’s development. This assured that the films and all materials were authentic. We also engaged the research team on the education project to assure the messages remained true to the findings from the research. Fostering collaboration with stakeholders: The key was listening fully to input and using that input and staying true to the actual words given by the women in the research study. The advisors had veto power during the review of the film concepts and messages. They participated in pilot-testing the materials, reviewing next drafts, grants and the final product. The project was developed by, with and for African American women. This is a community based approach which fosters collaboration and long term working relationships.
Costs and ExpendituresThe project started with a 3-year qualitative research study ($328,749) to determine reasons why some African American women eligible for free breast cancer screening decided not to have a mammogram. Once the research findings were completed, a 3-year education project was launched to develop and test new methods that addressed research findings. Costs for the 3-year education project include:
Year 1: $107,277, for new films, communication and education methods and messages;
Year 2: $105,434, the new tools were tested with target populations; and
Year 3: $55,000, the tools were refined and developed into a dissemination curriculum kit.
Funding sources for the research project include: Department of Defense, US Army Medical Research and Materiel Command, and Breast Cancer Research Program. Funding sources for the education project include: Susan G. Komen for the Cure and Puget Sound Affiliate.
ImplementationResearch project (2000 through 2003): The team developed a population base of African American women reached through the Washington Breast and Cervical Health Program outreach who declined a mammogram (approximately 800 women). Phone contact was attempted with each woman to invite her participation in the study. Community members were trained rigorously to implement qualitative interviews using the 13 questions and probing as appropriate for further elaboration. Interviews were completed with approximately 50 women. The interviews were tape recorded, transcribed verbatim, reviewed for accuracy and inductively coded across all interviews by question. The coding was reviewed across questions and the results were triangulated and integrated. This framework was compared to 10 key assumptions that form the basis for the Washington Breast and Cervical Health Program. The attitudes and beliefs of study participant about breast cancer screening are inconsistent with and refute virtually off the these assumptions. That explained why program outreach methods were ineffective in reaching this group of women.
Education Project (2004 - 2006):
1. Develop new culturally and subject-sensitive communication messages based on the research findings.
2. Implement focus groups to receive input on the overall communication messages and plan.
3. Create compelling film that engages each viewer (especially those who do not want to have a mammgram), addresses her complex fears of, and consequent rationalization for avoiding breast cancer screening and assists in processing that fear to permit consideration of new information and support for screening.
4. Develop brochure to complement the film's messages.
5. Launch a media campaign to compliment the key messages from the community education films and programs.
6. Produce a companion communication film for health care provider training that captures the study participants' beliefs about breast cancer screening and offers compelling solutions.
7. Develop training for health care providers that helps them respectfully communicate with and address concerns of clients and assess their own work environment for cultural competence and identify areas for change.
8. Pilot test and refine lay audience and health care provider training.
9. Produce curriculum kit for dissemination.
The goal of this practice is to increase the mammogram screening rate of African American women in King and Pierce Counties.
Objective 1: Reach 800 African American women with education program.
Performance Measures: The education program was pilot-tested with 1,283 African American women.
Outcome: 160% of the target number participated in the education sessions. The pilot project was completed and a wonderful new unique effective education curriculum kit was developed. African American women were able to overcome fear of screening, become better patient advocates and confront barriers to screening.
Objective 2: Train 100 health care providers to improve accessibility and customer satisfaction of African American women.
Performance Measures: The health care provider training was pilot-tested with 180 providers, including radiologists, primary care physicians, medical assistants and mammography radiology technicians.
Outcome: 180% of the target number participated in training. The pilot project was revised and an effective new curriculum kit was developed. Providers were able to more effectively communicate with clients resulting in much improved outcomes.
SustainabilityProject partners will continue to implement the project. In addition, project staff has shared the program during its development with multiple other partners in King and Pierce Counties and across Washington State. The kit will be distributed free to all these partners. This year project staff will take the curriculum kit to several national organizations to determine their interest in disseminating the kit. If they are not interested, project staff will explore the possibility of dissemination through our local public health department. Project staff has done so successfully with several other education projects including the Breastfeeding Triage Tool book and Family Life and Sexual Health curricula. Project staff have presented posters at 2 national conferences and will present a full session on the project this summer at the national Society for Public Health Education conference.
Lessons LearnedThe curriculum was pilot-tested with 1,283 African American women in 2005 and 2006. Evaluations demonstrate that the program is an effective education tool. Participants personally related with at least one woman in the film. People overwhelmingly identified with the emotional impact, acknowledging the "sisterhood" they felt after viewing the film.
A majority of viewers said the film helped them address some aspect of breast cancer, including overcoming fear, being a better patient advocate, confronting a barrier and ultimately that cancer did not have to be a death sentence. The health care provider training was pilot-tested with 180 providers including primary care physicians, mid-level practitioners, medical assistants, mammography radiology technicians and radiologists. The evaluations were very positive indicating increased knowledge of the beliefs about breast cancer and screening held by a sub-group of African American women who have decided not to have mammograms. It also increased their patient communications using the new tools.