ORIGINAL RESEARCH PAPER
Year : 2007 | Volume
: 20 | Issue : 2 | Page : 52-
An Innovative Partnership to Address Breast Cancer Screening among Vulnerable Populations
Monica E Peek
The University of Chicago Medical Center, Chicago, IL, USA
Monica E Peek
University of Chicago, Dept. of Medicine, MC 2007, Chicago, IL 60637
Context : Breast cancer is the most common non-skin malignancy among U.S. women. Vulnerable populations such as low-income women, racial/ethnic minorities, and the uninsured have lower rates of screening mammography use and bear a disproportionate burden of disease.
Objectives : The Breast Cancer Education Project (BCEP) was created to address the needs of medically underserved women in Cook County through high-quality breast cancer screening, education and support. The BCEP also provides a service-learning opportunity in which medical students can provide a valuable health service while obtaining important skills that enable them to work more effectively within medically underserved communities.
Conclusion : The BCEP is an innovative collaboration between academic medical centers, safety-net health systems, community based organizations and public health organizations. It represents a model for addressing issues of disparate access to breast cancer screening within vulnerable communities that contribute to higher breast cancer mortality.
|How to cite this article:|
Peek ME. An Innovative Partnership to Address Breast Cancer Screening among Vulnerable Populations.Educ Health 2007;20:52-52
|How to cite this URL:|
Peek ME. An Innovative Partnership to Address Breast Cancer Screening among Vulnerable Populations. Educ Health [serial online] 2007 [cited 2020 Sep 26 ];20:52-52
Available from: http://www.educationforhealth.net/text.asp?2007/20/2/52/101620
Breast cancer is the most common cancer affecting women in the United States (U.S.). It is estimated that, in 2006, an estimated 212 920 women in the U.S. were diagnosed with breast cancer and approximately 40 970 died from their disease (SEER, 2006). Breast cancer screening through mammography can detect tumors at an earlier stage, when they are more receptive to treatment. Despite the increased mammography rates for women in the U.S. over the past two decades, there are still significant disparities in the mammography screening rates among low-income women and women of color, particularly women without health insurance and recent immigrants to the United States (Blackman & Bennett, 1999; Swan & Breen, 2003). These disparities in breast cancer screening contribute to worse of breast cancer outcomes for vulnerable women (Chevarley, 1997; SEER, 2006).
There are a variety of barriers to medically underserved women receiving mammography. Structural barriers include cost, transportation issues, limited access to screening initiatives, lack of a regular medical provider and other institutional barriers. Other barriers reflect belief systems, cultural differences, language barriers, limited literacy and knowledge deficits. Studies show that medically underserved women have less access to informational resources and are less familiar with the screening guidelines for breast cancer.
Using the Towards Unity for Health model, the Breast Cancer Education Project (BCEP) brought key stakeholders together to increase the quality of equity of breast cancer screening services among medically underserved women living in Cook County, recognizing the inherent challenges and opportunities of such a model (Boelen, 2000). The BCEP has two primary objectives. First, we sought to establish a partnership between an academic medical center, a safety-net public health system, community organizations, advocacy groups and public health organizations to provide high-quality breast cancer screening, education and peer-group support to low-income women who are at risk for mammography underutilization. Second, we sought to create a service-learning opportunity for medical students in which they could: a) better understand the communities they serve and to establish cultural competencies in providing compassionate health care to vulnerable populations: b) learn about the social and environmental determinants of health; and c) provide a valuable service to women participating in the BCEP. The BCEP incorporates several principles of Towards Unity for Health (TUFH) including the education of health personnel, the adaptation of health services to improve community health, the use of innovative educational approaches (including community-based education and problem-based learning) and educational research.
Partners in the BCEP collaboration include Rush University Medical Center (an academic medical center located in urban Chicago), the University of Illinois at Chicago (UIC) School of Public Health, the Cook County Bureau of Health Services (CCBHS; one of the largest safety-net health systems in the U.S.), the Y-Me Breast Cancer Organization (the largest breast cancer support/advocacy organization in the U.S.), Sisters Network, Inc. (the only national African-American breast cancer support/advocacy organization in the U.S.), the American Cancer Society (one of the oldest and largest voluntary health organizations in the U.S.), and the Illinois Health Education Consortium (a public health organization whose mission is to improve health care for the underserved). Details about the role of the individual partner organizations are described in subsequent sections. The opportunity to establish the BCEP collaboration was provided through the Open Society Institute’s Medicine as Profession (MAP) fellowship awarded to the primary author (MP); the fellowship supports physicians’ work in health advocacy issues, including health disparities. The overlapping interests and complementary skills/resources of the partner organizations have provided a solid foundation for ongoing collaboration on the BCEP.
Medical Student Recruitment
Medical students at Rush Medical College are recruited during their pre-clinical years as part of the Rush Community Service Initiatives Program (RCSIP), a university-sponsored program the supports diverse student-learning experiences. Student participation in RCSIP is voluntary, but the vast majority of students participate in at least one service-learning program during their medical school experience. The BCEP has been able to accommodate all medical students interested in participating in the program.
The Cook County Bureau of Health Services (CCBHS) Mobile Mammography Unit provides free screening mammograms and referrals for clinical breast examinations (CBE) to women in the urban and suburban areas Cook County by way of community site visits. The Breast Cancer Education Project (BCEP) sought to enhance this program by providing health education, breast self-examination instruction, and peer support from medical students and members of community-based organizations. Medical student preparatory training and education for participation in the BCEP is provided through an intensive curriculum. The roles of the five key stakeholders identified by TUFH-health service providers, health professionals, the community, policy makers and the academic community-are described below.
Health Service Providers
Women receive several health service components through the BCEP-instruction on breast self-examination, health education, mammography and referrals for a clinical breast examinations (CBEs) and pelvic examinations. These services are provided through a variety of health service providers-medical students, mammography technicians, nurse practitioners and physicians.
Breast Examination Instruction: Medical students teach women, with the use of silicon models, how to perform breast self-exams using didactics, demonstration and “teach-back” methods. Shower cards with BSE instructions are distributed to every woman present and are provided by the American Cancer Society and the Y-Me National Breast Cancer Organization. BSE education is delivered via video instruction on those days when medical students are unable to participate with the Mobile Mammography Unit.
Health Education: Medical students use a model of health education that is based on adult learning theory. It includes informal discussions and directed story-telling, and incorporates educational visual aids. Students are taught to begin open-ended discussions, allowing the educational curriculum to be participant-driven. A range of women’s health topics are covered, including benign breast disease, menopause, breast cancer, osteoporosis and nutrition. The oral tradition remains an important form of communication within many non-European communities. Thus, the use of verbal and visual information is culturally appropriate and alleviates potential literacy barriers.
Mammography: Free mammograms are provided by certified mammogram technicians to asymptomatic women ages 40 and older. Women are not required to have a primary care physician (PCP), but are asked to provide their doctor’s contact information in order to communicate test results and facilitate potential diagnostic evaluation.
Referrals for CBE/Pelvic Exams: Although clinical breast examinations are an important adjunct to breast cancer screening, they are not currently provided on the Mobile Mammography Unit. However, referrals are made to CCBHS community health centers where clinicians provide CBEs and pelvic exams to complete the women’s health examination.
Health professionals include: 1) CCBHS clinicians (nurse practitioners and physicians) who provide clinical breast examinations and pelvic exams to women referred from the BCEP, as described above, and 2) Rush Medical College faculty who prepare medical students for BCEP participation. The medical student curriculum consists primarily of didactic sessions and self-directed learning. Students review case presentations and attend train-the-trainer sessions, cultural competency and community education workshops, and a mammography field-trip. Training involves three intensive 3-hour sessions that occur within the first six weeks of the academic year. Components of the curriculum are described below.
Core curriculum: The health curriculum covers a broad range of women’s health issues including benign breast disorders, menopausal symptoms and treatment, breast cancer risk assessment and screening, osteoporosis, and nutrition. Small didactic group sessions are led by steering committee students with faculty guidance. Peer-reviewed articles are made available to all participating students. A problem-based learning approach is then used to consolidate health information and to assess the students’ competency.
Health Education Skills: The faculty sponsor conducts train-the-trainer sessions on effective health education techniques and communication methods. Students are instructed to use accessible language, utilize culturally-appropriate formats, and use hands-on materials that facilitate the learning process. Students are also taught, using silicon breast models, how to conduct a clinical breast examination (CBE) and teach women how to do breast self-examinations. Role-playing is used to familiarize the students with these health education techniques.
Social Determinants of Health: The curriculum also includes a section on the social and environmental determinants of health that is integrated into a didactic session on physician advocacy. For example, students learn how lack of health insurance, competing health needs, poverty and environmental barriers can impact breast cancer screening behaviors and contribute to breast cancer disparities. Students also learn about our health care structure with an emphasis on safety-net institutions, illustrating venues for physicians to become change agents and exploring the linkages between physician advocacy and patient care.
Cultural Competency Skills: Cultural competency within health care can be defined as the ability to provide care to patients with diverse values, beliefs and behaviors, including tailoring the delivery of care to meet the patient’s social, cultural and linguistic needs. The Illinois Health Education Consortium (IHEC) conducts a cultural competency workshop where students learn about the ethnic composition, history and culture of the surrounding communities, including information on common health beliefs and behaviors related to breast cancer and screening. Initially limited to students in the BCEP program, the cultural competency training is now mandatory for all medical students participating in RCSIP service-learning programs.
The community works with the BCEP in three important ways: they are the link between the program and individual women who participate in breast health services; they help to educate medical students; and they provide peer support to patients receiving breast cancer screening.
Community linkage: The Mobile Mammography Unit interfaces with individual women through community-based organizations. The groups are responsible for securing the Mobile Unit, and identifying/screening women for mammogram participation. Community organizations are important in BCEP outreach to vulnerable women who might not otherwise seek breast cancer screening.
Medical student training: In this community-based educational workshop, members from Sisters Network, Inc. and Y-Me describe their mission and work, and provide unique perspectives on working with medical student volunteer programs. The students gain a deeper appreciation of the breadth of community programs available for low-income women needing breast cancer screening and support.
Peer support: Peer counselors from breast cancer support organizations provide a complementary strategy of education, testimony and support for women receiving breast cancer screening with the BCEP.
Policy Makers and the Academic Community
While the day-to-day activities of the BCEP do not directly involve policy makers, the program has been highlighted as a successful community-campus partnership (Peek & Haley, 2003), and described as a feasible model for other institutions and community-based organizations to implement. In addition, politicians are engaged at the community level in that many local officials utilize the Mobile Unit for health-related events in their communities.
The BCEP academic partners include Rush Medical College and the University of Illinois at Chicago (UIC) School of Public Health. One of the most challenging impediments to research within the African-American community is the widespread mistrust of academic medical institutions, where fear of unethical experimentation and community exploitation is common. The BCEP was able to utilize patients’ trust in our community-based partners to facilitate community-based participatory research. For example, members of Y-Me and the Sister’s Network were essential in the identification of community residents for participation in a qualitative study of women’s attitudes, beliefs and barriers to breast cancer screening (Peek, 2005; Peek et al, 2007). These research questions had been identified by community leaders as important in addressing breast cancer disparities. The academic partners also provided the evaluation component of the BCEP.
Evaluation of the program’s impact and success was conducted in several ways. First, we administered surveys to medical student participants at the program’s end, which included closed-coded questions on a 4-point Likert scale as well as open-ended questions that queried the strengths and limitations of the program. All students completed evaluations of the core curriculum (mean score: 3.65), cultural competency workshop (mean score: 3.70) and the social determinants of health workshop (mean score: 3.88). Qualitative feedback from the students has indicated a deepened appreciation of the social dynamics that impact health within medically underserved communities. We also administered a cultural competency self-efficacy instrument (5-point Likert scale) to all medical students participating in the RCSIP program and compared the results of students who volunteered with the BCEP program with those who had not, and found significantly higher scores among students who had participated in our breast cancer outreach program (mean score: 4.28 vs. 3.43; pSummary and Conclusions
The Breast Cancer Education Project represents an innovative collaboration that brings together health professionals and service providers, community based-organizations, academic researchers and public health organizations to meet the needs of low-income women for breast cancer screening and education.
It also provides a venue for future physicians to become better prepared to work within medically underserved neighborhoods. This service-learning project allows medical students to learn about women’s experiences, their health perceptions, cultural belief systems and their world view, which promotes an understanding of the populations the students may serve in their future as physicians. The combination of the cultural competency training and hands-on experience provides students with a basic understanding of the knowledge, skills, and behaviors required to provide compassionate care to individuals from other cultures. Thus, through campus-community partnerships such as the BCEP, the health professions can contribute to the meaningful education of future physicians as well as the potential reduction in health disparities among racial/ethnic vulnerable minority communities.
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