Mammogram Screenings within African

American Women Living in the State of Georgia

Carsen Swallen

Southeastern Cancer Research Society

Bringing Back Breast Cancer Awareness

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Abstract

The goal of this program is to decrease mortality due to lack of annual mammograms among
African American women aged 45-70. In Georgia, only 44 percent of those who have less than a
high school education and are uninsured, are receiving their mammograms every two years
(Georgia Department of Public Health, 2020). Annual mammogram screenings for African
American women in Georgia would allow for less deaths yearly amongst those women. The
theory that is driving this intervention is the health belief model which has been widely accepted
as the best practice for increasing mammogram usage. To combat mortality due to lack of annual
mammograms among African American women aged 45-70 in Georgia, a six-week program was
created. The program will roll out in October, which coincides with the month that is dedicated
to breast cancer awareness. Fifty willing African American women aged 45-70 will join the
educational program to learn about breast cancer and mammogram screenings. Participants will
learn how to perform a self-breast examination as well as visit a mammography facility at the
end of the six-week program. This program is requesting funding for a two-year period with
enough time allotted for evaluations. The program will be evaluated during, and at the
conclusion of the six weeks to determine the successfulness. Due to the strategies used, this
program will be easy to replicate across different parts of Georgia.
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Background

In Georgia, 31.7 per 100,000 African Americans die from breast cancer as compared to
22.6 per 100,000 African Americans nationwide (Komen, 2019). Additionally, African
American women have a higher breast cancer mortality rate by 39 percent compared to
Caucasian women (Komen, 2021). Ryan (2015) states that the economic burden of breast cancer
treatment in the United States in 2020 could reach $20.5 billion. With an estimated 276,480 new
cases reported for 2020, that is around $74,146 per person (Massachusetts Breast Cancer
Coalition, 2021). Those without health insurance can expect to pay more out of pocket for
treatment. This problem is tied to national priorities as the U.S Department of Health and Human
Services states, their goal is to “reduce cases of cancer related to illness, disabilities and death.”
In addition, the U.S Department of Health and Human Services also states that, their focus is on
promoting the use of evidence-based cancer screening programs for the next decade.

There are many risk factors that contribute to the high death rates of breast cancer among
African American women living in Georgia. According to the Centers for Disease Control and
Prevention (2020), being a woman is one of the main factors that influence one’s risk to
acquiring breast cancer. In addition, a woman’s age is also a risk factor for breast cancer as a
majority of breast cancer is found after the age of 50 (Centers for Disease Control and
Prevention, 2020). The American Cancer Society recommends that women should start receiving
annual mammograms starting at the age of 45 years old (Oeffinger et al., 2015). With breast
cancer being prominent in society, much attention has been drawn to protective factors.
According to the U.S. Department of Health and Human Services (2021), being physically active
and having a reproductive history can reduce a woman’s risk of breast cancer. Mammogram
screenings improve early breast cancer detection which increases the chance for the diagnosis to
be less fatal. It has been shown that the higher a woman’s education level is the more likely they
are to get mammograms. Georgia Department of Public Health (2020), states that only 44
percent of those who have less than a high school education and are uninsured are receiving their
mammograms every two years. Georgia Department of Public Health (2020), also states that 57
percent of those who have a college degree and are uninsured are receiving their mammograms
every two years. With health insurance that number only rises to 84 percent (Georgia
Department of Public Health, 2020). It is evident that with education, mammogram usage
increases. Annual mammogram screenings for African American women in Georgia would allow
for less deaths yearly amongst those women.
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Introductory
To improve usage of mammograms screenings within African American women aged 45-
70 years old who reside in the state of Georgia, a six-week intervention class was developed. The
six-week intervention was designed using the health belief model with evidence suggesting this
is the best practice for increasing mammogram usage. The total duration of the program will be
two years leaving time for evaluation and participant follow up. The program is highly
sustainable allowing others in the future to replicate this program across Georgia. Mortality due
to lack of annual mammograms among African American women can decrease if these women
had the education around breast cancer and mammogram screenings.

Intervention alignment matrix

The theory that is driving this intervention is the health belief model. Each activity targets
a certain construct in the health belief model to ensure the objectives are met. The matrix below
is an informative guide into how the program will be executed to accomplish the goal.

Program goal: To decrease mortality due to breast cancer among African American women aged 45-70 years old living in the state of
Georgia.
Objective Theory/ Intervention Possible Activities Evaluation Plan
Construct Strategy
The program participants will be Health Belief Health  A lecture and handouts describing what puts Pre and post questionnaire that
able to describe Model communication a person at risk for breast cancer asks the participants to recall the
4 risk factors for breast cancer by the (Perceived  Participants will create a list of their own risk risk factors they learned
last day of the program susceptibility factors for breast cancer
Health
)
education
The program participants perceived Health Belief Health  A community member will speak on their Pre and post questionnaire that
severity will increase by 40 percent Model communication experience with having breast cancer will ask the participants how
by the last day of the program (Perceived  Participants will learn statistical numbers serious they believe breast cancer
severity) associated with breast cancer rates is
Health
education
After educational lectures and Health Belief Health Participants will watch an educational video and Pre and post questionnaire that
classes, the African American Model communication receive handouts on the benefits of getting annual asks the participants to identify the
women aged 45-70 years old (Perceived mammograms benefits surrounding breast cancer
enrolled in the program will be able benefits) screenings
Health
to identify four benefits learned
education
about breast cancer screenings
After educational lectures and Health Belief Health  Participants will learn about free or reduced  Pre and post questionnaire
classes, the African American Model education ways to receive a mammogram asking the participants on a
women aged 45-70 years old (Perceived  Participants will learn about myths associated scale of 1-10 how much
enrolled in the program will have barriers) with breast cancer and screenings barriers impact their chances
Health
their perceived barriers surrounding  Participants will write down their own of receiving an annual
communication
breast cancer and screenings barriers so the program leader can address mammogram
decrease by 30 percent them  Pre and post questionnaire
Environmental  Free round-trip transportation will be that participants have to
provided by the program to a mammography determine if a statement is a
center for the participants to get their myth or fact
Health related
screening
community
service
By the end of the volunteer’s speech, Health Belief Health  Volunteer talks about their positive  Pre and post questionnaire
100 percent of participants will be Model (Cue education experience receiving a mammogram asking the participants how
given a sign-up sheet to attend the to action)  Participants will sign up for time slots for willing they are to receive
mammography facility attending the mammography facility their annual mammogram
Health
communication
 Observe how many
Environmental participants signed up/used
the transportation service
By the end of November 2022 when Health Belief Health Participants will learn how to perform a self-breast Pre and post questionnaire asking
the breast cancer and mammogram Model (Self- education exam if participants feel comfortable
screening classes have been efficacy) performing a self-breast exam
completed, the program participants
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self-efficacy will increase by 90 Health

percent communication

Environmental

Best Practices
Theory-based interventions have been widely used for improving breast cancer screening
rates among women for years. To determine a best practice, review articles were chosen to assess
the different effectiveness of breast cancer screening interventions. According to Naz (2018), out
of the thirty-six articles reviewed, twenty-three articles used the health belief model as an
intervention strategy for promoting breast cancer screening. All but one of the twenty-three
articles found a significant improvement for a majority of the constructs. While the interventions
were all shaped differently, the characteristics of the health belief model prove that it is an
effective theory to use for increasing breast cancer screening rates among women. Subsequently,
Lawal (2017) states that, using the health belief model helps further explore breast cancer
screening practices in communities. In addition, interventions that use the health belief model are
effective at improving screening (Lawal et al., 2017). Lawal (2017) states that a woman is more
likely to receive a mammogram if she has strong belief that receiving a mammogram will be
beneficial to her. The health belief model targets areas that pertain to not only the participants
emotional thoughts but their personal beliefs, which is why this theory is so effective. Targeting
these areas allow for stigmas and fear to be reduced within the participants. Naz (2018) also
states that, a successful health belief model intervention will use forms of lecturing, interactive
activities, and educational handouts. This model will be able to increase the participants health
motivations to receive a mammogram, while allowing that change to occur through the different
constructs represented within this theory. From this information, it is noticeable that the best
practice for improving breast cancer screening is to use the health belief model.

Timeline
The entire duration of the program will take two years to complete. With nine months to
prepare, the six-week intervention will launch in October. Year two will focus on data collection
and evaluating the program. The timeline below provides a month to month plan to ensure the
program is successful.

Tasks Year 1 Jan. Feb. Mar. Apr. May. Jun. Jul. Aug. Sept. Oct. Nov. Dec.
Contact school for classroom use
Purchase materials/supplies
Purchase breast exam simulator
Purchase visa gift cards
Print materials
Schedule transportation services

Inform mammography facility of

expected arrival dates
Hire program staff
Train assistant and volunteer

Development of pre and post

questionnaire
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Development of post
questionnaire for pilot test
Develop advertising plans
Advertise the program
Pilot test program
Collect data from pilot test
Change aspects of program
Request funds to implement the
total program
Participants selected for program
Implement total Intervention
Hand out pre-questionnaire
Travel to mammography facility
Mail post questionnaire
Collect data

Tasks Year 2 Jan. Feb. Mar. Apr. May. Jun. Jul. Aug. Sept. Oct. Nov. Dec.
Evaluate and analyze intervention
data
Follow up with participants
*Chart from Planning, implementing, and Evaluating Health Promotion Programs
Green = First two weeks of the month, Blue = Last two weeks of the month, Orange = Full month

Intervention
In Georgia there will be a 6-week educational program to address the health problem of
mortality due to lack of annual mammograms among African American women aged 45 -70. To
address this issue successfully, pilot testing will be used. This strategy will be used since this
specific program has never been implemented before. To ensure the program won’t fail, pilot
testing will aid to weed out problems or issues as well as to gain feedback on what the
participants enjoyed (McKenzie et al., 2017). This information for a new program is critical. To
implement pilot testing, there will be a small group of 15 participants who are a part of the
priority population. They will join a 6-week program that educates them on breast cancer and
mammograms. The pilot will be taught by the same facilitators and the same educational
materials as the real program. At the end of the pilot testing there will be an open discussion and
a questionnaire to evaluate the participants thoughts on the program. At the completion of the
pilot test funds will be requested to implement the total program.
The program will be launched by using a strategy of rolling out the program in October
which coincides with the month that is dedicated to breast cancer awareness. The topic of breast
cancer not only receives a lot of social media posts by individuals telling their stories but is also
discussed across other media outlets. This type of attention means participants will hear about
breast cancer outside of the information in the learning course. This is a huge benefit because it
may entice people to stick with and attend the program. The program launch will be on the first
week of October. To promote the program on the first day of implementation, the Centers for
Disease Control and Prevention director Rochelle P. Walenskey will join the program facilitators
in a speech about the importance of breast cancer month (Centers for Disease Control and
Prevention, 2021). During the first days of the program launch, the instructors will introduce
themselves and state their qualifications. This will allow the participants to become acquainted
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with the facilitators and understand the historical background of why an entire month has been
dedicated to the importance of awareness.

Participant recruitment
To begin the recruitment process, posters will be distributed around the metropolitan area
of Atlanta Georgia in high traffic walking areas. These posters will be educational for African
American women on mammograms and breast cancer. The intent of the posters is to engage the
target population into the conversation of breast cancer and mammogram screenings.
Additionally, participants will be recruited through a newspaper ad in the Atlanta Journal-
Constitution. In this newspaper ad, a quick response code will be present for willing participants
to scan. Once scanned they will be redirected to an online baseline questionnaire and a place to
leave their contact information. Program facilitators will then choose fifty participants based on
the inclusion criteria of the program. The inclusion criteria are participants must be African
American women, between the ages of 45-70, live in Georgia, have no prior history of breast
cancer, and have not received a mammogram in the last two years.

Program Evaluation
Following the completion of the program, the evaluation process will take around two
months in year two. Evaluating impact will be measured by comparing the participants pre and
post questionnaires on their knowledge gained and changes in the participants perceived severity.
To evaluate outcome, data will be gathered and analyzed to see if participants returned the next
year to receive a mammogram. The information from both impact and outcome evaluations will
be compared to conduct summative evaluation, which will determine the overall change in
participants at the end of the program. In addition, the entire program will be assessed as a whole
to establish if the intervention was effective for the target population when process evaluation is
conducted. Lastly, to conduct formative evaluation, observations into the participants willingness
to sign up for the mammography facility will be analyzed. For example, if there is a lack of
willing participants, the facilitator can ask the participants what their hesitations are. This in turn
will improve the outcome of the program as well as build on the participants comprehension of
breast cancer screening.

Sustainability
This program is highly sustainable since all materials used are widely available. This
would allow for the program to be replicated in other parts of Georgia. In conjunction with the
materials, the matrix and timeline are easy to follow which can allow others to implement this
program effectively. The future goal of this program is for it to be implemented all across
Georgia. If this were to happen, we would see an increase in breast cancer screenings among
African American women and a decrease in yearly mortality rates.

Conclusion
Mortality due to lack of annual mammograms among African American women aged 45-
70 living in the state of Georgia can decrease with the implementation of this program. The
program will be successful in achieving its goals as it is well known that using the health belief
model can improve the usage of breast cancer screening. It is more important than ever to give
these women the education needed to improve their quality of life and decrease their chances of
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acquiring late term breast cancer. The strategies used in this program will not only be easy to
replicate but be successful across the entire state of Georgia in the future.
8

References

Berzen, A.K., McNamara, C., Bayakly, A.R., O’Connor, J., Crane, B. (2015). Breast cancer in
Georgia, 2007-2011.
https://dph.georgia.gov/sites/dph.georgia.gov/files/Breast%20Cancer%20in%20Georgia
%2C%202007-2011.pdf

Centers for Disease Control and Prevention. (2020, September 14). What are the risk factors for
breast cancer? https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm

Centers for Disease Control and Prevention. (2021, October 6). Director. Rochelle P. Walensky,
MD, MPH. https://www.cdc.gov/about/leadership/director.htm.

Lawal, O., Murphy, F., Hogg, P., Nightingale, J. (2017). Health behavioral theories and their
application to women’s participation in mammography screening. Journal of Medical
Imaging and Radiation Sciences Research Informing Practice.
48(2),122-127.https://doi.org/10.1016/j.jmir.2016.12.002

Massachusetts Breast Cancer Coalition. (2021, January). Breast cancer statistics.

https://mbcc.org/be-informed/breast-cancer-statistics/.

McKenzie, J. F., Neiger, B. L., & Thackeray, R. (2017). Planning, implementing, and evaluating
health promotion programs: A Primer, 7th edition. Pearson.

Oeffinger, K. C., Fontham, E. T. H., & Etzioni, R. (2015, October 20). 2015 breast cancer
screening recommendations for women at average risk. Breast Cancer Screening for
Women at Average Risk. https://jamanetwork.com/journals/jama/fullarticle/2463262.

Ryan, Shane. (2015, September 12). The costs of breast cancer in the U.S.
https://costsofcare.org/the-costs-of-breast-cancer-in-the-u-s/

Susan G. Komen. (2019). Greater Atlanta affiliate of Susan G. Komen quantitative data report.
https://komenatlanta.org/wp-content/uploads/2013/08/Quantitative-Data-Report-Final.pdf

Susan G. Komen. (2021, August 19). Breast cancer statistics. https://www.komen.org/breast-

cancer/facts-statistics/breast-cancer-statistics/

U.S. Department of Health and Human Services. (2021, December 10). Breast cancer prevention
(PDQ)–patient version. National Cancer Institute.
https://www.cancer.gov/types/breast/patient/breast-prevention-pdq

U.S Department of Health and Human Services. Cancer.

https://health.gov/healthypeople/objectives-and-data/browse-objectives/cancer
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Budget
This is the requested amount for the two-year program.

TOTAL
BUDGET,
YEARS ONE
BUDGET ITEM YEAR ONE BUDGET   YEAR TWO BUDGET   AND TWO
                   
Fringe Salary Fringe
Benefit Requeste Benefit
  Salary Requested s Total   d s Total   Total
PERSONNEL                  
Key Personnel                  
$
Principal Investigator $10,482 $3,354 13,836   $1,572 $503 $2,075   $15,912

Co-Investigator $4,959 $1,587 $6,546   $827 $265 $1,091   $7,637

                   
Other Personnel                  
Part-time Program $ $
Assistant $2,340   $2,340   -   -   $2,340
                   
OPERATING
EXPENSES                  
$
Facilities     in kind       -   in kind
$
School custodian fee     $72       -   $72
$
Supplies     $29       -   $29
Client educational $
materials     $30       -   $30
$
Client incentives     $2,000       -   $2,000
Self-breast examination $
model     $514       -   $514

Postage     $122       $122   $244

$
Advertising     $690       -   $690
$
Miscellaneous     $200       -   $200
                   
TRAVEL
EXPENSES                  
Participant
transportation     $1,536       $0   $1,536
                   
 10

$2
TOTAL     7,915       $3,289   $31,204

Budget Narrative

I. Personnel
A. Key Personnel – Partial salary is requested for the time required to prepare for the
participant learning course, logistics, and grant proposals.
i. Principal Investigator [ - 5 hours per week in one year = 12.5% of their time ($10,482
plus fringe benefits calculated at 32%, totaling $ 3,354 per year) and – 3 hours per
week in year two for 3 months = 7.5% of their time = ($6,289 X 0.25 = $1,572 plus
fringe benefits calculated at 32%, totaling $2,075)]. Year one and year two will total
$15,912. The principal investigators salary was based on the median pay for a
principal investigator in Georgia (www.salary.com). The principal investigator will
oversee the entire program. They will co-teach the 6-week program alongside the co-
investigator, ensure community communication, ensure proper implementation of the
program, informing the participants enrolled in the program what the study is about,
keep records of the outcomes and data obtained from the program, and evaluate the
data obtained from the program. With the program consisting of 6 weeks, 9 months
was given to prepare for the logistics of how the program was going to run and work.
One month in year one was given to collecting the data. Lastly, two months was
given in year two to evaluate the data and one month was given to follow up with
participants. Since the Principal Investigator will only work 25 percent of the year in
year 2, that was reflected in their salary.
ii. Co-Investigator [ - 3 hours per week in one year = 7.5% of their time ($4,959 plus
fringe benefits calculated at 32%, totaling $6,546 per year) – 2 hours per week in year
two for 3 months = 5% of their time = ($3,306 X 0.25 = $826.61 plus fringe benefits
calculated at 32%, totaling $1,091)]. Year one and year two will total $7,637. The co-
investigators salary was based on the median pay for co-investigators in America
(www.zippia.com). The co-investigator will work closely with the principal
investigator to achieve the tasks listed above. The co-investigator will be responsible
for creating the pre and post survey/questionnaire. They will also oversee the part-
time program assistant and ensure everything they do is correct and follows
regulations. They will also co teach the 6-week program. In addition, the co-
investigator will be responsible for enrolling the participants into the program/study.
Lastly, the co-investigator will be responsible for sending postage to follow up with
participants a year later. Two months was given in year two to evaluate the data and
one month was given to follow up with participants. Since the co-investigator will
only work 25 percent of the year in year 2, that was reflected in their salary.

B. Other Personnel – Hourly wage is requested for the time required to prepare for
obtaining the supplies, materials, and advertising.
i. Part-time Program Assistant Investigator [ - 3 hours per week in year one = $15 per
hour x 3 hour per week x 1 year = $2,340). The part time program assistant will not
 11

be paid in year two as they are not needed after year one completes. The part time
program assistant will work with the community, participants, and the investigators.
This assistant will help advertise the program to the community members by running
newspaper ads as well as hanging posters. This assistant will also help with obtaining
supplies, materials, and sending post questionnaire postage to participants at the
completion of the program.
II. Operating Expenses
A. Facilities (in-kind). The use of a local district high school building will be of no charge
for the program.
B. School custodian fee ($72 in Year 1; $12 per hour x 1 hour of cleaning x 6 weeks = $72).
Since a classroom will be used after school hours, a school custodian will need to clean
the classroom after use. The average salary for a school custodian in Georgia is averaged
at $12 an hour. ($12 per hour x 1-hour x 6 weeks @ $72) (www.ziprecruiter.com).
C. Supplies ($28.77 in Year 1 = 28.77). Flash cards for participants to write down questions
(1 set of 500 @ $7.49) (www.amazon.com). A box of 36 BIC pens for writing is (1 set X
2 @ $6.09 = 12.18) (www.amazon.com). Loose leaf paper for participants who want to
take notes as well as to keep track of/sign in participants for each session (200 sheets x 3
@ $9.10) (www.amazon.com). These quantities are needed since there are 50 participants
who might use two pieces of paper per class session over the 6-weeks (50 x 2 pieces of
paper x 6 classes @ 600 sheets of paper).
D. Client educational materials ($30.40 in Year 1 = $30.40). Breast cancer fact sheet
handout for participants to quickly reference important information (in-kind-free online)
(www.cancer.org). Printing the fact sheet at FedEx will be around (¢.49 x 50 sheets @
$24.50) (www.FedEx.com). Educational booklet from the American Cancer Society, (50
copies @ $5.90 including tax) (www.cancer.org/materials). Educational videos (in-kind-
free online). (www.Komen.org). To display these videos a projector is needed, which will
be (in-kind) due to them being provided in the school classroom.
E. Client incentives ($40 in Year 1 x 50 participants = $2,000). Incentives for community
members who complete the program. After the 6-week program has ended each
participant will receive a $40 visa gift card. With around 50 participants per 6-week
program the estimated cost is ($40 x 50 @ $2,000).
F. Self-breast examination model. ($514 in Year 1 x 1 simulator = $514). A
mannequin/simulator will be used to demonstrate how to perform a self-breast exam. A
simulator will run (1 @ $514) (www.gtsimulators.com).
G. Postage ($122.16 per year X 2 years = $244.32). Postage is requested to follow up with
participants after the program. A post questionnaire will be mailed to the participants
home after completion of the course as well as a follow up survey a year after the
program. Enough stamps will be needed to send the mail and for the participants to return
the survey/questionnaire. Stamps are (Roll of 100 @ $58.00) (www.store.usps.com). Will
also be requesting allowance for envelopes for both sending and return. Envelopes are (1
pack of 50 x 2 @ $15.16) (www.walmart.com).Printing the survey/questionnaire at
FedEx will be around (¢.49 x 50 sheets x 2 for front and back print @ $49)
(www.FedEx.com).
 12

H. Advertising ($689.99 in Year 1 = $689.99). Centers for Disease Control and Prevention
free educational posters for African American women. Estimated cost for printing posters
(to hang around the community) at office depot (1 poster @ $12.99 x 10 posters @
$129.99) (www.cdc.gov). Newspaper ad to advertise the program. The news ad will be
featured in the Atlanta Journal-Constitution which has a high daily circulation This is
estimated to cost (1 ad @ $560) (www.geabler.com).
I. Miscellaneous. ($200 in Year 1 = $200). The miscellaneous section will be used as
allowance for any extra expenses that can’t be counted before the program starts. For
example, a participant needs an extra copy, or price for advertising has increased. This
can also include but is not limited to extra educational materials, extra printing, and extra
supplies. A requested allowance of (6-week program @ $200).
III. Travel Expenses
A. Participant transportation ($1,536 in Year 1). Travel to a mammography facility for
willing participants to receive their mammograms. The amount requested is estimated
based on the following:
i. Roundtrip bus travel to mammography facility. The participants will be split up
over three days. Estimated cost is ($460 per day x 3 days @ $1,380)
(www.bus.com).
ii. Bus driver fee ($13 per hour x 4 hours of bus usage x 3 days @ $156)
(www.careerexplorer. com)