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J Nurs Care Qual Vol. 29, No. 4, pp. 379–385 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Academic-Community Partnership Development Lessons Learned: Evidence-Based Interventions to Increase Screening Mammography in Rural Communities Frances Lee-Lin, PhD, RN, OCN, CNS; Lisa J. Domenico, MBA; Lauren A. Ogden, MPH; Venus Fromwiller, MA, BS; Nancy Magathan, MS, HED, RN; Sharon Vail; Paul N. Gorman, MD Early detection of breast cancer leads to higher survival; yet, women who live in rural areas have lower screening rates and receive diagnosis at later stages. Effective screening approaches have been published in scientific journals but are not easily available to and understandable by community members. This article describes the development of an academic-community collaboration to implement evidence-based interventions to increase screening. Key words: academiccommunity partnership, evidence-based practice, mammography, rural population, screening
Author Affiliations: School of Nursing (Dr Lee-Lin) and School of Medicine (Dr Gorman), Oregon Health & Science University, Portland; Knight Cancer Institute, Oregon Health & Science University, Portland (Mss Domenico and Ogden); Columbia Memorial Hospital Astoria, Oregon (Mss Fromwiller and Magathan); and Rimrock Health Alliance, Prineville, Oregon (Ms Vail). This study was supported by funding from the Susan G. Komen for the Cure (grant GCNCR0301C). The authors thank Judith Baggs for her editorial assistance. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Frances Lee-Lin, PhD, RN, OCN, CNS, School of Nursing, Oregon Health & Science University, 3455 SW US Veterans Hospital Rd, Mail Code SN-5N, Portland, OR 97239 ([email protected]).
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REAST CANCER remains the most commonly diagnosed cancer in women and is the second leading cause of women’s cancerrelated deaths in the United States. Five-year survival rates are significantly higher when breast cancer is detected at an early stage, and mammography is the “gold standard” for early detection.1,2 Despite widespread acceptance of screening mammography for early diagnosis of breast cancer, these benefits are not realized by all women. Screening rates are often lower in rural communities. Rural women are more likely to have a lower socioeconomic status and to live further from health care services, and they are less likely than urban residents to obtain cancer screening.3,4 Effective interventions are
Accepted for publication: April 12, 2014 Published ahead of print: June 4, 2014
DOI: 10.1097/NCQ.0000000000000071
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needed to improve screening rates in rural communities. Substantial research has been conducted on how best to increase rates of screening mammography among eligible women in general and among underserved women, including those in rural areas, in particular. However, these primary studies are too numerous and difficult to navigate for nonscientific audiences. Useful summaries of this information have been made available on the Internet, including The Community Guide5 and Research Tested Intervention Programs, but even Webbased information may not be easily available or applicable for individual communities. These shortcomings and the resulting need to disseminate evidence-based practices into actionable forms have been recognized.6 The purpose of this project was to improve the capability of rural communities to implement evidence-based interventions to increase screening mammography rates and to create sharable materials for use by other communities. To address this need, we conducted a systematic overview of the evidence on increasing screening mammography rates, collaborated with community partners to translate this review into an accessible lay language form, and worked together to combine this evidence with local knowledge to choose strategies and create sharable tools to implement those strategies in 2 rural Oregon communities. This was not an intervention study with screening mammograms as an outcome, although we did help get some mammography completed in the 2 rural communities. The purpose of this article is to disseminate lessons learned from real-life projects and partnerships with rural communities. METHODS Project overview To lay the groundwork for our project, we began with a systematic review of available systematic reviews focused on interventions to increase screening mammography. A total of 16 systematic reviews were included
in our review, which ultimately covered results of 245 original studies. The review relied heavily on randomized controlled trials. The evidence shows clear differences in the effectiveness of different interventions and quality of evidence supporting these interventions. Access-enhancing strategies (eg, prearranged appointment, reduced costs) had the greatest effect on increasing rates of screening mammography and were supported by the strongest body of evidence. Multicomponent interventions (eg, combination of interventions) were also effective and supported by strong evidence. The greatest impact and the strongest scientific evidence support programs that improve women’s access to screening mammography. The detailed review was published elsewhere.7 We invited community groups from rural areas to apply to collaborate on the project. We defined “rural” according to the Oregon Office of Rural Health working definition, which is geographic areas 10 miles or more radius from a city population center of 40 000 or more. Five applications from Oregon rural communities were evaluated on the basis of quality of the proposal (how responsive to solicitation), community need (lower breast cancer screening or higher late-stage diagnosis), and qualifications of organization (breast health knowledge, past success, connections to community, and resources). Our academic research team scored these independently and met to discuss the strengths and concerns of each proposal. Two Oregon communities were chosen by consensus. With each community, we collaborated over 9 months to (a) translate our evidence report into lay language version for lay community groups, (b) combine the information in the report with local knowledge of their communities to select evidence-based strategies for community intervention, and (c) create sharable tools to implement these strategies in their communities. Partners and projects The first community partner selected was Columbia Memorial Hospital in Astoria, Oregon, a rural community of 11 000 residents in
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Academic-Community Partnership Development Lessons Learned the northwest corner of the state. Columbia Memorial Hospital is a 25-bed, critical access hospital and level IV trauma center affiliated with the nonprofit Planetree Alliance. It has an active education department with experience in outreach for cancer prevention and screening. Initially, our Columbia Memorial Hospital partner planned to implement one-to-one patient-directed breast health education. After reviewing the evidence report and discussing with the research team, a multicomponent intervention was chosen including access-enhancing (appointment setting and financial assistance), patient-directed (one-onone client education), and clinician-directed (reminder letters from a clinician) strategies. Consistently, multicomponent interventions with access-enhancing strategies were more successful and yielded the biggest increases in mammography use.7-11 The strongest categories of mammography-enhancing interventions were access-enhancing interventions, resulting in 15.5% to 18.9% increase in mammography use from the literature.8,12 However, the most effective interventions such as the one our rural community partners selected, which combined access-enhancing and individual-directed strategies, yielded the largest intervention effect of 26.9%.12 In addition, we collaborated to develop evaluation tools to measure the effectiveness of the interventions and document the planning phase and implementation process. The content of this health program planning is provided in Supplemental Digital Content, Table (available at: http://links.lww.com/JNCQ/A94). The second community partner selected was the Rimrock Health Alliance in Prineville, Oregon. As part of the health alliance, Pioneer Memorial Hospital provides mammography services to a population of 25 000 in Prineville and the surrounding area. Rimrock had received health data showing that Prineville and other Cook County residents experience higher rates of late-stage diagnosis of breast cancer and lower screening mammography rates than the state average. To increase their screening rates, Rimrock planned to adapt a patient education colorec-
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tal screening video method that has been used in another clinic. Community partners and the hospital’s medical director agreed to participate in this project. The goals for the project were to raise mammography rates in Crook County, particularly for women older than 64 years, and to identify barriers to screening. In addition, physicians expressed a desire to better understand current guidelines. Guided by the evidence report, a combination approach of access-enhancing (financial assistance), patient-directed (breast health education DVD), and clinician-directed (breast cancer screening continuing medical education to clinicians) strategies were selected for Prineville. Focus groups were planned and conducted to collect data on barriers to screening. In addition, an online survey was codeveloped to gather more information on barriers to mammography screening in Crook County. Following implementation, the teams in Astoria and Prineville evaluated the usability of one another’s tools and materials and provided feedback to each other for improvement. A toolkit with the materials created by these 2 communities has been developed and can be adapted and used by other communities through health promotion interventions. FINDINGS/LESSON LEARNED We learned several lessons from this project: overall lessons learned for establishing academic-community partnerships, and lessons specific to projects and sites. Overall learning in establishing partnerships Pre (preparation) and post (evaluation) learning Our approach was to create materials that an inexperienced, but capable, health educator could use. In both cases, our communities had initial ideas about the interventions they sought to develop. Both subsequently modified their strategies (changed from singlecomponent to multicomponent intervention) on the basis of the evidence report.
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Both communities lacked a means to measure and evaluate activities they implemented. Without the proper baseline data gathered before implementation, evaluation of the impact of a project can be difficult. The research team’s experience was valuable in this regard, and the assistance the team provided with tools to measure and evaluate was well received by our community partners. There were differences in what could be achieved, given that one group (in Astoria) was part of a health system and the other (in Prineville) was a community health coalition. This difference was apparent when they needed to ascertain if the desired outcome, screening mammograms, had been completed. Because the Astoria team knew the radiology staff members and had daily interactions with them, tracking was easier for them. Their outreach efforts were conducted as a hospital program and therefore there was organizational cooperation. In addition, having a passionate local health educator was a critical success factor. This person was the problem solver and kept to the timeline, skills that were needed throughout the project. Communication, connection, and working relationship Distance can be a challenge when communicating with rural communities. It was important for the research team to travel to community partners’ locations, especially for the initial meeting to establish trust, working relationships, and collaborative roles. Travel costs also need to be included if the community partners are expected to visit the research team. We used a combination of in-person meetings and teleconferences. This helped both the community and academic partners, as in-person meetings were important when a working session was needed, but at other times, a shorter telephone call was all that was required to keep the project moving. The academic partner provided needed expertise to the community partners about understanding the evidence, measurement tools, and data analysis; the community partners contributed information relevant to what
works “on the ground.” They knew where to reach underscreened women, had working relationships with local health care providers and health departments, and implemented the program in the community. We believe that the projects would not have been as successful without the contribution of academics and community experts. Program planners when planning programs must combine scientific information with local knowledge about the people, resources, constraints, and health concerns in the community to have a successful impact. Time constraints and competing demands Both communities were eager to implement multiple strategies, but the community members learned that they needed to be realistic. While the goals were admirable, they were more ambitious than a small number of staff members in 1 site could manage. Some community partners who showed great interest at the beginning of the grant quickly became overloaded with their own work and were not able to participate as much as had been anticipated. In addition, projects usually take longer than expected and groups should plan for unexpected time delays. Astoria-specific project learning: Health care provider reminder letter When selecting clinics for collaboration, local planners need to know if clinics have low rates of screening mammography (baseline data). Our community partners initially were considering clinics that would be more willing to collaborate, but then turned our focus to where the need for improvement might be greatest. On the basis of the knowledge of local factors, we believed that low-income women would be in most need of our accessenhancing measures, as well as a reminder about preventive care. On the basis of their knowledge of clinic patients, the staff proposed that the reminder letter be brief, friendly, nonintimidating, and easy to read. The staff members believed that many low-income women see a letter from the
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Academic-Community Partnership Development Lessons Learned physician’s office and are afraid that it is a bill. They believed that if the letter did not look official, it was more likely to be opened. Therefore, inexpensive pink-colored stationery and a flowered envelope that conveyed a more informal but friendly approach were chosen. The clinic/health educator team wanted to manage the demands for mammography that office staff expected considering the staff members’ ability to handle an anticipated influx of women requesting appointments after receiving the reminder letter. The research team was asked to advise the clinic on the age breakdowns to reflect the potential differences in screening recommendations by clinicians (40-49 years old vs 50+) and insurance status (no insurance, private insurance, or Medicare). Together, it was decided to send letters in waves, 2 weeks apart over 2 months according to age and insurance status. This was the most successful mammography campaign the clinic had ever conducted. A total of 395 letters resulted in 93 office visits/mammography orders (23.5% response rate). Eighty-three of 93 women (89%) completed their mammograms (89% from mammogram orders; 21% from 395 letters sent). In addition, a new process was established in the clinic for monitoring patient compliance to mammography screening. Better linkages were established between hospital and clinic to access no-cost mammograms for lowincome women in the community. Specific project learning: Prineville experience Our community partner found that focus groups worked well in one community and not as well in the other. In Prineville, although we invited several groups at different times and offered a $10 gift card for participating, we were only able to have a single focus group of 4 women. The time of day did not seem to make a difference, and incentives were offensive to some of the participants. We decided to try an online survey using an extensive community e-mail distribution list (N = 200). The survey was open for 5 business days, Monday through Friday, and resulted in
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85 responses (43% response rate). A majority of respondents were white (92.9%) and aged 50 to 64 years (47.1%). More than half (55.4%) reported having a mammogram every year; however, only 40% reported that the most recent mammogram was within the past year. The primary care physician (92%) was identified as the main source of information for obtaining the guideline for having mammograms, followed by family and relatives (29%). Some other key findings included that 49% of respondents would be more likely to get a mammogram with physician recommendation; 73% were not concerned that mammograms would lead to unnecessary surgical procedures; 80% felt that regular mammograms gave them “peace of mind” about their health; and if there was no family history of breast cancer, 6% believed that mammograms were not necessary. Our continuing medical education for local physicians received mixed reviews from attendees. Physicians wanted to hear about the topic, but some believed that the continuing medical education did not present new information and lasted too long. When planning a community continuing education for health care providers, it is important to know the needs and level of knowledge of the audience, know the material the presenters are including, and control the length of time of the presentations. We recommend that materials should be reviewed by local content experts to be sure that it is what the audience wants and expects. We also organized “Bootin’ Out Breast Cancer,” a successful community fundraising activity. This multipartner, 1-day event brought us community awareness about breast cancer and the community’s need for free mammograms, helped raise money for mammograms, and opened the door for more partnerships on other events. DISCUSSION Consistent with prior studies, we found that it was feasible to have successful communityacademic partnerships to enhance health
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of rural communities.13-16 Open and ongoing communication is the key to build a strong foundation for collaboration.13 From our academic-community implementation pilot project, we learned that community leaders can learn and apply the principles of evidence-based scientific reports to develop more evidence-based programs for their communities. We confirmed that communities need to develop local and unique approaches that adapt evidence-based approaches to local conditions and constraints. As part of this process, communities can develop locally adapted tools that can be shared with other communities. We also believe that there needs to be a partnership and support from outside facilitators (such as the academic research team) working with the local community group to create a stronger impact. Partnerships between academic and community infuse new ideas, solutions, energy, innovations, and strength to both settings.13-16 Researchers, including nurse scientists, can expand the concept of academic-community partnerships by working with additional, perhaps more diverse, communities and looking at how much facilitation is necessary and for how long. Further research is needed to expand useful tools by fostering programs in varied communities, supporting their
development of new tools, created in forms that are locally suitable but potentially sharable or adaptable by other communities. Eventually, it would be possible to create a robust toolkit with adaptable, applicable tools and information that expands with the community of users. CONCLUSION This project was a “proof of concept.” We showed that the extensive amount of scientific evidence on strategies to improve rates of screening mammography could be synthesized into a single scientific report, which consisted of an overview of systematic reviews. It could then be translated to a lay-friendly format and assist communities in the selection of appropriate evidence-based strategies. In addition, we were able to codevelop materials necessary to implement interventions in local communities. On a small scale, we believe we were successful; however, work is needed to disseminate the tools created. An important component of community engagement is the evaluation of the community’s readiness and its understanding of the evidence report in implementing evidence-based interventions. Much has been learned and can be expanded from our collaborations between rural communities and academia.
REFERENCES 1. American Cancer Society. Breast Cancer Facts & Figures 2013-2014. Atlanta, GA: American Cancer Society; 2013. 2. Feig S. Effect of service screening mammography on population mortality from breast carcinoma. Cancer. 2002;95(3):451-457. 3. Casey M, Call K, Klingner J. Are rural residents less likely to obtain recommended preventive healthcare services? Am J Prev Med. 2001;21(3): 182-188. 4. Carney P, O’Malley J, Buckley D, et al. Influence of health insurance coverage on breast, cervical, and colorectal cancer screening in rural primary care settings. Cancer. 2012;118:6217-6225. 5. Truman B, Smith-Akin C, Hinman A, et al. Developing the Guide to Community Preventive
Services—overview and rationale. Am J Prev Med. 2000;18(1S):18-26. 6. Bowen D, Sorensen G, Weiner B, Campbell M, Emmons K, Melvin C. Dissemination research in cancer control: where are we and where should we go? Cancer Causes Control. 2009;20(4):473-485. 7. Gorman PN, Ogden LA, Holmer HK, Domenico LJ. Strategies to Improve Rates of Screening Mammography: What Does the Evidence Tell Us? A Guide for Breast Health Program Planners. Portland, OR: Knight Cancer Institute at Oregon Health & Science University; 2013. 8. Han HR, Lee JE, Kim J, Hedlin HK, Song H, Kim MT. A meta-analysis of interventions to promote mammography among ethnic minority women. Nurs Res. 2009;58(4):246-254.
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Academic-Community Partnership Development Lessons Learned 9. Hou SI, Sealy DA, Kabiru CW. Closing the disparity gap: cancer screening interventions among Asians— a systematic literature review. Asian Pac J Cancer Prev. 2011;12(11):3133-3139. 10. Masi CM, Blackman DJ, Peek ME. Interventions to enhance breast cancer screening, diagnosis, and treatment among racial and ethnic minority women. Med Care Res Rev. 2007;64(5):195S242S. 11. Sohl SJ, Moyer A. Tailored interventions to promote mammography screening: a meta-analytic review. Prev Med. 2007;45(4):252-261. 12. Legler J, Meissner HI, Coyne C, Breen N, Chollette V, Rimer BK. The effectiveness of interventions to promote mammography among women with historically lower rates of screening. Cancer Epidemiol Biomarkers Prev. 2002;11(1): 59-71.
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13. Meade CD, Calvo A. Developing communityacademic partnerships to enhance breast health among rural and Hispanic migrant and seasonal farmworker women. Oncol Nurs Forum. 2001;28(10):1577-1584. 14. Baker EA, Homan S, Schonhoff R, Kreuter M. Principles of practice for academic/practice/community research partnerships. Am J Prev Med. 1999;16(3S):8693. 15. Gazewood JD, Rollins LK, Galazka SS. Beyond the horizon: the role of academic health centers in improving the health of rural communities. Acad Med. 2006;81(9):793-797. 16. Corbie-Smith G, Adimora AA, Youmans S, et al. Project GRACE: a staged approach to development of a community-academic partnership to address HIV in rural African American communities. Health Promot Pract. 2011;12(2):293-302.
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J Nurs Care Qual Vol. 29, No. 4, pp. 379–385 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Academic-Community Partnership Development Lessons Learned: Evidence-Based Interventions to Increase Screening Mammography in Rural Communities Frances Lee-Lin, PhD, RN, OCN, CNS; Lisa J. Domenico, MBA; Lauren A. Ogden, MPH; Venus Fromwiller, MA, BS; Nancy Magathan, MS, HED, RN; Sharon Vail; Paul N. Gorman, MD Early detection of breast cancer leads to higher survival; yet, women who live in rural areas have lower screening rates and receive diagnosis at later stages. Effective screening approaches have been published in scientific journals but are not easily available to and understandable by community members. This article describes the development of an academic-community collaboration to implement evidence-based interventions to increase screening. Key words: academiccommunity partnership, evidence-based practice, mammography, rural population, screening
Author Affiliations: School of Nursing (Dr Lee-Lin) and School of Medicine (Dr Gorman), Oregon Health & Science University, Portland; Knight Cancer Institute, Oregon Health & Science University, Portland (Mss Domenico and Ogden); Columbia Memorial Hospital Astoria, Oregon (Mss Fromwiller and Magathan); and Rimrock Health Alliance, Prineville, Oregon (Ms Vail). This study was supported by funding from the Susan G. Komen for the Cure (grant GCNCR0301C). The authors thank Judith Baggs for her editorial assistance. The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Frances Lee-Lin, PhD, RN, OCN, CNS, School of Nursing, Oregon Health & Science University, 3455 SW US Veterans Hospital Rd, Mail Code SN-5N, Portland, OR 97239 ([email protected]).
B
REAST CANCER remains the most commonly diagnosed cancer in women and is the second leading cause of women’s cancerrelated deaths in the United States. Five-year survival rates are significantly higher when breast cancer is detected at an early stage, and mammography is the “gold standard” for early detection.1,2 Despite widespread acceptance of screening mammography for early diagnosis of breast cancer, these benefits are not realized by all women. Screening rates are often lower in rural communities. Rural women are more likely to have a lower socioeconomic status and to live further from health care services, and they are less likely than urban residents to obtain cancer screening.3,4 Effective interventions are
Accepted for publication: April 12, 2014 Published ahead of print: June 4, 2014
DOI: 10.1097/NCQ.0000000000000071
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needed to improve screening rates in rural communities. Substantial research has been conducted on how best to increase rates of screening mammography among eligible women in general and among underserved women, including those in rural areas, in particular. However, these primary studies are too numerous and difficult to navigate for nonscientific audiences. Useful summaries of this information have been made available on the Internet, including The Community Guide5 and Research Tested Intervention Programs, but even Webbased information may not be easily available or applicable for individual communities. These shortcomings and the resulting need to disseminate evidence-based practices into actionable forms have been recognized.6 The purpose of this project was to improve the capability of rural communities to implement evidence-based interventions to increase screening mammography rates and to create sharable materials for use by other communities. To address this need, we conducted a systematic overview of the evidence on increasing screening mammography rates, collaborated with community partners to translate this review into an accessible lay language form, and worked together to combine this evidence with local knowledge to choose strategies and create sharable tools to implement those strategies in 2 rural Oregon communities. This was not an intervention study with screening mammograms as an outcome, although we did help get some mammography completed in the 2 rural communities. The purpose of this article is to disseminate lessons learned from real-life projects and partnerships with rural communities. METHODS Project overview To lay the groundwork for our project, we began with a systematic review of available systematic reviews focused on interventions to increase screening mammography. A total of 16 systematic reviews were included
in our review, which ultimately covered results of 245 original studies. The review relied heavily on randomized controlled trials. The evidence shows clear differences in the effectiveness of different interventions and quality of evidence supporting these interventions. Access-enhancing strategies (eg, prearranged appointment, reduced costs) had the greatest effect on increasing rates of screening mammography and were supported by the strongest body of evidence. Multicomponent interventions (eg, combination of interventions) were also effective and supported by strong evidence. The greatest impact and the strongest scientific evidence support programs that improve women’s access to screening mammography. The detailed review was published elsewhere.7 We invited community groups from rural areas to apply to collaborate on the project. We defined “rural” according to the Oregon Office of Rural Health working definition, which is geographic areas 10 miles or more radius from a city population center of 40 000 or more. Five applications from Oregon rural communities were evaluated on the basis of quality of the proposal (how responsive to solicitation), community need (lower breast cancer screening or higher late-stage diagnosis), and qualifications of organization (breast health knowledge, past success, connections to community, and resources). Our academic research team scored these independently and met to discuss the strengths and concerns of each proposal. Two Oregon communities were chosen by consensus. With each community, we collaborated over 9 months to (a) translate our evidence report into lay language version for lay community groups, (b) combine the information in the report with local knowledge of their communities to select evidence-based strategies for community intervention, and (c) create sharable tools to implement these strategies in their communities. Partners and projects The first community partner selected was Columbia Memorial Hospital in Astoria, Oregon, a rural community of 11 000 residents in
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Academic-Community Partnership Development Lessons Learned the northwest corner of the state. Columbia Memorial Hospital is a 25-bed, critical access hospital and level IV trauma center affiliated with the nonprofit Planetree Alliance. It has an active education department with experience in outreach for cancer prevention and screening. Initially, our Columbia Memorial Hospital partner planned to implement one-to-one patient-directed breast health education. After reviewing the evidence report and discussing with the research team, a multicomponent intervention was chosen including access-enhancing (appointment setting and financial assistance), patient-directed (one-onone client education), and clinician-directed (reminder letters from a clinician) strategies. Consistently, multicomponent interventions with access-enhancing strategies were more successful and yielded the biggest increases in mammography use.7-11 The strongest categories of mammography-enhancing interventions were access-enhancing interventions, resulting in 15.5% to 18.9% increase in mammography use from the literature.8,12 However, the most effective interventions such as the one our rural community partners selected, which combined access-enhancing and individual-directed strategies, yielded the largest intervention effect of 26.9%.12 In addition, we collaborated to develop evaluation tools to measure the effectiveness of the interventions and document the planning phase and implementation process. The content of this health program planning is provided in Supplemental Digital Content, Table (available at: http://links.lww.com/JNCQ/A94). The second community partner selected was the Rimrock Health Alliance in Prineville, Oregon. As part of the health alliance, Pioneer Memorial Hospital provides mammography services to a population of 25 000 in Prineville and the surrounding area. Rimrock had received health data showing that Prineville and other Cook County residents experience higher rates of late-stage diagnosis of breast cancer and lower screening mammography rates than the state average. To increase their screening rates, Rimrock planned to adapt a patient education colorec-
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tal screening video method that has been used in another clinic. Community partners and the hospital’s medical director agreed to participate in this project. The goals for the project were to raise mammography rates in Crook County, particularly for women older than 64 years, and to identify barriers to screening. In addition, physicians expressed a desire to better understand current guidelines. Guided by the evidence report, a combination approach of access-enhancing (financial assistance), patient-directed (breast health education DVD), and clinician-directed (breast cancer screening continuing medical education to clinicians) strategies were selected for Prineville. Focus groups were planned and conducted to collect data on barriers to screening. In addition, an online survey was codeveloped to gather more information on barriers to mammography screening in Crook County. Following implementation, the teams in Astoria and Prineville evaluated the usability of one another’s tools and materials and provided feedback to each other for improvement. A toolkit with the materials created by these 2 communities has been developed and can be adapted and used by other communities through health promotion interventions. FINDINGS/LESSON LEARNED We learned several lessons from this project: overall lessons learned for establishing academic-community partnerships, and lessons specific to projects and sites. Overall learning in establishing partnerships Pre (preparation) and post (evaluation) learning Our approach was to create materials that an inexperienced, but capable, health educator could use. In both cases, our communities had initial ideas about the interventions they sought to develop. Both subsequently modified their strategies (changed from singlecomponent to multicomponent intervention) on the basis of the evidence report.
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Both communities lacked a means to measure and evaluate activities they implemented. Without the proper baseline data gathered before implementation, evaluation of the impact of a project can be difficult. The research team’s experience was valuable in this regard, and the assistance the team provided with tools to measure and evaluate was well received by our community partners. There were differences in what could be achieved, given that one group (in Astoria) was part of a health system and the other (in Prineville) was a community health coalition. This difference was apparent when they needed to ascertain if the desired outcome, screening mammograms, had been completed. Because the Astoria team knew the radiology staff members and had daily interactions with them, tracking was easier for them. Their outreach efforts were conducted as a hospital program and therefore there was organizational cooperation. In addition, having a passionate local health educator was a critical success factor. This person was the problem solver and kept to the timeline, skills that were needed throughout the project. Communication, connection, and working relationship Distance can be a challenge when communicating with rural communities. It was important for the research team to travel to community partners’ locations, especially for the initial meeting to establish trust, working relationships, and collaborative roles. Travel costs also need to be included if the community partners are expected to visit the research team. We used a combination of in-person meetings and teleconferences. This helped both the community and academic partners, as in-person meetings were important when a working session was needed, but at other times, a shorter telephone call was all that was required to keep the project moving. The academic partner provided needed expertise to the community partners about understanding the evidence, measurement tools, and data analysis; the community partners contributed information relevant to what
works “on the ground.” They knew where to reach underscreened women, had working relationships with local health care providers and health departments, and implemented the program in the community. We believe that the projects would not have been as successful without the contribution of academics and community experts. Program planners when planning programs must combine scientific information with local knowledge about the people, resources, constraints, and health concerns in the community to have a successful impact. Time constraints and competing demands Both communities were eager to implement multiple strategies, but the community members learned that they needed to be realistic. While the goals were admirable, they were more ambitious than a small number of staff members in 1 site could manage. Some community partners who showed great interest at the beginning of the grant quickly became overloaded with their own work and were not able to participate as much as had been anticipated. In addition, projects usually take longer than expected and groups should plan for unexpected time delays. Astoria-specific project learning: Health care provider reminder letter When selecting clinics for collaboration, local planners need to know if clinics have low rates of screening mammography (baseline data). Our community partners initially were considering clinics that would be more willing to collaborate, but then turned our focus to where the need for improvement might be greatest. On the basis of the knowledge of local factors, we believed that low-income women would be in most need of our accessenhancing measures, as well as a reminder about preventive care. On the basis of their knowledge of clinic patients, the staff proposed that the reminder letter be brief, friendly, nonintimidating, and easy to read. The staff members believed that many low-income women see a letter from the
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Academic-Community Partnership Development Lessons Learned physician’s office and are afraid that it is a bill. They believed that if the letter did not look official, it was more likely to be opened. Therefore, inexpensive pink-colored stationery and a flowered envelope that conveyed a more informal but friendly approach were chosen. The clinic/health educator team wanted to manage the demands for mammography that office staff expected considering the staff members’ ability to handle an anticipated influx of women requesting appointments after receiving the reminder letter. The research team was asked to advise the clinic on the age breakdowns to reflect the potential differences in screening recommendations by clinicians (40-49 years old vs 50+) and insurance status (no insurance, private insurance, or Medicare). Together, it was decided to send letters in waves, 2 weeks apart over 2 months according to age and insurance status. This was the most successful mammography campaign the clinic had ever conducted. A total of 395 letters resulted in 93 office visits/mammography orders (23.5% response rate). Eighty-three of 93 women (89%) completed their mammograms (89% from mammogram orders; 21% from 395 letters sent). In addition, a new process was established in the clinic for monitoring patient compliance to mammography screening. Better linkages were established between hospital and clinic to access no-cost mammograms for lowincome women in the community. Specific project learning: Prineville experience Our community partner found that focus groups worked well in one community and not as well in the other. In Prineville, although we invited several groups at different times and offered a $10 gift card for participating, we were only able to have a single focus group of 4 women. The time of day did not seem to make a difference, and incentives were offensive to some of the participants. We decided to try an online survey using an extensive community e-mail distribution list (N = 200). The survey was open for 5 business days, Monday through Friday, and resulted in
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85 responses (43% response rate). A majority of respondents were white (92.9%) and aged 50 to 64 years (47.1%). More than half (55.4%) reported having a mammogram every year; however, only 40% reported that the most recent mammogram was within the past year. The primary care physician (92%) was identified as the main source of information for obtaining the guideline for having mammograms, followed by family and relatives (29%). Some other key findings included that 49% of respondents would be more likely to get a mammogram with physician recommendation; 73% were not concerned that mammograms would lead to unnecessary surgical procedures; 80% felt that regular mammograms gave them “peace of mind” about their health; and if there was no family history of breast cancer, 6% believed that mammograms were not necessary. Our continuing medical education for local physicians received mixed reviews from attendees. Physicians wanted to hear about the topic, but some believed that the continuing medical education did not present new information and lasted too long. When planning a community continuing education for health care providers, it is important to know the needs and level of knowledge of the audience, know the material the presenters are including, and control the length of time of the presentations. We recommend that materials should be reviewed by local content experts to be sure that it is what the audience wants and expects. We also organized “Bootin’ Out Breast Cancer,” a successful community fundraising activity. This multipartner, 1-day event brought us community awareness about breast cancer and the community’s need for free mammograms, helped raise money for mammograms, and opened the door for more partnerships on other events. DISCUSSION Consistent with prior studies, we found that it was feasible to have successful communityacademic partnerships to enhance health
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of rural communities.13-16 Open and ongoing communication is the key to build a strong foundation for collaboration.13 From our academic-community implementation pilot project, we learned that community leaders can learn and apply the principles of evidence-based scientific reports to develop more evidence-based programs for their communities. We confirmed that communities need to develop local and unique approaches that adapt evidence-based approaches to local conditions and constraints. As part of this process, communities can develop locally adapted tools that can be shared with other communities. We also believe that there needs to be a partnership and support from outside facilitators (such as the academic research team) working with the local community group to create a stronger impact. Partnerships between academic and community infuse new ideas, solutions, energy, innovations, and strength to both settings.13-16 Researchers, including nurse scientists, can expand the concept of academic-community partnerships by working with additional, perhaps more diverse, communities and looking at how much facilitation is necessary and for how long. Further research is needed to expand useful tools by fostering programs in varied communities, supporting their
development of new tools, created in forms that are locally suitable but potentially sharable or adaptable by other communities. Eventually, it would be possible to create a robust toolkit with adaptable, applicable tools and information that expands with the community of users. CONCLUSION This project was a “proof of concept.” We showed that the extensive amount of scientific evidence on strategies to improve rates of screening mammography could be synthesized into a single scientific report, which consisted of an overview of systematic reviews. It could then be translated to a lay-friendly format and assist communities in the selection of appropriate evidence-based strategies. In addition, we were able to codevelop materials necessary to implement interventions in local communities. On a small scale, we believe we were successful; however, work is needed to disseminate the tools created. An important component of community engagement is the evaluation of the community’s readiness and its understanding of the evidence report in implementing evidence-based interventions. Much has been learned and can be expanded from our collaborations between rural communities and academia.
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Academic-Community Partnership Development Lessons Learned 9. Hou SI, Sealy DA, Kabiru CW. Closing the disparity gap: cancer screening interventions among Asians— a systematic literature review. Asian Pac J Cancer Prev. 2011;12(11):3133-3139. 10. Masi CM, Blackman DJ, Peek ME. Interventions to enhance breast cancer screening, diagnosis, and treatment among racial and ethnic minority women. Med Care Res Rev. 2007;64(5):195S242S. 11. Sohl SJ, Moyer A. Tailored interventions to promote mammography screening: a meta-analytic review. Prev Med. 2007;45(4):252-261. 12. Legler J, Meissner HI, Coyne C, Breen N, Chollette V, Rimer BK. The effectiveness of interventions to promote mammography among women with historically lower rates of screening. Cancer Epidemiol Biomarkers Prev. 2002;11(1): 59-71.
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