The Witness Project
History

In spite of living in the information age, cancer is still a fearful, stigmatized disease in rural minority communities, and people simply don't talk about it. But thanks to the Witness Project, a breast and cervical cancer education program that is increasing awareness and screening in one of the poorest areas in the nation, more and more African American women are talking about cancer.

The Witness Project was conceived and developed by two Little Rock social scientists, Dr. Deborah O. Erwin, a medical anthropologist specializing in cancer education and prevention in underserved populations, and Dr. Thea Spatz, a certified health educator with extensive research experience in adult education and prevention and screening behaviors. Erwin is associate director of education for the Winthrop P. Rockefeller Cancer Institute at the University of Arkansas for Medical Sciences. Spatz teaches health education at the University of Arkansas at Little Rock.

Developed in cooperation with the American Cancer Society, Arkansas Department of Health, Delta Health Education Center, and local churches and community groups, the Witness Project was the first program in Arkansas to target socioeconomically disadvantaged women through African American churches. Drs. Spatz and Erwin used anthropological fieldwork, individual interviews, and focus groups to assess the population´s needs and to develop and quantify the intervention study.

Participation in these discussions was an enlightening experience for the cancer survivors. They bonded with each other immediately, compared scars, and honestly explored their feelings about cancer. "I was 60 years old when I was told I had breast cancer," said Dorothy Ballard, who participated in an early focus group. "I went to the doctor every year for a checkup and had Pap tests, but he never examined my breasts. He never one time told me about mammograms. I was bitter."

The women agreed that testimonials, like Ballard´s, would be an effective way of delivering breast cancer education to other minority women. More importantly, five women - Dorothy Ballard, Gladys Hallman and her daughter (also named) Gladys Hallman, Ethel Davis, and Lillian Dokes - agreed to be the first Witness Role Models. The following year, five women from rural Phillips County - Cleo Dunnings, Ruby Lindsey, Alice White, Charlie Stayton, and Ollie Jennings - joined their ranks. The rest is history.

In churches, people witness to save souls. At the Witness Project, the cancer survivors witness to save the lives of their friends and neighbors. During their program, survivors "witness" to other women. They testify about their personal experiences with breast or cervical cancer, stressing the importance of early detection and screening. By telling their stories, the role models educate other women about the importance of early detection. After the witnessing session, a trained peer educator teaches BSE using ethnic models.

In 1991, a pilot study was funded by a Title XX Grant from the Arkansas Department of Health. Data from the pilot project was published in 1992. From 1992 to 1996, research on the Witness Project was supported by the Susan G. Komen Breast Cancer Foundation. In 1995, a 3-year proposal to the National Cancer Institute for an R25 Training Grant to expand the project into additional Delta counties was funded. Concurrently, a supplemental grant from the Centers for Disease Control, Cancer Prevention and Control Program, funded through Arkansas Breast and Cervical Cancer Control Program at the Arkansas Department of Health, was awarded to support research to validate the intervention´s effectiveness in increasing utilization of screening services through local health units.

In 1997, the Witness Project was awarded a 4-year cooperative agreement with the Centers for Disease Control to replicate, disseminate, implement and evaluate the model. The purpose of the replication package is to provide interested partners with an easily replicated package and technical assistance necessary for the development and maintenance of a successful Witness Project. Established projects in Wichita, Kansas; Bridgeport, Connecticut; Hattiesburg, Mississippi; Bloomington, Illinois; and Long Branch, New Jersey, agreed to serve as initial partners. With an advisory board comprised of Arkansas affiliates of national cancer education and outreach programs, the partners provide recommendations and guidance in design and implementation of the cooperative agreement. In 1998, Long Branch, New Jersey withdrew from the partnership of the grant due to non-renewal of funding by their primary sponsor.

The cooperative agreement has the potential to implement the model in six additional states. Two additional sites, Oakland, California, and a network of sites in Illinois were added in the fall of 1998 for the purpose of piloting the replication. Additional sites will be selected through an application process. For more information, please click here for FAQs.

The Witness Project received the National Honor Citation from the American Cancer Society in 1991. Locally, the program received the Wilowe Institute Achievement Award in 1993. The 1995 HOPE Award in the Outstanding Group Category was presented to the project by the Biennial Symposium on Minorities, the Medically Underserved & Cancer. One of 165 local cancer education groups across the country to be recognized during the 10th annual National Minority Cancer Awareness Week, the project received a National Cancer Institute Partnership Award in 1996 for outstanding efforts to reach minority populations with cancer information.

Design

During a program session, WRMs witness by talking about their experiences with cancer, stressing the importance of early detection, and answering questions about their personal experiences, fears and concerns. Witnessing is done by 2 to 5 WRMs to small audiences of up to 25 participants; at least 2 WRMs participate in each session to avoid the appearance of a "token" survivor. The educational session addresses the fears and beliefs many women hold about cancer, demonstrates that the diagnosis of cancer is neither a death sentence nor a punishment, and provides participants with accurate, personal information about cancer, early detection and treatment methods. Following each session, LHAs teach BSE using ethnic breast models, and provide information about available resources.

Programs follow the cycle of learning in the 4MAT¨ System (McCarthy B. Morris,The 4MAT System,Chicago:Excel, Inc., 1992). Educational material is presented sequentially to address four distinct learning styles and brain hemispheric preferences. Storytelling and experiential learning techniques are used in the intervention, rather than a traditional didactic presentation. The Witness Project® creates a personal connection between the messenger and the audience in a non-threatening atmosphere. The result is a cancer education intervention that works.

Social Learning Theory (SLT) addresses psychosocial dynamics and environmental influences that promote behavior change. SLT incorporates 11 concepts with specific implications for potential intervention strategies, including environment, expectations, reinforcements, and self-efficacy. The Witness Project includes nine concepts from the SLT, including using credible role models in a direct, one-on-one educational program. These concepts affect the interaction between individual cognitive factors, behavior, and the environment through direct, small-group settings. Witness Role Models, as defined by this theory, promote healthful norms and learning through skills training and they give positive social reinforcement for desired behaviors. (Perry CL, Baranowski T, Parcel GS. How individuals, environments, and health behavior interact: social learning theory. In: Glanz K, Lewis FM, Rimer BK (eds). Health Behavior and Health Education. San Francisco: Jossey-Bass Publishers, 1990, pp. 161-186.)

Although the Transtheoretical Model of Change (TMC) has primarily been applied to influencing addictive behaviors, there are enticing possibilities for using this model to refine health promotion and screening interventions. The TMC model suggests that individuals pass through a series of levels as they change their behaviors from precontemplative (no awareness of the problem or desire to change) to contemplative (beginning the process of making the change) to action (acting on the decision to change). Individuals move from one level to another and cycle back around over time. Appropriate activities encourage behavior change at certain levels. (Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: Applications to addictive behaviors. American Psychologist 1992; 47: 1102-1114.)

We hypothesize that many rural AA women reached in churches are at a precontemplative level of change. At this level, they require consciousness raising, dramatic relief, and environmental reevaluation in an intervention program, rather than a direct action, such as providing a mammography van on site. The theoretical model is being investigated as part of the current WP research program.