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Faith Moves Mountains II: A CBPR Appalachian Wellness & Cancer Prevention Program

PIs: Nancy Schoenberg, Mark Dignan

Project Management: Nell Fields, Gwen Whitaker

Co-investigators: Richard Clayton, Shelli Deskins, Jenna Hatcher, Debra Moser, Kevin Pearce, Brent Shelton, Tina Studts

Assistant: Rian DavisFunded by the NIH/NCMHD: R24MDOOZ757417/01/08-2/01/13

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Age-adjusted cancer mortality rates, selected cancers, 1996-2000

All Cancers Lung Colorectal

Cervix

Total Male Female Total Male Female Total Male FemaleUS 202.3 255.5 168.3 56.8 79.5 40.7 21.2 25.8 18.0 3.0

KY 228.9 301.8 182.1 77.8 114.3 52.3 23.7 29.4 19.7 3.8

Appal KY

237.5 312.3 186.2 83.7 124.1 53.7 23.5 27.6 20.6 4.0

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Age-adjusted Lung/Bronchus Cancer Incidence Rates by County in Kentucky

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Kentucky Smoking Prevalence

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CRC, cervical cancer, and breast cancer screening, BRFSS, 1999-2000

FOBT,FS, or colonoscopy

as recommended

Ever Had Pap

Never /+> 3 yr

Mammogram/

CBEas

recommended

Ever had Pap

Pap in last 3 yr

Pap >3 yrs

US 53.1% 94.8% 87.4% 11.4% 16.6% 71.2%

43.5% 92.6% 87.3% 11.8% 19.2% 70.2%

Appal KY 36.3% 90.8% 84.5% 14.8% 24.0% 62.7-59.4%

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Health Program Priorities: Findings from Focus Groups & InterviewsSource: Schoenberg, N.E., Hatcher, J., Dignan, M.B. Appalachian women’s perceptions of their community’s health threats. Journal of Rural Health. 24(1): 75-83, 2008

Approach: Faith-based Lay health advisors Broad ecologic, not just education

Focus: Primary & secondary prevention, wellness not just disease All adult women & men

Health priorities (Ranked)1. Drug abuse/medication dependence2. Cancer3. Heart disease and diabetes (tied)4. Smoking5. Poor diet6. Overweight7. Lack of exercise

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Specific Aims1. To pretest the research design, method, and evaluation plan for our CBPR

project, “Faith Moves Mountains: An Appalachian Wellness & Cancer Prevention Program,” with a focus on tobacco treatment and cancer screening interventions.

2. To partner with our faith-based and community partners to administer a theoretically informed, tailored lay health advisor intervention focusing on modifiable cancer risk factors including reducing/stopping smoking and increasing CRC screenings, Pap smears, and mammograms.

3. To evaluate the effectiveness of the intervention using a group-randomized design and to plan the dissemination of our research findings to other rural health disparities communities.

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Year 01: Goals

1. conduct 6 focus groups and 25 key informant interviews to verify determinants of targeted behaviors (smoking and cancer screenings)

2. pilot test all instruments and protocols 3. enroll churches and staff--add 45-50 churches to our

current roster of 25 churches4. recruit and train interviewers and lay health advisors5. conduct meetings to prepare the churches for the

intervention

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Years 02-04: Aim

• Aim: To partner with our faith-based and community partners to administer a theoretically informed, tailored lay health advisor intervention focusing on modifiable cancer risk factors, including reducing/stopping smoking and increasing CRC screenings, Pap smears, and mammogram rates.

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Overview of intervention protocol • A group-randomized, multi component trial that includes

a menu of modules prioritized by the community (smoking cessation and cancer screening).

• Evaluation will consist of baseline, posttest 1 and posttest 2 questionnaires (plus posttest 3 for delayed churches) & qualitative interviews.

• The program hopes to demonstrate the following: – (1) positive movement in the stage of readiness to undertake

targeted health behaviors; – (2) create measurable behavioral, attitude, and knowledge

change in the targeted health behavior

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Intervention participants

• 70 Appalachian churches: Churches will be randomly selected from a comprehensive list of the county churches and randomized to early or delayed intervention group.

• Anyone who wishes to participate in Faith Moves Mountains Wellness Program may do so, though no one under age 18 will be enrolled in the study. Total sample estimated at 1363.

• Early vs. delayed intervention

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2 Intervention types : Cooper-Clayton smoking cessation & LHA visits

The Cooper-Clayton Method: a comprehensive behavioral smoking cessation program. 44-47% of participants remain smoke-free 1 year after completing the program

During the first week of the program, participants keep a log of every cigarette they smoke to establish a baseline body nicotine level. During the following weeks, participants gradually reduce their nicotine intake through the use of nicotine gum or patches while attending weekly group sessions. During these sessions, fellow participants share their stories and encourage one another to stay smoke-free. At the end of this phase, nicotine intake drops to zero. During the final program phase, a Relapse Prevention program is offered.

We anticipate that offering the classes in local churches will encourage participation and retention, as churches are often viewed as warm, familiar, welcoming places oriented toward social support. We will train LHAs to become certified Cooper-Clayton method facilitators. We will also use the Cooper-Clayton method toolkit, which includes facilitator and participant guides, graduation certificates, and other supportive materials.

LHA motivational interviewing for CRC, breast & cervical cancer screening

Participants complete a cancer knowledge, attitudes, and behavior (KAB) screening questionnaire identifying motivators & barriers to screening & stage of readiness. Then LHA develops a personalized, tailored newsletter that lists all the participants’ barriers, the assets she or he listed to overcome these barriers, and community resources (from the community inventory) to facilitate screening

Personalized tailored messages delivered with MI by LHAs during home visit, using MI to encourage screening. Participant creates action plan to be recorded on the form adjacent to each barrier listed. Following completion of the action plan form, the LHA provides specific information on community resources. If the participant wishes, the LHA will assist in calling the participant’s provider or low cost/free health clinics and make the appointment before exiting the home. Following this home visit, the LHA will mail a tailored thank you letter to the participant, bulleting highlights from the exchange, including the specific action plan.

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Evaluation: Quantitative & Qualitative Assessments

• Quantitative: a) willingness to participate in the intervention; b) change in the stage of readiness to alter smoking and CRC, cervical cancer, or breast cancer screening; mediating variables including: (1) knowledge of the behavior; (2) decisional balance; and (3) self-efficacy.

• Qualitative: Debriefing exit interviews with participants (n= 20, ten from the early and ten from the delayed intervention groups); ten LHAs, randomly selected, and a subsample of key informants from the churches and community.