A Guide to Enhance
African American Women’s
Participation in Breast Cancer
Screening Outreach and
Case Management Services
A Guide to Enhance African American Women’s Participation in Breast Cancer
Screening Outreach and Case Management Services is a publication of the
“Community Based Model for Enhancing African American Women’s Breast
Cancer Screening Outreach and Case Management Services in Texas”
(AABCO) project funded by the Texas Cancer Council.
The material presented in this publication is copyrighted. Please contact the
author at the address below to obtain permission to use, reproduce and/or to
request additional copies. Your comments and suggestions are welcome.
African American Breast Cancer Outreach (AABCO)
Attention: Mary Lou Adams, PhD, RN, CS, FNP
The University of Texas at Austin
School of Nursing
1700 Red River Street
Austin, TX 78701-1499
Phone: (512) 471-9091
Fax: (512) 471-4910
AABCO Funded by
African American Breast Cancer Outreach, July 2003
The Texas Cancer Council expresses its sincere appreciation to Dr. Mary Lou Adams
and the AABCO staff for the fine work they have done in removing many barriers
African American women face in obtaining breast cancer screening, outreach, and
treatment in Texas. For over four years Dr. Adams, her forward-thinking advisory
committee and community health care experts in Dallas, Houston and Tyler, have
approached this issue as a problem that can be solved. The Council agrees; it must
be solved. This guide is evidence of what can be accomplished when individuals
who care take the initiative to find solutions.
Please use this guide to improve the lives of African American women in your
Mickey L. Jacobs, M.S.H.P.
Texas Cancer Council
P.O. Box 12097 Austin, Texas 78711 (512) 463-3190 FAX (512) 475-2563 Email: email@example.com
This publication was made possible through support from the Texas Cancer Council, a state agency
dedicated to reducing the human and economic impact of cancer on Texas through the promotion
and support of collaborative, innovative, and effective programs and policies for cancer prevention
and control. Key developers and contributors to this effort included:
Mary Lou Adams, PhD, RN, CS, FNP Heather Becker, PhD
Project Director Project Evaluator
African American Breast Cancer Outreach African American Breast Cancer Outreach
The University of Texas at Austin The University of Texas at Austin
School of Nursing School of Nursing
Austin, TX Austin, TX
Jeffrey J. Guidry, PhD Trina Reed Robertson, MA
Project Consultant Project Coordinator
Texas A&M University African American Breast Cancer Outreach
College of Education The University of Texas at Austin
Department of Health & Kinesiology School of Nursing
College Station, TX Austin, TX
Charla Carrington, BS K. Anoa Monsho
Administrative Assistant Independent Consultant
African American Breast Cancer Outreach Austin, TX
The University of Texas at Austin
School of Nursing
Michael Erard, PhD
Cain Center for Nursing Research
The University of Texas at Austin
School of Nursing
This publication was developed through the collaborative efforts of the African American Breast
Cancer Outreach (AABCO) Advisory Board. The AABCO Advisory Board consist of representatives
from the American Cancer Society and Susan G. Komen Breast Cancer Foundation, major cancer
advocacy agencies, state agencies including the Texas Department of Health and Texas Cancer
Council and community liaisons from the AABCO project sites in Dallas, Houston and Tyler, Texas.
African American Breast Cancer Outreach (AABCO) Advisory Board
Rich Ann Baetz, MSCRP Cheryl Ivory, MA
Research Associate Outreach Coordinator
Center for Health Statistics African American Breast Cancer Outreach
Texas Department of Health Harris County Hospital District
Austin, TX Houston, TX
Jewel Banks, M.Ed. Mickey Jacobs, MSHP
Outreach Coordinator Executive Director
African American Breast Cancer Outreach Texas Cancer Council
Community Oriented Primary Care Austin, TX
Parkland Health & Hospital System
Dallas, TX Cheryl Kidd, MPH
Director of Education
Heather Becker, PhD Susan G. Komen Breast Cancer Foundation
Research Scientist Dallas, TX
School of Nursing
The University of Texas at Austin Roxie Mayfield
Austin, TX Community Representative
Angie Colbert, M.Ed.
Associate VP for Health & Hospital Systems Margaret Méndez
Texas Division Bureau Chief
American Cancer Society Bureau of Women’s Health
Austin, TX Texas Department of Health
Community Representative Helen Miner, RN, PhD
Community Oriented Primary Care Center Director
Parkland Health & Hospital System Lake Country Area Health Education Center
Dallas, TX Tyler, TX
Kaye Goss-Terry, RT (M) Amber Paris, BAAS
Program Manager Outreach Coordinator
Texas Mammography Accreditation African American Breast Cancer Outreach
Texas Department of Health The University of Texas Health Science Center
Austin, TX Tyler, TX
Jeffrey Guidry, PhD Carl Piontek, RT (R)
Associate Professor Chief Tech
Department of Health & Kinesiology Radiology/COPC
Texas A&M University Parkland Health & Hospital System
College Station, TX Dallas, TX
Loretta Hanser, RT, (M) Jan Warfield
Mammography Coordinator Public Information Coordinator
Ben Taub General Hospital Breast & Cervical Cancer Control Program
Harris County Hospital District Texas Department of Health
Houston, TX Austin, TX
Claudia Himes, RN, BSN Velma Watson, RT (M)
Nurse Consultant Executive Director
Breast & Cervical Cancer Control Program My Place – A Women’s Health Resource Center
Texas Department of Health Houston, TX
Table of Contents
Chapter 1: Program Readiness: Small Organizations; Big Results 3
So You Want to Start a Program 3
Building Support for Your Program 4
Identifying Your Basic Needs 4
Assessing Your Community’s Readiness 5
Community Engagement 6
Visibility and Respect Within the Community 6
Establishing a Plan for Outreach 7
Targeted Outreach 8
Culture and Communication 12
African American Culture 13
Cultural Competence 14
Final Thoughts on Program Readiness 15
Chapter 2: Program Planning: Defining Your Program 16
Models and Theories 16
Evaluation and Goal Setting 20
Planning Your Program to Include Evaluation 20
AABCO Case Study: Have a Heart Project 24
Final Thoughts on Program Planning 25
Chapter 3: Program Development: Building Your Infrastructure 26
Financial Management 27
Volunteer Management 30
Dallas Case Study: SOV 30
Coalitions and Collaborations 31
The Dance of Coalition: Steps and Lessons 33
Collaborations in Action: AABCO Advisory Board 34
Final Thoughts on Program Development 35
Chapter 4: Program Implementation: Outreach and Inreach Activities 36
What is Inreach and How is it Done 37
Houston Case Study: Inreach 37
Accessing Media and Promotional Resources 39
Developing Partnerships With Other Community Organizations 40
Tyler Case Study: NBLIC 45
Final Thoughts on Program Implementation 45
Chapter 5: Putting it all Together: AABCO Project Description 46
Final Thoughts on Putting it all Together 49
Appendix I Community Needs Assessment Survey 50
Appendix II Mammography Barriers Checklist 55
Appendix III Literature Review for Up-to-Date Materials 57
Appendix IV Discussion Guide for Focus Groups on Breast Cancer Screening 59
Tips for Conducting Focus Groups 61
Appendix V Texas Cancer Council Guidelines for Goals and Objectives 62
Appendix VI Evaluation Tool for Data Collection: Outreach Activity Log 63
Appendix VII Client Satisfaction Survey 64
Appendix VIII Job Descriptions, Qualifications and Minimum Requirements 67
Appendix IX Checklist for Program Planning and Implementation 69
Checklist for Establishing Contacts and Developing Relationships 70
Types of Community Contacts 71
Figure 1: AABCO ZIP Code Target Map 11
Figure 2: AABCO Logic Model 17
Figure 3: AABCO Organizational Chart 28
Figure 4: Dallas Site Community Coalition and Partnerships 42
Figure 5: Houston Site Community Coalition and Partnerships 43
Figure 6: Tyler Site Community Coalition and Partnerships 44
Table 1: Work Plan 10
Table 2: Summary of Theories: Focus and Key Concepts 19
Table 3: AABCO Evaluation Plan 23
In 1998, through a grant from the Texas Cancer Council, we began a five-year campaign to
raise awareness of breast cancer and the importance of early detection. Specifically, we wanted
more African American women to get mammograms as a way to save lives and positively
impact families and communities. Out of a shared vision of a diverse coalition and community,
African American Breast Cancer Outreach (AABCO) was born. We have learned a number of
lessons as we implemented the five-year, community-based model. This manual contains the
essence of what we have learned.
As you can imagine, as a coalition that includes state agencies, universities, local hospitals and
major cancer advocacy groups such as the American Cancer Society and the Susan G. Komen
Breast Cancer Foundation, we have gathered and generated a great deal of information and
experience during this process. However, when you look beyond the statistics, beyond the
methodologies and the case studies, you find the lives of real women and their families who are
impacted by breast cancer.
Breast cancer remains the most common type of cancer among American women, accounting
for one of every three cancers diagnosed in the United States. Even though great strides have
been made in scientific knowledge about the disease, the exact cause of breast cancer, and
therefore a sure fire method of prevention, still eludes researchers.
We do know that the challenge of the disease is greater among African American women, who
die from breast cancer at a higher rate compared with white women. Higher death rates among
African American women are attributed to later stage of disease progress at diagnosis or a
greater likelihood of a more aggressive tumor that is harder to treat. Moreover, the five-year
survival rates for breast cancer are lower for African American women than for white women.
Although there are other early detection methods being researched right now, increased
participation in routine mammography screening - with subsequent detection and treatment of
the disease at an early stage - offers the best opportunity for decreasing mortality and improving
AABCO developed and is implementing and evaluating a culturally sensitive, community-based
model for outreach and case management to increase awareness as well as the numbers of
African American women screened for breast cancer. We chose the three communities -
Houston, Dallas and Longview/Tyler - that represent the source of more than 70% of breast
cancers found in African American women in Texas. We set out to spread the word and make
mammograms easily available, especially to women who are poor and medically underserved.
As worthy as this goal is, our efforts to reach this population of women would not have been so
successful had cultural awareness, sensitivity and competence not infused our work from its
inception. So intricately are issues of class, gender and especially culture woven into any
community-based health program, that to gloss over its implications can effectively guarantee
the failure of any program, no matter how needed. We at ABBCO feel strongly, and other
successful programs support this, that the higher the level of cultural competency of you and
your staff, the more you will be able to gain vital community support for your program.
One of the most compelling lessons we learned is that the smallest change in behavior can
make a tremendous difference in someone’s life. And the strongest way to do that is to form
relationships around a vision of healthy women and families. If you are passionate about this
kind of work, there is much reward that goes along with the hard work of public health promotion
in culturally diverse communities. Time and time again we saw how common ground, mutual
respect and shared vision brought women together as sisters.
We hope that this manual will help you make a difference in your community.
Mary Lou Adams, PhD, RN, CS, FNP
African American Breast Cancer Outreach (AABCO)
The University of Texas at Austin
School of Nursing
Small Organizations, Big Results
“One of the most important lessons we learned was that it
didn‟t necessarily take a huge investment of money to make a Lesson Learned #1
significant change. What we did take was a lot of work up We found that, although
front putting the infrastructure of the organization together, there is no shortcut
forming partnerships and weaving into the community in when it comes to
such a way that we became an important part of it. If you assessing need and
don‟t do these things, no amount of money that you spend is implementing an
going to make much of a change. Small organizations are in infrastructure, reviewing
many ways ideal for the task of health promotion.” existing literature saved
us a good deal of time.
As the saying goes, it’s more than a notion to put together a Publications such as the
program that aims to change the way people behave. In fact, most Journal of National Black
organizations do not have sufficient resources to responsibly Nurses Association,
assure the sufficient financial, legal, medical, and social support to Ethnicity and Disease,
sustain the project. It is very important to conduct a needs Cancer Nursing, The
assessment specific to the program that is being developed, not Journal of Clinical
just to determine the community resources available, but also to Oncology, and The
determine the community’s sense of need for the project. The only Oncology Nursing Forum
way a program like this can succeed is if it is truly community- provided information that
based. supported the
development of a
So You Want to Start a Program culturally based cancer
Developing an intervention program is a time-and labor intensive prevention outreach
process that does not happen overnight. One of the first things program among African
you will need to do is identify the problem or health need you want American women.
your program to address. A review of published literature can give
you information on what other communities have done. Once you
have determined your program’s focus, you should continue to
assess your program’s readiness by addressing the following
1) What is the need for this particular program in your
2) How will you determine there is a need for such a program?
3) Why do you feel there is a need to conduct your program?
4) What will you need to start a program to address the need?
5) What resources are available in your community?
Lesson Learned #2
It is also imperative to identify both the basic needs of the
Basically, the needs
community you hope to serve as well as the needs of the program
assessment is about
you are trying to develop.
information about your
Building Support for Your Program
A vital part of program planning is identifying potential funding
facts can be gathered
sources such as the type of agencies that will financially support
from existing data, but
community-based start-up programs. It is important to recognize
we learned that far more
that some local organizations will make in-kind contributions.
relevant information can
Others will provide direct financial support. One source of
only be learned by
information about potential donors can be found on the Texas
getting out into the
Department of Health’s Contracts and Grants website. You might
community you plan to
also search the Internet for foundations interested in supporting
serve and talk and listen
health related programs similar to yours. An important component
to people, recognizing
of your application to potential funders will be the beginning of
that some information
your needs assessment, which identifies the need for your
will be best gleaned
Good communication is
a necessary component Identifying Your Basic Needs
to this process. It is from When establishing a start up program, you must first have a
these beginning stages physical place or space to begin the work. You should also have
that cultural sensitivity is basic office equipment including a desk, telephone and access to
secured and cultural a computer, and people to implement the work, whether volunteer
competency developed. or paid. However, you have to realize that at least one person
must be hired to coordinate the program. It is also important to
realize that if you’re going to use an answering machine, your
message must indicate that someone will return the call by the
close of the business day. Someone then has to return the call.
Assessing Your Community’s Readiness
Never overlook performing a needs assessment for your project. It
can be your greatest tool for determining how ready for outreach
your community is. It can also help you cultivate advocates for
your program. Many of the people who are contacted during the
needs assessment process may end up as partners or community
resources when it’s time to begin implementation. The needs
assessment itself will provide the best information for defining your
project’s parameters, approach, and order of priorities.
Lesson Learned #3
A needs assessment is a way to examine resources, barriers and
needs for your community. There are many elements involved in A needs assessment is a
conducting a needs assessment. This is not a process to be taken vital part of preplanning for
lightly or rushed through, as the information gathered in this a project. It provides
process will truly impact the success of your program. You will information about your
need to gather information from your community partners. You will community, such as:
use census data, historical and cultural research, local directories,
Who lives in the
and other sources to determine whether or not the infrastructure
exists to support the program.
Who will require the
The needs assessment considers how the community’s population
changes, what medical and social support services are available, Who can provide the
and how willing those services are to serve the community. It service?
identifies other health care organizations and programs in the What are the resources
area, describing their services and access issues. An in-depth available to provide the
assessment will identify whether these organizations have been service?
successful and why. We have included an example of a survey in
What other organizations
Appendix I to help guide you through your needs assessment
are available to become
process for developing a breast cancer screening outreach
partners with you in your
program with African American women.
For AABCO, we knew there were not enough African American
women being screened in Texas. But we needed to gather more
information about what to do about this in a community setting.
We received a lot of our information from performing literature
reviews of current data from the American Cancer Society’s Facts
and Figures as well as the Texas Cancer Data Center. It’s likely
that most of your information will come from your community. How
many health-related institutions are located near you? Is
transportation to those facilities available for everyone? You will
find most answers to these questions in your community itself.
To be successful, your project must involve the community in the
program planning process from the very beginning. You will want
to be sure that the program is set up in an ethical, honorable
manner. That demonstrates that you believe in dignity for all
people and respect the responsibility of providing ethical care. It is
very important to get the permission of the community when doing
this type of work.
Lesson Learned #4
It is also important to establish positive alliances with respected
To be successful, your
members of the community you are trying to reach as you
community must be
consider developing programs and services for the community.
involved in the planning
Doing so reinforces the buy-in from the community. It also ensures
an endorsement of some kind from people in the community who
have signed off on the endeavor. It’s a good way to build trust and
mutual respect within the community. You must be sure that the
program reflects the values, beliefs and interests of the community
that you are targeting.
Visibility and Respect Within the Community
A culture of caring has to be a part of the outreach efforts,
because it conveys to participants that they are respected and
valued. Building trust is a very important component of targeted
outreach, as very often the people you are trying to reach have
not had positive experiences with the health care delivery system.
Building trust takes time and requires steadfast commitment to
deliver on what your program promises to accomplish.
Nothing will help your community engagement like repeated
support from the community. Once people connect with your
organization and recognize that you are committed to them, they
will begin to look for you. In all three sites, AABCO has enjoyed
the benefit of having clients or providers looking for our
outreach/case-managers because they know that we are there to
help. In Dallas, the AABCO outreach coordinator schedules
mammography screening events at community parks, local
shopping malls, and churches. She has often mentioned that she
Lesson Learned #5
is now screening for the fourth time women who had never been
screened before, some of whom call her wondering when they can Many African Americans,
get screened again. In Houston, the AABCO outreach regardless of social or
coordinator/case-manager does a good deal of her work within the economic status, have
hospital system. She often finds the hospital staff has clients some reservation about
waiting for her who need more information on breast cancer dealing with the medical
screening or simply need the right touch to get them to follow up community, particularly if
on the doctors’ orders. In Tyler, the AABCO outreach coordinator it involves unfamiliar
is often called upon to present breast health awareness testing or anything that
information to local high schools, colleges, churches, at health might feel like research.
fairs, and in the work place. There are many
experiences that have
Establishing a Plan for Outreach lead to this lack of trust.
If the focus of your program is to provide outreach, you will need All health promotion
to develop a plan for how you will get care for the women you are agencies have to
reaching. This care will include clinical screening services and overcome these trust
follow-up treatment for those diagnosed with cancer. One way to issues when recruiting
make a plan is by establishing agreements with partners who will African American clients.
provide the services needed for the people you wish to reach. The best way to do this
is to recruit volunteers
Developing a work plan is one tool you can use to assist in and staff from among the
planning your program activities. A work plan can also be used as community you are
a way to help you evaluate your program. Basically, a work plan is trying to reach.
a table of projected activities over a period of time, whether a
month, six months or a year. For example, for the first week of
your program, your activities may include finding a place or office
space to set up. For the second week of your program, it may be
to make contacts within your community. For the third week, it
may be to establish an advisory board and conduct meetings. A
work plan includes goals, objectives and a timeline. Table 1
provides an example of a work plan that you can use when
planning your program.
As you begin your program, you will need to identify and define
your target population, those who will be directly served by your
project. The target can be defined by any number of
characteristics such as age, ethnicity, religious affiliation,
geographic location, etc. If you’re targeting your group by age,
make sure to understand generational differences in attitudes and
beliefs about your particular area or topic. Because AABCO
needed a way to determine where its target population lived, we
sought assistance from staff at the Texas Department of Health,
who developed a ZIP code target map to determine where our
target population lived (see Figure 1). This is one example of
useful information you can gather about your target population.
Knowing where to find your target population is key when planning
outreach activities. Identifying the type of activities your target
population attends can also be a great help. Planning activities
around important cultural holidays, Juneteenth or Mother’s Day,
for example, is a successful way to reach your target population.
You will then want to determine where you will go to do outreach,
whether in churches, beauty shops, or community centers. And
lastly, you will need to know how you will conduct your outreach.
Are you planning to visit churches individually? Perhaps set up a
health fair? Will you go do the work on your own or work in
partnership with someone else?
Demographic information about your community can tell you how
many women live in your target area. It will not tell you what keeps
women from coming for screening, or what would encourage them
to get screened. As part of its needs assessment, AABCO
developed and administered a barriers survey to understand why
African American women at each of the sites were not having
mammograms (Appendix II). The checklist items were developed
based upon one of the project director’s clinical experiences
providing breast health services as well as review of the research
literature (see Appendix III). Both external barriers, such as
transportation and cost, and internal barriers, such as fear of
discovering a malignancy, were included in the items.
Outreach coordinators and volunteers distributed surveys to
women attending local community events and to African American
staff at a school of public health in Spring 1999. The three major
barriers identified by the 164 women in this study were: a) fear
that the x-ray might detect a cancer, b) the cost of the
mammogram, and c) not wanting to know if you have a cancer.
After the completion of the community needs assessment tool and
the barriers checklist, a plan to conduct focus groups at each site
was developed. Focus groups are small group discussions used
to gather information about particular topics. The focus groups
conducted by AABCO were designed to get more input from the
three different communities concerning their thoughts and
knowledge levels about breast cancer. The groups also suggested
ways to encourage women to get mammograms. Three to four
focus groups were conducted at each site. Each group was audio
taped and in most cases a note taker was present, too. Focus
group participants received a free meal as an incentive for their
participation. A sample discussion guide for a focus group on
breast cancer screening and tips for conducting focus groups can
be found in Appendix IV.
Table 1: AABCO Work Plan
Goals Objectives Activities Completion Date(s)
To develop, implement, and evaluate 1. To develop project Hire central project staff. Nov. 1998
a community-based model for infrastructure, establish
coordinated outreach and case policies and procedures for Develop and coordinate Project Advisory Nov. 1998
management to encourage African operation by development Committee.
American women’s participation in of a Project Policy and
early detection services for breast Procedure Manual. Recruit membership to advisory committee Nov. 1998
cancer in the state of Texas through collaboration with TCC, TDH-
BCCCP, ACS, Komen and community
organizations from participating sites.
Conduct initial Project Advisory Committee Nov. 1998
Meeting at UTSON and establish dates for
remaining three quarterly meetings.
Identify and select project sites. Nov. 1998
Make preliminary contact with BCCCP Nov. 1998
providers or a lead community organization
for the three sites.
Negotiate formal agreements (contracts) for Nov. 1998
Project site visit (UTSON); (a) Outline grant Nov. 1998
parameters, (b) Develop plans for needs
assessment in the target communities, (b)
Plan timeline and goals and (c) Define data
Figure 1: AABCO ZIP Code Target Map
In the focus groups women commonly talked about their fear of
finding cancer, fear of treatment side effects, and fear of
disfiguring surgery or losing a breast. Focus group participants at
each site also indicated that they felt that the focus group model
was a good way to educate women about breast health and
Lesson Learned #6 mammography programs. Some participants became so
Outreach is a way of interested in AABCO that they wanted to volunteer to work with
reaching out to people the project. Information from both activities encouraged AABCO to
who would not be develop personal outreach activities that took into account
reached through women’s fears about breast cancer and mammography screening.
Targeted outreach Culture and Communication
makes sense because it
defines parameters. For “For AABCO, community-based meant community rooted. In
instance, AABCO order to be effective in getting more black women—especially
targeted African economically disenfranchised, underserved women—to get
American women 40 mammograms, we had to be sensitive to a number of cultural
years of age or older. issues. Although we knew that we would have the greatest
This population had chance of success if African American women were working
been identified as not with each other to promote and provide access to
fully participating in mammograms, we could not assume that all African
breast cancer screening American women were culturally identical. We found the most
activities. Once we effective way to get a woman to go for screening was to have
determined our target one or more friends go with her. We had to be culturally
clientele we were able to competent and encourage facilities to have providers who
plan activities that looked like the women they served. That taught us a lot. It is
engaged these women very important for African American people to see
and increased their themselves represented within the organization that is
participation in seeking to provide services to them. It is also important that
mammography. This organizations be willing to provide services within the
measured outcome was community rather than expecting people to come to facilities
gratifying for all involved outside of the neighborhood.”
because it meant that
lives were being saved.
Working with different cultural groups or in culturally diverse
communities can be challenging to even the most experienced
health professional, especially if she is not familiar with a specific
community and its specific issues. Although various communities
have many aspects in common, knowing what is different about a
single community will help you interact more effectively in that
community. The way you approach a specific community can
make or break the success of any health promotion effort.
Culture is a shared set of beliefs, assumptions, values, and
practices; it determines how we interpret and interact with the Lesson Learned #7
world, and it structures our behavior and attitude throughout our
An individual from an
lives. To successfully promote health in the African American
institution or agency of
community, you have to recognize that the community consists of
the same ethnic group
individuals or groups who have different or multiple cultural
as the community will
identities. These variations in the way people identify with a
particular culture or cultures reflect the influence of several
guarantee that person
factors, including responses to different experiences in the
entry into or trust from
the community. Having
been trained outside the
History in the region as well as nation
community might place
that person in an
Family and peer influence
―outsider‖ frame, and the
individual will need to
demonstrate his or her
sincerity and true
interest in helping the
Where they live and length of time in the United States
community to deal with
Ability to code-switch (acculturation) narrowly or broadly
its particular needs and
How “community” is defined by an individual or group
African American Culture
The African American culture consists of shared cultural patterns
that bind African Americans together as an identifiable group who
are able to live together and function with ease. African American
culture is the blueprint in which African Americans think, feel, and
behave in society. The dimensions of African American culture are
spirituality, harmony, movement, verve, affect, communalism,
expressive individualism, oral tradition, and social time
Within the African American community there are gender and
generational differences as well as differences between urban and
rural residents. Many organizations trying to work within the
African American community overlook the multifaceted diversity
within that community. African American culture is not monolithic
within a city or even a neighborhood. In fact, multiple cultural
influences are often found within individual households.
Lesson Learned #8 Anyone involved in delivering health promotion and disease
prevention programs and services must develop cultural
Recognize the multi-
competence and sensitivity to the differences between you and
faceted diversity within a
the multicultural group with which you will be working. A culturally
community and use a
competent model of health care includes at least four processes:
cultural awareness, cultural knowledge, cultural skill and cultural
model that reflects:
encounter (Campinha-Bacote, 1994). The model reflects a
Cultural process that is ongoing, which means that the health professional
awareness should always be on a continuous quest to increase and improve
Cultural his or her abilities to work in a variety of cross-cultural settings:
knowledge cultural awareness, cultural knowledge, cultural skill and cultural
Cultural skill encounter.
encounter Cultural Awareness
Becoming more sensitive to your own biases and
prejudices toward different cultural groups. Examine your
own perceptions, stereotypes, and prejudices toward the
target group and be willing to suspend judgments, where
they exist, in favor of learning who people really are
instead of who you might think they are. This is one of the
most important steps you can take toward cultural
competence and sensitivity.
Gaining an understanding of different cultural groups
including their beliefs, values, lifestyle practices and ways
of solving problems in their world. Understand that there is
likely to be a significant diversity of beliefs and practices
different from those of the individuals planning the
intervention or service.
Utilizing cultural assessment as the first step in designing
treatment interventions for culturally diverse clients.
Assessment makes a practitioner familiar with a
community’s cultural values, beliefs, and ways of life as a
people living in the United States. Seek to establish early
and continuing support from the community for any
programs and services that are to be offered.
Working directly with culturally diverse groups in an effort
to refine one’s knowledge and skills. Take the time to make
multiple visits to the community where the target group
lives. Talk with community leaders and members, visit
important sites within the community, eat at local
restaurants, attend local events, and otherwise become
familiar with the community’s way of life.
Final Thoughts on Program Readiness
To begin a program, it is important to conduct a needs
assessment, which will provide valuable information about your
community. The needs assessment provides information about
your community’s strengths and resources. It also provides
valuable information that helps you to identify the weakness
and/or lack of resources within the community.
Defining Your Program
“We spent a lot of time on the front end defining, developing,
performing assessments, building infrastructure and
identifying community resources. All those months of
background work were absolutely necessary to the success
of a community-based model like this. By the time we got
really started out there, everyone knew what the goals were
and what we had to do to achieve them.”
Lesson Learned #9
Building your program
Models and Theories
around a proven theory
or model is an effective
A theoretical framework can help you understand what factors to
way of developing a consider when planning your program. Theories are a way to help
program so that you are
you organize the way you are going to put your program together.
basing the formation of
Theories can help us understand the nature of health behaviors,
your program on proven
explain the dynamics of the behavior, the process for changing
―best practices.‖ behavior, and the effects of external influences on the behavior.
Theories also highlight the importance of people’s beliefs in
understanding their behavior.
AABCO’s theoretical framework is based on the use of a logic
model (see Figure 2). A logic model is a graphic representation of
a project that illustrates the expected causal linkages between the
projected services and intended outcomes. The model has three
primary purposes: (1) to describe the components of a project, (2)
to describe the chain of expected causal linkages between the
components, and (3) to show the sequence between the
interventions and the outcomes (US, DHHS, 1996). The logic
model also has five components: (1) identification of the
Figure 2: Project AABCO Logic Model
The University of Texas at Austin School of Nursing
Community-based Model for Enhancing African American Women’s
Breast Cancer Screening Outreach and Case Management Services in Texas (AABCO)
Funded by the:
underlying assumptions/inputs about the project, (2) identification
of project activities, (3) identification of immediate
change/outcome(s), (4) intermediate change/outcome(s) and (5)
identification of the final project goals (US, DHHS, 1996).
All programs are based on assumptions, often implicit, about what
causes people to behave in certain ways. In the past, many public
health programs assumed that simply giving people good
information would cause them to adopt the targeted health
practice. We now know it isn’t that simple. Researchers have
proposed a number of models or frameworks to predict health
behaviors. You can locate information about health theories from
the references at the end of this manual. Look for programs that
Lesson Learned #10 have used these models by searching health databases or check
with your local health department to inquire about additional
resources. Seven of the most commonly used theories or
the emotions or feelings
frameworks are summarized in Table 2. As you look at the table,
women have about
you will see that AABCO was organized using key components
from the individual, interpersonal, and community levels.
screening may be as
important as educational
Promoting mammography is such a challenge that you should
information and should
identify precisely what barriers to early detection exist. This will
be incorporated into your
help you tailor interventions to specific populations, making your
promotion activities more effective and efficient in the long run.
Studies have shown that how women perceive barriers
determines whether or not they get screened for breast cancer.
While previous research has identified several barriers to African
American women’s use of mammography screening, not much is
known about how their beliefs, attitudes, and behaviors about
mammography screening are influenced by emotion.
In part, the predominant models used in the study of breast cancer
screening (e.g., the Health Belief Model, the Trans-theoretical
Model) either minimize or cannot accommodate the role of
emotion. There is also tendency in this research to overstate the
role of knowledge gained as sufficient to influence beliefs,
Table 2: Summary of Theories: Focus and Key Concepts
THEORY FOCUS KEY CONCEPTS
Stages of Change Individuals’ readiness to Precontemplation
Model change or attempt to Contemplation
change toward health Decision/determination
Health Belief Model Persons’ perception of Perceived susceptibility
the threat of a health Perceived severity
problem and the Perceived benefits of action
appraisal of Perceived barriers to action
recommended Cues to action
behavior(s) for Self-efficacy
preventing or managing
Consumer Processing by which Information processing
Information consumers acquire and Information search
Processing Model use information in their Decision rules/heuristics
decision making Consumption and learning
Social Learning Behavior is explained via Reciprocal determinism
Theory a 3-way, dynamic Behavioral capability
reciprocal theory in Expectations
which personal factors, Self-efficacy
environmental Observational learning
influences, and behavior Reinforcement
Community Emphasizes active Empowerment
Organization participation and Community competence
Theories development of Participation and relevance
communities that can Issue selection
better evaluate and Critical consciousness
solve health and social
Organizational Concerns processes and Problem definition
Change Theory strategies for increasing (awareness stage)
the changes that healthy Initiation of action
policies and programs (adoption stage)
will be adopted and Implementation of change
maintained in formal Institutionalization of change
Diffusion of Addresses how new Relative advantage
Innovations Theory ideas, products, and Compatibility
social practices spread Complexity
within a society or from Trialability
one society to another Observability
From Theory at a Glance: A Guide for Health Promotion Practice, National Institutes of Health, 1997.
attitudes and subsequent behavior. However, evidence suggests
that women’s feelings and emotion regarding breast cancer
screening is an important area warranting further study (Adams,
Becker, & Colbert, 2001; Champion & Scott, 1997; Phillips, Cohen,
& Moses, 1999). When you describe your program, keep in mind
that strategies addressing the emotions women have about
mammography screening – both positive and negative – may be as
important as educational information. Much of AABCO’s advertising
has focused on the positive emotional appeal of family to encourage
women to get mammograms.
Lesson Learned #11
We found it invaluable to Evaluation and Goal Setting
Community-based organizations don’t plan to fail. But in order to
what worked and what
succeed, individuals within organizations must create a set of
did not work for us. Not
written goals and measurable, achievable objectives. In order for a
only did this information
task to be considered measurable, specific standards of
allow us to celebrate
achievement must be available. Whether frequencies or
percentages, such as two hundred clients served or 10%
along the way—a key
population served, those standards must be clear to everyone
way to keep our
associated with the project. Organizations may state that curing
cancer is an outreach goal – even though such a goal is clearly
we learned valuable
more visionary than measurable. A more immediate goal for
lessons from our
outreach would be to make women aware of cancer issues.
Simply adding a specific number of women to be reached and
them as we went along
screened makes the goal measurable. AABCO was fortunate to
allowed us to brainstorm
have distinct guidelines from its funding source, the Texas Cancer
innovative solutions and
Council (TCC), to help establish appropriate goals and objectives.
develop new strategies.
These guidelines are included as Appendix V.
Planning Your Program to Include Evaluation
You should try to integrate the documents that you generate when
you evaluate with the data that you would normally collect during
project activities. Evaluation is often looked on as something akin
to a tooth extraction or tax audit, yet once it’s done everyone can
see the value in evaluation, especially when it’s done well.
Appendix VI includes an example of a data collection form used
by AABCO as a source of evaluation data. In this form you will see
specific figures for the number of clients seen, outreach activities,
materials distributed, and the number of women screened
(required data for the form). Funders often use other important
evaluation data, such as the number of volunteer hours donated at
each project site to measure community commitment to a project.
When you develop your evaluation, make sure to consider your
funder’s requirements, so you can gather the information that will
answer your funder’s specific questions.
As important as it is to evaluate the numbers of people we reach
through our programs, it is also important to consider other Lesson Learned #12
program indicators. You can examine the quality of the program
Evaluation is an
by measuring the perceptions of the women who are reached by
important aspect of
your program, as well as others who have contact with the
program planning and
program (i.e., community advisory committees, professionals to
whom you refer women for services, key informants in the
Develop your plans for
community). Also, ask yourself what realistic outcomes you can
evaluation of your
measure. What do you want women to be doing, thinking, or
project as you plan your
knowing as a result of the program? If the goal is for women to get
screened, how many make appointments to be screened? How
many actually get screened? How many come back for a repeat
screen on a yearly basis?
Collecting information directly from women in your “target
population” can help you understand if they see barriers to getting
mammograms that you could address in your outreach activities.
You can also assess women’s perceptions of your project. An
example of a survey that was used for the AABCO project can be
found in Appendix VII. For example, the AABCO project has
discovered that even when barriers such as cost and convenience
of screening services are overcome, some women are still
hesitant to go for mammography screening. Some are wary about
the procedure; others are afraid what they might find. Having
someone who encourages them and even goes with them to the
screening has helped some of the women overcome their
reluctance to be screened.
Since collecting and compiling evaluation information can be time-
consuming, consider involving volunteers in this effort. One
possible source of helpers might be college students looking for a
“real life” research, evaluation, or community health project
experience. Your volunteers will need to be trained, and if you
don’t have that expertise available in your organization, consider
contracting with an evaluation consultant who can help work with
you and your staff to develop an evaluation plan. This plan should
look at both the process and outcomes of your outreach efforts. It
should focus data collection methods on questions you and your
stakeholders want answered about your program, and identify or
develop appropriate data collection methods. In the evaluation
plan should be provisions for training your staff (including your
volunteers) to collect data systematically, as well as guiding you
and your staff in analyzing, interpreting, and reporting the
information. Table 3 depicts a portion of the evaluation plan used
by the AABCO project.
Finally, recognize that your data collection activities can serve
multiple purposes. For example, AABCO outreach coordinators
initially held focus groups to determine what would encourage
women to come for mammograms. Women attending focus
groups became so enthusiastic about AABCO that some of them
volunteered to help work with AABCO. Interviews or focus groups
with key individuals in your community about your project can not
only help you understand how to set up your program, but also
help you publicize your efforts. Finally, if you ask those who
receive services to rate the quality of those services, you send the
message that you want your service to be consumer-friendly.
Table 3: AABCO Evaluation Plan
Objective Data Source When Collected Criteria
Refine project Records review Reported quarterly in Project infrastructure
infrastructure Year 02 fully functional in Year
Increase culturally Records review Reported quarterly At least three
appropriate outreach outreach activities
during year 02
Surveys of Conducted yearly Satisfaction with
community contacts outreach activities;
and/or women in reported reduction in
target population barriers to screenings
Develop community Surveys of sites Conducted yearly Community coalitions
coalitions Records review Reported quarterly with at least 5 people
from various groups
meet at least once
yearly and undertake at
least one additional
activity per year to
support the project
Surveys of coalition Conducted yearly Satisfaction with their
members role in coalition
AABCO Case Study: Have A Heart Project
AABCO’s evaluation efforts helped the staff understand what
outreach activities worked best in which situations, as well as how
these activities could be improved. For example, the Have a Heart
project mobilized beauty shop owners and cosmetologists to
educate their clients about breast health awareness and to
encourage their clients to have mammograms. Forty-three beauty
shops participated in the project. AABCO outreach coordinators
set up training for the beauticians, but attendance was low at the
training sessions. The sites then had an AABCO representative
visit each beauty shop and discuss the program with the operators
The results were different in the three areas, one of which was
rural. While shops in all locations distributed materials, the rural
site in Tyler actually scheduled more women for mammograms as
a result of this project. Approximately one month after the project,
the outreach coordinators interviewed owners and cosmetologists
about the project. At the two urban locations, most indicated they
were too busy or just “didn’t get into the project.” Tyler owners and
operators, on the other hand, seemed to enjoy being part of the
The beauticians provided suggestions for improving the project in
the future. Their recommendations included involving beauticians’
trade organizations or cosmetic product suppliers who would
provide incentives for beauticians to participate, and redesigning
materials so they would fit better in the shops. They also
recommended involving shops more actively in the initial planning,
seeking out the support of persons who are influential to owners
and operators, and having volunteers visit shops to promote the
project or help out with the project in particularly busy shops.
These findings helped us think about how to make this project
even more effective in the future. In addition, they pointed out that
what works well in one location (a rural site where beauticians
may have more time to talk with their clients) may not work so well
Final Thoughts on Program Planning
Program planning is an organized process. It includes goal
setting, development of measurable objectives, activities to meet
the objectives and the development of outcome measures.
Program planning also includes an evaluation plan to measure
Building Your Infrastructure
The AABCO project consists of a central office and three project
sites. The central office staff includes a project director (50%), a
project coordinator (50%), an administrative assistant (100%), a
project evaluator (10%), and a consultant on community coalition
building. A program operating in only one site might rely on a full-
time outreach coordinator and clerical support staff. A complete
Lesson Learned #13
duplication of the project would require the central office staff to
As you develop your provide coordination and administrative support to three sites
infrastructure, you will separated by differing community resources and administrative
need to make sure you structures. The central staff manages grants, provides multi-site
are developing positive strategic planning and promotion, and gives technical assistance.
relationships with Even duplication of a single site would require that additional staff
whoever houses your at the project site fulfill many responsibilities held by staff at the
program – whether a central office. Qualifications for key personnel and a job
church, shopping center description for the outreach/case-manager are included as
or large multi-faceted Appendix VIII.
institution – to garner
their support. The outreach/case-managers are the only site-based AABCO staff
whose salary is paid by the project. However, in order for the
project to function well, it’s necessary to have the support of a
project site coordinator who is employed by the organization that
houses the project, as well as a volunteer base within the
community being served. The project site coordinator’s primary
responsibilities to the project are to facilitate the smooth
integration of the AABCO project within the host institution and to
provide day-to-day supervision/guidance for the outreach/case-
The outreach/case-manager is responsible for the daily operations
of the project site. An important part of the project’s daily
operations involve developing and coordinating volunteers and
community partners, as well as navigating the health care system.
These partners and volunteers contribute greatly to the amount of
work that can be done in any given community. Managing
volunteers requires having job descriptions that clearly outline the
duties and responsibilities of volunteerism in your particular
project. Management also encompasses making sure meaningful
tasks are developed and being respectful of people’s time.
If your program is community-based, it is important for your
community to know where it fits into your program. AABCO
illustrated this through the use of a schematic called an
organizational chart (see figure 3). An organizational chart
provides information that determines who does what and where Lesson Learned #14
they fit in the overall scope of your program. In the organizational
Determine what your
chart, you will see site advisory and professional boards as well as
personnel needs are and
site community coalitions. They have all worked very closely with
develop your job
staff to develop and implement AABCO activities and policies.
requirements for these
persons as part of your
Financial management is an area in which many programs
struggle. For smaller programs, it is important to have
organizational support that can provide legal and accounting
expertise. This expertise will be critical when annual contracts are
being renewed and reviewed. It will also support managing and
negotiating fiscal relationships between subcontractors and the
parent organization. This must be a formal relationship so that the
institution providing this fiscal support has the authority to provide
the necessary checks and balances that will help your
organization fulfill its financial responsibility to the funding entity.
These responsibilities include spending money in appropriate
categories, paying your staff in a timely manner, documenting
expenditures within the funding cycle, and securing event-specific
Figure 3: Project Organizational Chart
The University of Texas at Austin School of Nursing
Community-Based Model for Enhancing African American Women’s
Breast Cancer Screening Outreach and Case Management Services in Texas (AABCO)
Project The University of Texas at Austin Consultants
Advisory School of Nursing
Mary Lou Adams, PhD, RN, CS, FNP Account Clerk
Evaluation Project Project
Coordinator Coordinator Administrative
Site 1 Site 2 Site 3
Outreach Outreach Outreach
Coordinator Coordinator Coordinator
Site Site Site Site Site Site Site Site Site
Advisory Community Professional Advisory Community Professional Advisory Community Professional
Committee Coalition Committee Committee Coalition Committee Committee Coalition Committee
grant funds within an appropriate time frame. Respecting these
financial responsibilities can make or break a new program.
Because the host organization will provide the infrastructure
support, it is important that it understands how a community-
based program can benefit its organization.
Like any other profession, health care outreach and promotion is
ever-changing. That’s why it’s very important that your staff be
current with the new medical protocols and policies as well as with
the changing strategies for reaching their clientele. Providing staff
with opportunities and resources to increase their knowledge on a
continuing basis will play a significant part in the success of your
organization. It’s part of treating your staff like professionals.
Orientation is also an opportunity to help your staff operate
efficiently within the organization. Any orientation should provide
clear expectations, guidelines to institutional procedures, and the
best ways to get things done in accordance with institutional
expectations. It should also introduce staff to the organization’s
structure and chain of command and inform them of what
decisions they have authority to make on their own and which to
refer to someone else. This orientation should establish clear
performance criteria, which will let your staff know what is required
AABCO sends project staff to statewide or national conferences
annually to support their continuing education. It has also helped
outreach coordinators seek their own development opportunities
through other cancer control agencies. Our partners have
supported these staff development efforts by providing
scholarships to various conferences and workshops. A number of
organizations, such as the Texas Department of Health, the
American Cancer Society, Physician Oncology Education
Program (POEP), and the Nurse Oncology Education Program
(NOEP), periodically provide free or inexpensive staff
development on various health topics.
Volunteers provide a great deal of support for the project by
actively taking on portions of the outreach work. This outreach
work involves much more than passing out brochures or going to
health fairs. That’s why you need to be organized – it’s the way
you let volunteers know what tasks need to be done and how they
relate to the project’s overall mission. Involving your volunteers in
the planning of activities encourages them to be more committed
to your project and feel that their work is valued.
Dallas Case Study: SOV
The AABCO project has created a very successful model for
volunteer recruitment and development. This model is unique
because it educates volunteers in what’s expected of them at the
same time it provides incentives to encourage them to participate
as volunteers over the course of a year. This model, Survivors,
Outreach and Volunteers (SOV), is a team-building initiative to
bring women together to develop strategies to increase breast
health awareness for priority populations. SOV utilizes a daylong
shopping bus trip where potential volunteers learn about their
roles and breast health awareness while traveling to their
shopping destination. This method provides a unique opportunity
to help volunteers develop as a team. SOV consists of breast
cancer survivors who help to provide outreach and women who
just wanted to volunteer from the community who care about
breast cancer issues. We discovered that 2/3 of AABCO
volunteers we surveyed had not been previously involved with
traditional cancer advocacy organizations and AABCO was a
good way to involve them in cancer outreach and education.
Coalitions and Collaborations
“We have been able to accomplish our goals because of the
relationships we developed. One of the most rewarding
aspects of this work is that when you work within an effective
coalition, when key people in the community— representing a
diversity of constituencies—come together to get something
done, it is so powerful. As it was once said, „A small group of
thoughtful people could change the world. Indeed, it's the
only thing that ever has.‟ Frustrating as it can be to work with
other people, agendas, and resources, it is the only way to
build a community-based model that will change lives.”
As the well-known African proverb “it takes a village to raise a
child” teaches us, it also takes a coalition that reflects the diversity
of the community to solve problems within that community. Most
coalitions experience similar challenges, and all have to establish
a core set of values. For instance, inclusion and respect is vital
when working in multi-dimensional and diverse communities. All
coalition participants must be accepted and respected for their
contributions to the coalition and the community.
A coalition is formed when community groups, leaders, agencies
or organizations identify an existing condition as an important
issue or problem they want to address. The solution to that
condition requires the efforts of more than one person, agency, or
organization. In some cases, calls for proposals from public or
private agencies specifically require the applicant be a broad-
based coalition or part of one. They may also ask that a coalition
be created if one does not exist. In either case, one or more
individuals, agencies, or organizations take the initiative to search
for potential partners. The search can be a series of private
conversations with other leaders, or it can be a public call,
invitation, or challenge to others to mobilize and come together.
Coalitions are important because they can:
Enable organizations to become involved in new and
broader issues without sole responsibility
Demonstrate and develop widespread public support
Maximize the power of individuals and groups through joint
Minimize duplication of effort and services
Help mobilize more talents, resources, and approaches to
influence an issue
Provide an avenue for recruiting participants from diverse
Exploit new resources in changing situations.
The following is an excerpt from The Art of Coalition Building, A
Guide for Community Leaders, Cherie Brown, The American
Jewish Committee, 1942.
Building a coalition is an art requiring distinctive attitudes
and skills. Above all, it requires individuals and groups to be
willing to overcome feelings of separateness and
powerlessness, and to join forces with others in a spirit of
mutual understanding, patience, and flexibility.
In our increasingly diverse communities, issues of race,
ethnicity, gender and gender orientation, abilities and
disabilities, education, and age play an important role in
interpersonal dynamics and communications. Inclusiveness
requires special attention to diversity, which should be viewed
as a resource rather than a barrier. Diversity demands cultural
sensitivity and cultural competency from all involved.
Often, the agency or organization with the primary responsibility
for addressing the issue is the one that determines whether or not
a broad-based coalition is the best strategy for addressing the
need. This is a critical time when the decision must be made if a
coalition is the most appropriate configuration to address the
You can find a checklist in Appendix IX of what you need to
consider as you decide whether or not to form a coalition The
checklist contains conditions that, when met, point toward a
coalition as the most appropriate vehicle for action. Completing
this step will ensure that investing the time and effort to start a
coalition is a decision supported by the community.
The interactions taking place during this stage are critical for the
survival of the new entity. One of the key elements is a leadership
style that fosters participation and is inclusive, not exclusive. The
most important criteria for inclusion in the initial group are:
individuals and organizations representative of those
community segments which are stakeholders in the
those who are most affected by the social problem at the
center of the effort, and
those who have access to the resources needed to find a
solution to the problem.
When initial players agree how to work together, that marks the
beginning of the coalition.
The Dance of Coalition: Steps and Lessons
Fortunately, there are many successful community-based
coalitions we can learn from. The Texas Department of Health
Coalition Task Force captured lessons learned from other
coalitions in Coalition Building: A Healthy Community is
Everyone’s Business, (Texas Department of Health, 1996). Some
of the lessons learned are provided below:
Identify an issue to champion or seek clarity on the pre-
determined issue for coalition action.
Determine whether a coalition is the most efficient and
appropriate strategy to address the issue.
Determine if there is another group that is adequately
addressing the issue.
Research the issue in relation to demographics,
geographical impact, population affected, and community
Determine what function the coalition is going to serve -
whether communication, cooperation, or collaboration - in
relation to the community as a whole.
Determine what tasks would need to be performed for the
coalition to exist and be successful.
Determine what entities would be most beneficial in the
coalition based on preliminary tasks.
Prepare a short, direct sales pitch to present to persons to
be approached for participation, which includes information
about the issue.
Identify the people to be contracted.
Hold the first group meeting.
Collaborations in Action: AABCO Advisory Board
The AABCO coalition is very active and critical to the development
of resources and data that has allowed the project to be
successful. The members of the coalition include representatives
from the American Cancer Society and Susan G. Komen Breast
Cancer Foundation, major cancer control advocacy agencies,
state agencies including the Texas Department of Health and the
Texas Cancer Council, and the representatives of the project sites
and community liaisons from Dallas, Houston and Tyler, Texas.
Input from these groups has included data that has helped to
define project sites, target groups, and community screening
facilities. Board members have also provided in-kind support in
the form of outreach materials, resource guides and community
contacts. They also provide critical information that keeps the
project informed of policy and protocol changes that will eventually
effect how the project conducts business.
The primary role of advisory board members is to serve as
advocates. Some advisory board members do assist with
fundraising for the program – whether it be holding events for the
project or writing grants to other organizations. This helps to
implement the project by developing broad community support
through their sphere of influence within the community. Advisory
board members play an active role in the organization’s life by
providing advice and feedback on project activities, supporting the
acquisition of materials and resources to facilitate project
activities, disseminating information about project activities within
this organization and the wider community, and helping solve
barriers to mammography screening for African American women.
Final Thoughts on Program Development
The infrastructure of your project includes your personnel, site
location, and mechanisms for fiscal management. It also includes
developing and maintaining coalitions and collaborations to assist
you with advocacy and the garnering of resources for your
Outreach and Inreach Activities
“The African American Breast Cancer Outreach project has
incorporated and adapted activities from many other cancer
organizations. There are two important things to remember:
(1) you do not have to reinvent the wheel by creating all of
your own outreach activities, and (2) it takes several contacts
for outreach to be effective with the African American
Lesson Learned #15 community. The activity that has been particularly successful
Using or incorporating with the African American Breast Cancer Outreach project
outreach activities that has been direct one-on-one contact with clients and
have been developed by community health activities at the workplace, holiday
other organizations and celebrations, and churches. Often this activity has been
fine-tuning them to meet conducted with the support of partner agencies like the
the cultural needs of American Cancer Society, the Susan G. Komen Breast Cancer
your population is a way Foundation, and other Texas Cancer Council-sponsored
to conduct outreach projects. These partnerships have enabled AABCO to
activities that are unique leverage its impact with the resources of the partnering
to your population. agencies. This has allowed AABCO to effectively use its
resources to extend an activity that has already been
developed and adapt it for African American consumption.
AABCO has collaborated with the American Cancer Society
to develop the Pink Ribbon Sunday campaign. We have
increased African American participation in the Komen Race
for the Cure, and we have worked with the Texas Department
of Health to focus attention on breast cancer awareness by
participating in the Breast Cancer Awareness Day and Wreath
Dedication in cities where project sites are located.”
You have to come up with creative, effective ways to reach your
target population, in order to effectively disseminate breast cancer
prevention, awareness, and detection information. AABCO has
implemented activities in unique ways to reach the African
American population that helps us get the word out about our
services and implement our program.
What is Inreach and How is it Done
In large public medical systems, people access some medical
services without being aware of all the services that are
appropriate for them. It is sometimes challenging to get these
people to use preventative and screening services that are
available. They don’t use them because they lack time, lack
awareness, have financial difficulties, or have fears about the
medical system. In the long run, this under-utilization ends up
costing the client and the medical system. That’s why it’s useful to
develop inreach programs that target existing consumers who
would benefit from the medical community’s preventative and
early detection services, including breast cancer screening.
Inreach is not unlike outreach. Both draw a targeted group of
people to services that they are not using or that they are under-
utilizing. Inreach, however, involves a more specific and narrowly
defined population. Often information about the population has
already been gathered and is easily accessible so strategies can
be more personalized. This information can be used to target
efforts to reach this population most effectively.
Houston Case Study: Inreach
The Harris County Hospital District (HCHD) is a large public health
system serving one of the largest urban areas in the state. The
hospital district found that women were not keeping appointments
for screening services provided through the Breast and Cervical
Cancer Control Program (BCCCP). The BCCCP is a grant-funded
project that provides free or low cost mammography screening for
women who do not have insurance or cannot afford the co-
payment. AABCO developed an inreach plan to help HCHD
increase the show rate of Breast and Cervical Cancer Control
Program clients for annual and follow-up screening. The AABCO
Outreach Coordinator sends out reminder letters, which are
followed by a telephone reminder for African American women
scheduled to be seen at the Breast Clinic of the hospital site with a
high percentage of African American clientele. Women reached
through this activity have expressed appreciation for the reminder
and have shown up for an otherwise forgotten appointment or
rescheduled. The hospital staff also call on the Outreach
Coordinator to educate and encourage women they see who are
reluctant to get mammograms.
Outreach, by definition, requires that trained volunteers or
personnel know the cultural group they work with and the health
practices they are endorsing. That way they can bring in a target
population for a specific service. Simply providing reading
Lesson Learned #16
materials (i.e., passing out brochures) is often not enough.
Develop creative ways to Coupled with the provision of reading materials, one-on-one
encourage people to interaction with knowledgeable people will enhance outreach
volunteer with your activities.
experience with SOV Volunteers gain knowledge of the target group they’re working
provided a fun way of with to assess their community. Volunteers work with community
recruiting and retaining gatekeepers to recruit persons to assess community resources
volunteers. and barriers. They provide credible educational materials by
adapting existing educational materials to be more effective with
the target population. They also develop resource networks to
overcome community and cultural barriers, provide monitoring
through record keeping, and assist in evaluation. (You should note
that volunteers will need some training to ensure confidentiality of
patient medical records, as mandated by law.) Volunteers also
play key roles in developing educational programs, scheduling
screening events, and actively recruiting other volunteers to
develop a community-wide network to address community needs.
The mission of AABCO is to provide outreach services, educate
African American women, and motivate them to take personal
action for their wellness. Many times, outreach work requires
types of one-on-one activities. Our volunteers help AABCO reach
a much larger population than one outreach/case-manager could
reach. Because many African American women don’t understand
what breast health is, additional outreach volunteers are needed
to explain breast health in easily understood terms. AABCO
outreach workers’ responsibilities include educating women about
breast health, providing information about cancer risks and
screening guidelines, setting up screening events in the
community, providing transportation to screening locations,
teaching women how to do breast self-examinations (BSE), and
Lesson Learned #17
educating women on the importance of performing BSE on a
monthly basis. Partner with those who
best understand how to
Accessing Media and Promotional Resources persuade people, such
It is important to take advantage of opportunities to work with the as professional
media to develop promotional material. Every opportunity should advertising agencies, to
be taken and created to use local radio stations, news programs develop your media
and local newspapers to get the message across. These kinds of activities.
promotional activities should be conducted along with other more
hands-on kinds of activities and more personal contact.
AABCO has been able to use the media in conjunction with
holiday-focused outreach activities, such as the Mother’s Day
Campaign that included distribution of Mother’s Day greeting
cards and a school art contest. The art contest also focused on
the importance of mothers in the lives of their family. This
message was used because market research conducted with J.
Walter Thompson (JWT) Specialized Communications Group
determined that family-focused messages are most effective with
African American women. The card included a message from
family that encouraged women to participate in breast cancer
The media has also been used in conjunction with African
American holiday activities such as Juneteenth. AABCO
leveraged free advertising with paid promotional spots to increase
the impact of outreach activities planned at local parades and
Juneteenth celebrations in the community. Posters, fliers and
brochures were developed and distributed around these
celebrations. AABCO has been particularly fortunate in being able
to access one of the top communications and marketing firms to
assist in the development of promotional strategies for all three
project sites. Although the resources were not available to fully
implement the marketing plan developed for AABCO, many of the
strategies have been implemented creatively using resources
available from the project partners. Any organization attempting to
duplicate AABCO’s outreach activities should consider the
assistance of professional marketers.
Developing Partnerships With Other Community
It is important to realize that all of your resources will not
necessarily be cancer-related. Many women’s groups will provide
tremendous support in terms of volunteers, ideas for accessing
large numbers of clients, and other in-kind support. These groups
will include sororities, church groups, and professional and civic
Building relationships with both social and professional
organizations is valuable on many levels. First, it will provide your
organization with different perspectives on the challenges you
face in reaching your target population. It will also provide both
human and material resources, as your partners will want your
clients to be aware of their organizations as well. Finally, your
client base will expand as your partners include you. Recognizing
the value your organization can offer their clients, they will allow
you access to their outreach events and share your materials with
It’s also important to reciprocate the support offered by other
organizations by sitting on advisory boards and committees. This
is especially beneficial when working with other cancer or health
care organizations. You will be amazed at how much you can
build your body of knowledge simply by participating in these
endeavors. It’s also a way to infuse cultural sensitivity into
services provided to your target community.
One of the benefits of working with women’s resources as well as
participating in other organizations’ advisory boards and
committees will be the assistance it gives you in identifying
locations to hold outreach events. It’s important to find out where
outreach has been successful for other organizations and what
kinds of outreach are more successful in different parts of the
community. Locations that have been recommended to AABCO
have included beauty shops, churches, local parks, health fairs,
and work places.
AABCO has been fortunate to have outreach/case-managers who
have cultivated the interest of many individuals and health-related
organizations. These groups have provided a good deal of support
and resources within the local community surrounding the project
sites. As Figures 4 through 6 illustrate, the outreach/case-
managers are aided by community organizations that provide
skills and client resources from nutrition to cancer treatment.
Although partnerships were formed in each site among major
cancer advocacy groups, each site also formed partnerships with
organizations specific to its own community. The rural setting and
smaller community of the Tyler site makes it necessary to build
broader coalitions than the urban sites do. That site eventually
formed partnerships beyond the African American community.
What you have to do is determine who your individual partners will
Figure 4: Dallas Site Community Coalition and Partnerships
Parkland Health & Hospital System St. Paul Hospital African American Churches in the Dallas Area
Dallas Independent School District Baylor Hospital Maverick Basketball Team
National Council of Negro Women Zeta Phi Beta Sorority, Inc.
American Cancer Society, Dallas Metro Texas Screen Graphics, Inc.
Dallas Recreation and Park System Southwest Center Mall
Sisters Network, Inc. Ortho BioTech
Delta Sigma Theta Sorority, Inc. DALLAS South Dallas Diabetes Society
Bridge Breast Center Kroger Food Stores of Dallas, TX
YMCA at Loop 12 Dallas Panhellenic Council
Wells Fargo Bank Gilda’s Club
YWCA of Abilene, Texas Lunar Temple
Susan G. Komen Breast Cancer Foundation YWCA at Ross Avenue
Susan G. Komen Breast Cancer Foundation Methodist Hospital Susan G. Komen Breast Cancer Foundation
*Dallas Affiliate, Race for the Cure Austin Affiliate, Race for the Cure
*Outreach Coordinator is a board member
Tyler Case Study: NBLIC
The Tyler project site provides an example of how developing
partnerships with other organizations can greatly impact the
success of your program. When AABCO was begun there, there
was no Breast and Cervical Cancer Control Program (BCCCP) in
the Tyler area. So, members of the National Black Leadership
Initiative on Cancer (NBLIC) and the project director of AABCO
worked with the Texas Department of Health to establish one. The
NBLIC is a broad-based community organization that was
established in 1991 in order to raise cancer awareness within the
African American community. The initial site manager for Tyler is a
founding member of the NBLIC Tyler chapter. She was one of the
two nurses who began the NBLIC. This important initiative, which
began with 7 people at its first meeting and has grown to a
coalition of more than 25 agencies, 75 churches, and 200
individual members, has been very instrumental to the success of
AABCO in Tyler.
Final Thoughts on Program Implementation
Program implementation involves understanding and conducting
activities for service delivery. To increase the numbers of women
screened for breast cancer, we used both inreach and outreach
activities. Inreach allowed AABCO to assist the institution with its
screening needs, while outreach brought in women from the
community for breast cancer screening who were not involved
with the health care system.
Putting it all Together
AABCO Project Description
“To put it all together we had to consider several things. We
felt very strongly that we had to have places for women with
no insurance to go for screening. AABCO chose to work with
agencies that were also BCCCP contractors. At the end of the
day, you can educate and raise awareness to a very high
degree and not necessarily change behavior if access is an
issue. We set up screening outreach programs so as soon as
women became aware of how mammography could change
their lives, it was easy to go have one done. And do you know
what worked best? These women were going in groups,
taking their friends and their sisters and their mothers. But
the program didn‟t stop there. For those women whose
follow-up screening indicated the possibility of cancer, the
program provided access to treatment options they might not
have otherwise had. We also made sure that an evaluation
plan was in place to measure the success and failure of the
The primary purpose of the AABCO project is to refine, implement
and evaluate a culturally-sensitive community-based model to
enhance African American women’s participation in early
detection and follow-up services for breast cancer in three specific
communities (two urban and one rural) in Texas. The project is a
five-year pilot with the first two to three years as a period of
refinement and development and years four and five as those of
full implementation and evaluation.
The AABCO project was designed to increase the numbers of
African American women screened for breast cancer in Texas,
especially those that are poor and underserved. Screening rates
are not as high as they should be for this population. In 2002, it
was estimated that 203,500 women will develop breast cancer in
the U.S. and that 10,500 of these cases will be in Texas (ACS,
2002). Approximately 1000 of these new breast cancers will be
diagnosed in African American Texans (Texas Data Cancer
Center, 1998). Data from the Behavioral Risk Factor Surveillance
System (BRFSS) for 1996 revealed that 23% or 51,586 African
American women 40 years and older had never had a
mammogram (1996). For African American women 50 years and
older, 34,421 had not had a mammogram within the past two
A culturally sensitive community-based model for outreach and
case management with the core components of: (1) utilization of
outreach coordinators, (2) development of site community and
professional advisory committees, and (3) development of
community coalitions to promote education and awareness within
the specific communities, was implemented and evaluated in three
specific communities of Texas (Houston, Dallas and
Longview/Tyler). Together these three targeted areas represent
the estimated source of 70% of breast cancers that will be
diagnosed in African American women in Texas (Texas Data
Cancer Center, 1998). In these communities, settings where
underserved African American women may receive services but
are not fully utilizing them, such as those already designated as
BCCCP programs, were chosen as sites.
The project focused on implementing this model through
numerous activities, which had several goals. These goals were
as follows; (1) build the infrastructure of the project by
coordinating planning and support of an overall project advisory
committee comprised of members from the Texas Cancer Council,
the American Cancer Society, the Susan G. Komen Foundation,
the Texas Department of Health (TDH) BCCCP and community
representatives from the communities selected as sites; (2) select
BCCCP projects or community organizations to serve as sites for
the project; (3) provide technical advice and training on culturally
sensitive outreach, and case management strategies; (4) evaluate
the project to determine its effectiveness; and (5) disseminate
information on the model and the outcomes. We wanted to
determine if this project’s community-based model is generalizable
to other communities for eventual use statewide.
The African American Breast Cancer Outreach project (AABCO)
was developed with many resources already committed to
providing financial, legal and medical support. Because AABCO
was administered through an existing organization that could
provide legal and fiscal oversight, it did not have to seek this
expertise. AABCO was very fortunate to be situated within a
university system that would not allow any legal contract to be
initiated independently by individual programs within the
university. This has meant that the project director did not have to
seek (and pay for) legal counsel when developing contracts of any
The Texas Cancer Council (TCC) has provided the primary
funding for the project through annual grants. The University of
Texas at Austin School of Nursing has provided some of the
required office space. The Texas Department of Health Breast
and Cervical Cancer Control Program has been a source for
mammography screening as has the Susan G. Komen Breast
Cancer Foundation. The American Cancer Society has provided
educational materials as well as opportunities for staff
development, incentives for both needs assessment, marketing
research and outreach.
All of these resources have been critical in the success of the
project but the work could not have been done without
subcontractors in Dallas, Houston and Tyler. Each subcontractor
required their own set of resources to function in its community.
These included resources to help them function within their
supporting institutions, the African American community, and the
local cancer control community. All of the AABCO partners have
contributed directly or indirectly by providing resources at each of
the project sites. However, many other resources have been used
based on what resources are available in each of the individual
Final Thoughts on Putting it all Together
Planning, implementing and evaluating a project is a multi-stage
process. It allows a program to determine if it has been effective in
achieving its intended goals. This process worked for AABCO, as
we reached over 90,000 people with breast health messages,
ensured that 7,000 African American women were screened and
identified 96 cancers, which were successfully treated during the
course of the project. We hope that you will find this manual
helpful as you embark on your endeavors to create new programs.
Community Needs Assessment Survey to Support
Mammography Screening Programs for African American Women
I. Know your target population:
A. How many African American women over the age of 40 are in your community?
B. How many of these women are below the poverty level?
II. Know about mammography and follow-up breast health services:
A. What facilities provide mammography in your community?
B. Where do African American women in your community receive mammograms?
C. Is there a Breast and Cervical Cancer Control Program (BCCCP) provider in your
D. How easy is it for African American women to access these services?
1. How long is the wait to get a screening mammography?
2. How long is the wait to get a diagnostic mammography?
3. How long is the wait for other diagnostics services (i.e., biopsy, ultrasound)?
4. How convenient are the hours for screening mammography?
5. Are the facilities easy for African American women to get to?
6. Do African American women feel welcome at these facilities?
E. Where in your community are there physicians and nurses to provide:
1. Clinical breast exams?
2. Follow-up diagnostic services?
3. Follow-up treatment services?
F. If services already exist, and African American women don’t use them, what are the
barriers? (consider accessibility issues, financial issues, lack of physician referral,
negative attitudes toward mammography screening, time constraints, don’t see
anyone like themselves at facilities)
III. Know resources in your community:
A. Who are the gatekeepers or people who influence African American women’s health
B. What resources or organizations can help you with your outreach to African
American women? (consider churches, beauty shops, other private businesses, and
C. What media and promotional resources exist in your community?
D. Is there an American Cancer Society (ACS) unit or field office in your community?
E. Is there a Susan B. Komen Breast Cancer Foundation affiliate in your community?
F. If so, do these organizations sponsor activities in the African American community?
G. What other sources do you have for volunteer assistance?
H. Who can you call on to serve on a community coalition to support your outreach?
IV. Know your infrastructure support:
A. Are you a part of an organization that will support this outreach activity?
B. If so, what support will the organization provide?
Personnel (both paid and volunteer)
Other in-kind contributions (please describe)
C. What outreach programs have you, or your organization, set up before?
D. What helped make these programs successful and what made them difficult?
Mammography Barriers Checklist
WHY WE DON’T GET BREAST CANCER X-RAYS
Women don’t get breast cancer X-rays (mammograms) for many reasons. Please check
the box to show us how much each of these problems or reasons keeps the women you
know, and yourself, from getting breast X-rays. We plan to use this information to help us
make breast cancer screening services better, and we thank you for taking the time to
give us your ideas.
Big Less of a Not a
problem/ problem/ problem/
reason reason reason
1. Cost of breast X-ray (mammogram)
2. Too hard to figure out where to go for X-ray
3. Lack of transportation to the X-ray office
4. Taking time off from work
5. Don't think about getting a breast X-ray
6. No one to stay with children or grandchildren
7. Worry the breast X-ray might find cancer
8. Doctor/Health provider hasn’t said to do it
9. Forget to make an appointment
10. Not sure how old a woman should be to have a
11. Don't think breast X-rays can save their life
12. Breast X-ray hurts too much
13. Don’t think they are likely to get breast cancer
14. Takes too long to get an appointment
15. People who perform X-rays don't treat them with respect
16. Don’t know how the breast X-ray is done
17. Too many other things going on in their lives
18. Nobody in the family has had breast cancer
19. Worry the X-ray might give them cancer
20. Don’t think they need a breast X-ray
21. Don't want to know if they have cancer
Big Less of a Not a
problem/ problem/ problem/
reason reason reason
22. No one they know talks about getting breast X-rays
23. Breast X-rays aren’t always accurate
24. Other (please describe) _______________________________________________________
Have you had a mammogram before? yes no
If yes, when was your last mammogram? _______________
How often do you examine your breasts to check for cancer?
Never Less than 5 times a year 6-10 times a year Monthly
Does checking your breasts for cancer remind you to get a yearly mammogram? yes no
Please give us some information to help us understand our results. Your answers will be kept
Your date of birth: ___ ___ ____ Your gender:
Month Day Year Female Male
African American Hispanic Anglo Other______________________________
The highest grade you completed in school:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Do you have:
HMO Medicaid Medicare Private Health Insurance Other ___________
Do you have a regular place to go for health care (other than an emergency room)? yes no
Other comments about getting mammograms (breast X-rays)?
Thank you for your help!
Literature Review for Up-to-Date Materials
Adams, M. L., Becker, H. & Colbert, A. (2001). African-American women’s perceptions of
mammography screening. Journal of National Black Nurses Association, 12(2), 44-48.
American Cancer Society. (1998). Cancer facts & figures for African Americans 1998-
1999. Atlanta, GA: American Cancer Society.
American Cancer Society. (1999). Breast cancer facts & figures 1999-2000. Atlanta, GA:
American Cancer Society.
Baldwin, D. (1996). A model for describing low-income African American women’s
participation in breast and cervical cancer early detection and screening. Advances in Nursing
Science, 19, 27-42.
Breen, N. & Kessler, L. (1994). Changes in the use of screening mammography:
Evidence from the 1987 and 1990 National Health Interview Surveys. American Journal of
Public Health, 84, 62-67.
Campinha-Bacote, J. (1994). Cultural competence in psychiatric mental health nursing:
A conceptual model. Nursing Clinical of North America, 29, 1-8.
Casey, S, Plomer, K., Tenney, M., Krakauer, E., Knoll, V., & Coyne, C. (1995). Breast &
cervical cancer screening: Barriers and use among specific populations. A review of literature
prepared for public health planners. Denver, CO: AMC Cancer Research Center with funding
from the U.S. Centers for Disease Control and Prevention Cooperative Agreement No.
Champion, V.L. (1999). Revised susceptibility, benefits, and barriers scale for
mammography screening. Research in Nursing & Health, 22, 341-348.
Champion, V. L., & Scott, C. R. (1997). Reliability and validity of breast cancer screening
belief scales in African American women. Nursing Research, 46, 331-337.
Gaston, M. H. & Moody, L. E. (1995). Improving utilization of breast and cervical cancer
screening in your office practice. Journal of the National Medical Association, 87, 700-704.
Gonzalez, V.M., Gonzalez, J.T., Freeman, V., & Howard-Pitney, B. (1991). Health
promotion in diverse cultural communities. Palo Alto, CA: Stanford Health Promotion Resource
Huff, R. B. & Kline, M. V. (1999). Promoting Health in Multicultural Populations: A
handbook for practitioners. Thousand Oaks, California: Sage Publications.
Kang, S. H., Bloom, J. R., & Romano, P. S. (1994). Cancer screening among
African American women: Their use of tests and social support. American Journal of Public
Health, 84, 101-103.
Phillips, J. M., Cohen, M. Z., & Moses, G. (1999). Breast cancer screening and African
American women: Fear, fatalism, and silence. Oncology Nursing Forum, 26, 561-571.
Schechter, S. & Herrmann, D. (1997). The proper use of self-report questions in effective
measurement of health outcomes. Evaluation & The Health Professions, 20, 28-46.
Sung, J. F. C., Blumenthal, D. S., Coates, R. J., & Alema-Mensah, E. (1997).
Knowledge, beliefs, attitudes, and cancer screening among inner-city African American women.
Journal of the National Medical Association, 89, 405-411.
Tessaro, I., Eng, E., & Smith, J. (1994). Breast cancer screening in older African-
American women: Qualitative research findings. American Journal of Health Promotion, 8, 286-
Texas Department of Health Coalition Task Force. 1996). Coalition Building: A Healthy
Community is Everyone’s Business. Austin, TX: Texas Department of Health.
Thompson, B., Montano, D. E., Mahlock, J., Mullen, M., Taylor, V. (1997). Attitudes and
beliefs toward mammography among women using an urban public hospital. Journal of health
care for the poor and underserved, 8, 186-201.
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(Conference Edition, in Two Volumes). Washington, DC: U.S. Government Printing Office.
Discussion Guide for Focus Groups on Breast Cancer Screening
I. INTRODUCTIONS (10 min)
A. Welcome. We appreciate you joining us today for our discussion group. We will
be discussing African American women’s beliefs about breast cancer and
mammography screening. Have any of you ever participated in a similar group
discussion, sometimes known as a focus group?
B. There are certain “rules” that we try to keep in mind during the discussion to be
sure we get the information we need:
There are no right or wrong answers. We have these groups because
we expect to hear a variety of opinions or responses. We are not here
to judge each other’s opinions or thoughts.
Your responses will remain confidential. It is not important as to who
said what; only the information itself is important to us. Nor will we
contact you in the future.
Speak one at a time. You will notice that we will be recording the
session. This is for report writing purposes only; for us to refer back to.
It is difficult to hear the tape clearly if we are speaking over each other.
Give everyone a chance to speak. Again, everyone’s opinion is equally
important to us.
Are there any questions before we begin?
C. Introductions. Since we will be spending some time together, it might be helpful
to know just a little bit about each other. Begin by asking an easy question that
gets everyone talking, such as asking people to introduce themselves.
II. Question/Answer Session
A. What comes to mind when African American women hear the term “breast
Probe(s): How likely is it for African American women to get breast cancer?
What does “risk” mean?
What happens to women who have breast cancer?
B. What do African American women feel is their best defense against breast
Probe(s): What do “detection” and “screening” mean?
What screening activities can help women and their doctors find
(Discuss pros and cons of all screening methods mentioned)
C. What have you heard about mammograms?
Probe(s): What does mammography mean?
What happens when a woman gets a mammogram (both positive
When should a woman get a mammogram?
D. What are some things that keep women from having mammograms?
Probe(s): Access barriers, environmental barriers, attitudinal barriers
E. What are some things that could be done to encourage or make it easier for
women to get a mammogram?
Probe(s): Social supports (who is most influential in getting women to come
in for screenings), changes in screening systems, providers’
sensitivity, educational/outreach activities.
Where do women receive information or advice?
What should the message be like? (Note: you might show women
some of the outreach materials you have developed and ask their
What would encourage women to get rescreened?
A. Summarize major points made by group.
B. Last thoughts: Is there anything about breast cancer screening that you would
like to say but didn’t get a chance? Does anyone have questions about breast
cancer screenings I can answer for you?
C. Thank group for their participation.
Tips for Conducting Focus Groups
1. Gather background information to inform you about why the focus group is being
conducted and how the information will be used.
2. Use purposive sampling to identify who should be recruited to participate (i.e., decide what
demographic or other background characteristics are salient).
3. Seek out people like your target audience for advice on how to recruit participants and
how to conduct the focus group with them. Be sensitive to differences in communication
patterns among different cultural groups.
4. Consider the likely dynamics produced by any particular combination of individuals in the
same focus group (ex: avoid having people of clearly different SES, or mixing patients and
providers when discussing service issues).
5. Plan what resources will be needed, including participant incentives (such as snacks),
equipment, recruitment materials, person power.
6. Locate a quiet, comfortable, “neutral” environment for the focus group.
7. “Quality answers are directly related to quality questions” so plan your discussion guide
carefully. Avoid close-ended questions that elicit short answers. Begin with general
questions and conclude with the moderator’s summary.
8. Provide each participant with information about the purpose of the study to minimize their
tacit assumptions about the purpose. In some situations it may be helpful to give them the
questions in advance so they can give thought to their responses.
9. Let the purpose of the focus group determine how structured and directive the moderator
becomes in the group. Moderators pace questions, encourage everyone’s input, probe
unclear or inconsistent comments, monitor time, and summarize major points.
10. Have a “human” recorder, in addition to a tape-recorder, attend the session if at all
possible. This person can record non-verbal information, manage logistics, and debrief
with the moderator after the session.
11. The number of focus groups needed will vary depending upon the topic, but more than
one is almost always necessary. Because conducting groups and analyzing results can
happen at the same time, insights acquired in initial groups can be used to refine
questions used in later groups.
12. In analyzing the data, ask yourself three questions: (1) What was known and then
confirmed or challenged by the study; (2) What was suspected and then confirmed or
challenged by the study; and (3) What was new that wasn’t previously suspected.
Adapted from Focus Groups by Richard Krueger (Sage Publications), 1998.
Texas Cancer Council Guidelines for Goals and Objectives
A GOAL is the end toward which project efforts are directed. Goals should generally be no more than
two sentences in length and provide a clear direction for action, reflect your priorities, be unrestricted
by time, and reduce the burden of cancer on Texans when accomplished. Goals for TCC projects
should also support the Texas Cancer Plan goals listed below:
Prevention Information and Services: Reduce the risks for developing cancer by increasing the
availability and effectiveness of education programs and materials.
Early Detection and Treatment: Detect and diagnose cancer earlier, increase access to and use
of treatment and services, and reduce barriers to services.
Professional Education and Practice: Enhance health care professionals knowledge, skills, and
practices in Texas.
Cancer Data and Planning: Design and implement comprehensive cancer data systems.
Texas Cancer Plan goals, supported by the project, must be identified in the Work Plan. Examples of
project goals might be “Strengthen cancer prevention knowledge in rural communities of Texas”;
“Maximize public and private resources available for cancer prevention and treatment of medically
underserved residents of Travis County”; “Improve cancer treatment knowledge of physicians in
Texas”; or “Increase awareness of the dangers of smokeless tobacco to the youth of Harris County.”
OBJECTIVES constitute the major endeavors to accomplish the goals. More detailed than goals,
objectives have shorter time frames (12 months or less) and state quantity (people reached, modules
produced, etc.). An objective is connected to a particular goal, achievable, measurable, and sets the
direction for activities. A single goal may have multiple objectives. (Objectives should state the
specific number of people who will be reached, the specific number of workshops that will be
Examples of objectives might be “Educate 2,000 Texas youth on the dangers of smokeless tobacco”;
“Produce a video on breast self examination and provide it to five churches in Tyler”; “Conduct 20
workshops on cancer screening/treatment techniques for nurses in Public Health Regions 9 and 10”;
or “Provide nutrition and cancer risk reduction training to 30 school nutritionists in Tarrant County.”
Texas Cancer Council Funding Application, FY2002
Evaluation Tool for Data Collection: Outreach Activity Log
June – Aug. ________ Sept. – Nov. ________ Dec. – Feb. ________ Mar. – May ________
DATE ACTIVITY HOW MANY PEOPLE ATTENDED (A), TOTAL VOLUNTEER NAME VOLUNTEER
EDUCATED (E), SCREENED (S), NUMBER HOURS
SERVED WITH FANS (F), OR OTHER (O) REACHED (include travel time)
A E S F O (unduplicated)
TOTAL TOTAL Donated Hours
Details on Screening Numbers
Of the people screened (total screened) how many were seen for the first time? ___________
How many stage 1 cancers were identified? ______ stage 2?_______ stage 3? ______ stage 4? ______ stage unknown? _____
Client Satisfaction Survey
CLIENT SURVEY OF AFRICAN AMERICAN BREAST CANCER OUTREACH
UT AUSTIN, SCHOOL OF NURSING
INTRODUCTION: My name is and I am helping the African American Breast
Cancer Outreach, also known as AABCO, evaluate their services. Your name was given to me by
(name of outreach coordinator) the outreach coordinator in because we were interested
in what you think about our program. Any information you give me will be confidential and your name
will not be on this form. All comments both positive and negative are welcome. The questions should
only take about 5 - 10 minutes. Would you be willing to answer a few questions at this time?
(If answer is NO) Will you be willing to reschedule for another time?
Date/Time to reschedule
1. Which AABCO activities, have you participated in?
ACS Tell a Friend Links Walk-a-thon Outreach Materials
Before Time Runs Out (Play) Live Radio Remote Pink Ribbon Sunday
Breast Cancer Awareness Day Minority Cancer Week Press Release
Have a Heart Mobile Mammography Units PSAs/News Media
Health Fairs/Community Event Mother’s Day Campaign SOV Bus Trip*
Komen Race for the Cure NBLIC Awards Banquet TDH Wreath Project
Juneteenth Celebration NBLIC Cancer Awareness Breakfast Word of Mouth
*Survivors, Outreach & Volunteers (SOV) Bus Trip/Shopping Extravaganza
Fans, Potholders, Magnets, Snack Clips, Mirrors, Pens, Pencils, Posters, Flyers
2. Which, if any, was your favorite AABCO activity and why?
3. Were there any particular take home messages that stuck with you after attending AABCO
4. Did these activities increase your knowledge or understanding about breast cancer and the
importance of early detection?
4a. If yes, please (list activity)
no increase little increase major increase N/A
no increase little increase major increase N/A
no increase little increase major increase N/A
4b. (If no increase) Was there something that could have been presented differently?
5. Prior to AABCO, did you know someone personally who was affected by breast cancer?
Yes (if yes, please specify) No
Friend Other (please list)
6. Prior to your AABCO experience, had you had a mammogram?
Yes No (see 6b)
6a. If yes, when was your last?
Within the year
Year or longer ago
6b. If no, were you considering having a mammogram after participating in an AABCO activity?
1. Did you get a mammogram?
Yes No (see 6b2)
2. (If NO) Could you tell me a little bit about what prevented you from receiving a mammogram?
Schedule Availability Resources
7. Do you feel participating in AABCO activities influenced you to get a mammogram?
No influence little influence major influence N/A
7a. If yes, tell us how
8. Do you plan to continue to get annual mammograms?
9. Are there other things AABCO could do to help you with your health care needs?
Thank you for your time!
Job Descriptions, Qualifications and Minimum Requirements
Licensure: Must be Licensed by the State of Texas Board of Nurse Examiners
Education: Baccalaureate in Nursing with a Master’s Degree required. Ph.D. desired
Experience: Minimum of five years as a Professional Nurse. Previous experience in cancer
screening, program development , operation and administration. Knowledge of cultural
Responsibilities include but are not limited to:
Develop, administer, implement and evaluate the project
Select and negotiate contracts with project sites
Supervise project personnel
Prepare written reports of project activities for funding agencies
Education: Ph.D. in area related to evaluation research
Experience: Minimum of two years experience in evaluation research
Responsibilities include but are not limited to:
Develop evaluation tools in collaboration with project director
Oversee data collection in collaboration with project director
Analyze data in collaboration with project director
Assist with writing of reports related to evaluation in collaboration with project director
Education: Master’s Degree
Experience: Experience in health education and outreach
Experience in a major cancer organization
Responsibilities include but are not limited to:
Assist with the collection of evaluation data
Perform data entry
Assist with data analysis
Assist with preparation of project reports
Coordinate project details and activities
Supervise project’s Administrative Assistant
Education: High school degree; good communication skills; business training, including office
management and word processing skills required. College courses in business
management and complex computer utilization desired. College degree with emphasis on
communication and marketing optimal.
Experience: At least two years experience in office management
Responsibilities include but are not limited to:
Communicate and interact cordially with project site personnel
Answer incoming calls regarding project activities.
Schedule and assist with coordination of advisory meetings and site visits
Prepare minutes of project meetings
Inventory and requisition supplies or equipment as needed
Word process letters, reports, forms and other materials from notes or rough drafts
Composes routine correspondence
Assist with travel/meeting plans
Education: Ph.D. in Health Education or related field
Experience : Research in program development relating to cancer prevention and treatment
Responsibilities include but are not limited to:
Provide technical assistance with development of outreach materials
Outreach/Case Management Coordinator:
The primary responsibility of the Outreach/Case Management Coordinator for this project continues to
be to enhance African American women’s breast cancer screening outreach and case management
services in the selected priority areas in Dallas, Houston and Tyler.
The specific program of work for the Outreach/Case Management Coordinator will continue to be to:
1. Develop, implement and market activities involved with the project
2. Establish outreach and case management strategies to increase access and availability of
screening and follow-up services for African American women
3. Maintain frequent interaction with and provide monthly written report of project activities to Project
Director at The University of Texas at Austin School of Nursing
4. Establish/Maintain community coalitions, site project advisory group, site professional group.
5. Conduct needs/assets assessments for assigned areas
6. Collect and compile data
7. Record observations and evaluate results
8. Recommend new policies and procedures for improvement of program activities
9. Perform related duties as required
Checklist for Program Planning and Implementation
1. Have you established a community advisory group with:
Representation of your targeted groups
The ability to provide valuable links with the community
Skills and resources that will be useful to the program
2. Have you identified community needs and concerns by way of:
Public meetings or forums
Interested party analysis
3. Have you determined the community’s priorities, taking into account:
Political and economic conditions
4. Have you developed program goals and objectives?
5. Have you decided on program strategies which:
Fit with the resources and needs of the community
Consider the beliefs, values, and practices of the community
Reflect field testing
Dispel health misconceptions
6. In order to implement your program, have you:
Prepared a time line for program implementation
Listed people to be involved and resources needed
Hired staff (preferably from the community)
Developed linkages with other community agencies, as appropriate
Planned to carry out an evaluation
7. Have you chosen appropriate methods and questions for:
From Health Promotion in Diverse Cultural Communities
by Gonzalez, V.M., Gonzalez, J.T., Freeman, V., & Howard-Pitney, B., (1991)
Checklist for Establishing Contacts and Developing Relationships
1. Have you assessed your own organization’s level of commitment to the community in terms
of the following?
2. In your exploration of the community, have you learned about the following?
Its physical layout
The routines and activities of the population at different times of the day and week
The major institutions and businesses
The major gathering places
3. Have you developed the following?
A community profile
A community resource directory
4. Have you identified the following community contacts?
Political figures and government officials
Community and health service workers
Other professional and business leaders
Informal community leaders
5. Have you considered which method you will use to obtain the information you want? Check
as many of the following as are appropriate.
Case study/In-depth interview
6. Have you sought out key individuals with whom you will work closely? If so, have you
Their type of motivation
Their social and political status within the community
Their potential contribution
7. Are you prepared to approach all of your community contacts in a way that can help you win
8. Can you give back to the community as much as (or more than) you take, in the following
By keeping your contacts informed of progress
By offering to help people in their own community work
By giving recognition to those who help you
From Health Promotion in Diverse Cultural Communities
by Gonzalez, V.M., Gonzalez, J.T., Freeman, V., & Howard-Pitney, B., (1991)
Types of Community Contacts
Local health educators
Public health nurses
Community health workers
Unlicensed health professionals
Traditional healers (e.g. curanderos, shaman, herbalists, spiritualists, medicine men, root
women, voodoo priests, etc.)
Members and volunteers of voluntary health agencies
Clients of health related services
Social Service Contacts
Social and eligibility workers
Counselors (mental health, substance abuse and others)
Refugee or immigrant sponsors or advocates
Elected officials/political leaders
Tenant association members
Block/neighborhood association members
Civil rights and community activists
Union leaders and workers
Local Professional Contacts
Clergy (e.g. ministers, priests, nuns, monks, etc.)
Lay religious leaders or church groups workers
Teachers and other school personnel
Police/peace officers, particularly community service officers
Minority business leaders (e.g. members of the Chambers of Commerce)
Other Miscellaneous Contacts
Ethnic media personalities, editors, writers, etc.
Community and social club leaders (e.g. Girl Scouts, Boy Scouts, campus student
Coaches or leaders of various sports groups (in school or community based programs like PAL,
Bus drivers and other transit workers
From Health Promotion in Diverse Cultural Communities
by Gonzalez, V.M., Gonzalez, J.T., Freeman, V., & Howard-Pitney, B., (1991)
The University of Texas at Austin
School of Nursing
1700 Red River Street
Austin, TX 78701
Parkland Health & Hospital System
Community Oriented Primary Care
9202 Elam Road
Dallas, TX 75217
Harris County Hospital District
2525 Holly Hall, #258
Houston, TX 77054
The University of Texas
Health Science Center
11937 US Hwy 271
Tyler, TX 75708
AABCO Funded by: