An AVON Foundation Proposal

Blair Whitley, RN, BSN

Maria del C. Davila, RN, BSN

Liselle Tchasso, RN, BSN

I. Executive Summary

“Caught Pink Handed”

Breast cancer affects one in eight women and is the number one cause of cancer death among women in the United States. When detected early, the overall five year survival rate is approximately 89%, according to the National Cancer Institute 2012. Although African-American women (AAW) are not the largest group to get breast cancer, they are, however, the group with the highest mortality rate, 32% higher than white women (CDC, 2012). They are diagnosed at later stages of the disease with higher incidences of large tumors, metastatic disease and lymph node involvement. Possible reasons for the later diagnoses could include lack of knowledge of the disease, lower socioeconomic status and lack of affordable healthcare. Early detection is key to improving the mortality rates among AAW; this is where the program “Caught Pink Handed” can be implemented.

The goal of the program is to educate young AAW about the importance of performing self breast exams (BSE), detecting abnormalities and being able to report them to their healthcare providers. Objectives for the program Caught Pink Handed includes:

  1. The participants will explain the importance of SBEs and identify abnormalities early.
  2. The participants will demonstrate proper technique for SBE.
  3. The participants will identify normal vs. abnormal findings when completing an SBE.
  4. The participants will list their risk factors for developing breast cancer.
  5. Participants will trace family history of breast cancer using a family health history.
  6. The learner will identify community resources to contact if abnormal results are found.
  7. Facebook will be used monthly to remind participants to perform SBE.

This grant is being requested from the Avon Foundation’s Women Breast Health Outreach Program (BHOP) whose goal is to link medically underserved women to breast health education and screenings. Per the attached Budget Proposal the total amount requested is $33,649.00 over a two year period. This amount includes the start up cost of the program as well as materials needed, time of the personnel involved in the planning, implementation and evaluation of this program and incentives for participants.

The target population will be 50 AAW ages 22-26 years old from the Friendship Missionary Baptist Church, a predominantly African-American church in an underserved area of Charlotte, North Carolina. According to Underwood and Dobson (2004), faith based settings are the venue of choice for education and outreach programs in the African-American community. Leaders include Blair Whitley, RN, Maria del C. Davila, RN, Liselle Tchasso, RN as well and the church’s parish nurse Brenda Thrasher, FNP. A pre-test will be given to all participants to assess their knowledge of breast cancer and breast self exams. The learning activity will include a drama presentation meeting the objectives of the program since this type of activity has been proven to be effective in teaching this particular population. Narratives done by two African-American breast cancer survivors will provide a more personal side of the effects of this disease on the lives of individuals. The Nurse Practitioner (NP) will provide information and statistics about breast cancer as well as risk factors and discuss the importance of early detection and the use of the BSE. She will then demonstrate the proper way to perform a breast self exam using a model and the participants will return demonstration to the leaders. The leaders will provide information about Facebook (online social media) such as acquiring an account, resources for free Internet access if they don’t have a home computer, and how the monthly messages will be delivered. Current breast cancer information such as links to other websites, awareness activities in the community and a reminder to do their monthly BSE are all included in the monthly Facebook message. On this day, lunch will be provided and a post-test will be given to evaluate learning. Calendars will be provided also as a tool for remembering when to perform their BSE and literature from the Avon Foundation about breast health will be provided so they can go into their community and share this new knowledge.

After twelve months the participants will be asked to return to engage in a discussion group about their activities over the past year, challenges, success stories as well as taking a second post-test to assess knowledge retention. Their incentive will be a $25 gift card for participation as well as knowing that they can possibly save not only their life, but the life of another by the acquired knowledge from this program. Our goal is as each woman learns about breast cancer and the importance of the BSE, she can impact her community by teaching another woman, mother, sister, aunt, friend to decrease the mortality rate of breast cancer in African-American women.

II. Narrative

Background of Avon Foundation

The Avon Foundation was founded in 1955 and is now the largest corporate philanthropy dedicated to women's causes globally ( The mission of the Avon Foundation for Women Breast Health Outreach Program (BHOP) is to link medically underserved women to breast health education and screening services. The goals are to provide low-income, underinsured, and other marginalized populations targeted, customized approaches to help them obtain education and screening services (AVON, 2012).

Current Programs and Accomplishments

Over the last 19 years, Avon philanthropy has raised and donated more than $860 million to breast cancer programs around the world, supporting cutting-edge research to find a cure for or prevent breast cancer as well as programs that enable all patients to access quality care. Funding supports awareness and education, screening and diagnosis, access to treatment, support services, and scientific research. Avon BHOP is currently funding 120 community outreach and breast cancer screening programs nationwide in 2012 (AVON, 2012).

How We Can Help Avon

Avon BHOP supports programs that recruit women for both first-time and annual screenings develop partnerships, work with health care providers to ensure proper clinical follow-up for abnormal screening results, incorporate the use of evidence-based strategies to recruit clients for screening, including one-to-one education, small media (videos, brochures, letters) and support to overcome structural barriers. This request is being used to offer education in the form of drama, narrative, and social media to young, African American women concerning the importance of screening for breast cancer. While only 5% of breast cancer diagnoses are in people under the age of 40 (AVON, 2012), this population needs health awareness and promotion in order to detect abnormalities in its early stages.

Problem Statement

This program is to educate young African American women between the ages of 22-26 about the importance of self-breast exams, identifying abnormalities, and resources to contact if abnormalities are found.

Differences in the breast cancer burden of African-American women (AAW) compared with white American women are well documented. The Center for Disease Control (CDC) recognizes that AAW are more likely to be diagnosed at later stages of the disease, and have larger tumors, and métastases into the lymph nodes and other parts of the body (CDC, 2012). African Americans have a lower incidence rate overall, but a 32% higher mortality rate because they are diagnosed at a later, more advanced stage.

One study evaluated age-specific breast cancer stage distributions and incidence rates of triple-negative breast cancer (TNBC) in a population-based tumor registry. For women aged <44 years, incidence was highest among African American women and they had higher incidence rates of stage III and IV disease and a higher incidence of TNBC in all age categories. They suggest that mammographic screening for early detection of breast cancer is particularly relevant for younger African-American women (Amirikia, Mills, Bush, & Newman, 2011).

Another study suggests that AAW and lower income women need to be targeted for early detection. Many of the analyses among younger women (20-39 years) reported that very little disease occurrence in young AAW was associated with the socioeconomic factors studied. The gaps in knowledge identified included the lack of an explanation of early onset breast cancer with high penetrance as well as an explanation of African-American women's resistance to self-examination and mammography screening and other barriers to diagnostic treatment (Campbell, 2002).

In October 2006, the Sinai Urban Health Institute released a groundbreaking study on alarming disparities in breast cancer mortality rates between African-American and white women in Chicago. The findings were astonishing, demonstrating that the breast cancer mortality rate for African-American women in Chicago is 68% higher than that of white women, a disparity that cannot be explained by genetics alone. This publication proved that more needs to be done to improve breast cancer awareness, access, screening and treatment for AAW (Whitman, Orsi, & Hurlbert, 2012).

Program Development

Research shows that African American women have a lower incidence of breast cancer overall but higher mortality rate from this disease. This program approach was developed based on a study that examined the relationship between participation in a culturally-sensitive Breast Cancer Education program and help-seeking behavior of asymptomatic African American women for breast cancer screening. Delayed help-seeking behavior for breast cancer detection is one of the significant factors in late-stage diagnosis and poorer survival. Results from the study show a significant correlation between participation in the Breast Cancer Education Program and the help-seeking behavior for breast cancer screening (Austin-Valere, 2010). This program was developed to educate in hopes that breast cancer screening would increase among young AAW.

Best Practices in Use

This program uses best practices as set by the American Cancer Society. The guidelines and recommendations vary somewhat among the organizations, however, the American Cancer Society recommends clinical breast examinations every three years for women 20 to 30 years of age and every year for women 40 years of age and over; yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Breast self-exams (BSE) are advised beginning in their 20s, benefits and limitations of BSE should be explained, women should know how their breast normally feel, and how to report any changes to their health care providers (American Cancer Society, 2011).

Implementation Plan

The goal of this program is to educate young AAW about the importance of breast self-exams and early detection of any abnormalities found, and how to report these changes. See Logic Model (Appendix D) also. Objectives include:

1. The participants will explain the importance of SBEs and identifying abnormalities early.

2. The participants will demonstrate proper technique for SBE.

3. The participant will identify normal vs. abnormal findings when completing a SBE.

4. The participants will list their risk factors of developing breast cancer.

5. Participants will trace family history of breast cancer using a family health history.

5. The learner will identify community resources to contact if abnormal results are found.

6. Facebook will be used monthly to remind participants to perform SBE.

When implementing this program, a target population of up to 50 AAW between the ages of 22-26 years old that attend Friendship Missionary Baptist Church in Charlotte, NC will be included. Underwood and Dobson (2004) concluded that culturally sensitive interventions, educational programs and literature are needed to reach AAW and positively impact AAW's compliance with breast cancer screening guidelines. They also found that a greater percentage of AAW preferred faith-based settings as the venue of choice for breast cancer education and outreach programs, when compared to salons and social service centers (Underwood and Dobson, 2004). Therefore, the program will be held in the fellowship hall of Friendship Missionary Baptist Church in Charlotte, NC. Flyers (see Appendix A), announcements in the church bulletin, and verbal communication from the Parish Nurse will be used to advertise the program. Immediately following church, ladies will join in the fellowship hall and pizza with drinks will be provided. At 1:00, the program will start; program schedule:

1. Welcome and Introductions

Leaders: Blair Whitley, RN; Maria del C. Davila, RN; Liselle Tschacco, RN

Staff: Parish Nurse, FNP of facility used to be liaison with church and to teach proper self breast exam to participants; two breast cancer survivors to tell personal story; four “Actresses” in skit to educate on breast cancer through drama performance.

2. Pre-test

A pre-test will be given to evaluate beginning knowledge, see Appendix B.

3. Drama Performance

The program will start with a drama performance by four actresses to begin to meet the objectives. In a study evaluating drama performances as an educational tool, results indicated that the play succeeded in increasing knowledge and awareness about breast cancer and intentions to improve health related behaviors (Livingston et al., 2009).

4. Two Breast Cancer Survivor Testimonies

Narratives appear to have particular value in certain population sub-groups; identifying these groups and matching them to specific communication approaches may increase effectiveness (Kreuter et al., 2010).

In one study, narratives produced stronger cognitive and affective responses immediately, which, in turn, influenced message processing and behavioral correlates. Narratives reduced counterarguing and increased cognitive rehearsal, which may increase acceptance and motivation to act on health information in populations most adversely affected by cancer disparities (McQueen, Kreuter, Kalesan, & Alcaraz, 2011).

5. Parish Nurse, FNP, to demonstrate proper way to conduct self-breast exam on model.

6. Gather Facebook information

Give instructions for receiving messages and replying to questions sent. Bi-monthly messages and reminders to perform self-breast exams will be sent to each participant. Social networking such as Facebook is an excellent resource to disseminate information and you have a selective audience (Harris et al., 2011).

7. Post-test to evaluate if knowledge was gained to reach objectives (See Appendix C).

8. Calendars will be given to each participant to mark when they have done their self-breast

exam; a card will be given to each participant that gives instructions on how to perform the self-breast exam as a reminder.

9. After 12 months, participants will participate in a second post-test to evaluate if knowledge

was obtained and if monthly self-breast exams were conducted. $25 Target gift card will be given to each person as incentive for participating in the program.

Outcomes and Evaluation

Measurable outcomes will be determined by the results of the pre-test and post-test to evaluate if knowledge was gained during the informational session. These questions will focus on the objectives to make sure all were met. Our goals include:

  • 100% of participants will increase scores based on knowledge of breast cancer between the pre-test and post-test given.
  • 100% of participants will be able to properly perform a self breast exam.
  • 75% of participants will conduct monthly self breast exams.
  • 75% of participants will report passing their knowledge to family and friends.
  • 75% of participants will use Facebook to forward new information to others.
  • 100% of participants will use Facebook to receive monthly reminders and information concerning breast cancer to enhance their knowledge base.
  • 100% of participants will recall community resources if needed for breast abnormalities.

During the year, participants will receive reminders and messages from the staff about breast cancer and self-breast exams. There will be a question that is sent to the message board of each participant to review material that was taught in the educational session, and they can post a response back to show participation. A post-test after one year will evaluate if participants performed self-breast exams monthly after reminders were sent to their Facebook message board. Another outcome to evaluate after one year is if the participants retained the knowledge, as well as passed the knowledge to any other friends or family members.

This program is designed to educate and help make life-changing habits in the lives of young African American women. If our program is successful, our outcomes will last much longer than the scheduled year. They include:

  • 75% of participants will conduct monthly self breast exams.
  • 75% of participants will report signs and symptoms to be aware of with breast tissue, and the importance of reporting abnormalities.
  • 100% of participants will have increased knowledge on the last post-test and evaluate how this program has helped them.
  • This program will encourage women to reach out to family members, friends, and ladies in their social media networks to provide information on breast cancer.
  • This program could decrease the amount of breast cancer caught in a late stage.
  • This study will provide knowledge and skills to properly perform self breast exams and address early signs and symptoms of breast cancer. If proven helpful, the target audience could be expanded and a larger number of participants could be reached.
  • This program could change the growing statistics of young female African Americans dying from breast cancer.

The data will be evaluated after the first year to see if objectives were met by comparing pre-tests and post-tests. The program will then be modified accordingly and offered in another church congregation. The goal is to have up to three programs going yearly as staff can adjust to the workload.