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?