Faith Moves Mountains assessed the effectiveness of a faith-placed LHA intervention to increase Pap test use among middle-aged and older women in Appalachian Kentucky. The significant difference in the proportions of treatment versus wait-list control group participants who reported being screened at Follow-up 2 (i.e., after the treatment group had received the intervention and the wait-list control group had not) demonstrated the intervention’s effectiveness.
As with many community-based projects, FMM depended upon the efforts of local residents, often requiring a delicate balance of community needs and scientific procedures. For example, recruitment of churches and participants progressed more slowly than anticipated. Initial attempts to implement a probability sampling scheme proved futile, as randomly selected churches did not respond to “cold calls” and letters. While shifting to snowball sampling may have impacted generalizability of findings (Shelton et al., unpublished results
), it was a necessary step to achieve acceptable participant enrollment. Despite the need for such trade-offs, a significant intervention effect was detected. This finding is important, particularly in the context of a community-based intervention to increase cervical cancer screening among vulnerable women in a disproportionately affected region of the U.S.
These results add to the literature supporting the effectiveness of individualized interventions via LHAs (e.g., Dignan et al., 1998
; Green, 1977
; Paskett et al., 2011
). While a small percentage of participants were screened following the educational luncheon, nearly one-quarter of the sample obtained Pap tests after receiving the LHA intervention. Leveraging church connections to facilitate LHA-provided remediation of barriers to screening appears to be an effective strategy to increase Pap test use among Appalachian women outside of screening recommendations.
Overall, 31.9% of all FMM participants reported being screened for cervical cancer during the study period. This result is on the high end of rates reported in other community-based intervention studies targeting cervical cancer screening. A systematic review of 46 studies published from 1980 through 2001—all of which evaluated similar sociologic, cognitive, and behavioral interventions—reported increases in Pap test use rates ranging from 2.7% to 36.0% (Yabroff et al., 2003
). In contrast to clinic-based intervention studies, which often report higher rates of Pap test use among participants (e.g., Paskett et al., 2011
), community-based projects often yield lower screening rates than achieved by FMM in the current study.
Secondary analyses found that age and cervical cancer screening history were associated with Pap test receipt. Independent of treatment group, women in the second-to-oldest group were significantly less likely than those in the youngest group to report receiving a Pap test. Perceptions of reduced risk for cervical cancer with increased age may underlie this finding (Marlow et al., 2009
), despite recommendations that screening not be discontinued until at least age 65 for most women (ACS, 2011b
; U.S. Preventive Services Task Force, 2003
In addition, controlling for treatment group, women who were furthest outside ACS screening guidelines had significantly lower odds of being screened during the study, compared to women who were more recently screened. The majority (80.3%) of rarely or never screened participants did not obtain Pap tests throughout the study. This group reported baseline attitudes and beliefs about cervical cancer and screening that differed from those reported by recently screened women (Hatcher et al., 2011
); for example, compared to recently screened participants, higher proportions of rarely or never screened women believed that cervical cancer has symptoms and that screening causes worry. In addition, Hatcher and colleagues found that rarely or never screened women reported different barriers at baseline, compared to recently screened women. These included part-time employment, perceiving screening as too expensive, and lacking a usual health care source. Finally, at baseline, even a health provider’s direct recommendation was perceived as less influential by the rarely or never screened, compared to the recently screened (Hatcher et al., 2011
). These differences may underlie the apparently reduced effectiveness of the intervention among rarely or never screened Appalachian women, who may be at the greatest risk of ICC. Future analyses will investigate barriers to screening still identified by rarely or never screened participants post-intervention, with the goal of refining the intervention to increase its impact among this vulnerable subgroup.
This project had several limitations. First, the study employed a small, relatively homogenous sample from a limited geographical region. This concern is mitigated by representativeness of the sample to the demography of the central Appalachian region (U.S. Census Bureau, 2010
). Another limitation is reliance on self-report data. However, studies have demonstrated 70% positive and 95% negative predictive value of recall for Pap tests (McGovern et al., 1998
; McPhee et al., 2002
). Additionally, recruitment of churches and individual participants progressed more slowly than anticipated, resulting in a non-random sample of churches as recruitment sites and a smaller sample size than planned. Despite these shortcomings, a significant treatment effect was still detected. For dissemination purposes, participant identification of barriers is an important aspect of the intervention. In this study, barriers were gleaned from the baseline assessment; in practice, barriers could be assessed prior to or at the beginning of the LHA home visit. However, this study did not address potential differences in the timing or approach to assessing barriers. Finally, unintended and unmeasured effects may have existed, related to the faith-placed nature of the project. Specifically, participants within a single church could be randomized to either the treatment or the wait-list control group, allowing potential contamination. Because this may have “watered down” the intervention effect, future efforts should consider measurement of contamination and a group-randomized design with churches as the unit of randomization.
Despite these limitations, the RCT design of FMM enabled the detection of a significant intervention effect. Results are notable for three additional reasons. First, since past behavior often predicts future behavior (Ouellette and Wood, 1998
; Sutton, 2004
; Weinstein, 2007
), it is likely that the women who obtained Pap tests during FMM will maintain cervical cancer screening in the future. Second, the target population included hard-to-reach women. One-third of FMM participants were rarely or never screened, presenting significant challenges to behavior change. Despite the relative lack of behavior change within this subgroup, FMM was one of the first projects in the region to successfully recruit and enroll a substantial number of these women in research. Although recruitment of these unlikely research participants was successful, the intervention was least effective for them. However, the data provided by this vulnerable subgroup will supply valuable information for modifying the intervention. Finally, FMM developed an infrastructure for future projects, which will investigate the effects of community-based, faith-placed interventions to improve other health behaviors in this region.
To our knowledge, this project was the first to combine a LHA approach with faith-placed recruitment, tailored home visits, and tailored newsletters focused on participant-identified barriers to screening. As a novel strategy to reduce a recognized health disparity experienced by hard-to-reach Appalachian women, results of the current study support further efforts in this vein.