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Rural Outreach Makes a Difference: Increasing Breast and Cervical Screening Among Tennessee Rural Appalachian Women Barbara (Bobbi) P. Clarke, PhD, RD Professor, Extension Health Specialist and Co-Director, UT Center for Community-Based Health Initiatives SERA 19 Health Conference September 10, 2007 Share with You A successful 4 year national and state partnership measuring the impact of education on increasing screening services Program Model Program successes: strategies and impacts Conclusions which may be useful for other partnerships Did you know… Early detection of cancer through screening saves lives. Cervical cancer is preventable. 80% of women diagnosed with cervical cancer are have not been screened. Unscreened groups include women over the age of 50, uninsured or underinsured women, minorities, and low-income women, especially those in rural areas. Breast cancer is one of the leading causes of cancer deaths in women. Just being a women puts one at risk for these cancers. National Team UP Partnership American Cancer Society Centers for Disease Control and Prevention National Cancer Institute United States Department of Agriculture Cooperative Extension Service TEAM UP Partnership Purpose: Increase breast and cervical cancer screening rates among rarely and never screened women in eight states with high-mortality counties. Multi State Partnership Eight States with high-risk counties: Alabama Georgia Illinois Kentucky Mississippi Missouri South Carolina Tennessee Tennessee State Steering Committee American Cancer Society Mid-South Division Cervical Cancer Coalition of Tennessee National Cancer Institute – Mid-South Region Cancer Information Service Susan G. Komen for the Cure, Knoxville Affiliate TN Department of Health’s Breast and Cervical Screening Program – state and regional staff University of TN Extension’s Public Health Education Program – state and county staff Co-chairs: Mary Jane Dewey and Bobbi Clarke Appalachian Region of TN Medical service shortages Geographic isolation Socioeconomic and cultural factors are barriers Appalachian women: proud, private, wanting to “take care of their own” Research conclusions: fear, fatalism, misinformation from family and friends, distrust of professionals, lack of knowledge about community screening services, perceived level of risk for these cancers TEAM UP TN Project Goals Increase access to screening services by women who are aged 50 through 64, low income, under or uninsured, rarely or never screened by promoting the services of the Tennessee Breast and Cervical Screening Program. Utilize a unique partnership approach to reach rural Appalachian women. Program Model Build county organizational capacity Develop process strategies Develop impact component Anticipated an empowerment component Conceptual Model Build county organizational capacity County partnerships FUNDERS HEALTH CARE COMMUNITY EXTENSION Selection of Pilot County Identified high-risk counties (NCI data) Evaluated the resources in these counties Chose eastern half of the state 11 rural Appalachian counties Commitment of counties Rates of breast and cervical cancer Identified 2 control counties based on breast cancer mortality rates, demographic mix and rurality. Team Up Pilot Counties County Partnership Structure Core team members: UT Extension (facilitator), ACS, CIS, Regional TN Breast & Cervical Screening Program Additional members specific to the county: Komen for the Cure, businesses, survivors, hospitals, cancer centers Identified outreach interventions based on their understanding of screening barriers unique to women in their respective counties Enrollment and screening to eligible women and followup if needed provided by county health department. Establish Regional Buy-in Video conference with regional directors of the three regional offices of the Tennessee Department of Health Orientation meetings with 11 UT Extension educators and regional program leaders. Meeting with all of the above to finalize plans. Build Infrastructure to Launch the Project Establishing technical competence Generic Plan of Work for Extension educators Primer on Women’s Cancers – January, 2005 Statewide Professional Development Conference – 3 regional sites, 48 Extension educators, Spring 2005 Update on Women’s Cancers TN BCSP, ACS, CIS, Primer on Women’s Cancers, TEAM UP TN, Komen Foundation Understanding About Barriers to Screening Focus Groups Sisters Network Latino women Literature Review African American women, Appalachian women, Latino women Evidenced-based programs Key Informant Telephone Interviews UT Extension educators Health Department staff Identify/Develop Resources Resources from National Cancer Institute/CIS – not low literacy Promotional Exhibits and Brochures Mammogram Pap Test Power Point Presentations Spread the Word About Mammograms and Pap Tests Identify/Develop Resources TN Breast and Cervical Cancer Promotional Brochure Posters Team UP Tennessee Web site http://teamup.tennessee.edu/ TEAM UP Tennessee Program Coordinator Funding $289,000 - TN Breast and Cervical Cancer Screening Program Promotional Brochure $10,000 – Komen Mini Grants $14,000 National Cancer Institute $16,000 American Cancer Society $3,500 USDA $35,000 UT Extension Program Model (cont.) Develop process strategies Community-based strategies – minimum of 3 strategies (distribute educational materials, mass media activities, educational programs and community events, county promotional campaigns) Clinic-based strategies – screening plus (training health professionals, screenings, visual prompts in exam rooms, exhibits in waiting rooms and free-screening days) External funding Program Model (cont.) Develop impact component 2004 Base-line data from TBCSP 2006 UT Extension System for University Planning, Evaluation and Reporting (SUPER) Specific educational indicators were developed Screening Results – Tracked use of services for 3 years. – Four fold increase over control counties in the number of women served. – 9 free-screening days • Reached more women in 9 days the 9 county health departments reached in a year. Tennessee Breast and Cervical Cancer Screening Program Increase in Number Served by Regions in Team Up Project 500 NERO 450 ETRO 400 UCRO control 350 300 250 200 150 100 50 0 FY2003 FY2005 FY2006 Fiscal Year FY2007 Screening Results –Screened more older women Tennessee Breast and Cervical Cancer Screening Program Number of Served by Age Group Through Team Up Project 400 350 Number of Patient 300 250 NERO ETRO 200 UCRO 150 M&W Co 100 50 0 < 40 40-64 FY 2005 < 40 40-64 FY 2006 < 40 40-64 FY 2007 Screening Results 20 percent of the women screened over the 3 years met the never or rarely definition Tennessee Breast and Cervical Cancer Screening Program Number of Paps Through Team Up Project 2005-2007 120 Number of Pap 100 80 NERO ETRO 60 UCRO control 40 20 0 All Pap FY 2005 Never or Rarely All Pap FY 2006 Never or Rarely All Pap FY 2007 Never or Rarely Tennessee Breast and Cervical Cancer Screening Program Number of Mamms Through Team Up Project 350 Number of Mamm 300 250 200 NERO ETRO 150 UCRO M&W Co 100 50 0 All Mam Never or Rarely FY 2005 All Mam Never or Rarely FY 2006 All Mam Never or Rarely FY 2007 2006 Educational Impact Conducted 176 educational programs/events reaching 2,850 women. Outreach programs included Mother/Daughter Teas, Women’s Teas, Pamper Me Day, African American Church Service Programs, Women’s Day Fairs, Church Delivered educational programs, Health Fairs 340,479 Indirect contacts (39 exhibits, 39 newspaper articles, 29 radio programs, 5 TV programs) Through post-surveys, 90% knowledge increase, 93% attitude improvement, 90% intent to change screening behaviors 2006 Partnership Impact – County partners met 132 times – 343 volunteers assisted in the implementation of program activities. – 1,499 UT Extension personnel hours were spent on the project. – 476 hours in direct (face-to-face) contacts with target population. Conceptual Model (cont.) Empowerment component Interaction among the partners at state and county levels Partners brought clout, diversity (range of skills, expertise and cultural perspectives) Commitment to project All partners benefited from project Successes energized the partnerships Strong incentive to sustain and build further on these relationships Conclusions Packaged the resources of the university outreach unit, cancer focused organizations and the breast and cervical cancer screening programs along with community members and stakeholders. Brought cancer education and screening directly to community members. Resulting in increased screening rates among target audiences. Sharing the same mission and success has energized county partners. Future Sustain state and county partnerships. Expand TEAM UP TN to other counties across the state Support the TN Comprehensive Cancer Control Plan Maintaining state and county partners Address other cancers Develop a state wide cancer education program Questions?