Program Design

Phase one:  The Champion Health Belief Model questionnaire was used to measure objectives 1 and 2.  Health beliefs were measured using Champion’s revised Health Belief Model Scale (CHBMS) (Champion, 1999). For the purpose of this study, only items related to breast health awareness (BHA) were used.  The questionnaire consisted of 42 items: perceived susceptibility of breast cancer (5 items); seriousness of breast cancer (7 items); benefits of BHA; (6 items); barriers to BHA (6 items); confidence (11 items); and health motivation (7 items).  For each items, participants were asked to rate their level of agreement using a five-point Likert scale from one (strongly disagree) to five (strongly agree).  The internal consistency reliability of the instrument has been associated with a Cronbach alpha ranged from 0.73 to 0.91.  Sociodemographic information such as age, marital status, years of education, employment status and religion; and breast cancer related variables (i.e., family history of breast cancer, regular gynaecologic visits, education about breast cancer and BHA, and source of breast cancer information) were collected using a questionnaire that was developed by the researchers.  The self-reported questionnaire were administered to women who attended a presentation on breast health and to women at a health fair.  Women who attended the presentation on breast health were recruited on the day of the presentation to participate in the study.  As women arrived for the presentation, they were greeted by the research team, their eligibility to participate was assessed, the purpose of the study was explained, the informed consent procedures were discussed, and signed consent obtained.  On the day of the scheduled health fair, women were recruited to participate in the study.  As women registered to be seen at the health fair, they were assessed for eligibility to participate in the study, the purpose of the study was explained and the informed consent procedures were discussed.  Once the women volunteered to participate in the study, they were escorted to a private room where they completed the CHBM questionnaire.  Prior to the presentation and health fair, flyers were placed around the St. Mark Parish and a public service announcement was made on the local radio station inviting women to attend the presentation and the health fair.  At both events, the women who agreed to participate were assured that their responses would be kept confidential.  The self-administered questionnaires was distributed, and completed forms collected, by the research team.

Phase two:  A Community-Based cultural Train-the-Trainer program will be developed.  The Train-the-Trainer program will be based on the guidelines of the International Cancer Society (ICS), will be grounded in Grenadian culture and dialect and will also be based on information gathered from Phase 1 of the project.  A breast cancer curriculum utilizing information from the International Cancer Society and information gathered from the questionnaire will be used.  Cultural specific barriers will also be addressed, to affectively modify beliefs and attitudes toward breast health awareness.  Teaching and learning strategies will include didactic lectures, story-telling, role playing, and simulation instruction and field exercises. The proposed “Train-the-Train program will consist of five teaching sections. Section one: Breast pathophysiology/ Breast epidemiology, global breast cancer incidence rate, Caribbean breast cancer incidence rate, Grenada’s breast cancer incidence rate; Section two: Breast health, breast cancer prevention, screening, early detection, diagnosis and treatment; Section three: Communication Skills and teaching methodology, role playing exercises; Section four: Simulation activities using breast models; Section five: Field Exercise and program evaluation. Twelve local women will be selected through a series of focus groups held with women from St. Mark.

Phase 3:  Community outreach:  The implementation of community outreach and education activities by CHEs in St. Mark Parish, Grenada.

Through a series of focus groups, twelve women in the St. Mark Parish will be selected to be CHEs.  The focus group approach is in line with Community-based Participatory Research methodology.  Community-based participatory research utilizing Community Health Educators has been reported to be an innovative means of promoting health among groups that lack resources (Kim, et. al., 2005). Selection will be based on the wiliness of the women to participate, their knowledge about their community and their ability to speak and write English.  Once the CHEs are selected, they will attend a four day Train-the-Trainer educational program.  Each CHE will receive USD$50.00 for attending the Train-the-Trainer program.  Upon completion of the Train-the-Trainer program, the CHEs will be expected to train at least two women in the community per week for a total of six months.  Assuming each CHE trains 2 women each month for six months, it is expected that a total of 576 women in the St. Mark Parish will receive breast health education and will begin developing breast health awareness. Each of the CHEs will be given a training manual developed by the research team to be used during the community outreach.  Random monthly assessment of the CHEs will be conducted by Dr. Haynes-Smith to ensure ongoing consistency of practice among the CHEs.

“Liming,” a popular term used in the Caribbean to mean “hanging out” or just people sitting around socializing will be the foundation of the community outreach.  The CHEs will utilize the concept of “liming” to meet with other women and teach about breast health.  This approach will be less intrusive that a formal approach.  Each woman who receives the breast health education will be given a cash voucher of USD$20.00 to use towards their next doctors’ visit.  The purpose of the voucher is to help with the cost of a physician visit and to track the number of women who received a clinical breast examination during a visit with their physician.  The women will have six months to use the voucher, and hopefully this will encourage the participants to make follow up visits with the collaborating physicians.  The collaborating physicians will collect the vouchers as part of the data collection process.  Three local physicians have agreed to be referring physicians (see letter of support).  The referring physicians will collect the vouchers and perform a clinical breast examination during the visit.  The voucher will be used to determine the number of women who receive a clinical breast examination. Dr. Clarice Modeste will coordinate this aspect of the project.

Phase 4:  The evaluation of the Train-the-Trainer program to determine whether the CHEs’ knowledge about breast health increased after the training.

Pre- and Post- test questionnaires will be administered to the CHEs. Additionally, the CHEs will be required to complete a BHA return demonstration and will be evaluated by the use of a BHA skills check-off sheet that will be developed by the investigators.