Comprehensive community health promotion models typically combine community organization and citizen participation principles with behavioral theories to address ways to generate change at the individual and policy levels (Bracht, 1990). Social workers new to community practice struggle with the complex interplay of these theories and the need to develop skills necessary for working successfully with diverse community groups. Using an eight-year cancer prevention project, the North Carolina Breast Cancer Screening Program (NC-BCSP), as a case study, this article describes both the "science and art" (Greenwood, 1961) of conducting a successful community health promotion program. It examines how social ecological theory, social work community organization models, and principles underlying institutionalization of health promotion programs form the conceptual foundation for NC-BCSP. The article also provides examples illustrating the "art" of generating participation by both lay and professional individuals to make community health promotion efforts succeed in a seemingly resource-poor, rural area. Although the project's objectives are specific to increasing breast cancer screening rates among older African American women in rural North Carolina, many of our "lessons learned" could apply to other health or mental health promotion programs. The article concludes with guidelines for social workers who plan to conduct their own community health promotion programs.
BACKGROUND: THE PROBLEM AND THE SETTING
Breast cancer incidence in North Carolina, as it is nationally, is higher in white women; however, African American women have a 28 percent higher breast cancer mortality rate (Leserman et al., 1993). Higher mortality rates result, in part, from diagnosis at a later stage of disease. African American women are more likely to be diagnosed with late-stage disease than white women (45 percent compared with 33 percent) (Leserman et al., 1993). Later diagnosis is related to lower rates of regular breast cancer screening. In one study in rural eastern North Carolina, half as many African American women (27 percent) as white women (54 percent) reported having had a mammogram in the past year (Fletcher et al., 1993). The differences between these groups in mortality, stage of diagnosis, and screening rates are particularly disturbing given the estimated 30 percent of breast cancer deaths that could be prevented if women over the age of 50 were screened in accordance with published guidelines (Hamblin, 1991).
Given these disparities researchers have underscored the need for comprehensive community-oriented interventions to increase breast cancer screening rates in African American communities (Fletcher et al., 1993; Haynes & Mara, 1993; Worden et al., 1994; Zapka, Stoddard, Maul, & Costanza, 1991). NC-BCSP is one such program. The program is based in five rural, low-income, medically underserved counties in eastern North Carolina (Earp, Altpeter, Mayne, Viadro, & O'Malley, 1995). These counties encompass 1,200 square miles and are sparsely populated; only two towns have populations that exceed 5,000. African Americans are a larger portion of the total population than in North Carolina as a whole, ranging from 30 percent to 60 percent across the five counties. About 6,500 African American women over age 50 live in this region. Poverty rates are 50 percent to 100 percent higher than for the state as a whole, with older African American women two to three times more likely to be poor than white women (U.S. Bureau of the Census, 1990). Access to health care in these rural counties is limited. There is only one physician for every 1,300 people (North Carolina Department of Environment, Health, and Natural Resources, 1992), and two counties have been designated as "areas having difficulty in obtaining accessible screening services for breast cancer" by the state's Division of Adult Health Promotion.
NC-BCSP CONCEPTUAL ROOTS AND PROGRAM DESIGN
NC-BCSP's community health promotion approach is based on several related and reinforcing theoretical constructs. …