Faith Moves Mountains (FMM) is a community-based participatory intervention designed to reduce the disproportionate burden of cervical cancer among Appalachian women by increasing Pap test use. Initiated in 2004, FMM has partnered with 30 churches in rural, Appalachian Kentucky through which most participants have been recruited. The four counties in which FMM operates are rural and considered economically distressed13
. FMM involves a multi-phase process of educational programming and tailored lay health counseling. Currently, we have completed all activities aside from evaluation.
Our sample consists of approximately 430 Kentucky Appalachian women who have not received a Pap test according to standard guidelines14
. One-third of the participants have not obtained a Pap test for over five years, precipitously increasing their chances of being diagnosed with invasive cervical cancer15
. Given their geographic isolation, low socioeconomic status, and overall challenging life circumstances, participants are frequently labeled “hard to reach.”
We found that the same issues that stymie optimal preventive care challenge participant recruitment. Such constraints include competing time demands (i.e., child care, elder care, and work schedule make it difficult to take time for interviews), mistrust and fear, geographical distance, and lack of resources (i.e., transportation and telephone) 16
. Many women seldom leave the county in which they reside and many have not been to a physician’s office for decades17
. Our 18 month development work suggested that recruiting through the churches, a local and trusted institution, would allow us to reach eligible women.
Our first challenge focused on recruiting churches. Through varied means (using utility listings, monitoring Easter time church listings in local newspapers, reviewing lists with clergy, etc.), we developed a comprehensive list of churches in the focal counties, and mailed invitations to randomly selected churches. Several problems emerged. First, the invitations brought little response. Most churches in the region lack the resources to have a staff member to open mail, let alone commit to an unfamiliar project. Large congregations function as a safety net and are reluctant to participate in yet another project. The few churches that did respond affirmatively likely would differ dramatically from a more typical church. Second, congregations in the region splinter, close down, consolidate, and crop up anew. Although our list was as comprehensive as possible, our sampling efforts could not adequately account for the dynamic world of rural, community churches. Finally, randomly selecting churches made little sense without understanding the geographical and social context. For example, two churches appeared on our first randomized list, one to control and one to experiment; however, we realized that these were sister churches, with joint Bible studies, a shared pastor, cooperation on special events, and overlapping membership. Our church recruitment strategy changed from a randomized design to a more feasible and internally valid quasi-experimental design using a convenience sample that closely approximated the regional distribution of religious denominations.
Forsaking passive approaches like mail recruitment, we pursued a “pavement hitting” approach. We spent extensive time knocking on doors, calling on the minister or his wife, and getting the word out about the project. In addition to attending many church services, Bible studies, and meetings, our community staff participated in volunteer efforts (food or clothing giveaways), church fundraisers, and county festivals. Participant recruitment approaches were also modified. Initially, we had anticipated that each congregation would supply us with a roster of age-eligible women, and that we would randomly select women, contact them, and, if eligible to participate, twelve women would be recruited from each congregation. Several circumstances complicated this plan, including; (1) many churches are not comfortable providing membership rosters and most are especially uncomfortable estimating women’s ages; (2) many frequent attendees are actually not church members and thus not on the roster; (3) a special invitation made to only selected individuals to participate in a cancer-related project was deemed as frightening, and some churches have too few members to provide twelve participants while others have many women who are not only eligible but really wanted to be included.
Our revised recruitment protocol was more consistent with cultural norms of inclusivity, politeness, and food sharing. We invited anyone interested in learning more about cancer to join us at an educational luncheon. The minister, his wife, the leader of the women’s groups or health ministry (if they existed) introduced our project staff from the pulpit and advocated for this educational luncheon. Our staff members generally connected with a church “cheerleader.” The luncheon was deemed a non-threatening, social, enjoyable meeting with friends and neighbors rather than stigmatizing. We assessed eligibility and undertook our informed consent and baseline interview procedures prior to the educational activities, and the educational luncheon was open to all—men, women, young, and old. As is fairly typical in rural communities, the word of mouth about our friendly staff, good programming, and great food encouraged churches and eligible women to join us.
We soon learned, however, that although church involvement is fairly common in Kentucky Appalachia18
, we were overlooking key sectors by limiting our work to the four walls of established churches. Indeed, some of the hardest to reach women felt stigmatized by churches or otherwise were uncomfortable in formal church settings. We recruited theses women through church outreach efforts, like Bible studies at the housing project, church food giveaways, and church-sponsored facilities, including day cares and nursing homes where employees might fall behind on Pap tests.
We also gained access to hard to reach women by confronting our incorrect assumptions. For example, although lower income women are more likely to lack current Pap tests, since nearly one-third of eligible women age 50 + in the region are out of compliance19
, even women from affluent congregations were eligible to participate in our project. Additionally, although we anticipated that religiously conservative congregations would be reluctant to participate in a project involving discussion of sexual organs, many of these denominations felt particularly passionate about their involvement since their members tend to be close knit and disproportionately affected by cervical cancer.
Another important element to our success in accessing hard to reach rural women involved heavily investing in local residents. Having our logo designed by a local graphic artist, using the local print shop for our tee-shirts and letterhead, employing county residents for IT, transcription, catering, and most other goods and services helped to infuse the community with our project. Additionally, careful selection of our project leadership was a key element in recruitment and retention efforts. Rather than selecting our project manager on irrelevant but standard employment criteria (e.g., having a college degree), our selection was based on the recommendations of trusted local colleagues, her social standing in the community, and other characteristics that must be assessed subjectively (trustworthiness, judgment, persistence).
At 7%, attrition rates for FMM have been low. We speculate that the same factors that encourage a high enrollment rate account for the high retention rate. These factors include flexibility with all the recruitment process, modification of existing protocols to account for local circumstances, inclusivity with initial recruitment, extensive face to face contact by local residents, liberal use of local talent, and careful selection of key project leadership.