Faith Moves Mountains (FMM)

Cervical cancer takes the lives of approximately 4,000 women in the United States each year. High poverty levels, issues with health communication and education, and cultural issues strongly contribute to the high levels of cervical cancer experienced by underserved women. Women living in rural counties of Appalachia have consistently demonstrated higher rates of cervical cancer mortality than women residing in other parts of the country. In these areas, poverty levels are above the national average, and the population is geographically isolated, lacks transportation, and experiences issues with inadequate housing and environmental and occupational hazards. These factors limit access to education and adequate health care, resulting in lower rates of cervical cancer screening and increased mortality rates. In recent years, faith-based organizations and settings have played an important role in facilitating health improvement in vulnerable populations. Interventions guided by lay health advisors using church-based social networks and community supports may help reach rural, underserved Appalachian women to increase screening rates and reduce cervical cancer disparities in this region.

Faith Moves Mountains (FMM) is a community-based intervention delivered by lay health advisors (LHAs) to Appalachian women ages 40-64. Administered through churches and other faith-based settings, FMM is designed to increase rates of Papanicolaou (Pap) tests and reduce the incidence of cervical cancer. The intervention, developed through ethnographic and survey research in communities in Appalachian Kentucky, draws on three conceptual frameworks: community-based participatory research (CBPR), the PRECEDE-PROCEED model, and social cognitive theory (SCT). Key principles incorporated from CBPR include addressing community needs and priorities and identifying resources within the community. The PRECEDE-PROCEED model provides a general framework for the intervention by identifying factors that influence health behavior: predisposing factors (e.g., knowledge, self-efficacy, attitudes), reinforcing factors (e.g., social support), and enabling factors (e.g., health insurance coverage). Elements borrowed from SCT include use of social networks, faith communities, and health education.

Women are recruited to participate through their faith-based institution (e.g., church), where they complete a baseline assessment to identify their barriers to screening (e.g., transportation, lack of health insurance, attitudes regarding cervical cancer and screening). Subsequently, the LHA, who is demographically similar to participants and may be a member of the faith institution, prepares a 4-page newsletter tailored to address the screening barriers the participant identified in the baseline assessment. The LHA schedules a 2-hour home visit with the participant a month after the baseline assessment to provide education on cervical cancer and screening; review the participant's barriers and strategies for overcoming them, with support from the tailored newsletter; and develop an action plan to address each of the participant's screening barriers. If the participant agrees, the LHA provides assistance in contacting the participant's health care provider or free or low-cost health clinics to schedule a Pap test before leaving the home. Two weeks after the home visit, the LHA contacts the participant to address any participant questions and to inquire about any progress made with the action plan.

This program uses intervention approaches recommended by the Community Preventive Services Task Force: small media interventions (Cervical Cancer Screening), one-on-one education interventions (Cervical Cancer Screening), patient navigation services to increase cancer screening and advance health equity (Cervical Cancer Screening) and multicomponent interventions (Cervical Cancer Screening). This program also uses the following intervention approach for which the Community Preventive Services Task Force finds insufficient evidence: interventions to reduce structural barriers for clients (Cervical Cancer Screening). Insufficient evidence means the available studies do not provide sufficient evidence to determine if the intervention is or is not effective. This does not mean that the intervention does not work. It means that additional research is needed to determine whether the intervention is effective.

-- 16 hours for training LHAs initially, plus 8 hours annually for retraining/feedback

-- 30-90 minutes for interviewers to conduct the baseline assessment

-- 30 minutes for LHAs to prepare each newsletter

-- 30 minutes for LHAs to schedule the participant home visit and make the visit reminder call and follow-up calls

-- Approximately 2 hours for LHAs to conduct the home visit

The intervention is intended for women ages 40-64 in Appalachia.

The intervention is designed for use by faith-based settings in Appalachia.
 

Required resources to implement the program include the following:

-- Lay Health Advisor Training Manual
-- Newsletter and Action Plan
-- Example of Tailored Newsletters Components

For costs associated with this program, please contact the developer, Nancy Schoenberg. (See products page on the EBCCP website for developer contact information.)

A randomized controlled trial compared the effect of the intervention and a wait-list control on cervical cancer screening among Appalachian women. Female participants were recruited from 29 churches located in Kentucky's Harlan, Knott, Letcher, and Perry counties, which are among the most economically distressed counties in Kentucky and the country. Most participating churches were typical of the region in that they were small, with less than 50 female adult members. Participant eligibility criteria included being 40-64 years old, being able to speak English, and being non-adherent with the American Cancer Society's cervical cancer screening guidelines at the time of the study (i.e., no Pap test within the previous 12 months).

Participants described their ethnicity as non-Hispanic; 95.1% were White, 4.6% were Black, and 0.3% were American Indian. The ages of participants were as follows: 20.0% were 40-44, 20.0% were 45-49, 23.8% were 50-54, 22.9% were 55-59, and 13.3% were 60-64.

Eligible women were invited to an information session at the church to receive an overview of the study. Participants completed informed consent forms and a baseline assessment. Interviewers offered to administer assessment documents orally to mitigate literacy concerns. The 88-item baseline assessment measured sociodemographic and health-related characteristics; history of cervical cancer screening; cervical cancer screening knowledge, attitudes, and behaviors; and barriers to cervical cancer screening. Participants received $25 for completing the baseline assessment and any subsequent interviews. Study participants (n=345) were randomized to intervention (n=176) or wait-list control (n=169) conditions.

Study participants attended an educational lunch program at the church hosted by local project staff to learn about cervical cancer screening and prevention. Four months after baseline, an additional assessment was completed to determine how many participants received screening after the lunch. Five months after baseline, the intervention was delivered to the treatment group. Eight months after baseline, the follow-up assessment was completed, after which the wait-list control group received the intervention. Approximately 6 months after the follow-up, both groups completed an exit interview reassessing cervical cancer screening status.
   
The primary outcome was receipt of a Pap test at follow-up. Additional analyses investigated factors associated with obtaining a Pap test.

• A greater percentage of intervention group participants than control group participants obtained a Pap test at follow-up (p=.04).

 

Additional Findings

• At the assessment conducted after the educational lunch (prior to the intervention), 6.8% of intervention group participants and 6.5% of control group participants obtained a Pap test.

• A secondary analysis that controlled for treatment group and church showed that age and screening history were associated with screening at follow-up. Higher rates of screening were found among women aged 40-44 compared with those aged 55-59 (p=.02) and among recently screened women compared with rarely/never screened women (p<.001).

• At exit interview, a significant proportion of wait-list control group participants who had not received a Pap test at follow-up had received one after participating in the intervention (p<.001). Further, 13.8% of intervention group participants who had not received a Pap test at follow-up had received one by exit interview.