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The Robeson County Outreach Screening and Education (ROSE) Project

Program Synopsis

Designed to increase mammography screening among low-income rural women, this intervention delivered by lay health advisors includes three in-person health education home visits and two follow-up phone calls to address barriers and assist in making mammography appointments, as well as two mailed postcard reminders. The study showed an increase in mammography rates.

Program Highlights

Purpose: Designed to increase mammography screening by addressing barriers to obtaining a mammogram among low-income, rural women (2006).
Age: 40-65 Years (Adults), 65+ Years (Older Adults)
Sex: Female
Race/Ethnicity: American Indian, Black (not of Hispanic or Latino Origin), White (not of Hispanic or Latino Origin)
Program Focus: Awareness Building and Motivation
Population Focus: Medically Underserved
Program Area: Breast Cancer Screening
Delivery Location: Home
Community Type: Rural
Program Materials

Preview, download, or order free materials on a CD

Implementation Guide

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Several large studies conducted worldwide show that breast cancer screening with mammograms reduces the number of breast cancer-related deaths in women aged 40 to 69, particularly in women over the age of 50 years. The National Cancer Institute recommends that women aged 40 and older have a screening mammogram (X-ray of the breasts) every 1 to 2 years.

The Robeson County Outreach, Screening and Education (ROSE) Project offers education on breast care, breast cancer, and breast cancer screening to women over the age of 40 and provides assistance to low-income, rural women overcoming barriers to obtaining a mammogram. The goal of the ROSE Project is to use lay health advisors (LHAs) to deliver an individualized, home-based health education intervention to improve rates of mammography screening in a population of women who are traditionally underserved by cancer control efforts-specifically, low-income Caucasian, African American, and Native American women living in rural areas.  LHAs are minority residents in the community with a background in health care or the social sciences who have received training to deliver the program.

The ROSE Project consists of three in-person home visits 30 to 90 minutes in duration with two follow-up phone calls to assist in making a mammography appointment and discuss any remaining barriers to obtaining a mammogram, and two postcard reminders that address the woman's stage of change in relation to obtaining a mammogram and offer assistance in setting up a mammogram appointment. The intervention is delivered over a 10- to 14-month period.

Implementation Guide

The Implementation Guide is a resource for implementing this evidence-based program. It provides important information about the staffing and functions necessary for administering this program in the user's setting. Additionally, the steps needed to carry out the program, relevant program materials, and information for evaluating the program are included. The Implementation Guide can be viewed and downloaded on the Program Materials page.

This program uses intervention approaches recommended by the Community Preventive Services Task Force: small media interventions (Breast Cancer Screening), one-on-one education interventions (Breast Cancer Screening), patient navigation services to increase cancer screening and advance health equity (Breast Cancer Screening) and multicomponent interventions (Breast Cancer Screening).

Training: LHAs must successfully complete one week of intensive training, participate in follow-up weekly phone or in-person meetings with an LHA supervisor, and attend additional follow-up training sessions during the program.

Program Implementation: Implementation occurs over a 10- to 14-month period and involves:
-- First home visit: up to 60 minutes
-- Second home visit: up to 90 minutes
-- Two follow-up phone calls (during months 2 and 6): no duration specified
-- Two follow-up postcard reminders (during months 4 and 8)
-- Third and final home visit (during months 10 through 14): up to 90 minutes

The intervention targets minority and low-income women living in rural areas who are over 40 years old.

The intervention is delivered in the home of each individual and includes follow-up phone calls and mailings.

Interventionists are lay health advisors, primarily minority women residents in the community with a background in health care or the social sciences (for example, a nurse, social worker or teacher). LHAs should possess good social and organizational skills, a professional demeanor, and the ability to work flexible hours. Successful completion of LHA training is verified though a comprehensive written examination, conducting practice intervention sessions, and performing a breast self-examination on breast models.
The following materials are required:
-- CHE (Community Health Education) Manual
-- Visit 1 materials
-- Visit 2 materials
-- Visit 3 materials
-- Phone call follow-up materials (month 2) (includes a mailed Staging Card)
-- Phone call follow-up materials (month 6) (includes a mailed Staging Card)

For inquiries related to staff training, please contact the Principal Investigator (P.I.) for this program.  The P.I.'s contact information can be viewed on the Products page.

A randomized clinical study evaluated the effects of the ROSE Project intervention versus a comparison condition, in which participants received a physician letter and a National Cancer Institute brochure on cervical cancer. The primary outcome of interest was the rate of mammography utilization among study participants. Additional outcomes of interest included perceived barriers, beliefs, and knowledge related to mammography screening.

Eight hundred ninety-seven women over 40 years of age at 4 federally funded community health centers who had no record-verified mammography in the past 12 months and no pending mammography scheduled were randomly assigned to either the intervention group (453 women) or the comparison group (444 women). Study participants were 33% African American, 42% Native American, and 25% White, with an average age of 55 years. Overall, 83% of study participants were defined by one or more of the following criteria: a household income of less than $20,000 per year, no private health insurance, and/or no high school/GED diploma. The most frequent reported barriers to obtaining a mammogram reported at baseline were cost (54%) and lack of encouragement from a doctor (45%). The most commonly reported negative beliefs about mammography were that radiation from the procedure can cause cancer (41%), that it hurts - i.e., is painful (41%), and "I feel okay, so why bother getting a mammogram" (31%). In terms of baseline knowledge, 44% of the women believed that "the only good treatment for breast cancer is an operation to remove the breast", only 32% were aware of the recommendation to begin getting mammograms at age 40, and 90% had no knowledge of the Breast and Cervical Cancer Detection Program (BCCDP) in Robeson County that provides free mammograms to low-income women.

Data were collected at baseline and follow-up (12 to 14 months after random assignment) with a survey containing 12 items related to barriers, 4 items related to beliefs, 12 items related to knowledge, and 4 items related to health care access. Composite scores were calculated separately for barriers, for beliefs, and for knowledge.  A high composite score on barriers indicated many barriers to obtaining a mammogram, whereas a high composite score on beliefs indicated more positive beliefs about mammography, and a high composite score on knowledge indicated more accurate knowledge about mammography and breast cancer.  Analyses of the primary outcome, receipt of a mammogram in the past 12 months, were carried out on 95% of the original randomized sample. Pre-post analyses of the interview survey data were carried out on 91% of the original randomized sample.

  • Among women assigned to the intervention group, 42.5% had medical record-verified mammography in the 12 months prior to follow-up, compared with 27.3% of women assigned to the comparison group (p<.001). By racial group, more African American intervention group women than African American comparison group women (p=.008), more Native American intervention group women than Native American comparison group women (p=.002), and more Caucasian intervention group women than Caucasian comparison group women (p=.024) obtained a record-verified mammogram in the 12 months prior to follow-up assessment. 

    Graph of Study Results

  • Women assigned to the intervention group had a lower average barrier score at follow-up than women assigned to the comparison group (p<.001).
  • Women assigned to the intervention group had a higher (i.e., improved) average belief score at follow-up than women assigned to the comparison group (p=.004).
  • Knowledge scores increased significantly from baseline to follow-up for both intervention group women (p=.002) and comparison group women (p<.001). However, knowledge scores at follow-up were not significantly different between the two groups after adjusting for baseline.

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Updated: 04/25/2023