2 2 Program Budgeting and Financial Analysis Name University Evidence Based Practice I: Assessment and Design January 20, 2019 Program Budgeting and Financial Analysis Every initiative requires financial resources, and that is why it is essential to prepare a budget for a program. A program project, at its core, is developed for a specific activity. It includes the revenue and the expenditure components for that particular project. Many organizations use program budgets for successful implementation of their initiatives. By listing all the sources of revenues and expenditures, it is possible to control all the financial activities in which a project takes part in (U.S. Small Business Administration, n.d.). Another important aspect in healthcare programs is financial analysis. Policymakers must perform financial analysis for effective allocation of resources and determination of economic benefits of a given initiative (U.S. National Library of Medicine, 2008). This paper discusses the budgetary requirements and cost-effectiveness of a breast awareness campaign among African American women in Baltimore County Maryland. Program Budget A functional budgeting system, which deals with the inputs and outputs of a program or a project is adopted for this breast cancer awareness program among African American women in Baltimore County Maryland. According to Kettner, Moroney, and Martin (2017) functional budgeting systems usually focus on management and are mainly concerned with a program's efficiency and productivity. Because of its principal purpose, functional budgeting system is generally thought of as efficiency budgeting. The primary goal of this breast cancer awareness program is to increase awareness and enhance access to breast cancer screening as well as diagnosis among African American women. Like in any other budget, there are various sources of revenues and expenditure items for this program’s budget (see Table 1). Table 1: Budget Line Items for Breast Cancer Awareness Program Revenues Amount Total Membership contribution $ 100,000 Special Events $150,000 Government contracts and grants $250,000 Program income $300,000 Endowment income $50,000 Other income $50,000 Third party payments $100,000 Total Revenue $1,000,000 Expenditures Development and distribution of educational materials $100,000 Breast cancer educational workshops $230,000 One-on-one breast cancer health education $70,000 Salaries and wages $200,000 Rent $30,000 Utilities $20,000 Equipment $50,000 Supplies $50,000 Transport $150,000 Telephone $50,000 Other (miscellaneous) $50,000 $1,000,000 A budget comprises of two principal sections: the revenue part and the expenditure part (Hodges & Videto, 2011). The total budget required for six months, from the start up to the completion of this campaign, is 1 million United States dollars. The program incom.

1. 2
2
Program Budgeting and Financial Analysis
Name
University
Evidence Based Practice I: Assessment and Design
January 20, 2019
Program Budgeting and Financial Analysis
Every initiative requires financial resources, and that is why it
is essential to prepare a budget for a program. A program
project, at its core, is developed for a specific activity. It
includes the revenue and the expenditure components for that
particular project. Many organizations use program budgets for
successful implementation of their initiatives. By listing all the
sources of revenues and expenditures, it is possible to control
all the financial activities in which a project takes part in (U.S.
Small Business Administration, n.d.). Another important aspect
in healthcare programs is financial analysis. Policymakers must
perform financial analysis for effective allocation of resources
and determination of economic benefits of a given initiative
(U.S. National Library of Medicine, 2008). This paper discusses
the budgetary requirements and cost-effectiveness of a breast
awareness campaign among African American women in
Baltimore County Maryland.
Program Budget
A functional budgeting system, which deals with the inputs and
outputs of a program or a project is adopted for this breast
cancer awareness program among African American women in

2. Baltimore County Maryland. According to Kettner, Moroney,
and Martin (2017) functional budgeting systems usually focus
on management and are mainly concerned with a program's
efficiency and productivity. Because of its principal purpose,
functional budgeting system is generally thought of as
efficiency budgeting. The primary goal of this breast cancer
awareness program is to increase awareness and enhance access
to breast cancer screening as well as diagnosis among African
American women. Like in any other budget, there are various
sources of revenues and expenditure items for this program’s
budget (see Table 1).
Table 1: Budget Line Items for Breast Cancer Awareness
Program
Revenues
Amount
Total
Membership contribution
$
100,000
Special Events
$150,000
Government contracts and grants
$250,000
Program income
$300,000
Endowment income
$50,000
Other income
$50,000

3. Third party payments
$100,000
Total Revenue
$1,000,000
Expenditures
Development and distribution of educational materials
$100,000
Breast cancer educational workshops
$230,000
One-on-one breast cancer health education
$70,000
Salaries and wages
$200,000
Rent
$30,000
Utilities
$20,000
Equipment
$50,000
Supplies
$50,000
Transport
$150,000

4. Telephone
$50,000
Other (miscellaneous)
$50,000
$1,000,000
A budget comprises of two principal sections: the
revenue part and the expenditure part (Hodges & Videto, 2011).
The total budget required for six months, from the start up to
the completion of this campaign, is 1 million United States
dollars. The program income membership contribution accounts
for 10% of the total revenue. By organizing special events such
as sporting activities, this campaign intends to raise 15,000
dollars, which is 15% of the total revenue. Program income
from various activities like sales of branded shirts is expected
to raise 30% of the total revenue. Government grants and
contributions will account for 25% of the total revenue. From,
third party payments such as nongovernmental agencies, this
awareness campaign will raise $100,000 in revenues.
Endowment income and other income will contribute 5% each to
the total amount of financial resources required for successful
implementation of this campaign.
These revenues will go toward development and distribution of
educational materials, which will account for $100,000 of the
entire budget. This medium is because there is a need to
develop and distribute materials that are culturally appropriate
to the African American population to realize the program's
goals and objectives. Also, it is important to organize
educational workshops for trainers from which they can learn
appropriate methods and techniques for spreading the program’s
purpose to the target population. Also, it is important to arrange
for educational workshops for community leaders and women
groups from where they can be sensitized about the importance
of breast cancer screening and diagnosis. This activity is
expected to cost 23% of the entire expenditure. Trainers must

5. also have one-on-one educational sessions with the most
affected group for successful sensitization, and this will account
for 7% of the total expenditure. Total salaries for the program's
director, two counselors, three training specialists, and four
support services staff is $200,000 for the six months. There is a
need to rent an office from where the administrative functions
can be carried out. Other utilities like electricity and waters,
transport and telephone are also important for successful
implementation of the program. Office supplies like pens and
books as well as equipment like personal computers and
projectors are other essential requirements.
Break-Even Analysis
Dirubbo (2006) defined break-even as a point at which revenue
is equal to expenditure. As such, the break-even point focuses
on the minimum expectation for a program's revenue. All
revenues earned after break-even analysis point represent
margin over profit. Conducting a break-even analysis is
necessary to determine the break-even point for this breast
cancer awareness program among black American women.
Mathematically;
Break-Even Point = Fixed cost/Contribution margin
Contribution margin = sales price per unit- variable cost per
unit.
For this campaign, 30,000 branded shirts will be sold at $10
each to raise revenue of $300,000
Out of the $1 million, variable cost is expected to account for
40% with the remaining 60% as fixed costs. The variable cost
will be incurred on 100,000 program participants. Therefore;
Fixed cost = $600,000

6. Variable cost per unit = $400,000/100,000
=$4
Selling price per unit =$10
The Break-Even Point = $600,000/($10-$4)
= $100,000
Budget Variance
Sometimes budgets have variance when revenues do not match
with the expenditures (Hodges & Videto, 2011). As for this
program, a budgetary variance may arise if the sale of branded
shirts does not meet the intended target of surpassing the
intended number of 30,000 branded shirts. Also, failure to
receive $250,000 in grants from the government may lead to a
variance in the budget. An increase in the cost of developing
and distributing educational materials may adversely affect the
budget. A favorable variance may also arise if the cost of
generating and distributing educational materials is lower than
the budgeted figure of $100,000. Changes in economic
performance may affect the prices of equipment such as
personal computers, which may affect the budget either
favorably or adversely. An increase in the cost of a personal
computer will cause an adverse variance while a decrease in the
price of a computer will lead to a favorable variance.
Financial Analysis

7. Program owners can use different methods of financial analysis,
whose suitability, according to the United States National
Library of Medicine (2008), depended on the purpose of an
assessment, availability of data plus other resources. Some of
the commonly used financial analyses are the cost of illness
analysis, cost-effectiveness analysis, cost consequence analysis,
and cost-benefit analysis. Others are cost-utility analysis, cost
minimization analysis, and budget impact analysis. Cost-
effectiveness analysis is the appropriate method for this
awareness campaign
Cost-Effectiveness Analysis
The cost-effective analysis is the comparison of costs measured
in monetary units against the non-monetary outcomes (U.S.
National Library of Medicine, 2008). In essence, it compares
the costs plus health effects of a program or an intervention to
assess the degree to which it can be considered as providing
value for money. This medium can enable decision-makers to
determine whether or not to allocate resources for a particular
program (Palumbo, Sikorski & Liberty, 2013). Mathematically;
Cost-effectiveness ratio = cost of intervention A ($)-cost of
intervention B ($)
effect of intervention A- effect of intervention B
We can assume that at the cost of $1million, the breast
awareness campaign would help educate 100,000 women of the
benefits of screening and mammography to compute the cost-
effectiveness ratio. Alternatively, a screening coordination
program may be used to help lessen the problem of breast
cancer among Black American women. This program is
anticipated to cost 2.5 million dollars and reach only 80,000

8. women.
Cost effectiveness analysis for cancer awareness
program=$1,000,000-2,500,000
100,000-80,000
= -70
The negative incremental cost of effectiveness ratio for cancer
awareness campaign implies that by adopting the program rather
than screening coordination initiative, there is an improvement
in the number of women reached out to and reduction in cost.
Conclusion
In conclusion, budget preparation is an important component of
a program. At least 1 million dollars will be required for the
successful implementation of this awareness program. More
than half of these resources will be allocated on some important
budgetary elements like preparation of educational materials,
organization of workshops and salaries. An analysis of break-

9. even point shows that revenue will equate expenditure at
$100,000 for this program. Most importantly, the cost-
effectiveness analysis proves that a breast awareness campaign
is more effective than screening coordination.
References
Dirubbo, N. E. (2006). Break-even analysis--can I afford to do
this? The Nurse Practitioner, 31(7), 11. Retrieved from
https://ezp.waldenulibrary.org/login?url=https://search.ebscohos
t.com/login.aspx?direct=true&db=mnh&AN=16862051&site=eh
ost-live&scope=site.
Hodges, B. C., & Videto, D. M. (2011). Assessment and
planning in health programs (2nd ed.). Sudbury, MA: Jones &
Bartlett Learning.
Kettner, P. M., Moroney, R. M., & Martin, L. L. (2017).
Designing and managing programs: An effectiveness-based
approach (5th ed.). Thousand Oaks, CA: Sage.
Palumbo, M. V., Sikorski, E. A., & Liberty, B. C. (2013).
Exploring the cost-effectiveness of unit-based health promotion
activities for nurses. Workplace health & safety, 61(12), 514-
520. Doi: https://doi.org/10.1177/216507991306101203.
Hiatt, J. (2006). ADKAR: a model for change in business,
government, and our community. Prosci.
U.S. Small Business Administration. (n.d.). Writing a business
plan. Retrieved January 17, 2019 from
http://www.sba.gov/category/navigation-structure/starting-
managing-business/starting-business/writing-business-plan.
U.S. National Library of Medicine. (2008). HTA 101: IV. Cost
analysis methods. Retrieved January 17, 2019 from
http://www.nlm.nih.gov/nichsr/hta101/ta10106.html.
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10. Program Design Elements
Name
University
Evidence Based Practice I: Assessment and Design
January 6, 2019
Program Design Elements
A program is only successful when it does not only achieve its
objectives but also meets or exceeds stakeholders' expectations.
It is the stakeholders who take responsibility of ensuring that a
project reaches its goals. They remain accountable and sacrifice
their time and resources for the good of the project. The success
of a project depends on the involvement of all key stakeholders.
Some of the familiar stakeholders include the community, the
government, organizations, project managers and project
sponsors (Kettner, Moroney & Martin, 2017). This paper
discusses the importance of involving community members and
organizations in the process of developing goals and objectives
for a breast cancer awareness program among African American
women.
Stakeholder Involvement
Importance of Involving Representatives in Goal Development
Involvement of representatives in goal development is a vital
process that ensures the needs and expectations of the target
population are catered for in the project (Hodges & Videto,
2011). There are various benefits associated with the
involvement of representatives in the process of developing
goals and objectives for the breast cancer awareness program
for the selected population. It is undeniable that engaging the
representatives can lead to the accommodation of local agendas

11. within the local and national programs that aim at reducing
breast cancer among African American women.
Consideration of the stakeholders’ needs and interests
throughout the evaluation process is critical to productive
development of interventions. Representatives can play a major
role in the process of goal development of programs targeted at
African American women who have breast cancer. Given that
many campaigns and communication efforts are complex and
sophisticated, stakeholders normally help in identifying the
right objectives and ensuring that the outcomes are utilized to
make a difference (Hodges & Videto, 2011). Stakeholders are
much more likely to not only support the program assessment
but also act on the program’s outcomes. Their involvement
ensures that the suggestions and areas of differences are solved
throughout the development process which in turn has the
benefits of preventing conflicts or sabotage of the entire
project.
Stakeholders Involved in the Program Planning Process
The community is one of the relevant stakeholders who will be
involved in the program planning process. Soong et al. (2015)
asserted that community members have the responsibility of
identifying and evaluating problems that are healthcare oriented
and solve them amicably. The efforts directed at solving such
problems must also accommodate the possible barriers to the
solutions. Breslau et al. (2015), in their support, indicated that
the community solution to health problems start from the
activities of the community members which implies that
African-American women community can solve the problem if
they are involved right from the initiation phase of the project
to its implementation phase.
Other than the community, organizations will also be involved
in the program planning process because organizations can
provide technical, financial and mobilization assistance as well
as media sponsorship for successful implementation of the
breast cancer awareness program among African American
women. Kettner, Moroney, and Martin (2017) asserted that

12. organizations could financially sponsor the logistics and
planning activities of a health awareness program. Media
organizations can enhance program implementation by
advertising the program, broadcasting radio and television
jingles as well as granting interviews. Government agencies and
local partners can provide technical and mobilization support.
These initiatives can play significant roles in influencing
African American women's perception of breast cancer
awareness and prevention.
How Representatives can be Involved
Various strategies can be used to undertake stakeholder
engagement for breast cancer programs among African
American women. Some methods, according to O’Haire et al.
(2012) include partnership, participation, consultation, and push
communications as well as pull recommendations. Partnership
programs entail establishing shared accountability and
responsibility with stakeholders. Fawcett and Ellenbecker
(2015) indicated that partnership involves close cooperation and
information sharing. It should also require an engagement
method in which part of the team is included in the delivery of
tasks or with the responsibility for a specific area. This method
is characterized by the establishment of limited ways of sharing
responsibilities. In conference strategy, stakeholders
participate, but team members are not accountable and cannot
influence anything outside of consultation boundaries.
Push communication strategy is a one-way stakeholder
engagement mechanism. When using push communications,
organizations can spread a message across all stakeholder
groups. This medium can alternatively be directed specific
individuals with the utilization of communication channels like
social media, emails, podcasts and broadcast media (O'Haire et
al., 2012). Furthermore, they can use the nominal group
technique. Stakeholders ideas and views can be obtained
through a nominal approach that is free of interference and
threats (O’Haire et al., 2012). The method enhances creativity
and open sharing of information.

13. Every individual in the group has the freedom to share and learn
new ideas. Stakeholders can choose the proposed ideas. This
approach aims at promoting open communication of views and a
listing of predetermined needs from stakeholders in non-
hierarchical discussion forums (O’Haire et al., 2012). This form
of engagement aims at structuring discussions when groups are
having problems in reaching universal agreement on complex
issues.
Program Design Elements
Program Mission, Goals, Objectives and Activities
Mission: To eliminate breast cancer as a significant health
problem among African American women by preventing breast
cancer and diminishing suffering from breast cancer through
education and advocacy
Goals
Objectives
Activities
To promote awareness about breast cancer prevention
By 2020, increase to 75% proportion of African American
women who understand the importance of annual clinical breast
exams
Identifythe population who underutilize clinical breast exams
Develop a media campaign to educate African American women
about the benefits of early breast cancer detection
Train faith-based organization members on how to educate their
congregations about the benefits of breast cancer screening
To increase early detection of breast cancer through screening
By 2020, increase to 60% the proportion of Black American
women who have received a mammogram screening
Reduce depictions of breast cancer screening among African
women

14. Advocate for increased clinical breast cancer examination and
mammography among black American women
Devise targeted and effective mass media campaigns
To improve the quality of life of breast cancer survivors and
their loved ones
By 2020, decrease breast cancer-related deaths for Black
American women by 50%
Promote existing best practice programs
Develop guidelines for best practice programs that advocate for
and promote healthy living
Market existing programs for breast cancer survivors
Program Gantt Chart
Activities
Month and Year of Plan
01/2019
02/2020
03/2020
04/2020
05/2020
Identifythe population who underutilize clinical breast exams
Develop a media campaign to educate African American women

15. about the benefits of early breast cancer detection
Train faith-based organization members on how to educate their
congregations about the benefits of breast cancer screening
Reduce depictions of breast cancer screening among African
American women
Advocate for increased clinical breast cancer examination and
mammography among black American women
Devise targeted and effective mass media campaigns
Promote existing best practice programs

16. Develop guidelines for best practice programs that advocate for
and promote healthy living
Market existing programs for breast cancer survivors
References
Breslau, E. S., Weiss, E. S., Williams, A., Burness, A., &
Kepka, D. (2015). The implementation road: Engaging
community partnerships in evidence-based cancer control
interventions. Health Promotion Practice, 16(1), 46-54.
https://doi-
org.ezp.waldenulibrary.org/10.1177/1524839914528705
Fawcett, Jacqueline, and Carol Hall Ellenbecker. "A proposed
conceptual model of nursing and population health." Nursing
outlook 63, no. 3 (2015): 288-298.
https://doi.org/10.1016/j.outlook.2015.01.009.
Hodges, B. C., & Videto, D. M. (2011). Assessment and
planning in health programs (2nd ed.).
Sudbury, MA: Jones & Bartlett.
Kettner, P. M., Moroney, R. M., & Martin, L. L. (2017).
Designing and managing programs: Aneffectiveness-based

17. approach. (5th ed.). Thousand Oaks, CA: Sage
O’Haire, C., McPheeters, M., Nakamoto, E., LaBrant, L., Most,
C., Lee, K., ... & Guise, J. M. (2011). Engaging stakeholders to
identify and prioritize future research needs. Methods Future
Research Needs Reports, No.4. Retrieved from
https://ezp.waldenulibrary.org/login?url=https://search.ebscohos
t.com/login.aspx?direct=true&db=mnh&AN=21977526&site=eh
ost-live&scope=site
Soong, C. S., Wang, M. P., Mui, M., Viswanath, K., Lam, T. H.,
& Chan, S. S. (2015). A “community fit” community-based
participatory research program for family health, happiness, and
harmony: Design and implementation. JMIR Research
Protocols, 4(4). https://doi-
org.ezp.waldenulibrary.org/10.2196/resprot.4369.
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Initial Analysis for Program Planning
Name
University
Evidence Based Practice I: Assessment and Design
December 23, 2018
Initial Analysis for Program Planning
Breast cancer is a common type of cancer affecting women in
the whole world, and in the United States, it is one of the most
leading causes of cancer death (The American Cancer Society,
2012). Irrespective of the significant improvements made in
breast cancer detection, diagnosis as well as prevention, the
American Cancer Society (2012) indicated that black American
women are still unequally affected by breast cancer. White

18. women have a 90 percent five-year survival white African
Americans have a five-year survival rate of 78 percent, which is
lower than that of other races as well as ethnic groups in
America (The American Cancer Society, 2012). Therefore, there
is a need for a new plan of action and methods to advocate for
the prevention of breast cancer, decrease its mortality, as well
as enhance survival rate among Black American women. The
purpose of this paper is to establish an initial analysis for
program planning and needs assessment of the issue of the
breast cancer in black American women in the United States of
America
Problem Identification and Target Population
Compared with Caucasian female, black American women have
increased mortality rates and are more likely to be diagnosed
with the disease prior the age of 40 years. Breast cancer
incidence and mortality rates trends demonstrate varying
patterns among different races. Whereas African American
females have a lesser lifetime risk of suffering from cancer of
the breast, they have an increased mortality rate than white
American women (Allicock, Graves, Gray & Troester, 2013).
Greater breast cancer-related deaths are occurring among black
American women with nearly 33 percent higher risk of loss of
loss due to breast cancer than white American females. A recent
report showed that black American females with cancer of the
breast have a poorer prognosis when compared to white women
that were diagnosed at the same age and stage (Yedjou et al.,
2017).
Social Cognitive Theory for African Women with Breast Cancer
The social cognitive theory utilizes several concepts associated
with behavioral change. First, there is self-efficacy concept
which is a belief that people have the ultimate control over their
health and can do whatever they want. Second, there is the
expectation concept which focuses on the behavioral change

19. outcome (Hodges & Videto, 2011). For instance, a patient must
go for regular checkups to keep her health in check and at the
required standard. Self-control is another important concept of
the social cognitive theory. This provides patients the autonomy
as well as total control over their behavior change. Most
importantly, African American can, through observational
learning, observe whatever white women are doing to increase
their survival rates. Finally, it is possible to reinforce the theory
using incentives like free checkups as well as rewards for every
patient who regularly visits the hospital for checkups (Hodges
& Videto, 2011).
Social cognitive theory is appropriate for assessing the problem
of breast cancer among Black American women. This is because
the theory focuses on the effect of individual experiences, other
peoples' activities and actions as well as environmental aspects
on the behavior and health status of the affected population.
This is made under the consideration that breast cancer is
treatable but can also be fatal if advanced. Also, the social
cognitive theory offers support in a social context by installing
self-efficacy expectations and utilizing observational, and other
reinforcements to achieve the desired behavioral change and
perception (Hodges & Videto, 2011).
Literature Review
The phenomenon of higher cancer of the breast mortality among
black American females in the America involves various
factors. Black American females are more prone to suffer from
the cancer of breast at an early age, to get the diagnosis at a
later disease stage as well as to die from breast cancer than
other women of other racial groups (Karcher et al., 2014). For
more than four decades, the United States has witnessed an
expansion in the five-year relative survival rate for breast
cancer for both white and black American females. In any case,
there is as yet a significant racial distinction with new data
revealing that the 5-year survival rate for black American and

20. Caucasians women is standing at 79 percent and 92 percent,
respectively (Coughlin, 2015).
The contrast in survival rate is because of the diagnosis at a
later stage as well as poorer stage-specific survival rates amid
black American females (Coughlin, 2015). It is believed that
various factors, both biological and non-biological, contribute
to the higher mortality rate among African American women.
Some of the biological factors include more treatment-resistant
tumors as well as more aggressive histology. The common non-
biological factors are access to care and attitudes about seeking
care (Daniel et al., 2018). Given that the non-biological factors
are more mutable compared to biological factors, there is a need
to develop proactive measures to address the increasing
mortality rates among African American women (Daniel et al.,
2018).
Efforts to prevent breast cancer-related deaths have focused on
various risk factors like the promotion of physical activity,
reduced alcohol consumption, taking of balanced diet as well as
early detection through regular mammography (Albuquerque,
Baltar & Marchioni, 2014). In as much as, recent data from a
national survey in the United States show that black American
females are as unlikely as white females to have had
mammograms in the recent past, some patient locations and
geographical localities still have some black-white disparities in
mammogram rates as well as referrals for breast cancer
evaluation and detection. These are caused by socioeconomic
factors like family income as well as educational attainment
(Coughlin, 2015).
Cancer of the breast screening rates are low amid low-income,
uninsured as well as underinsured households which lead to
higher mortality rates due to breast cancer among these
populations (Coughlin, 2015). Another issue is of some Black
American females having misconceptions about breast cancer

21. etiology, about their risk factors of breast cancer as well as
barriers to receiving timely screening and treatment (Yedjou et
al., 2017). Black American women who are at risk are unlikely
than their white counterparts to be aware of the present
guidelines as well as recommendations related to preventive
measures (Coughlin, 2015).
Needs Assessment
Needs Assessment Approach
Monsen et al.'s Problem-Analysis Framework will be used to
identify the needs of black American females in reducing
mortality rates due to breast cancer. According to Annan et al.
(2013), Monsen et al.’s problem analysis framework of 2008
focuses on clear conceptualization and clarity of facts to
provide focused interventions. The framework is divided into
five major phases, with phase 1 requiring therapist and
researchers to focus on the background information, role as well
as expectations. In phase 2, there is a need to prepare the initial
guiding hypothesis for the problem under study. Phase 3 is
about identifying the problem dimensions, and phase 4 is about
the preparation of an integrated conceptualization. In phase 5, a
researcher or a therapist must prepare an intervention plan and
implementation strategy. Finally, phase 6 is about monitoring as
well as the evaluation of actions and outcomes.
Method of Data Collection
The data collection methods that will be used for the study
include questionnaires and interviews. The questionnaires will
be in print and electronic form depending on the convenience of
the respondents. The importance of allowing for flexibility so to
allow the respondents to choose the type channel through which
they can respond to the questions is that the respondents may be
busy in income-generating or any other activities and as such,

22. may have limited time to answer the questionnaires (Derguy et
al., 2015). Thus, electronic questionnaires will allow for
convenience since busy respondents can answer the questions at
their free time in their mobile phones, tablets, or PCs. The
questionnaires will contain semi-structured-open-ended
questions to allow for flexibility and respondents' free
expression. Apart from the questionnaires, face-to-face and
telephone interviews will also be conducted depending on the
respondent's convenience. Respondents who will have enough
time at their disposal: those who are confident will take face-to-
face interviews whereas those who are busy, shy, or value their
privacy will take telephone interviews.
Potential Challenges and Possible
Solution
s
The possible challenges that will be encountered during the
data-gathering process are poor cooperation by the respondents.
This is because the study deals with breast cancer, which is a
sensitive subject among women. Besides, there may be fears of
ethical and privacy issues by the respondents in which they may
believe that their health information and identities can be
exposed in the study, which can significantly reduce the turnout
and cooperation of disclosure of accurate information by the
respondents. Different distant data-collection options will be

23. provided such as online questionnaires and telephone interviews
to increase the likelihood of cooperation. Ethical and privacy
issues will be solved by involving community stakeholders and
assuring the respondents of maximum privacy since their real
names will not be used.
References
Albuquerque, R. C., Baltar, V. T., & Marchioni, D. M. (2014).
Breast cancer and dietary patterns: a systematic
review. Nutrition reviews, 72(1), 1-17.
https://doi.org/10.1111/nure.12083.
Allicock, M., Graves, N., Gray, K., & Troester, M. (2013).
African American women's perspectives on breast cancer:
Implications for communicating the risk of basal-like breast
cancer. Journal of Health Care for the Poor and Underserved,
24(2), 753–767. Doi: 10.1353/hpu.2013.0082.
American Cancer Society. (2012).Cancer facts and figures for
African Americans 2011–2012. Atlanta, GA: American Cancer
Society. Retrieved from:
https://www.cancer.org/research/cancer-facts-statistics/cancer-
facts-figures-for-african-americans.html
Annan, M., Chua, J., Cole, R., Kennedy, E., James, R.,
Markúsdóttir, I., ... & Shah, S. (2013). Further iterations on
using the Problem-analysis Framework. Educational Psychology

24. in Practice, 29(1), 79-95. DOI: 10.1080/02667363.2012.755951
Coughlin, S. S. (2015). Intervention approaches for addressing
breast cancer disparities among African American women.
Annals of Translational Medicine & Epidemiology, 1(1), 1-12.
Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4283773/
Daniel, J. B., Gaddis, C. L., Legros, J. R., Bennett, M. D., &
Turner, N. C. (2018). Breast Cancer Knowledge, Beliefs and
Screening Practices among African American Women in a Rural
Setting: A Pilot Study. International Journal of Health
Sciences, 6(1), 29-38. DOI: 10.15640/ijhs.v6n1a3
Hodges, B. C., & Videto, D. M. (2011). Assessment and
planning in health programs. (2nd ed.). Sudbury, MA: Jones &
Bartlett Learning.
Karcher, R., Fitzpatrick, D. C., Leonard, D. J., & Weber, S.
(2014). A community-based collaborative approach to improve
breast cancer screening in underserved African American
women. Journal of Cancer Education, 29(3), 482–487. Doi:
10.1007/s13187-014-0608-z.
Yedjou, C. G., Tchounwou, P. B., Payton, M., Miele, L.,
Fonseca, D. D., Lowe, L., & Alo, R. A. (2017). Assessing the
racial and ethnic disparities in breast cancer mortality in the
United States. International Journal of Environmental Research
and Public Health, 14(486), 1-14. Retrieved from:

25. https://doi.org/10.3390/ijerph14050486
Running head: PROGRAM EVALUATION
1
PROGRAM EVALUATION
5
Program Evaluation
Student’s Name
Institution
Program Evaluation
Application of Social Cognitive Theory in Information Science
and Education
Social cognitive theory first started as a social learning theory
by Albert Bandura for application in psychology. Jenkins, Hall,
and Raeside (2018) asserted that, regarding the deployment of
social cognitive theory in understanding information seeking
behavior and use, the social cognitive theory had been used to
explore significant areas. Such areas like consumption of social

26. media content, information retrieval skills in the academic field,
information retrieval skills at the workplace, information
literacy in the educational field and day to day life information
seeking. For instance, Kim (2010) used the theory to explore
expectation differences in students of different genders when
using university library website resources. With regards to
knowledge sharing, Jenkins et al. (2018) found that social
cognitive theory has been used to explore various fields like
blogging and knowledge management systems.
In the field of education, Erlich and Russ-Eft (2011) reviewed
the application of social cognitive theory to academic advising
for assessment of student learning. Specifically, the researchers
applied the social cognitive theory concepts of self-regulated
learning as well as self-efficacy for the study. This medium is
because these concepts have been successfully applied to
education. The idea that learners should be able to recognize,
create as well as choose their career plans for successful
navigation through their college life contains the elements of
self-efficacy concept and self-regulated learning. For instance,
Erlich and Russ-Eft (2011) indicated that the confidence in
achieving academic plans at a given level could be an indication
of a student’s ability to perform academic planning activities at
a complex level, which is a demonstration of increased efficacy.
Learner’s self-regulated learning skills may help in
understanding the learning mechanisms by which a learner

27. acquired the strategies and tactics for performing academic
planning activities with independence and sophistication.
Program Timeline
Project Goal
Related Objective
Activity
Duration
To promote awareness about breast cancer prevention
By 2020, increase to 75% proportion of African American
women who understand the importance of annual clinical breast
exams
Identify the population who underutilize clinical breast exams
January 1, 2020-January 31, 2020
Develop a media campaign to educate African American women
about the benefits of early breast cancer detection
February 1,2020-March 30, 2020
Train faith-based organization members on how to educate their
congregations about the benefits of breast cancer screening
February 1,2020-March 30, 2020
To increase early detection of breast cancer through screening
By 2020, increase to 60% the proportion of Black American

28. women who have received a mammogram screening
Reduce depictions of breast cancer screening among African
women
February 1, 2020-April 30, 2020
Advocate for increased clinical breast cancer examination and
mammography among black American women
February 1, 2020-April 30, 2020
Devise targeted and effective mass media campaigns
April 1, 2020-May 30, 2020
To improve the quality of life of breast cancer survivors and
their loved ones
By 2020, decrease breast cancer-related deaths for Black
American women by 50%
Promote existing best practice programs
March 1, 2020-May 30, 2020

29. Develop guidelines for best practice programs that advocate for
and promote healthy living
February 1, 2020- April 30, 2020
Market existing programs for breast cancer survivors
March 1, 2020-May 30, 2020
The outcomes of this project will be examined using a formative
evaluation which is conducted during the actual operation of the
program and uses data gathered during the program cycle. It
also provides information during the implementation of the
program to help in determining the extent to which the program
is being implemented according to the program’s design. The
formative evaluation will also answer questions about the
program implementation as well as to focus on process
objectives and enable the manager to determine whether
modifications should be made to program operations even
before the program has completed its first year (Kettner,
Moroney & Martin, 2017).
There will be a need to identify the population who
underutilize clinical breast exams to achieve the program's first
goal of promoting awareness about breast cancer prevention
among African American women. This medium will develop a
media campaign that educates the target population about the

30. benefits of early breast cancer detection and train faith-based
organization members on how to educate their congregations
about the benefits of breast cancer screening. Various activities
like reducing depictions of breast cancer screening among the
target population, advocating for increased clinical breast
cancer examination and mammography and preparation of
targeted and effective mass media campaigns are essential in
attaining the program's second objective of increasing early
detection of breast cancer through screening. Finally, to
improve the quality of life of breast cancer survivors and their
loved ones, there will be a need to promote existing best
practice programs, develop guidelines for best practice
programs that advocate for and promote healthy living, and
market existing programs for breast cancer survivors.
References
Erlich, R. J., & Russ-Eft, D. (2011). Applying social cognitive
theory to academic advising to assess student learning
outcomes. NACADA Journal, 31(2), 5-15
Hall, H., & Jenkins, L. (2018). Applications and applicability of
social cognitive theory in information science research. Journal
of Librarianship and Information Science, 1-12. Retrieved from
https://journals.sagepub.com/doi/abs/10.1177/096100061876998
5

31. Kettner, P. M., Moroney, R. M., & Martin, L. L. (2017).
Designing and managing programs: Aneffectiveness-based
approach. (5th ed.). Thousand Oaks, CA: Sage.
Kim, Y. M (2010). Gender role and the use of university library
website resources: A social
cognitive theory perspective. Journal of Information Science
36(5), 603-617.
A Qualitative Evaluation of a Faith-Based Breast
and Cervical Cancer Screening Intervention
for African American Women
Alicia K. Matthews, PhD
Nerida Berrios, BA
Julie S. Darnell, MHSA, AM

32. Elizabeth Calhoun, PhD
This article presents a formative evaluation of a CDC Racial
and Ethnic Approaches to Community Health
(REACH) 2010 faith-based breast and cervical cancer early
detection and prevention intervention for African
American women living in urban communities. Focus groups
were conducted with a sample of women
(N = 94) recruited from each church participating in the
intervention. One focus group was conducted in each
of the nine participating churches following completion of the
6-month REACH 2010 intervention.
Transcribed data were coded to identify relevant themes. Key
findings included (a) the acceptability of receiv-
ing cancer education within the context of a faith community,
(b) the importance of pastoral input, (c) the
effectiveness of personal testimonies and lay health advocates,
(d) the saliency of biblical scripture in rein-
forcing health messages, (e) the effectiveness of multimodal
learning aids, and (f) the relationship between
cervical cancer and social stigma. Study findings have
implications for enhancing faith-based breast and
cervical cancer prevention efforts in African American
communities.

33. Keywords: faith-based intervention; breast cancer; cervical
cancer; African American women
Primary among the target strategies for reducing cancer health
disparities is to
increase access to and participation in cancer early detection
screening by racial and
ethnic minorities (United States Department of Health and
Human Services [USD-
HHS], 2000). Breast cancer and cervical cancer are two
important foci for reducing
cancer health disparities among underserved minority women
because of the wide-
spread availability of effective early detection screening
methods for these cancers
(United States Preventive Services Task Force, 1996). African
Americans in particular
are an important target population for outreach screening efforts
(Blackman, Bennett,
& Miller, 1999; Hayward, Shapiro, Freeman, & Corey, 1988;
Mamon et al., 1990;
643
Alicia K. Matthews, University of Illinois, College of Nursing,

34. Chicago. Nerida Berrios, Julie S. Darnell,
and Elizabeth Calhoun, Northwestern University, Institute for
Health Services Research and Policy Studies,
Chicago, Illinois.
Address correspondence to Alicia K. Matthews, University of
Illinois at Chicago, College of Nursing,
845 S. Damen Ave., Chicago, IL 60612; phone: (312) 996-7885;
e-mail: [email protected]
This study was funded by the Centers for Disease Control and
Preventions/REACH 2010 (Grant CDC
00121). The authors would like to acknowledge the
contributions of the REACH 2010 coalition members.
Health Education & Behavior, Vol. 33 (5): 643-663 (October
2006)
DOI: 10.1177/1090198106288498
© 2006 by SOPHE
Marcus et al., 1992; Swan, Breen, Coates, Rimer, & Lee, 2003;
USDHHS, 2000). Faith-
based interventions offer a potentially effective strategy for
increasing access to health

35. education and screening programs for African Americans and
other underserved popu-
lations (Kerner, Dusenbury, & Mandelblatt, 1993; Kotecki,
2002). In this article, we
present a formative evaluation of a CDC Racial and Ethnic
Approaches to Community
Health (REACH) 2010 faith-based breast and cervical cancer
early detection and pre-
vention intervention for African American women living in
urban communities.
Rates and Outcomes of Breast and Cervical Cancer
for African American Women
Breast cancer is the second most common cancer in women,
with an estimated
203,500 new cases expected to occur among women in the
United States each year
(Armstrong, Hall, & Wingo, 2002; Ries et al., 2000). Although
cervical cancer is less
common than breast cancer, statistics for 2003 suggest that
12,200 women would be
diagnosed with cervical cancer and about 4,100 women would
die as a result of the dis-
ease (American Cancer Society [ACS], 2002). Breast and

36. cervical cancer survival rates
are improving for most groups of women; however, African
American women are lag-
ging behind in the gains being achieved in 5-year cancer
survival rates (ACS, 2000,
2002; Armstrong et al., 2002; Ries et al., 2000).
Researchers have identified a clinical basis for differential
cervical and breast cancer
survival rates based on ethnicity (Edwards, Gamel, Vaughan, &
Wrightson, 1998; Lannin,
Mathews, & Mitchell, 1998). Primary among these clinical
factors is that African
Americans are more likely to be diagnosed with more advanced
stages of cancer com-
pared with Caucasians (Ghafoor et al., 2002). For example,
routine screening with Pap
tests has increased the likelihood of detecting preinvasive
lesions or early stage disease,
resulting in survival rates of greater than 90% in women falling
into those diagnostic cat-
egories (ACS, 2002). Approximately 60% of the cervical
cancers diagnosed in the United
States occur in women who have never received a Pap test or
who have not been screened

37. in the past 5 years (National Institutes of Health, 1996).
Similarly, research specific to
breast cancer attributes a proportion of the racial and ethnic
disparity in survival rates to
barriers to cancer early detection screening (Edwards et al.,
1998; Lannin et al., 1998).
Consequently, a reduction in breast and cervical cancer
incidence and mortality rates
could be attained by increasing screening among women who do
not adhere to recom-
mended screening guidelines (Saslow et al., 2002; Swan et al.,
2003). Innovative strate-
gies are needed to improve breast and cervical cancer
educational outreach and screening
among underserved populations of women.
Faith-Based Health Interventions
According to data from the 1994 General Social Survey (J. A.
Davis & Smith, 1994),
55% of adults in the United States attend religious services at
least once a month. Rates of
church attendance are even higher among African Americans,
with 67% of adults attend-
ing church at least once monthly (J. A. Davis & Smith, 1994).

38. As such, churches represent
a potential venue for health outreach and education in the
general population as well as
underserved subpopulations (Fox, Stein, Gonzales, Farrenkopf,
& Dellinger, 1998).
Over the past several years, a growing body of literature has
supported the role of
culturally specific, church-based programs in improving the
health status of vulnerable
populations (Kerner et al., 1993; Lasater, Becker, Hill, & Gans,
1997) including African
644 Health Education & Behavior (October 2006)
American communities (Kerner et al., 1993; Kotecki, 2002). For
example, the church
has been used as a convenient and meaningful intervention site
for a variety of health
programs including smoking cessation (Stillman, Bone, Rand, &
Levine, 1993), pre-
vention and management of hypertension (Smith, 1989),
cardiovascular disease pre-

39. vention (Turner, Sutherland, Harris, & Barber, 1995), prostate
cancer education
(Weinrich et al., 1998), asthma education (Ford, Edwards,
Rodriguez, Gibson, & Tilley,
1996), cervical cancer control programs (D. T. Davis et al.,
1994), and maintenance of
mammography screening (Duan, Fox, Derose, & Carson, 2000),
to name a few.
Church-based interventions are likely to be effective in African
American communities
because they capitalize on four important principles (Kotecki,
2002): the central role of the
church in the African American community (Hatch & Derthick,
1992); the strong link
between faith and health in the African American community
(Stolley & Koenig, 1997);
the acceptability of addressing educational, physical, and social
issues in a church setting
(Braithwaite, & Lythcott, 1989; Olson, Reis, Murphy, & Gehm,
1988); and the increased
efficacy of bringing health education to people within their
belief context (Kotecki, 2002).
In addition, health education volunteers from within the church
organization have been

40. shown to effectively deliver behavior change programming
while also providing a social
support system for adopting and maintaining new behaviors
(Lasater et al., 1997).
To increase the effectiveness of faith-based interventions in
underserved communi-
ties, additional research is needed to identify best practices
within a faith-based context.
Moreover, additional information is needed to inform the
conduct of behavior change
interventions in the unique community environment of a
religious institution. These
gaps in the literature could be addressed by obtaining process
data on faith-based inter-
ventions conducted in underserved communities.
Formative evaluations are an acceptable strategy for identifying
and refining the crit-
ical elements of an intervention program (Bhola, 1990). The
purpose of a formative
evaluation is to ensure that the goals of the intervention are
being achieved and to iden-
tify and improve problem areas (Hardy & Boaz, 1997).
Qualitative methods are appro-

41. priate in the conduct of formative evaluations (Patton, 1997).
For example, focus groups
can be used for program development and evaluation (Krueger
& Casey, 2000), to gain
clarity on the way people experience a program (Hebbeler &
Gerlach-Downie, 2002),
to obtain information on participants’ attitudes and values
(Lutenbacher, Cooper, &
Faccia, 2002), and to clarify and add detail to the information
obtained from quantita-
tive surveys (Hebbeler & Gerlach-Downie, 2002; Naylor,
Wharf-Higgins, Blair, Green,
& O’Connor, 2002). As such, qualitative studies are an
appropriate and useful tool for
guiding intervention planners in the design of new programs or
the refinement of
programs that reach identified outcomes (Hebbeler & Gerlach-
Downie, 2002).
Specific Aims
The objective of this study was to conduct a qualitative
formative evaluation of a
CDC REACH 2010 faith-based breast and cervical cancer early
detection and preven-

42. tion intervention for African American women living in urban
communities. The over-
arching research interest of the REACH 2010 education and
screening intervention was
to determine if faith-based interventions are effective at
increasing (a) knowledge about
breast and cervical cancer risk factors and screening guidelines
and (b) intentions to
adhere to cancer early detection screening recommendations.
A formative evaluation of the REACH 2010 breast and cervical
cancer education
and screening program was conducted at the conclusion of the
first 6 months of the
Matthews et al. / Faith-Based Cancer Screening Intervention
645
intervention. The qualitative phase of the evaluation sought to
obtain additional infor-
mation regarding the following five questions: What are
participants’ attitudes regard-
ing the role of the church in promoting health? How aware were

43. participants of the
various program and church-sponsored breast and cervical
cancer activities? How
effective was the breast and cervical cancer
education/curriculum? What were facilita-
tors and barriers to cancer screening? What recommendations
did participants have for
improving the intervention program? These questions were used
to understand whether
the faith-based cancer intervention was experienced as
appropriate and acceptable, to
identify and provide feedback on key elements of the
intervention, and to determine
how to improve the overall impact and effectiveness of the
program.
Given the paucity of information about the conditions most
conducive to effectively
providing faith-based cancer prevention programs, findings
have implications for estab-
lishing best intervention practices within religious institutions,
aiding in the identifica-
tion of new areas of investigation, and informing health
educators about strategies for
improving faith-based cancer screening programs.

44. METHOD
Procedures
Overview of Focus Group Methodology. Qualitative methods
such as focus groups
are useful tools for investigating a new area of research,
designing questionnaires,
developing new intervention protocols, and interpreting findings
(Denzin & Lincoln,
2003; Morse, 1994). In addition, qualitative methods are
appropriate when conducting
research in communities about which very little information
exists (Bernard, 1994;
Matthews, Cummings, Thompson, List, & Olopade, 2000).
In a focus group, relatively homogeneous groups of participants
are brought together
to discuss a specific topic (Denzin & Lincoln, 2003). Unlike a
probability sample-based
survey, the unit of analysis in the focus group is the group, not
the individual (Krueger,
1994). As such, the observations drawn from individuals are not
independent nor are the

45. individuals or the groups a probability sample from a known
population (Goldman &
McDonald, 1987; Krueger, 1994). Specific guidelines for
sample size in focus group
studies have not been established. Nonetheless, Morse (2000)
suggested that a total of
30 to 40 participants provide sufficient breadth of input to
explore a new area. More
important, saturation of themes is a better determinant of
whether additional focus
groups should be conducted rather than a given number of study
participants (Krueger
& Casey, 2000). Saturation refers to the point at which no
additional themes are gener-
ated when data from additional participants are included
(Krueger & Casey, 2000).
Saturation was reached in terms of new themes and diversity of
opinion with our sam-
ple of 94 participants.
REACH 2010 Breast and Cervical Cancer Education
Intervention. The main goals
of the REACH 2010 faith-based health promotion intervention
were to increase breast
and cervical cancer knowledge and screening among

46. underserved women. Contacts
were made with more than 700 women as part of the
intervention. Female congregation
members of participating churches were the target audience for
the intervention.
Churches were eligible for participation if they were located in
communities with high
646 Health Education & Behavior (October 2006)
proportions of African Americans, high proportion of
community members living at or
below the poverty level, and high incidence rates of cancer
based on health department
census statistics. Table 1 shows basic descriptive information
about the participating
churches and the community-level data for the neighborhoods
surrounding participat-
ing churches. Given that congregation members may travel from
other communities to
attend a church, the extent to which the sociodemographic
characteristics of each
member of a participating church match those of the

47. surrounding community is
unknown. Furthermore, several of the churches were located in
more economically
diverse communities. However, demographic data from our
program participants sug-
gest that a significant proportion of women with lower
education and socioeconomic
status are being reached by our intervention (see Table 2).
As part of the larger intervention project, women in
participating churches were
exposed to 6 months of education and outreach activities
focused on increasing cancer
knowledge and early detection. Intervention activities included
both “standard” and
“variable” components. Standard educational activities were
developed by the REACH
intervention team and were delivered in a uniform manner at all
participating churches.
Variable educational and outreach activities were those initiated
and delivered at each
individual church.
One to two standardized education sessions were held at each
church. Delivery of

48. the standard educational curriculum was based on a “train the
trainer” model. This
model required that each church identify one to two church
members to receive train-
ing from the intervention staff to become lay health educators.
After training was
received, lay health educators delivered both the standard and
variable educational
activities at their churches. Lay health educators taught from a
culturally specific, faith-
oriented education curriculum developed by the REACH 2010
intervention team. The
curriculum also included demonstrations of breast self-
examinations and information
about local resources for mammograms and Pap smears. At each
church, educational
events were publicized by the lay health educators and
reinforced by an announcement
from the pastor.
Following the standardized education sessions, lay educators
from each church team
developed and promoted their own unique package of cancer
awareness activities. The
variable church-sponsored activities were delivered by lay

49. educators and meant to
increase awareness and cue screening behaviors. Sample
church-sponsored variable
activities included recruiting congregation members to personal
testimonials about
experiences with breast or cervical cancer, integrating messages
about cancer screen-
ings into weekly church sermons, including screening reminders
in church bulletins,
establishing health ministries, and facilitating access to clinical
screening services.
Additional church-initiated strategies included posting breast
and cervical cancer infor-
mation in church newsletters, hosting snack and chat groups,
sending out cancer screen-
ing reminder cards, and sponsoring Breast Cancer Awareness
Month events.
Once each church had completed all of the standards and
variables outlined in its
individual plan, a two-part evaluation process was conducted.
The first part of the eval-
uation consisted of a written follow-up survey of female
congregation members at par-
ticipating churches to track changes in knowledge and screening

50. behaviors and
effectiveness of the intervention among women exposed to the
intervention. Further
aims were to identify which aspects of the intervention were
effective in increasing
knowledge and cueing women to seek timely screening services.
(Presentation of the
quantitative findings is beyond the scope of this article.)
Matthews et al. / Faith-Based Cancer Screening Intervention
647
Ta
bl
e
1.
C
om
m
un

51. ity
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s
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52. g
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53. so
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54. ith
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55. C
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ith
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56. co
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at
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57. ci
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58. ity
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59. M
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60. at
in
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61. la
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62. f
(p
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)
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63. s
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64. 18
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en

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f
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ity
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re
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92. ea
lth
I
nv
en
to
ry
.
648
Although survey data are useful in conducting program
evaluations, important
process detail may be lost. Using focus groups after a survey
can add detail to the infor-
mation generated by a quantitative survey (Hebbeler & Gerlack-
Downie, 2002; Naylor
et al., 2002). Therefore, the second part of the evaluation
consisted of a series of focus

93. groups. Focus group participants were a subsample of the
women who completed the
6-month follow-up survey. The aim of the focus group
evaluation was to gather addi-
tional data about the intervention components that were
perceived to be the most effec-
tive in increasing awareness and promoting screening behavior.
Focus group participants were asked to provide honest feedback
about the REACH
2010 standard programming and the variable activities
sponsored by their individual
churches. To facilitate open communication and to ensure
participants that their com-
ments would be kept confidential and anonymous, demographic
information was not
collected from focus group participants. Demographic data on
the entire sample of
women completing the 6-month written survey are included in
Table 2. The demo-
graphic composition of the focus group participants is thought
to approximate that of
the larger sample of study participants. However, the lack of
demographic data on focus
group participants is an acknowledged limitation of the study.

94. Recruitment. The pastor from each church selected a lay health
advocate from the
congregation to oversee the standard and variable intervention
activities at that site,
including participant recruitment. The lay health advocate used
a standardized screen-
ing form when contacting women to participate in the focus
groups. Focus group par-
ticipants were obtained in one of two ways. First, a volunteer
sample of congregation
members were recruited from the target churches and enrolled
into the study. Second,
a purposive selection of attendees (Patton, 1990) who completed
one of the standard
education sessions were invited to participate in the focus
groups. Combined, these two
recruitment strategies increased the likelihood that a variety of
factors such as income,
age, educational backgrounds, and participation in standard
educational sessions were
accounted for in the final focus group sample.
Participant Enrollment. Eligibility criteria for participating in
the focus groups

95. included being (a) female, (b) a church attendee, (c) English
speaking, (d) aged 18 years
or older, (e) able to give informed consent, and (f) willing to
participate in a focus
group. Individuals responding to study recruitment efforts were
screened for eligibility
by the lay health advocate either in person or by telephone.
Women meeting eligibility
criteria were given an explanation of study purposes, the focus
group process, and the
benefits and risks of participating in the study.
Conduct of Focus Groups. A focus group was conducted with
female congregation
members from each of the participating African American
churches (N = 9) following
completion of the 6-month intervention. Each focus group
session included approxi-
mately 6 to 10 women, for a total of 94 participants. Focus
groups were conducted
according to standardized methodology established by Krueger
(1994) and included
using trained moderators (N = 4) to guide the structured
discussion, holding immediate
postsession debriefing to summarize and highlight important

96. findings, and carefully
reviewing verbatim transcriptions of audiotapes of each session.
The moderators facilitated each focus group session using a
study guide (outlined
below). An interdisciplinary team of researchers developed the
moderator’s guide. Each
focus group session lasted approximately 2 hr and was
audiotaped and professionally
Matthews et al. / Faith-Based Cancer Screening Intervention
649
Ta
bl
e
2.
R
E
A

97. C
H
20
10
6
-M
on
th
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ol
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p
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rv
ey

98. :D
em
og
ra
ph
ic
s
of
A
fr
ic
an
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99. an
W
om
en
Su
rv
ey
T
yp
e
M
ea
n
A
ge
(
Y

100. ea
rs
)
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du
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tio
n
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ar
ita
l S
ta
tu
s
In
co

101. m
e
B
re
as
t c
an
ce
r
49
<
H
ig
h
sc
ho

102. ol
=
5.
6%
Si
ng
le
=
31
.7
%
<
$2
0,
00
0

103. =
22
%
fo
llo
w
-u
p
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ig
h
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=
26

104. .2
%
M
ar
ri
ed
=
35
.6
%
$2
0,
00
0-
$2
9,

105. 99
9
=
16
.7
%
(N
=
66
8)
So
m
e
co
lle
ge

106. =
36
.4
%
D
iv
or
ce
d
=
13
.8
%
$3
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00
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107. $3
9,
99
9
=
16
.3
%
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le
ge
o
r
hi

108. gh
er
=
27
.3
%
W
id
ow
ed
=
14
.1
%
$4
0,
00

109. 0-
$4
9,
99
9
=
14
%
$5
0,
00
0
or
m
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e

110. =
19
.7
%
C
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47
<
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111. ol
=
6.
1%
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=
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%
<
$2
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=
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112. .2
%
ca
nc
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ig
h
sc
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=
32
.3
%
M
ar

113. ri
ed
=
34
.3
%
$2
0,
00
0-
$2
9,
99
9
=
19

114. .4
%
fo
llo
w
-u
p
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m
e
co
lle
ge
=
35
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115. %
D
iv
or
ce
d
=
14
.1
%
$3
0,
00
0-
$3
9,
99

116. 9
=
19
.4
%
(N
=
73
2)
C
ol
le
ge
o
r

117. hi
gh
er
=
22
.1
%
W
id
ow
ed
=
14
.3
%
$4
0,

118. 00
0-
$4
9,
99
9
=
11
.9
%
$5
0,
00
0
or
m
or

119. e
=
15
.1
%
N
O
T
E
:N
um
be
rs
d
o
no

120. t a
dd
to
1
00
%
b
ec
au
se
o
f
m
is
si
ng
d

121. at
a.
R
E
A
C
H
=
R
ac
ia
l a
nd
E
th
ni

122. c
A
pp
ro
ac
he
s
to
C
om
m
un
ity
H
ea
lth
.

123. 650
transcribed. Written consent was obtained before focus group
participation. Participants
received $25 for their involvement.
Analyses. Qualitative data transcribed from the focus group
sessions were coded and
managed using a computer software package, QSR NUD-IST
NVivo 1.3 (Richards,
1999). While keeping the original evaluation questions in mind,
we sorted, categorized,
and arranged the statements into themes. When necessary,
themes were modified or fur-
ther broken down into subthemes. In addition, we used thematic
analysis to analyze tran-
scribed data (Shontz, 1985). Thematic analysis of the
participant responses focused on
the general agreement among participants in each group (e.g.,
was this attitude or belief
held by other members in the same focus group?), consistency
of findings across groups

124. (e.g., was this attitude or belief also reported by participants in
the study who were in
different focus groups?), and concordance among the
assessments of observers (e.g., was
there agreement among observers about the attitude or belief
being expressed?).
Compiling numbers and percentages of participant responses is
not appropriate for focus
group research (Krueger & Casey, 2000). Instead phrases such
as, “Several participants
strongly agreed that . . .” or “The opinion was prevalent that . .
.” were used to convey
the level of agreement with a statement or attitude (Krueger &
Casey, 2000).
Literature reviews, investigators’ a priori understandings, the
moderators’ guide, and
the qualitative text itself informed the process of the thematic
identification. Two inde-
pendent raters reviewed the transcripts for response to key study
themes and the con-
sistency of responses among participants and across groups.
Examining the pattern of
responses across groups is important in determining the level of
agreement with atti-

125. tudes and beliefs. For example, consistency in responses
suggests that an attitude may
be more similarly experienced by the focus group participants
and not simply an idio-
syncratic viewpoint or, alternatively, whether a concept should
be explored in greater
depth. Coding categories were then used to summarize key ideas
in the combined focus
groups as described by Stewart and Shamdasani (1998). Final
reported focus group
findings were derived from the analysis of all focus groups
collectively, although sub-
themes that were not prevalent in all focus groups were
identified. Given our interest in
the overall attitudes and perceptions of the focus group
participants, results were not
reported separately by church.
Our initial coding was presented to the focus group moderator
and the qualitative
analysis team members (PI, and three key personnel on the
study) for further discus-
sion. Following the team members’ discussion and analysis,
where appropriate, the ini-
tially agreed on set of coding topics was expanded to capture

126. new themes. This iterative
process resulted in a thorough evaluation of the key topics on
the moderators’ guide,
assessment of common themes that were prevalent but not
initially assessed as part of
the moderators’ guide, and identification of subthemes that
emerged after subsequent
probing of key themes.
RESULTS
Key qualitative findings are described below and are organized
according to
our evaluation of the following broad categories associated with
the REACH 2010
intervention: (a) role of the church in promoting health, (b)
awareness of breast and cer-
vical cancer activities at their church, (c) education/curriculum
effectiveness, (d) facil-
itators and barriers to cancer screening, and (e)
recommendations for improving the
Matthews et al. / Faith-Based Cancer Screening Intervention
651

127. intervention program. Illustrative comments from focus group
participants are included
where appropriate.
Role of Church in Promoting Health
Effective development and promotion of faith-based health
initiatives are predicated on
attitudes and perceived relationships among religion,
spirituality, and health. A number of
themes emerged that provide support for the acceptability and
appropriateness of faith-
based initiatives focused on health outcomes among African
American women. These
include the relationship between religion and health, the role of
religious leaders in health
promotion, and the effectiveness of personal testimonials in
cueing health behaviors.
Relationships Among Religion, Spirituality, and Health. Across
each of the focus
groups, members were consistent in their affirmation of the
clear role of religion and

128. the church in caring for the physical and spiritual health of the
congregation. A range
of issues associated with this relationship was discussed. The
first was the view that
good health is a gift from God. For example, several
participants cited scripture pas-
sages that they believe indicate God’s clear mandate for
individuals to care for the body
as a temple of Christ.
It [the bible] speaks of the body as a temple and caring for it
and so that just gives us the
instruction that it is our responsibility, our charge from the
Almighty, to care for our bod-
ies to the best of our ability.
Participants also cited the importance of spirituality, faith, and
trust in God as a
means of coping with problems, including health threats.
Previous studies have
described higher levels of religiosity and use of religious and
spiritual coping strategies
when comparing African Americans to other Western groups
(Bourjolly, 1998; Koenig,
1998; Steffen, Hinderliter, Blumenthal, & Sherwood, 2001).

129. Similar to these prior stud-
ies, reliance on religious beliefs or spirituality was strongly
endorsed as a coping strat-
egy by group participants. Although some participants stressed
the formal role of the
church and religion in addressing problems, most participants
focused on the more gen-
eral role of faith and spirituality in maintaining health or
recovering from an illness. For
example, one participant described her confidence in the power
of faith to protect her:
First of all, you can keep on praising God and not be scared
because he is going to walk
you through everything. So there is nothing to worry about.
The Role of Religious Leaders in Health Promotion. Related to
the issue of man-
dated responsibility for caring for the body was the
presupposition that ministers are
responsible for both the spiritual and physical health of the
congregation. Focus group
participants believed that a lack of health knowledge and
awareness was a major factor
contributing to the poor health of African American women.

130. Because church ministers
have a great deal of influence with congregation members, they
are viewed as especially
effective in setting a health-focused agenda for the church and
in serving in the role of
health educator and promoter for the church.
That’s what a pastor is supposed to do; look after the total.
That’s how we were raised by
our senior pastor, that we are concerned about the total man, the
total everything.
652 Health Education & Behavior (October 2006)
They’ll hear it [health messages] from him and he has an effect
on a lot of churches. One
thing our pastor does is he pushes breast cancer 100% and he
tells it to those who may not
want to listen.
Although there was agreement regarding the role of the church
and ministers in
health promotion, a minority of participants had a different

131. perspective. Some partici-
pants believed that although recovery from an illness is often
addressed in church, it is
usually in the form of a personal testimony, and other aspects of
health or health edu-
cation are not routinely addressed.
You don’t usually do that [discuss health] unless someone is
giving his or her testimony
on “look what God has done for me.” You don’t hear that in
church. You don’t get preven-
tion and all that other stuff. Church is where you go to get
better because the Lord is going
to bless you but you usually don’t get this part.
Church Testimonials. Giving testimony is a long-standing
African American church
tradition whereby an individual will provide the congregation
with an example of how
he or she has been personally blessed by God. Testimonies
given by church members
that were focused on health had a tremendous impact on focus
group respondents and
reinforced the importance of getting a mammography or Pap
test.

132. This last one [mammogram] I got when Ms. X stood up there
and told us about herself
[gave a testimony]. It really hit home. My friends and I still
today pray for her and I say
“let me go now.” It had been 6 years [since last mammogram]
and when she stood there
and talked to us about her situation, I made an appointment
immediately.
In this remark, the participant makes a direct connection
between a personal testi-
mony given by a member of her church and her consequent
arrangement of a mam-
mography appointment. The testimony given by Ms. X provided
a strong cue to action.
In addition, personal testimonies given by women who
identified themselves as breast
cancer survivors had an impact on participants. As one
participant described,
I think that one of the things that I was impacted by was when
Ms. Y came to one of our
sisterhood meetings. Just her testimony by itself made such a
huge impact on me. Because

133. otherwise, it was just a meeting . . . but when she said “breast
cancer survivor” that really
got my attention.
Awareness and Knowledge of Program
An initial step in assessing awareness of the Reach Out Breast
and Cervical Cancer
Education program was to ask women whether they had heard
about the program at
their church. The majority but not all of the focus groups
participants were aware of
the project and specific programming activities at their church.
In terms of specific
activities, each church was given flexibility in the identification
and pursuit of activ-
ities of greatest interest and potential utility to their
congregations. The variable
church-sponsored activities that were thought to be most
effective in increasing
awareness about breast and cervical cancer risk factors and
screening recommenda-
tions included pastor announcements, church bulletin notices,
posted flyers, personal
testimonials of church members, health fairs, and the presence

134. of on-site mammo-
graphy vans.
Matthews et al. / Faith-Based Cancer Screening Intervention
653
The standard education sessions offered across all church sites
were also viewed as
informative. In particular, the focus on the educational sessions
on risk factors for breast
and cervical cancer made an impact on women, because many
reported having no
previous knowledge of these factors. Overall, the health
information received from the
combined intervention and church-sponsored activities was
reported to have raised
individual levels of awareness about breast and cervical cancer.
The responses of focus group participants indicated differences
in participants’
awareness and involvement in cervical cancer education and
screening activities com-
pared with breast cancer activities. For example, few of the

135. women in the focus groups
could describe any of the cervical cancer education activities at
their church.
Additionally, few women reported attending any activities
specifically geared toward
increasing cervical cancer education and screening.
Alternatively, most of the women
in the groups were aware of or had personally attended a breast
cancer educational
activity. Attitudinal factors may have played an important role
in reducing participation
in cervical cancer education and screening activities. For
example, social stigma was
reported to be a barrier to attending the cervical cancer
educational sessions or dis-
cussing this aspect of health with other congregation members.
The reason that the women were not showing up [at the cervical
cancer educational ses-
sions] was because of the fact they figured that they would be
stigmatized. They’ll think I
got it. [Other women in the church ask] Who was at the
meeting? That is what happens
afterwards.

136. The young ones will not talk with you about it [abnormal Pap
tests] or anything because
of us [older women] to attach a stigma to them.
Education/Curriculum Effectiveness
Studies have identified sociocultural factors affecting cancer
rates and outcomes
among racial and ethnic minorities including knowledge of
cancer risk and use of clin-
ical screening and early detection services (National Cancer
Institute Cancer Screening
Consortium for Underserved Women, 1995). Given the well-
documented knowledge
deficits in the African American community in health education
in general and cancer
education in particular, the focus of the standard educational
session was to target
known informational deficits and to motivate screening
behavior. For example, lack of
knowledge and training in how to correctly conduct breast self-
examinations is a fre-
quently cited barrier to conducting this specific breast cancer
early detection strategy
(Fish & Wilkinson, 2003).

137. Women who attended the standard educational sessions
positively evaluated the con-
tent of the material presented. In particular, information about
breast self-examinations
was rated highly. The breast models and other visual and hands-
on learning aids were
mentioned as being effective teaching tools for reinforcing the
activity of self-breast
examinations. The lay health advocate’s and pastor’s role in
providing the educational
curriculum was also well received.
There are a lot of times we do not do enough self-examination
of ourselves or we do not
know how. . . . That is what impacted me the most is to examine
ourselves and be sure to
check and to have our breast mammogram. I have one once a
year.
654 Health Education & Behavior (October 2006)
I became aware of it though our pastor . . . we are able to pick

138. up on a whole lot of things
that we actually were not aware of and she [the advocate] was
very informative.
Screening Behaviors
Screeners and nonscreeners in each group were queried to
determine facilitators and
barriers to early detection cancer screening.
Factors Promoting Screening. When asked about factors that
prompted them to get
regular breast screenings, participants commonly reported a
history of a breast abnor-
mality or breast cancer in their families. As noted in an earlier
section, the church pas-
tors played an important role in raising cancer awareness for
first time screeners. In
addition, pastors who provided encouragement to their female
members to get mam-
mograms seemed to be effective in motivating screening
initiation or adherence.
Personal testimonies at program-related activities motivated
several participants to get
screened for the first time and/or to continue with regular

139. screening. Lay health advo-
cates who formed personal relationships with the women in the
church were also seen
as providing an important role in promoting screening.
The [lay church advocate] was really on it because a lot of
times I had it in the back of my
mind to really get one [mammogram] but I had not had one in 4
or 5 years—she came up
to me and said did you have one and stayed on my case. I ended
up going and like I said
I recently had my mammogram.
Barriers to Screening. Nonscreeners typically cited one of four
primary barriers to
regular cancer screening: lack of awareness, fear of cancer, too
few cues to action (e.g.,
forgetting), and negative experiences with the screening
process. In terms of negative
experiences, nonscreeners perceived mammograms as being
more painful compared
with screeners. One woman describes,
A lot of our people [African Americans] will say “I am not
having a mammogram because

140. it hurts.” I try to encourage people and say I have never had one
that hurts. It is the tech-
nician. A lot of us do not get those exams because we have
heard a lot of people say it hurts
and I am not going to do that.
I think one main reason is people are afraid. Even though you
know it’s good for you,
you are afraid that if you have the test done they will find
something you are not ready
to face.
Social stigma was revealed as an unanticipated barrier to
screening. Specifically, the
perceived association with promiscuity and cervical cancer was
noted to be a major bar-
rier to Pap screening. For example, participants noted that the
possibility of getting a
positive result on a Pap test led to negative feelings such as
shame attributable to the
link between cervical cancer and promiscuous sexual behaviors.
Furthermore, women
in the focus groups suggested that the association between
cervical cancer and promis-
cuity contributes to women failing to disclose abnormal lab

141. results to support networks,
such as family and friends. Finally, older women in the group
acknowledged that they
were aware of women who have not received adequate support
when diagnosed with
cervical cancer because of stigma.
Matthews et al. / Faith-Based Cancer Screening Intervention
655
A lot of people [who] think they may have it think there is a
stigma with it. You know there
is just a stigma to the thing that might be connected sexually
with transmitted diseases and
people tend to draw away from that. People think you are being
promiscuous.
If you tell me that this is 90% a sexually transmitted disease
then it’s just like people with
HIV and AIDS. They [women with abnormal tests] don’t want
to come out and say it until
they have no choice. It’s not something that you feel
comfortable talking about.

142. Improving the Process
Women reported several methods that may be effective in
educating and motivating
women who do not participate regularly in breast or cervical
cancer screening. The first
recommendation was to continue the on-site educational
sessions and to conduct them
more frequently. The participants believed that the continuity of
faith-based activities
would ensure that the women in the congregations would
eventually hear the message
and become more motivated to obtain early detection screening.
My pastor said to us that the reason why he says things over and
over because we are not
getting it. You got to keep putting it out there [early detection
messages]. Someone is going
to get it and then when somebody else gets it they are going to
tell somebody and it
becomes contagious once you start telling it.
A second recommendation aimed at promoting screening
activities was to increase

143. the use of personal testimonies in the education and awareness
sessions. Incorporating
the personal testimonies of cancer survivors was thought to
increase awareness and
interest in cancer screening because of two valued practices in
the African American
community—the religious and cultural practice of “giving
testimony” and the cultural
value of honoring “lived experience” over the opinion of
experts.
A third recommendation was to increase the availability and
dissemination of writ-
ten materials aimed at basic cancer education and providing
specific information about
screening referrals. Suggestions for dissemination of written
materials included posting
flyers, placing notices on church bulletin boards, and including
a health awareness sec-
tion in the church bulletins and newsletters. Continuing to
provide on-site mammogra-
phy vans was also viewed as an important method for reducing
barriers associated with
seeking and obtaining referrals for screening.

144. When I found out we were having a mobile van I was so
impressed. I was so happy
because I know that there are women that never have gone [for
screening].
A fourth recommendation was to increase the use of targeted
health education and
outreach via written educational formats. Targeted messages
were thought to be a
means for increasing health information in harder to reach
subgroups within the church.
For example, targeted messages were viewed as being of
particular importance in
reaching younger and older church members.
Finally, the development of church health ministries was viewed
as an important
strategy not only for increasing cancer knowledge and screening
but also for address-
ing the range of health threats facing the African American
community. The strength of
this recommendation was corroborated by the observation of the
evaluation team.
Specifically, those churches with a health education
infrastructure already in place were

145. best able to take maximum advantage of the REACH 2010
breast and cervical cancer
656 Health Education & Behavior (October 2006)
education program. Several churches have begun plans to
establish a health ministry as
a direct result of the program intervention.
No [we don’t have a health ministry]. . . . We are in the process
right now of developing
that yes. We have that on our outreach plan and we have already
networked with a nurse’s
organization to house that here.
DISCUSSION
The objective of this study was to qualitatively explore the
attitudes, beliefs, and
behaviors associated with breast and cervical cancer screening
among African American
women in a faith-based study. A number of important themes
emerged from the qualita-

146. tive data that have implications for the improvement and
delivery of faith-based health
promotion interventions for African Americans (see Table 3).
First, physical health was
viewed as an appropriate topic to be addressed within the
context of faith-communities.
In this regard, there was a strong dynamic between the general
role of faith and spiritu-
ality and the more formal role of religion and the church.
Consequently, both spiritual-
ity and religion should be considered when establishing project
parameters. For
example, biblical passes relating to trust and faith in God as a
spiritual protector can be
incorporated into messages aimed at reducing stress and
enhancing coping with cancer
screening procedures. In addition, biblical scripture making
specific references to caring
for the “body as a temple of Christ” can be incorporated into
health promotion messages
as religious cues to action. Furthermore, the attitude and
behavior of pastors, including
the content of weekly sermons, can be highly effective in
enhancing health education and
establishing a health-focused agenda for a congregation.

147. Faith-based interventions can also be enhanced when
interventionists adopt practices
naturally occurring in the church environment to deliver and/or
reinforce program spe-
cific goals. For example, giving personal testimonials is a long-
standing tradition in
many African American churches. Study findings suggest that
the personal testimonies
given by church members had a solid impact on the focus group
respondents and were
instrumental in reinforcing program goals of increasing cancer-
screening behaviors.
Personal testimonies may be effective as an intervention
strategy for several reasons.
First, providing testimony is highly consistent with the oral
tradition of African
Americans, that is, engaging in a verbal exchange of
information whereby the infor-
mation provided is often acquired from lived experience.
Second, focus group partici-
pants revealed very empathetic reactions to personal
testimonies. Among focus group
participants, the ability to “relate” to the personal experience of
a fellow congregation

148. member served as a strong cue to action. Although not
specifically discussed by focus
group participants, personal testimonies may also dispel the
prevailing belief that
screening procedures are always painful or that cancer is an
automatic death sentence.
Focus group data also indicate that faith-based health
interventions in the African
American community must address barriers to screening.
Multiple levels of barriers
need to be targeted including those generic to women in general
(e.g., fear or lack of
access), barriers specific to African American women (e.g.,
mistrust of the medical sys-
tem), and barriers that may be more prevalent among women in
faith communities (e.g.,
stigma associated with specific medical conditions or health
risks). For example, two
focus group studies with African Americans suggested the
continued presence of social
stigma associated with cancer in the African American
community (Matthews et al.,
2000; Matthews, Sellergren, Manfredi, & William, 2002). In
these studies, stigma was

149. Matthews et al. / Faith-Based Cancer Screening Intervention
657
658 Health Education & Behavior (October 2006)
Table 3. Summary of Key Qualitative Findings
Topic Subheader Qualitative Findings Implications
Role of church in health • Church seen as an appropriate •
Faith-based interventions
promotion context for health are acceptable to faith
information. communities.
• Spirituality and religion both • Incorporating aspects of
play a role in health. spirituality and religion
• Ministers influence their may enhance health
congregation’s attitudes about promotion messages.
health and behavior. • Ministers can be

150. important spokespersons
for change.
Awareness and • Educational sessions and • Strategies useful in
knowledge church activities were useful increasing awareness
of programs in increasing awareness about included pastor
breast and cervical cancer. announcements, church
• Personal testimonies are an bulletin notices, and
effective cue to action. flyers.
• Immediate access to screening • Interventions should
increases participation. adopt naturally occurring
church practices such as
testimonies.
• Mammography vans were
effective.
Education/curriculum • Education session and church •
Multilevel interventions
effectiveness activities both reinforced are effective.
early detection. • Lay health advocates are

151. • Hearing risk factors from effective educators.
African American women • Visual aids/breast models
helped to change attitudes. are effective learning
• Knowledge of breast self- tools.
exams was improved with
hands-on education.
Screening behaviors • REACH program motivated • Findings
support role of
women to get screened for the faith-based interventions
first time. in health behavior
• More women get regular Pap change.
tests than mammograms. • Additional research
• Regular screeners have is needed to identify
positive attitudes about and address barriers
screening and fewer barriers. to screening.
• Social stigma may be a barrier • Interventions must
to screening. address generic barriers,
cultural barriers, and

152. barriers unique to faith
communities.
(continued)
largely associated with the presumption of cancer as contagious,
as a death sentence or,
at a minimum, as a highly debilitating disease.
Within faith communities, social stigma may be further
heightened for those cancers
perceived to be linked with sexuality or immoral behavior. For
example, focus group
participants reported that stigma associated with cervical cancer
is prevalent and has
been exacerbated by the recent discovery of the role of sexually
transmitted infections
(human papillomavirus) in the etiology of cervical cancer (e.g.,
Bosch et al., 1995;
Walboomers et al., 1999). These data suggest that a possible
unintended consequence
of the public health initiatives aimed at raising awareness of the
link between sexual

153. activity and cervical cancer has been an increase in the level of
stigma associated with
the disease for some segments of the African American
community.
The association between cervical cancer and promiscuous
sexual behavior may pose
unique obstacles for increasing cervical cancer education and
screening within faith com-
munities. To facilitate acceptance of program goals, research
personnel must be particu-
larly sensitive in how they address health issues believed to be
associated with immoral
or stigmatized behaviors. For example, addressing the health
consequences of specific
lifestyle practices should not be viewed as conveying tacit
approval of any behavior
viewed as inconsistent with church teachings. Instead, an
approach can be adopted
whereby church doctrine and health promotion can be
simultaneously supported.
Public awareness and education about the effectiveness and
availability of breast and
cervical cancer screening services are important components in

154. reducing disparities.
Lay health advocates who were selected by their pastors and
who were members of the
congregation were viewed as particularly effective in delivering
education, motivating
screening behaviors, and providing supportive encouragement
for health promotion.
Strategies used by lay church advocates that were viewed as
effective in increasing
awareness and health education included incorporating health
messages into church
bulletins, displaying information in the church setting,
providing visual and hands-on
learning aids, and providing written materials that explicitly
advertised the availability
of free screening services. Previous studies have demonstrated
the effectiveness of
using lay health educators in community-based cancer
prevention programs for African
American women (Erwin, Spatz, Stotts, & Hollenberg, 1999).
Identifying and training
lay health advocates directly from the congregations of
participating churches may
increase the credibility of the educator because of the presumed
congruency of the

155. educator’s religious belief systems with those of the religious
institution.
Matthews et al. / Faith-Based Cancer Screening Intervention
659
Table 3. (continued)
Topic Subheader Qualitative Findings Implications
Improving the process • Continuity of education • Community
partners and
sessions at churches program participants can
requested. play an important role in
• Senior and youth outreach developing and refining
efforts are needed. interventions.
• Development of health
ministers at churches will
help sustain efforts.
NOTE: REACH = Racial and Ethnic Approaches to Community
Health.

156. Study Limitations
Focus group methodology is an acceptable and effective method
to obtain informa-
tion from racially and ethnically diverse populations. Because
the evaluation team is
primarily interested in participants’ subjective experiences with
breast and cervical can-
cer education and screening, focus groups allow for open-ended
discussion and per-
sonal expression. Limitations arise because these focus groups
were conducted from an
exploratory standpoint and because demographic data were not
collected on focus
group participants. Future studies should be conducted to
determine how these findings
generalize to larger more representative samples of African
American women.
Implications
Church-based interventions inherently capitalize on the
qualitative; linking personal

157. faith and health is often subjective in nature. As such,
qualitative methods, specifically
focus group strategies, are a promising research methodology
for developing and refin-
ing faith-based cancer projects for ethnic and racial minority
women. Tailoring educa-
tional and intervention programs to targeted populations can
increase the effectiveness
of health programming (Kreuter, Strecher, & Glasman, 1999).
However, systematic
evaluation of faith-based interventions is needed to improve
program design and imple-
mentation and to refine programs to meet the needs of different
populations (DiIorio
et al., 2002). Results from the current study provide a solid
starting point for assisting
health educators interested in establishing faith-based health
promotion interventions
for African American women. Key findings include the
importance of the role of the
pastor, the effectiveness of personal testimonies, the
effectiveness of lay health advo-
cates, the saliency of biblical scripture in reinforcing health
messages, the effectiveness
of multimodal learning aids, and the relationship between

158. stigma and cervical cancer.
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