Problem: Among women in South Carolina, breast cancer was the most commonly diagnosed cancer and the second leading cause of cancer death from 2010-2014.1 This initiative focused on Orangeburg County due to a combination of low average household income and low cancer screening rates.2
1Centers for Disease Control and Prevention and National Cancer Institute. (2017). United States Cancer Statistics: 1999-2014. Retrieved from https://apha.confex.com/apha/2017/mediafile/Handout/Paper385940/USCS_FactSheet.pdf
2County Health Rankings & Roadmaps, South Carolina. (2018). Retrieved from: http://www.countyhealthrankings.org/app/south-carolina/2018/rankings/outcomes/overall
PSE Change Solution: South Carolina’s Department of Health and Environmental Control, Division of Cancer Prevention and Control, Comprehensive Cancer Control Program, collaborated with the Regional Medical Center (a nonprofit medical facility whose mobile services van provides digital mammography at remote sites throughout the region); Husqvarna (the largest industrial employer in the county, employing 500 women at this worksite); and the Best Chance Network (South Carolina’s Breast and Cervical Cancer Early Detection Program) to hold screenings at the Husqvarna plant. Through this initiative, 148 women received screening, with referrals to appropriate follow-up care given as necessary.
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Among women in South Carolina, breast cancer was the most commonly diagnosed cancer and the second leading cause of cancer death from 2010-2014 (CDC and National Cancer Institute, 2017). From 2009 to 2013, there were an annual average of 73 new female breast cancer cases diagnosed and 17 deaths from this disease in Orangeburg County (Orangeburg County Health Profile, 2016). This initiative focused on Orangeburg County due to a combination of low average household income and low cancer screening rates (County Health Rankings & Roadmaps, 2018).
To counter low breast cancer screening rates, South Carolina’s Department of Health and Environmental Control (DHEC), Division of Cancer Prevention and Control (DCPC) developed a worksite cancer screening initiative. DCPC effectively collaborated with internal and external partnerships to implement this PSE initiative (Step 1: Engage):
- The Regional Medical Center (RMC), a nonprofit medical facility in Orangeburg whose mobile services van provides digital mammography at remote sites throughout the region;
- Husqvarna, the largest industrial employer in Orangeburg, SC, who readily agreed to hold screenings at its plant. Five hundred women were employed at this worksite;
- The Best Chance Network (BCN), South Carolina’s Breast and Cervical Cancer Early Detection Program. BCN has provided breast and cervical cancer screenings to women in South Carolina who meet age, income and other eligibility guidelines for 27 years.
- The Comprehensive Cancer Control Program (CCCP) initiated outreach with Husqvarna, providing technical assistance to management and breast and cervical cancer screening awareness to employees. CCCP also provided information on other screenable cancers, tobacco cessation, and additional chronic diseases, including diabetes.
- Upon entering into a provider contract with BCN, RMC was able to provide mammograms utilizing a system of prior authorization (PA) codes, described below.
In addition to supplying the mobile services van, RMC was affiliated with three local patient-centered medical homes: Family Health Centers, Inc. (Orangeburg), Medical Center of Santee and Singleton Health Care Orangeburg. These relationships allowed women who were eligible to receive onsite screening to also receive access to a medical home and enrollment in WISEWOMAN, a heart disease and stroke prevention health screening and lifestyle education program. The medical home provided comprehensive health care, including any follow-up indicated by their screening mammograms, and WISEWOMAN offered healthy lifestyle coaching and additional health care screenings.
- Prior to beginning on-site screening, Husqvarna provided its female employees with an additional 15-minute break to meet with staff from RMC to assess their eligibility for this initiative (based on BCN screening criteria).
- Husqvarna and RMC staggered these sessions (and the subsequent screenings) to accommodate employees working on different shifts.
- Eligible employees were issued PA codes that entitled them to an onsite mammogram.
- When a fewer than expected number of employees initially sought PA codes, DCPC staff visited the plant’s cafeteria and engaged employees in conversation. Staff members learned that many women were fearful of obtaining screening due to misperceptions about breast cancer screening and prognosis. In response, staff informally met one-on-one with the women to address their questions and concerns regarding screening. These one-on-one sessions resulted in a marked increase in the number of women obtaining PA codes for screening (Step 3: Assess).
- While in the cafeteria, male employees approached staff to ask about the availability of cancer screenings for men. When conversations revealed that some were hesitant about some cancer screenings, staff shared information about alternative testing methods.
- One week later, project partners returned in the mobile services van to perform mammograms; Husqvarna again provided 15-minute breaks. Twenty-seven women were screened the first day.
- Along with providing mammograms, DCPC staff provided materials on other types of cancer screening for both women and men, including cervical, colorectal and prostate cancer, along with additional educational materials.
- From September to December 2017, 148 PA codes were assigned and 148 women were screened on the mobile unit.
- Symptomatic women were referred to one of the three medical homes for appropriate follow-up care.
- Numerous female and male employees received educational materials that increased their knowledge of cancer and cancer screening methods.
- As a result of the one-on-one conversations with Husqvarna employees, RMC gained a broader understanding of this community’s health care concerns.
- Prior to this initiative, Husqvarna had explored the development of an employee wellness program. They now plan to move ahead to implement it.
- Husqvarna will continue to host RMC for monthly screenings through at least 2018.
Success Factors and Key Questions Addressed
Was enough awareness about the PSE change established to ensure successful and seamless implementation? If so, how did you generate awareness?
Yes. DCPC, RMC and Husqvarna generated awareness through one-on-one employee counseling and the distribution of written materials provided by BCN and DHEC. Husqvarna’s Health and Safety Department also promoted on-site screening.
Were stakeholders committed and engaged?
The partners remained engaged through the original screening period. They have also continued monthly on-site screenings through 2018 and expressed their commitment to continue the work in 2019 to help ensure that these efforts will be sustained.
Describe how sufficient resources were secured to ensure successful implementation and sustainability of the PSE change.
Sufficient resources were identified during planning and assessment meetings with RMC, Husqvarna and DCPC to identify roles and responsibilities. As noted above, RMC provided its mobile services van at no cost. Husqvarna allowed employees additional break time to obtain PA codes and screening. RMC also provided employees who lacked insurance with information about obtaining coverage through Medicaid, the Affordable Care Act, or other sources. For women needing follow-up treatment, employees could utilize the Family and Medical Leave Act.
How will you continuously engage stakeholders to keep momentum going?
As part of this systems change, DCPC is working with Husqvarna and RMC to develop and implement written policies to guide on-site screening at Husqvarna through the year 2022. DHEC will continue to communicate with its partners to resolve conflicts and provide technical assistance. The Division is also in the process of developing an action plan that can be applied to any worksite wellness program and has taken preliminary steps to expand this initiative to other additional worksites.
In addition, RMC used questionnaires to evaluate these efforts, with results pending (Step 7: Evaluate).
For an additional source of public cancer education, visit the South Carolina Cancer Alliance. To learn more about the health status of Orangeburg and two nearby counties, see the Tri-County Health Network’s report of its community health need assessment.
The written materials distributed from the mobile services mammography van included: “Breast Cancer: What You Need to Know,” “Breast Cancer in Young Women,” “Colorectal Cancer Screening,” “Prevent Cervical Cancer,” “Screening for Prostate Cancer,” “Health Tips for Men about Prostate Cancer: What You Can Do,” “Genital HPV Infection – CDC Fact Sheet,” and “HPV and Men – CDC Fact Sheet.”
County Health Rankings & Roadmaps, South Carolina. (2018). Retrieved from: http://www.countyhealthrankings.org/app/south-carolina/2018/rankings/outcomes/overall
South Carolina Department of Health and Environmental Control. (2016). Orangeburg County Health Profile. Retrieved from: http://www.scdhec.gov/Health/docs/LocalCancerFactSheets/SCOrangeburgCountyCancerProfile.pdf
Centers for Disease Control and Prevention and National Cancer Institute. (2017). United States Cancer Statistics: 1999-2014. Retrieved from https://apha.confex.com/apha/2017/mediafile/Handout/Paper385940/USCS_FactSheet.pdf
Resources to Support Similar Evidence-Based Initiatives
The Community Guide:
• Breast Cancer Screening: Reducing Barriers