Pink and Black Peer-to-Peer Education

State: MA Type: Model Practice Year: 2011

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"Boston’s population is over 589,000. Slightly more than half (51%) are people of color and one in every five people live below the poverty level. There are over 140,000 Black residents, of whom approximately 53,000 are adult Black women, our target audience. According to the 2000 U.S. Census approximately three-quarters of Boston’s Black population can be found in four neighborhoods. Residential segregation has many effects and is linked to many health inequities including breast cancer.

According to the Health of Boston, cancer (all types combined) is the leading cause of mortality for Boston residents. Breast cancer follows lung cancer as the leading cause of death from cancer for women. Black Bostonians have an 11% higher death rate from all cancers than White Bostonians, despite slightly higher screening rates, which suggests access to service is not the reason for higher mortality rates. The Commission’s 2005 Disparities Report found that while Black women over 40 in Boston have higher screening rates and are less likely than White women to be diagnosed with breast cancer, they are more likely to die of the disease The Pink and Black Peer-to-Peer education project addresses the issue of breast cancer inequities among Black women. In Boston, the breast cancer mortality rate is 40.0 per 100,000 population for Blacks compared to 18.5 per 100,000 for Whites. Recognizing that individuals are more receptive to receiving health information from people that resemble them and with whom they are familiar, this project utilizes Black women breast cancer survivors from Boston neighborhoods to increase breast health awareness among women of color. Operating on small donations and volunteer time from the Pink and Black Ambassadors—Black women survivors of breast cancer--the project has reached an average of 100 Black women per month in the Boston Metropolitan Area. At the present time, science is focusing on three root causes of this inequity: later stage diagnosis, poor follow-up and follow-through, and genetic differences. The Pink and Black Peer-to-Peer education project’s goal is to eliminate racial inequities and reduce the mortality rate through increased breast health awareness, improved patient-physician communication, enhanced information and referral about breast cancer resources, and survivor support.

This practice was implemented following an October, 2005 poster campaign featuring 9 Black women breast cancer survivors promoting the slogan, “Pink isn’t the only color associated with breast cancer.” Calls streamed in from the public wanting to meet the women on the poster, hear their personal stories and testimony and gain knowledge from them. The Boston Public Health Commission (BPHC) and the women felt the positive reaction from the community deserved a continued public health response. Studies indicate that within the African-American community and other communities of color peer-to-peer communication yields successful results. The Pink and Black peer educators are breast cancer survivors and members of the local community. Sharing their personal stories--including information about early detection, medical treatment, follow-up and access to services--the Pink and Black peer educators are powerful advocates to help eradicate breast cancer. This project builds and enhances BPHC’s interest in reaching the most vulnerable and underserved populations. The Pink and Black Campaign has won national and local recognition for its unique model. In 2006, the National Public Health Information Coalition awarded BPHC a Gold Award for Excellence. In 2007, Boston Mayor Thomas M. Menino and the women from the poster were honored by The Ellie Fund, a regional breast cancer organization. On April 30, 2008 Pink and Black ambassadors received the Health Champion Award in recognition of service on behalf of Communities of Color in greater Boston. In December 2008, the Pink and Black ambassadors received the David Mulligan Award for Service"

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Boston Public Health Commission
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Pink and Black Peer-to-Peer Education
"Boston’s population is over 589,000. Slightly more than half (51%) are people of color and one in every five people live below the poverty level. There are over 140,000 Black residents, of whom approximately 53,000 are adult Black women, our target audience. According to the 2000 U.S. Census approximately three-quarters of Boston’s Black population can be found in four neighborhoods. Residential segregation has many effects and is linked to many health inequities including breast cancer. According to the Health of Boston, cancer (all types combined) is the leading cause of mortality for Boston residents. Breast cancer follows lung cancer as the leading cause of death from cancer for women. Black Bostonians have an 11% higher death rate from all cancers than White Bostonians, despite slightly higher screening rates, which suggests access to service is not the reason for higher mortality rates. The Commission’s 2005 Disparities Report found that while Black women over 40 in Boston have higher screening rates and are less likely than White women to be diagnosed with breast cancer, they are more likely to die of the disease The Pink and Black Peer-to-Peer education project addresses the issue of breast cancer inequities among Black women. In Boston, the breast cancer mortality rate is 40.0 per 100,000 population for Blacks compared to 18.5 per 100,000 for Whites. Recognizing that individuals are more receptive to receiving health information from people that resemble them and with whom they are familiar, this project utilizes Black women breast cancer survivors from Boston neighborhoods to increase breast health awareness among women of color. Operating on small donations and volunteer time from the Pink and Black Ambassadors—Black women survivors of breast cancer--the project has reached an average of 100 Black women per month in the Boston Metropolitan Area. At the present time, science is focusing on three root causes of this inequity: later stage diagnosis, poor follow-up and follow-through, and genetic differences. The Pink and Black Peer-to-Peer education project’s goal is to eliminate racial inequities and reduce the mortality rate through increased breast health awareness, improved patient-physician communication, enhanced information and referral about breast cancer resources, and survivor support. This practice was implemented following an October, 2005 poster campaign featuring 9 Black women breast cancer survivors promoting the slogan, “Pink isn’t the only color associated with breast cancer.” Calls streamed in from the public wanting to meet the women on the poster, hear their personal stories and testimony and gain knowledge from them. The Boston Public Health Commission (BPHC) and the women felt the positive reaction from the community deserved a continued public health response. Studies indicate that within the African-American community and other communities of color peer-to-peer communication yields successful results. The Pink and Black peer educators are breast cancer survivors and members of the local community. Sharing their personal stories--including information about early detection, medical treatment, follow-up and access to services--the Pink and Black peer educators are powerful advocates to help eradicate breast cancer. This project builds and enhances BPHC’s interest in reaching the most vulnerable and underserved populations. The Pink and Black Campaign has won national and local recognition for its unique model. In 2006, the National Public Health Information Coalition awarded BPHC a Gold Award for Excellence. In 2007, Boston Mayor Thomas M. Menino and the women from the poster were honored by The Ellie Fund, a regional breast cancer organization. On April 30, 2008 Pink and Black ambassadors received the Health Champion Award in recognition of service on behalf of Communities of Color in greater Boston. In December 2008, the Pink and Black ambassadors received the David Mulligan Award for Service"
Health inequities are differences in health status and mortality rates across population groups that are systemic, avoidable, unfair, and unjust. In Boston and across the country there are a number of racial and ethnic health inequities that are striking even when other factors like income or education are accounted for. For example, while White women are more likely to be diagnosed with breast cancer, Black women have a higher death rate, despite higher rates of screening. Cancer is the leading cause of death among Boston residents, responsible for more deaths than heart disease, stroke, or injuries. Race and ethnicity are also associated with cancer risk. White women have the highest incidence rate for breast cancer; however, Black women have the highest breast cancer mortality rate. Breast cancer follows lung cancer as the leading cause of death from cancer for women. Boston Mayor Thomas M. Menino has taken on the fight against cancer with great commitment and vision, showing what can be accomplished when a Mayor addresses a major public health problem through community-based services. Since 1995, the city’s public health agency has developed a number of effective community-based cancer screening programs including the Pink and Black Peer-to-Peer education project.
Agency Community RolesThe mission of the Boston Public Health Commission is to protect, preserve and promote the health and well-being of Boston residents, particularly those most vulnerable. The Pink and Black campaign was launched under the leadership of the Boston Public Health Commission and has been supported by the City for five years. As the lead agency for the launch of the Pink and Black poster campaign and creator of the peer-to-peer education component, the Commission supports this practice through a variety of ways. As mentioned earlier, the community work of Pink and Black is supported primarily by volunteer time and efforts of breast cancer survivors. However, the Boston Public Health Commission’s commitment to eradicating health inequities warranted the stretching of resources to build upon and sustain the project. A number of programs and offices have been harnessed to support the effort: Research – Our Research Management team works with other departments both internal and external to gather and publicize research findings and other developments which solidify the need to address the health inequities related to Black women and breast cancer. Outreach - The Outreach department is a portal of reactive, as well as planned activity, where projects stretch across teams to create an informed and powerful voice on breast health. The department takes a proactive approach to identifying populations and sub-groups, catchment areas and best practices for information dissemination with respect given to health literacy barriers. The Outreach department supports the Pink and Black Ambassadors by convening monthly meetings and providing staff support. Communications - the Communications Office supports all Pink and Black communication efforts and strategies. It is responsible for managing and creatively communicating the Pink and Black brand to ensure its message resonates, attracts and retains the support, reputation and influence it needs to deliver its vision of a future free of health inequities. Our communications department provides expert support through new media, media relations, brand development and design. Costs and ExpendituresBoston’s population is over 589,000. Slightly more than half (51%) are people of color and one in every five people live below the poverty level. There are over 140,000 Black residents, of whom approximately 53,000 are adult Black women, our target audience. According to the 2000 U.S. Census approximately three-quarters of Boston’s Black population can be found in four neighborhoods. Residential segregation has many effects and is linked to many health inequities including breast cancer. According to the Health of Boston, cancer (all types combined) is the leading cause of mortality for Boston residents. Breast cancer follows lung cancer as the leading cause of death from cancer for women. Black Bostonians have an 11% higher death rate from all cancers than White Bostonians, despite slightly higher screening rates, which suggests access to service is not the reason for higher mortality rates. The Commission’s 2005 Disparities Report found that while Black women over 40 in Boston have higher screening rates and are less likely than White women to be diagnosed with breast cancer, they are more likely to die of the disease The Pink and Black Peer-to-Peer education project addresses the issue of breast cancer inequities among Black women. In Boston, the breast cancer mortality rate is 40.0 per 100,000 population for Blacks compared to 18.5 per 100,000 for Whites. Recognizing that individuals are more receptive to receiving health information from people that resemble them and with whom they are familiar, this project utilizes Black women breast cancer survivors from Boston neighborhoods to increase breast health awareness among women of color. Operating on small donations and volunteer time from the Pink and Black Ambassadors—Black women survivors of breast cancer--the project has reached an average of 100 Black women per month in the Boston Metropolitan Area. At the present time, science is focusing on three root causes of this inequity: later stage diagnosis, poor follow-up and follow-through, and genetic differences. The Pink and Black Peer-to-Peer education project’s goal is to eliminate racial inequities and reduce the mortality rate through increased breast health awareness, improved patient-physician communication, enhanced information and referral about breast cancer resources, and survivor support. This practice was implemented following an October, 2005 poster campaign featuring 9 Black women breast cancer survivors promoting the slogan, “Pink isn’t the only color associated with breast cancer.” Calls streamed in from the public wanting to meet the women on the poster, hear their personal stories and testimony and gain knowledge from them. The Boston Public Health Commission (BPHC) and the women felt the positive reaction from the community deserved a continued public health response. Studies indicate that within the African-American community and other communities of color peer-to-peer communication yields successful results. The Pink and Black peer educators are breast cancer survivors and members of the local community. Sharing their personal stories--including information about early detection, medical treatment, follow-up and access to services--the Pink and Black peer educators are powerful advocates to help eradicate breast cancer. This project builds and enhances BPHC’s interest in reaching the most vulnerable and underserved populations. The Pink and Black Campaign has won national and local recognition for its unique model. In 2006, the National Public Health Information Coalition awarded BPHC a Gold Award for Excellence. In 2007, Boston Mayor Thomas M. Menino and the women from the poster were honored by The Ellie Fund, a regional breast cancer organization. On April 30, 2008 Pink and Black ambassadors received the Health Champion Award in recognition of service on behalf of Communities of Color in greater Boston. ImplementationObjective 1: To provide peer-to-peer breast cancer awareness and education and survivor support to 500/1000 Black women through community and faith-based workshops annually. Activities:• Develop a culturally appropriate on-boarding training curriculum • Train core group of Pink and Black Ambassadors • Conduct an inventory of speaking engagement venues including places of worship • Coordinate outreach and speaking engagements to at risk populations The development of the on-boarding educators training was based on findings from the focus groups and interviews with Black women breast cancer survivors – the core group of women that are now referred to as Pink and Black Ambassadors. The training contained information about breast health, environmental factors, healthy eating, Health of Boston report (cancer data) and educator’s roles and responsibilities. The original core group of ambassadors, initiators of the transition from a poster campaign to an education project, was the first group of which the curriculum was tested. The women’s personal experiences with cancer had to be matched with breast cancer facts and information that was appropriate for our targeted audience. Those without previous public speaking experience were taught presentation skills and techniques. Faith-based organizations are historically trusted institutions in the African American community. For this, we researched and developed partnerships with those organizations known for their on the ground connections with communities of color. Results of a recent survey administered to faith based leaders, revealed breast health is of concern and interest of worshipers and they welcome the opportunity to incorporate awareness efforts into their ministries. To-date, Pink and Black Ambassadors have organized three annual Pink and Black days at respected places of worship. The community’s familiarity with the initial core group of ambassador’s sparked curiosity created a demand for public speaking engagements. We developed a participation request form necessary for tracking and monitoring the community’s request for survivor appearances. Additionally, there is a proactive approach to identifying and securing venues such as faith-based organizations which allow the women to reach at risk populations and groups. Timeframe: The trainings involved 2 hour trainings conducted over a period of 4 weeks. As new ambassadors are recruited the process for getting them up to speed is the same. As a City agency, we have access to an extended amount of data and information including addresses of both private and public organizations. Our list of faith-based organizations consisted of over six hundred registered locations of which we updated by contacting each church to confirm they were still operating. This process was extremely involved and took over thirty days to complete. During the process we learned Pastors and Reverends lead several congregations simultaneously and or relocate from one establish to the next quite often. Keeping the list of places of worship up-to-date and accurate is an on-going process. For sustainability purposes, it’s important that the pink and black peer-to-peer project is promoted to the public often. We often send letters of interest to provide breast health education to organizations serving our targeted audience. Objective 2: To increase access to care by reducing structural barriers (health insurance, transportation, language, knowledge of available services). Activities: • Refer uninsured women to the Mayor’s Health Line for enrollment assistance • Link women to the Cancer Ride program for transportation to treatment • Design and distribution of Survivorship Toolkit • Pink and Black Ambassadors assist with appointment scheduling The Mayor’s Health Line, a program of the Boston Public Health Commission is a free information and referral service provided to uninsured and underinsured populations. 
Objective 1: To provide peer-to-peer breast cancer awareness and education and survivor support to 500/1000 Black women through community and faith-based workshops annually. Performance measure(s): Number of community and faith-based workshops conducted Data Collection: Request for workshops and workshops actually conducted: Evaluation results: Since the launch of the initial poster campaign in 2005, there has been an increase demand for survivors to share their personal stories. Community agencies request the presence of pink and black peer educators at women’s health events, health fairs, conferences and what is formally referred to as pink and black days at places of worship 3 to 5 times a month. This request rate is up from 7 to 10 requests a year during year one and two of the education project. Feedback Activities: The increased demand for breast cancer education is indicative of the community’s interests to address breast health issues. The Pink and Black Peer-to-Peer project has moved beyond sporting pink ribbons during breast cancer awareness month. Volunteers are committed to increasing awareness twelve months of any given year and not just during the month of October.   Objective 2: To reduce structural barriers (health insurance, transportation, treatment and language by increasing knowledge of health rights and responsibilities through the distribution of a survivor’s toolkit. Performance measure: Results of a survivor needs assessment administered during a monthly Pink and Black meeting indicated the need for post-diagnosis support for survivors. Data collection: Key informant interviews Evaluation results: To-date there have been over 500 toolkits distributed by pink and black educators and approximately 70 survivor referrals made to treatment summary distribution locations. Feedback Activities: Most breast cancer survivors don’t feel that medical providers, more specifically primary care providers, are involved in and or have an understanding of their care when treatment ends. Both physical and emotional problems can arise as a result of cancer. To address survivor’s physical and psycho-social needs, pink and black educators partnered with Dana Farber Cancer Institute to develop a “survivorship toolkit.” The toolkit--complete with information about the value in obtaining treatment summaries and long-term recommendations--has as its goal of improving the lives of survivors through empowerment as well as raising awareness in the medical community of the many issues survivors face after treatment. Objective 3: Reduce breast cancer mortality among Black women in Boston through the development of tools that support cultural and linguistic literacy appropriate approaches for eliminating breast cancer inequities. Performance measure(s): Results of a community needs assessment suggested that breast health is a private and sensitive topic that is not usually discussed with others and health information is usually too complicated to interpret. Results also indicated women in Boston are ready to take it upon themselves to right breast health inequities by developing cultural and linguistic appropriate breast health materials and delivering the messages themselves. Data collection: Key informant interviews. Cancer mortality data, Massachusetts Department of Public Health Evaluation results: Since 2005, Pink and Black has grown from its 9 original ambassadors to seventeen women who travel throughout Boston spreading the word about the effects of breast cancer among Black women. There has been a decrease in female breast cancer mortality between 2006 and 2008 of 19% (HOB 2010). The overall survival rate is higher even though Black women’s mortality rate exceeds that of white women. Year Mortality (all) Black women White women 2006 27.9 43.2 24.3 2007 19.2 33.9 16.3 2008 22.7 40.0 18.5 Target: 22.3 deaths per 100,000 females. Baseline: 27.9 breast cancer deaths per 100,000 females occurred in 1998 
Stakeholder commitment: For this practice, we focused on building capacity by enhancing the strengths of survivors. One asset of the Pink and Black Peer-to-Peer project approach is the intrinsic motivation of breast cancer survivors willing to volunteer their time to help other cancer survivors. It was the original core group that solicited the support of the Commission to expand the effort beyond visual media to an education project. As a survivor driven practice, volunteers are committed to sharing their personal triumphs with cancer and learning and sharing up-to-date accurate breast health information with community residents. In this practice, the use of lay community educators has proven to increase empowerment, reduce barriers to care and assist with improving patient-provider communication. The practice was built on a community directed approach which fosters joint planning in all areas, promising stakeholder’s ownership of self-identified deliverables and project outcomes. Through monthly meetings, we learn of the women’s perception of breast cancer, treatment experiences and barriers to care. By identifying volunteer’s perceptions, skills and aspirations and making their vision part of the programs design helps gain consensus and buy-in. Other stakeholders include but are not limited faith-based organizations and Dana Farber Cancer Institute. Boston is home to hundreds of Black churches, temples, and non-traditional places of worship. There is an unmet need to provide outreach, resources and education to residents who frequent these settings. Boston’s Morning Star Baptist Church, a well-known well-established Black church was the first to host what is now being referred to as “Pink and Black” days. Breast health education activities sponsored by pink and black ambassadors, has become a regular request from faith-based leaders since the inception of the project. Dana Farber Cancer Institute is well-known for its state of the art research and development endeavors. Collaborative efforts with this lead agency on cancer issues continue to be established for leaders within value the connections and relationships pink and black ambassadors have developed within communities of color. Plans to sustain the practice: With limited resources, we will continue to rely heavily on volunteer services of survivors who because of their relationships and community connections are interested in improving the quality of their own care as well as the care of others in similar situations. To be successful, our practice requires the recruitment and training of new volunteers frequently, a minimum 2 new recruits annually. Veteran ambassadors use their social networks and community connections to recruit interested survivors. We will seek to sustain the practice through built relationships with public and private organizations. Pink and Black embraced a mini-grant opportunity offered by Dana Farber Cancer Institute through its Survivorship on the Road program. The program has as its goal to reach survivors where they live and work, similar to the Pink and Black Peer-to Peer model. Visitors of the mobile health van will gain knowledge of medical, functional and psychological consequences of cancer and its treatment, while offering survivors and community-based provider’s education about follow-up care. The health van has the capacity to provide visitors with treatment summaries and care plans. For this collaborative effort, the Boston Public Health Commission agrees to 1) identify and book venues and or events for the Survivorship on the Road program, 2) create a patient navigation system to link van users to primary care and pink and black survivor support and 3) develop an evaluation tool. The grant agreement will end July 2011. Pink and Black will request future funding if the opportunity presents itself. As the lead agency, the Boston Public Health Commission will continue to support the project 
 
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