Running Head: Duval County Breast Cancer Education Program

Duval County Breast Cancer Education Program

Healthy People 2020 Objective: Reduce the female breast cancer death rate

Sarah Garber, Jasmine Henry, Adna Muminovic, Lauren Suggs

University of North Florida

October 15, 2018

Running Head: Breast Cancer in African American Women 2

Section 1: Literature Review and Needs Assessment

Over the past 20 years, overall breast cancer mortality rates have declined in the United

States (Amirikia, Mills, Bush, & Newman, 2011). The decline in mortality is mostly due to

mammography screening which commonly leads to earlier detection (Amirikia et al., 2011).

However, breast cancer is still the second leading cause of cancer deaths among women

(Richardson, Henley, Miller, Massetti, & Thomas, 2016). The Centers for Disease Control and

Prevention reports that approximately 237,000 new cases of breast cancer are diagnosed and

41,000 deaths occur in the United States women each year (CDC, 2018). In 2015, 15,860 new

cases of breast cancer diagnosed in Florida (Florida Department of Health, n.d.). Of those cases

in Florida, 679 were in Duval County (Florida Department of Health, n.d.).

While overall rates of breast cancer incidence and mortality are important, mortality rates

in the African American population are a pressing concern. African American women are

disproportionately affected by breast cancer. Their incidence rate is similar to that of white

women, but their mortality rates are much higher (Richardson et al., 2016). This is concerning

because among all races, African American women are receiving the most mammograms (Susan

G. Komen Foundation, 2018).

This presses the question: why are African American women dying the most even though

they are the population that receives the most screenings for breast cancer? Some behavioral

reasons contributing to the higher mortality rates of breast cancer in African American women

include later detection, lack of follow up after an abnormal mammogram, and low adherence to

treatment. Contributing to these behaviors are predisposing and enabling factors such as

socioeconomic status, genetic makeup, and lack of race specific knowledge of breast cancer

(Patel et al., 2014).

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Despite the fact that most women agree that the “More I know about a disease, the more

control I have,” only 30% of women report that they know enough about breast cancer (Sadler et

al., 2007). This is a key component to the lack of treatment adherence, because women who

report that they feel well educated about breast cancer were statistically more likely to adhere to

breast cancer screening methods such as breast self-exams, clinical exams, and mammograms. A

perceived lack of knowledge also leads to later screenings which can allow cancer time to spread

and progress to its deadliest forms. Adding to this is the socioeconomic status of the African

American women which may limit the resources devoted to health screenings. Patel et al. found

that women with an annual household income of <$15,000 were significantly less likely to

receive a mammogram than those with higher incomes. Women with lower economic statuses

reported struggling with the cost of finding childcare during appointments, transportation and a

lack of actual healthcare insurance (Patel et al., 2014). This lets the women feel that health

screenings are not their first priority and can be delayed until they have better financial standing.

Once the women finally decide to participate in breast cancer screenings, the next

behavioral limitation is shown through a lack of follow up after an abnormal exam. It is

reasonable to be scared about a positive test result; however, a lack of treatment will only

exacerbate the situation. This could be caused by a lack of knowledge of the high risk African

American women face due to genetics. In a study to ascertain which health concerns are top

priority to African American women, Sadler et al. found that at least one-third of the sample

population feels that breast cancer is one of the most dangerous concerns. Despite this, it is not

commonly known that many women with an ancestry derived from sub-Saharan Africa are

predisposed to contracting triple-negative breast cancer as well as an early onset. Triple negative

breast cancer is a more difficult form of cancer to treat because it is resistant to therapy and
Running Head: Breast Cancer in African American Women 4

systemic treatments and is classed in a more aggressive basal breast cancer subtype (Newman,

2015). It is reasonable to assume that if all African American women knew about their high

susceptibility to such a deadly cancer and were educated on the treatment options provided to

them, it could lead to increased follow-through after a positive breast cancer screening.

Non-adherence to screening and treatment guidelines is also a behavioral reason for the

high mortality rates seen in African American women. Some factors contributing to this are,

once again, socioeconomic status and knowledge. Women in a 2017 study reported that

transportation and childcare were their main concerns of continued visits to a treatment center

(Freedman et al., 2017). Also, a marked level of distrust in clinics and clinicians targeted towards

low income populations. This is important as Sadler et al. found that recommendations made by

one’s health care provider was the second largest predictor to continued adherence to a treatment

plan.

Due to these behavioral reasons, there is a great need in Duval county to increase

education about breast cancer in African American female populations that have a lower

economic status. Prior to implementing a program specific to the target population in Duval

County, one must assess previous and current efforts and barriers and limitations occurring

within the county and within similar populations. Assessing these efforts would allow for

improved planning and hopefully a more successful outcome for future programs.

Previous studies have been conducted in churches in low socioeconomic areas in hopes

of promoting breast cancer screening. According to Coughlin (2004), churches are an ideal place

to incorporate health education because they are an important part of African American

communities. A benefit of implementing a breast cancer screening awareness and education

program in a church would be that the participants already attend the church. In addition, the
Running Head: Breast Cancer in African American Women 5

church community is made up of people of all ages. By reaching out to the variety of women

present, we would have a better chance of increasing breast cancer screenings in younger

women. Coughlin (2004) also states that the use of culturally tailored health promotion messages

will increase motivation, be perceived as more personally relevant, and increase the likelihood of

behavior change.

An intervention program in North Carolina targeted low income African Americans who

were 40 years and older in the church community. This program consisted of chart reminders,

community outreach strategies, distribution of literature, and community events. Another project

was done in Arkansas and it focused on training breast cancer survivors to promote early

detection and self-breast exams. The setting of survivor based educational program was

predominantly in African American churches in the rural area. Both studies reported increased

early intervention practices in African Americans in the rural communities.

Literature suggests that educating African American women in settings where they

frequently gather and feel comfortable, like churches, increase the overall effectiveness of

education and encourages them to improve their health. In an attempt to decrease breast cancer

mortality rates among African American women in Duval County, we chose to utilize a church-

based program that has previously been implemented in African American churches in the

Northeast United States, called the Breast Cancer Awareness and Education Program (BCAEP).

When previously implemented, the program was successful in increasing knowledge about:

breast cancer in general, higher breast cancer mortality among African American women,

warning signs, risks and ways to mitigate risk, and the availability of low-cost or free

mammograms. (Brown & Cowart, 2018). We plan to model a program using the information and

layout of this program. Our program will be located in an African American church in downtown
Running Head: Breast Cancer in African American Women 6

Duval County and consist of two sessions. The first session will consist of education and the

second session will consist of a skills training and education. The intervention will occur on

Sunday afternoons after church service. We will allow a 30-minute break between church and

the beginning of the program and will provide lunch as an incentive during the break. Each

component will be one hour long. Three months following the completion of the program, a

post-test will be administered following church.

Currently in Duval County there are several programs centered around the topic of breast

cancer. The Florida Breast and Cervical Cancer Early Detection Program (FBCCEDP) is

administered through the Health Department and provides low or no cost screenings if eligibility

requirements are met (Florida Department of Health, 2018). The DONNA Foundation provides

programs for education and awareness at events around Jacksonville and provides financial

assistance and support for those living with breast cancer through the DONNA CareLine (The

Donna Foundation, n.d.). Baptist Buddy Check 12 is a self-awareness program through Baptist

Health that promotes having a reliability partner and doing monthly self-examinations (Baptist

Health, n.d.). Bosom Buddies Breast Cancer Support is a program through the Women’s Center

of Jacksonville, which provides information and resources to women affected by breast cancer as

well providing information and referrals to underinsured or uninsured women in need of breast

health care (Women’s Center of Jacksonville, n.d.).

In contrast to other programs being implemented in Jacksonville, our program targets

African American women. More specifically, our program informs these women of risks specific

to their race. Like some of the current programs, our program will connect these women to

resources within the community that will allow them to follow up after an abnormal screening

and complete treatment. We will be teaching them how to correctly perform a breast self-exam
Running Head: Breast Cancer in African American Women 7

and what abnormalities to look for. We have created flyers, bookmarks and posters to entice

interest in our program and connect participants with local resources.

It is crucial for women to know what is or what could be going on with their bodies.

Education is the first step in changing a person’s behavior and by educating these women, we

anticipate that there will be an increase in not only the amount of mammography screenings, but

an increase in follow up appointments, and treatment. African American women would benefit in

a tremendous way if they put forth the effort to engage in a program like the one presented. This

would not only improve the health status of these women, but it would also pave the way toward

educating more people across the country about breast cancer in Americans nationwide.
Running Head: Breast Cancer in African American Women 8

Section 2: Goals and Objectives

Goal: To reduce breast cancer mortality in African American women in Duval County. (To

reduce the female breast cancer rate in African American women in Duval County.)

Objectives:

• By the end of the program, 75% of the participants will report being “very satisfied” with

the education session.

• By the end of the skills training session, 95% of the participants will be able to correctly

perform a self-breast exam.

• Three months after the program, 50% of the participants will report performing a breast

self-exam during the last month.

• Ten years post program, breast cancer death rates in African American women will be

reduced by 10% overall in Duval County.

Running Head: Breast Cancer in African American Women 9

Section 3: Theory and Activity

Concept Definition Application Specific activities that will

address these (for your
project)

Perceived One’s opinion of Define population(s) at During the education section,

Susceptibility chances of getting risk, risk levels. we will present statistics on
condition Personalize risk based the incidence rates and
on a person’s features mortality rates of breast
or behavior. Make cancer.
perceived susceptibility We will also address the
consistent w/ actual higher rates of deadly triple
risk. negative breast cancer and
higher mortality in African
American women.

Perceived One’s opinion of Specify consequences We will address the costs of

Severity how serious a of the risk and the later stage diagnosis of breast
condition and its condition. cancer and the costs, both
consequences are monetarily and physically,
during the education
component. Later stages of
breast cancer could lead to
mastectomy, job loss,
increased treatment, etc.

Perceived One’s opinion of Define action to take: During the education

Benefits the efficacy of the how, where, when; component, we will explain
advised action to clarify the positive the differences in cost and life
reduce risk or effects to be expected. expectancy when the breast
seriousness of cancer is found at a later stage
impact versus earlier stage. Prevention
screening is much cheaper
than treatment and earlier
diagnosis is associated with
better outcomes.
Running Head: Breast Cancer in African American Women 10

Perceived One’s opinion of Identify & reduce Following the skills training
Barriers the tangible and barriers through we will address where and
psychological reassurance, correction how women can find free or
costs of the of misinformation, low-cost resources for breast
advised action incentives & assistance. cancer such as mammography
screenings and treatment
during the resources education
session.

Cues to Strategies to Provide how-to During the program, we will

Action activate information, promote provide the participants with
“readiness” awareness, reminders. bookmarks (and the church)
that have the steps for a breast
self-exam, hang signs/posters
(awareness/ self-exam
reminders) in the church, and
ask the pastor to give the
church members a monthly
reminder to complete a breast
self-exam.

Self-Efficacy Confidence in Provide training, During the second phase of the

one’s ability to guidance in performing program, we will provide a
take action action, progressive goal skills training (video and
setting, reinforcement, professional demonstration) to
demonstrate behaviors, demonstrate how to perform a
reduce anxiety. breast self-exam. During the
training, we will ensure that
each participant can correctly
perform an exam.
Running Head: Breast Cancer in African American Women 11

For our activity on increasing early diagnosis of breast cancer in African American

women we will conduct workshops after two church services. During the church service, an

announcement will be made to notify all women that there will be breast cancer workshops after

two of their services. Flyers will be posted on the church’s announcements board and in the

female bathroom. The two main objectives we wish to accomplish in our self-breast exam skills

training are that by the end of the program, 75% of the participants will report being “very

satisfied” with the breast cancer program overall and 95% of the participants will be able to

correctly perform a self-breast exam.

On the first day of our intervention, we will conduct an information session explaining

the severity and risk factors of breast cancer for African American women. These women will

become aware of the fact that just because of their African American background, they are

classified in a group that has the highest mortality rate. We will explain the differences in cost

and life expectancy when the breast cancer is found at a later stage versus an earlier stage; we

will include precautions that can be taken to ensure that the cancer is found at an earlier stage. In

addition to all of that information, we will emphasize that prevention screening is much cheaper

than treatment and earlier diagnosis is associated with better outcomes. Before the start of the

session, the women will be provided with a light lunch that should take approximately half an

hour. This will let the women relax for a bit after church service. At the beginning of this

information session we will distribute a pre-test which should take around 5-10 minutes to

complete. The entire session should take up approximately one hour. The materials needed for

this particular information session are printed copies of the pretest along with pens, a PowerPoint

presentation, and the technology needed to view it.

Running Head: Breast Cancer in African American Women 12

Two weeks later on our second intervention day we will hold a skills training session

which should take about one hour, just like the first intervention session. We will begin with a

small lunch for the women right after church service. The women will then be shown a short, but

detailed, two-minute skills training video that depicts the steps of conducting a self-breast exam.

The materials needed for the video portion are a TV, HDMI cable, and access to the video saved

on a jump drive. After the video is presented to the group, a trained professional will demonstrate

how to conduct the breast self-exam once more. The women will then be given time to practice

on themselves while surrounded by us and the professional who can help guide each woman that

is struggling, in the right direction. It is crucial that these women leave the session knowing how

to perform an accurate breast self-exam and knowing that having a skill like this could save their

lives one day. At the very end of the training session, women will be allowed to ask questions or

stay back if they choose to personally talk to anybody. Flyers with information on how often a

self-breast exam should occur, the steps to complete one, and what to look for will be handed out

as the women leave.

In approximately three months, the same survey that was administered as a pre-test will

be administered again as a post-test to the same group of women. This step will give us feedback

as to how much the women learned from the sessions, how much they remembered, and if they

actually incorporated these skills into their lives. As a result of this post-test, we will see if our

program has met the goals and objectives that we initially planned.
Running Head: Breast Cancer in African American Women 13

Section 4: Evaluation

We will begin the recruiting process at the First United Methodist Church two months

prior to the start of our program. We plan to meet with the pastor approximately four months

prior to the start of the program to ask permission to implement our program. We hope to have

the pastor and a church elder review the program to ensure cultural competency and ask

suggestions on how to best approach and interact with the church members during the program.

Two months prior to the start of the program, we plan to have the pastor start making

announcements about the program during church each Sunday. We will have a church elder as a

contact person for the project that can answer questions and put members in contact with us. We

plan to provide the pastor and church elder with flyers (dates, information, contact information,

etc.). The signup sheet will be located in a central location in the church. There will be 25 slots

available for the program and women will be asked to attend both sessions and complete a

posttest if they sign up.

For this program, we have three objectives. These objectives are:

Learner Objective-By the end of the skills training session, 95% of the participants will
be able to correctly perform a breast self-exam.
Behavioral Objective- Three months after the program, 50% of the participants will
report performing a breast self-exam during the last month.
Outcome Objective- Ten years post program, breast cancer death rates in African
American women will be reduced by 10% overall in Duval County.
In order to evaluate the success of each objective, we have chosen to use three different methods.

The learner objective will need an in-person observation of each participant during the training

session. After the women have watched the video and have been shown how to correctly perform

a breast self-exam (BSE) by a trained physician, they will be asked to practice performing one

using a breast model. The physician and four trained program volunteers will walk around the
Running Head: Breast Cancer in African American Women 14

room to observe participants performing an exam on the models, correct any errors, and answer

any questions. The signup sheet that was used to recruit the women will be used to tally how

many were able to perform a BSE correctly by the end of the skills training.

To evaluate the behavioral objective, we will use data from the post test. Three months

after the program, the women will be gathered in the same room to take a post test. There will be

a question on the test that directly correlates with the behavioral objective. This data will be

cleaned and coded by an external evaluator to ensure the highest credibility. The data collected

from the questions will determine whether or not 50% of the participants performed a breast self-

exam in the last month. This will show if the program was able to increase the number of women

performing BSEs. If there is a noted success in the education and skills program within the

church, then we would like to recreate this system in other, similar churches.

The outcome objective will be evaluated using data from the Florida Department of

Health. Florida Department of Health charts publishes yearly data on death rates in African

American women by county. We will use this data to collect yearly death rates of African

American women in Duval County and create a line graph to show if the program reduced the

rates of breast cancer in this group.

All data collected through this program will be processed and analyzed by an external

evaluator. This will ensure the credibility of the program and provide an objective

perspective. After completing the evaluation, we will share the results with our stakeholders,

funding agency, and program participants. These stakeholders include the City of Hope

organization, Susan G. Komen organization and the Florida Department of Health. All results

will be simplified and disseminated to all the participants through the pastor or a willing church

elder.
Running Head: Breast Cancer in African American Women 15

Breast Cancer Intervention Survey

Introduction-

This study is being conducted on breast cancer prevention. The following 11 questions

will be multiple choice, True/False, and fill in the blank. Please answer every question with

complete honesty, as your survey will be completely anonymous and strictly private. This

survey should take only 5-10 minutes to complete. Thank you for responding and for your time.

___________________________________________________________________

1. What is your current age? __________________

2. Have you ever heard of breast cancer?

o Yes

o No

3. If yes, what are your sources of information? (check all that apply)

o Books

o Media (TV, Internet, Radio, etc.)

o Hospital

o School

o Lecture/Seminar

o Friends

o Other __________________________
Running Head: Breast Cancer in African American Women 16

4. Which of the following are risk factors of breast cancer? (check all that apply)

o Age

o Younger age at first period

o Giving birth for the first time after age 35 (or not having given birth)

o Family history of breast cancer (mother, sister or daughter)

o Number of past breast biopsies

o Number of breast biopsies showing atypical hyperplasia (benign breast condition)

o Race/ethnicity

o Mutation in the BRCA1 or BRCA2 gene

o I do not know

5. Have you ever been taught to do a breast self-exam?

o Yes

o No

6. During the last month, did you perform a breast self-exam?

o Yes

o No

7. At what age should breast self-exams be started?

o From puberty

o From 20 years old

o From 30 years old

o From 40 years old

o After menopause

o I do not know
Running Head: Breast Cancer in African American Women 17

8. How often should a breast self-exam be performed?

o Daily

o Weekly

o Monthly

o Yearly

o I do not know

9. How often do you perform a breast self-exam?

o Daily

o Weekly

o Monthly

o Yearly

o I do not perform BSEs

10. What is the best time to perform a breast self-exam?

o During pregnancy

o During period (Menstruation)

o After period (Menstruation)

o During pregnancy

o I do not know

11. Do you know where you can get a low-cost or no-cost mammogram?
o Yes
o No
Running Head: Breast Cancer in African American Women 18

Section 5: Budget and Timeline

Personnel:

Physician $10,000

External Evaluator $10,000

4 Health Educators- $10,000 each $40,000

Childcare Supervisor- $100 per hour, 4 hours $400

Incentives:

Walmart Gift Cards for Attendees- 25 @ $25 each $625

Walmart Gift Card for Church Elder $100

Food for education and Training Session $4,000

Materials:

Printing cost (Bookmark, Flyers, Pre- and Post-test Surveys) $500

25 Breast Cancer Models from Susan G. Komen In-Kind

Total Cost $65,625

 Duval County Breast Cancer Education Program
January 2019-December 2019
Tasks January February March April May June July August September October November December
Create Materials X
Recruit Physician X
Develop Educational Outline X
Present Program to Pastor X
Recruit Elder X
Have Elder Review Program Materials X
Finalize and Print Materials X
Prepare Incentives X X
Begin Advertising Within Church X X
Pastor Announcements X X
Elder Initiates Participant Sign-up X X
Education Session 1 X
Send Pre-Test Surveys to External X
Running Head: Breast Cancer in African American Women

Evaluator
Education Session 2 X
Post-Test X
Disperse Gift Card Incentives X
Send-Post-Test Surveys to External
X
Evaluator
Interpret Results X X X
Develop Evaluation Report X X
Dissiminate Report to Stakeholders X
and Funding Agency
Share Finding with Participants X
19
Running Head: Breast Cancer in African American Women 20

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