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Integrated Community Education Model:

Breast Health Awareness to Impact
Late-Stage Breast Cancer
LaDonna Northington, RN, DNS, Tina Martin, RN, PhD, FNP-BC, Jean T. Walker, PhD, RN,
P. Rene Williams, PhD, RN, Susan P. Lofton, PhD, RN, Janet R. Cooper, PhD, RN,
Cynthia H. Luther, DSN, FNP, RN, and Sheila D. Keller, PhD

Race and ethnicity play roles in breast cancer mortality, particularly for African American women. As a result, a three-
pronged integrated community education model (i.e., faith-based, community, and state agencies) was generated and
tested in a medically underserved area with high mortality rates from breast cancer to increase participation in breast
health education, provide early screening and detection practices, and provide access to annual mammograms and referral
sources. The model provided three women with life-saving early diagnoses, in addition to providing potentially hundreds
of women with a network of breast health, self-monitoring, and referral sources for future issues.

B
reast cancer is the most common nonskin can-
cer in women, the number one cause of cancer At a Glance
deaths in Hispanic women, and the second most Breast cancer mortality is higher among African American

common cause of cancer deaths in Caucasian, women than Caucasian women of comparable age and cancer
African American, Asian Pacific Islander, Ameri- stage because this population is more likely to be diagnosed
can Indian, and Alaska Native women in the United States in advanced stages.
(American Cancer Society [ACS], 2009). About 230,000 cases
Psychological and social barriers to breast health in African

of invasive breast cancer are estimated to be diagnosed, and
American women include lack of health insurance, financial
about 40,000 deaths are expected from the disease annually
burden, preconceived beliefs or lack of knowledge, under-
(ACS, 2011; National Cancer Institute [NCI], 2011). Mortality
treatment, cultural views of past events with the healthcare
is linked to the stage of cancer at time of diagnosis, with later
system, and attitudes regarding screening procedures.
stages having poorer prognoses. Race and ethnicity play seri-
ous roles in these statistics (NCI, 2011). In Caucasian women, More publicity, outreach programs, and education should be

the incidence of breast cancer is highest; however, African implemented to counter the lack of information available.
American women have a greater breast cancer mortality rate
than any other racial or ethnic group. They present with
more advanced disease at a younger age and have lower rates 2003). African American women are 1.52.2 times more likely
of adherence with the screening guidelines for mammog- to die from breast cancer than Caucasian women (Lisovicz et
raphy (Lisovicz et al., 2006; Stelger, Samkoff, & Karoullas, al., 2006; Stelger et al., 2003).

LaDonna Northington, RN, DNS, is a professor, Tina Martin, RN, PhD, FNP-BC, is the director of the accelerated BSN program and a professor,
Jean T. Walker, PhD, RN, is a professor, P. Rene Williams, PhD, RN, is an associate professor and the director of continuing education, Susan P.
Lofton, PhD, RN, is a professor, Janet R. Cooper, PhD, RN, is an assistant professor, Cynthia H. Luther, DSN, FNP, RN, is an assistant professor,
and Sheila D. Keller, PhD, is an assistant professor and senior director of research and evidence-based practice, all in the School of Nursing
at the University of Mississippi Medical Center in Jackson. The authors take full responsibility for the content of the article. This work was
funded by the Mississippi Institute for Improvement of Geographic Minority Health, a subaward of the National Institutes of Health (1-CPI
MP061018-03). The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and
free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the independent peer
reviewers or editorial staff. (Submitted September 2010. Revision submitted November 2010. Accepted for publication December 8, 2010.)
Digital Object Identifier: 10.1188/11.CJON.387-392

Clinical Journal of Oncology Nursing Volume 15, Number 4 Integrated Community Education Model 387
Cultural Issues time to talk with their patients before and after clinical breast
examinations (CBEs) and medical procedures, such as mam-
for African American Women mograms, to help alleviate insecurities.
Many African American women are doubtful that cancer treat-
The disparity between African American and Caucasian ments work and use their faith in God as the primary source for
women has been attributed to a number of psychological and healing (Lisovicz et al., 2006). The church, particularly in rural
social reasons, including lack of health insurance, financial southern communities, serves as a strong and highly visible entity
burden, preconceived beliefs or lack of knowledge regarding for support, education, and guidance in health care, particularly
the importance of screening, attitudes regarding screening when a health crisis exists. Bowie, Wells, Juon, Sydnor, & Rodri-
procedures, cultural views of past events with the healthcare guez (2008) found that those who had stronger religious beliefs
system, and undertreatment (Fouad et al., 2004; Frisby, 2002; of health were more likely to have their first mammogram by the
Thomas, 2004, 2006). Susan G. Komen for the Cure (2007) recommended age of 40 than those who had weaker religious be-
noted that, liefs of health. Churches strong influence for a majority of African
American women led the current studys investigators to deter-
[A]rranging reliable and affordable transportation, need to
mine this was the best way to reach this underserved population.
arrange for time off work, scheduling child care, and saving
Churches also are an integral part of the community and are
to make copayments for each treatment were emphasized
accessed easily, even by those who are not a part of the congrega-
as financial burdens primarily in rural areas, but was a chal-
tion. The investigators believed that developing partnerships with
lenge for urban women as well (p. 3).
congregations and providing healthcare screenings, educational
Several authors have cited a lack of information regarding the awareness, referrals, financial assistance, transportation, and
availability of services to healthcare providers and underserved treatment could provide a powerful impetus for the study.
African American women as another barrier to early screening, Eight communities in the United States had evidence of signifi-
suggesting that more publicity, outreach programs, and educa- cantly higher mortality rates from breast cancer for all women
tion should be implemented to rectify this common problem (Susan G. Komen for the Cure, 2007). The Susan G. Komen for
(Danigelis, Worden, Flynn, Skelly, & Vacek, 2005; Susan G. Ko- the Cure (2007) study also identified several common factors
men for the Cure, 2007). among these eight communities that influenced the statistics.
Frisby (2002) and Susan G. Komen for the Cure (2007) dis- One of the major factors revolved around little to no access to
cussed psychological responses that have been identified as screening because of a lack of insurance coverage and poor
personal factors inhibiting African Americans from participat- socioeconomic status. The issue of access to care, coupled with
ing in cancer health-promotion behaviors, such as fear, fatal- higher mortality rates in those counties, served as the impetus
ism, and misperceptions about the disease. For example, some for the current study.
women were afraid of finding a cancerous lump, and some The purpose of the study was to generate and test an inte-
believed incorrectly that mammography reduces the incidence grated community education model in a medically underserved
of breast cancer or that breast cancer is not a serious disease. area. Goals were designed to increase participation in breast
Others shared a lack of belief in the efficacy of breast cancer health education, provide early screening and detection, and
treatment, with many participants sharing a belief that surgery provide access to annual mammograms and referral sources
caused cancer to spread throughout the body (Susan G. Komen for treatment of problems, thereby decreasing the disparity in
for the Cure, 2007). a population of higher-risk women.
Frisbys (2002) study also suggested that a lack of media
sources designed specifically to inform African Americans about
risk factors and preventive measures could be interpreted by Research Objectives
these women as proof that breast cancer is not their problem or
The objectives of the current study were to identify the
that they rarely would develop the disease. Providing culturally
psychosocial and cultural issues and barriers that affect breast
sensitive health information to reinforce teaching is essential to
health screening and early detection practices in the study
reach African Americans of all socioeconomic and educational
population, identify any perceived differences between rural
levels (Coleman et al., 2003).
and urban areas in terms of breast health care, develop and im-
Thomas (2004) asserted that cultural beliefs embedded in
plement a culturally sensitive educational program to empower
memories and personal feelings about breasts also may act as
these women to become more active in breast health, provide
barriers and serve as negative influences on African American
specific interventions to facilitate access to breast health screen-
womens willingness to engage in breast cancer screening. In
ing and treatments, and evaluate the success of the Train the
an exploratory study involving 12 African American women
Trainer sessions by surveying breast health with a self-report
with middle-to-high incomes, Thomas (2006) summarized
follow-up with the study population.
the womens descriptions of their first mammogram experi-
ence as painful, impersonal, embarrassing, and feelings
of humiliation with no explanation from the physicians or Methodology
nurses about what to expect (p. 368). The women shared
that it was common in their families to avoid open discussion The project was written and developed by a team of investiga-
about breast health practices, and particularly breast cancer. tors from an academic health science centers school of nursing,
The participants suggested that healthcare providers take the located in the southern United States. The research team obtained

388 August 2011 Volume 15, Number 4 Clinical Journal of Oncology Nursing
grant funding from the states Institute for Improvement of Geo-
graphic Minority Health, a subaward of the National Institutes of School of Nursing
Health. Institutional review board approval was obtained. Breast health awareness curriculum
The target county selected for the study was one of the eight Train the Trainer sessions
communities identified by Susan G. Komen for the Cure (2007) Student support
Transportation
as having high mortality. The selected county had a population
of about 88,000 people. Fifty-two percent of the population
was female and 59% was Caucasian, 38% was African American,
and 1% was Hispanic (U.S. Census Bureau, 2006). The median Faith-Based Community Screening Locations
income for a household in the county was $46,970; about 10% of Four churches participated.
families and 14% of the population were below the poverty line.
More than 25% of the population in seven towns located in the
target county was below the poverty level. Those towns also had County Medical Center
the areas of greatest concentration for medically underserved Screening mammograms
women within the county.
The investigators developed a three-pronged, integrated com-
munity intervention model (i.e., faith-based, community, and Faith-Based Community Ministry,
state agencies) to impact late-stage breast cancer diagnoses in an Caring Hands Clinic
underserved rural area (see Figure 1). The Integrated Commu- Order mammograms.
nity Team hoped to provide specific services to 100 medically Receive results.
underserved and uninsured women of all ages and races from
the rural southern county. The investigators developed com-
munity partnerships with a number of organizations. Normal Abnormal
The school of nursing provided outreach Train the Trainer No referral Referral
seminars on breast health education to 20 key women in 10
churches in the county. In addition, each screening session re-
quired that each participant would receive printed educational State Department
of Health
materials; an interactive educational session on breast self-ex-
aminations (BSEs), provided by school of nursing faculty; and a Breast and cervical cancer
program
CBE, provided by volunteer nurse practitioners. Undergraduate Medicare or Medicaid
and graduate nursing students provided educational sessions enrollment
and collected data.
The Caring Hands Clinic, a faith-based church ministry in the Note. All participants were offered transportation between the screen-
county, served as the primary provider to order and receive mam- ing locations and the county medical center.
mogram results and establish follow-up for clients, as needed.
Figure 1. Integrated Community Education Model
The local county medical center, which includes a hospital and
an outpatient clinic, served as a partner to provide the screening
mammograms on four designated Saturdays, marketed as Pink Implementation
Lady Days. The screening mammograms, along with radiologist
interpretation, were provided to 19 uninsured women who were The first phase of the project was developing and conduct-
financially unable to pay for the services. The nominal fee of $105 ing the Train the Trainer sessions. Each training session lasted
per person was covered by the grant. Women with insurance, about two hours and consisted of various teaching and learning
Medicaid, or Medicare were given a CBE and then referred to their strategies, including didactic lecture, videos, hands-on prac-
primary care providers for mammography, as necessary. tice, and demonstration, along with return demonstrations for
The state department of healths breast and cervical cancer teaching BSE methods to others and successful responses to
program served as the primary referral source. The program participant-driven questions, as part of the evaluation process.
enrolled women with abnormal mammograms into the program The participants also served as resources to elicit women to at-
and then into Medicare or Medicaid for follow-up, biopsy, and tend the Pink Lady Days for free breast screening outreach and
treatment, as necessary. education. Each participant in the Train the Trainer sessions
A network of four churches in the county area, chosen for received a facilitators guide, educational video and materi-
their easily accessible locations within the community, was se- als, and a breast model to learn and then teach the most cur-
lected to serve as the screening locations for the Pink Lady Days, rent information regarding breast health. Study investigators
and to participate in publication of the events. Each church held taught the new trainers recommended methods of BSE using
one event, for a total of four Pink Lady Days. The Pink Lady Days breast models. The investigators also taught the new trainers
also were publicized through the local radio station, in addi- how to teach others using the breast models. Seven sessions of
tion to flyers posted in local businesses. A contract with a cab Train the Trainer were conducted, attended by 20 participants
company for transportation of clients to and from the churches representing 10 county churches. The investigators developed
and the mammography center was coordinated by one of the the curriculum for the Train the Trainer sessions, planned the
investigators. implementation of the curriculum, contacted 10 local churches

Clinical Journal of Oncology Nursing Volume 15, Number 4 Integrated Community Education Model 389
to identify key women leaders for training, and conducted the
sessions onsite at the four selected churches.
Table 1. Sample Characteristics
The goals of the sessions were to educate key women lead- CHARACTERISTIC X
ers of the church about the importance of breast health and
Age (years) 52
provide information related to breast cancer awareness, how
to perform BSEs, and how to provide education to others in the CHARACTERISTIC n
communities.
Age (years)
The second phase of the project was to provide four Pink
20 or younger 2
Lady Days implemented in four county churches on four sepa- 2129 4
rate Saturdays. These sessions were held to provide educational 3039 6
information to women from the community (e.g., practice sta- 4049 15
tions, printed materials) and to provide a CBE by a nurse prac- 5059 13
6069 5
titioner. Prior to the CBE, participants were asked to complete
70 or older 5
a form about insurance and resources. All demographic data No response 3
were recorded anonymously. Several additional questions were Race
included to determine the psychosocial and cultural barriers for African American or black 48
the participants in the current study. Caucasian or white 5
Marital status
If any woman had an abnormal CBE and met the criteria for
Single 18
a free mammogram (i.e., no payment source), the woman was Married 16
transported to the mammogram center via the taxi and then Divorced 10
back to the church. Women with abnormal CBEs and a pay Widowed 6
source were referred to their primary care provider for evalua- No response 3
Financial data for pay source
tion and follow-up.
Medicare or Medicaid 20
Private insurance 14
Uninsured 19
Results N = 53
A total of 53 participants attended the Pink Lady Day screen-
ings, including 20 women who participated in the Train the
Psychosocial and Cultural Issues Affecting
Trainer sessions. Forty-eight participants (90%) were African
American and five (10%) were Caucasian. The average partici-
Screening and Early Detection Practices
pant age was 52 years, with a range from 1271 years (see Table All participants indicated they knew about mammograms
1). Fifteen participants (28%) were in the 4049 year age range, prior to the screening date, and 70% of all participants aged
the target population for the project. 40 or older indicated they had had a previous mammogram.
All participants aged 40 and older (n = 38) were asked Sixteen (31%) indicated the lack of funds as the primary reason
when they last received a mammogram. About half of the for not obtaining regular mammograms. Of the 18 participants
participants had received a mammogram within the last one (34%) that indicated they had never had a mammogram, 10
to two years, with the other half never receiving one. Nine par- cited the following reasons: lack of financial resources (n = 7),
ticipants aged 4049 years never had received a mammogram. lack of access to healthcare provider (n = 1), lack of transporta-
Seventeen participants indicated a family history of breast tion (n = 1), and lack of trust in healthcare providers (n = 1).
cancer, with six participantswho all fell into the 39 years and Thirty-three participants (62%) indicated they performed
younger age rangeindicating both a sister and mother as hav- BSEs on a monthly basis. For the women not performing BSEs,
ing cancer. One participant was a breast cancer survivor that the following responses were given as reasons: do not know
had been diagnosed at age 40 and was now 71. how to perform (n = 6), forget (n = 3), embarrassed to touch
Nineteen participants who met the financial no-pay-source body in that way (n = 2), time (n = 2), and dont understand
requirement were sent for mammography. Of the 19 mammo- the importance (n = 1).
grams performed, 10 returned with abnormal results requir- Participants were asked several open-ended questions, such
ing follow-up. Each of these participants was referred to the as What new information have you learned today? The fol-
breast and cervical cancer program for enrollment and long- lowing were their responses: proper technique for breast
term follow-up. Of the 10 participants referred with abnormal self-exam, how important it is, everything, improvement
mammography, five were evaluated with spot compression in present way of doing exam, signs of breast cancer, effec-
re-examination, and three were referred to a breast oncologist tiveness of doing it, better caring for myself, what a lump
for biopsy. As a result of the program, three participants, aged feels like, to have a mammogram every year, and being able
49, 48, and 37 years and all African American women, were to share the information.
diagnosed as having early-stage breast cancer. The 37-year-old It was evident from the participant responses that they ex-
woman had an abnormal CBE and a family history of breast can- perienced many of the same psychosocial and cultural issues
cer and, therefore, was sent for mammography even though she previously identified in the literature review, such as lack of
was below the target age for the project. The outcomes for each trust for the healthcare system and healthcare providers and
of the project objectives are described in the following sections. correlation of disease with certain religious beliefs.

390 August 2011 Volume 15, Number 4 Clinical Journal of Oncology Nursing
Perceived Differences Between Rural and testicular self-examinations (TSEs) among men in a geo-
and Urban Residents graphically defined area of Pakistan. Postintervention, significant
improvements were reported in BSE and TSE practices as a result
One question asked participants: What things would keep you of the educational intervention at the community level.
from going to a doctor if you found a knot/lump in your breast, or The previously mentioned studies clearly link the positive in-
found drainage coming from your breast? Responses included fluence of community-based health education models on health
fear of cancer, scared/fear, shy, no pain, no insurance, practices. The data demonstrated in these studies support the
finances, and lack of knowledge. Similar responses were given current study methodology and the ongoing practice of faith-
to the question, What reasons would keep you from having a based educational interventions at the community level by key
mammogram? leaders. The current research project provided three women with
life-saving early detection for breast cancer. The integrated com-
munity model also provided potentially hundreds of women with
Discussion an ongoing source of breast health, self-monitoring, and referral
sources for problems in the future. The strengths of the study are
The results of the current study that explain why women that it (a) provided important information, (b) used teamwork
do not receive regular mammogram screenings are validated to get the project off the ground in a short turnaround time, (c)
in the literature. Reasons cited in the current study as well as identified women at risk for breast cancer, (d) raised awareness in
in the literature include cost or lack of finances, access, lack of the community regarding the importance of breast health, (e) cre-
knowledge, fear, mistrust of healthcare providers, and lack of ated networking opportunities to continue education and inter-
primary healthcare provider (Ahmed, Fort, Fair, Semenya, & vention within the community, (f) established ongoing partner-
Haber, 2009; Lopez, Khoury, Dailey, Hall, & Chisholm, 2009; ships formed between education, service, and community (e.g.,
Nigenda, Caballero, & Gonzlez-Robledo, 2009; Schueler, Chu, churches), and (g) provided an ever-expanding pool of breast
& Smith-Bindman, 2008). health knowledge and referral sources for women with breast
The results of the study that identify barriers affecting the health problems. Limitations for the study include the potential
health of African American women and women of lower socio- for bias by using faith-based institutions in the interventions and
economic status also are supported by the literature. Of particular recruiting women who are more likely to have mammograms. In
concern is the lack of knowledge, as previously noted by other addition, limited generalizability of the findings may exist related
researchers (Ahmed et al., 2009; Avis-Williams, Khoury, Lisovicz, to women who are not affiliated with nor have access to a faith-
& Graham-Kresge, 2009). based institution. Another limitation is the small sample size. The
Rodriguez, Bowie, Frattaroli, & Gielen (2009) linked commu- authors believe that the timing of the grant activities impacted the
nity churches with community partner assessments to address sample size by providing less time for advertising and marketing
health disparities in an underserved community. They found that strategies to be implemented.
the best results occurred when the religious or spiritual program
elements did not overpower the importance of reaching commu-
Implications and Recommendations
nity participants with critical healthcare information.
Lisovicz et al. (2006) used the well-developed Deep South The purpose of the current study was to generate and test an
Network, which encompassed two southern states in academic effective integrated community education model to reduce late-
and community settings, to address cancer disparities in the Af- stage breast cancer diagnoses in medically underserved women.
rican American community using a model based on community The integrated community model was effective in assisting with
theory by Paulo Freer. The projects goals were to promote cancer early breast cancer detection.
awareness and early detection practices, generate awareness of Replication of the study in other rural areas would help to
clinical trials, and provide current and culturally relevant key can- validate findings. Identification and involvement of key leaders
cer messages on a large scale to target populations. A grassroots in communities also might encourage a larger number of partici-
community infrastructure was used to build partnerships within pants. Follow-up studies at designated periods with community
communities. Community health advisors were trained to spread participants might provide additional information related to
cancer awareness messages within underserved populations. The ongoing access to care and determine whether barriers were
results of their actions were impressive increases in Papanicolaou overcome. The findings from the current study can be compared
smears and mammograms within the study population. to national and state data related to breast health knowledge
Adams (2007) designed and described the African American and barriers to the provision of care. This community partner-
Breast Cancer Outreach project, intended to positively impact ship model may be duplicated easily for future projects, which
the number of African American women screened for breast may include additional educational components regarding facts
cancer in Texas. The project specifically targeted were poor and about current cancer treatments to dispel myths and reduce
medically underserved women. A primary lesson learned was the fear. That hopefully would reduce the fear of the diagnosis of
effectiveness of structured team building and networking with breast cancer and encourage women to remain vigilant in breast
community leaders in underserved areas. Using this community health and to seek medical diagnosis and treatment before
model significantly impacted the number of women screened for the cancer advances. The largest barrier to obtaining routine
cancer. Shallwani, Ramji, Ali, and Khuwaja (2010) used a similar mammography in this underserved population was the lack of
research methodology, creating a community-based health educa- financial resources. With current and projected healthcare cost
tion intervention plan to positively impact BSEs among women containments, that barrier will remain difficult to overcome.

Clinical Journal of Oncology Nursing Volume 15, Number 4 Integrated Community Education Model 391
The investigators concluded that a community-based referral Lopez, E.D., Khoury, A.J., Dailey, A.B., Hall, A.G., & Chisholm, L.R.
system with a flexible network linkage to churches, nonprofits, (2009). Screening mammography: A cross-sectional study to com-
community organizations, and state or local health centers pro- pare characteristics of women aged 40 and older from the deep
vides the strongest likelihood to overcome financial constraints. South who are current, overdue, and never screeners. Womens
Health Issues, 19, 434445. doi:10.1016/j.whi.2009.07.008
Author Contact: Jean T. Walker, PhD, RN, can be reached at jwalker@umc National Cancer Institute. (2011). Breast cancer. Retrieved from
.edu, with copy to editor at CJONEditor@ons.org. http://www.cancer.gov/cancertopics/types/breast
Nigenda, G., Caballero, M., & Gonzlez-Robledo, L.M. (2009). Bar-
reras de acceso al diagnstico temprano del cncer de mama en
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1), S53S56. for reading this article and taking a brief quiz on-
Frisby, C. (2002). Messages of hope: Health communication strate- line. To access the test for this and other articles,
gies that address barriers preventing black women from screen- visit http://evaluationcenter.ons.org/Login.aspx.
ing for breast cancer. Journal of Black Studies, 32, 489505. After entering your Oncology Nursing Society
doi:10.1177/002193470203200501 profile username and password, select CNE Tests
Lisovicz, N., Johnson, R.E., Higginbotham, J., Downey, J.A., Hardy, and Evals from the left-hand menu. Scroll down
C.M., Fouad, M.N., . . . Partridge, E.E. (2006). The Deep South Net- to Clinical Journal of Oncology Nursing and
work for cancer control. Building a community infrastructure to choose the test(s) you would like to take.
reduce cancer health disparities. Cancer, 107(Suppl.), 19711979.

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