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Teaching Breast Self-Examination Through Pantomime:

A Unique Approach to Community Outreach
Michelle Nickerson, AD, and Patricia Potter, RN, PhD, FAAN
Cancer educators should pursue strategies to improve African American womens adherence to breast cancer screening. Successful educational approaches consider the cultural context and belief systems of African Americans. Storytelling provides a forum in which women teach one another through personal testimony. The Witness Project of St. Louis created an innovative approach to storytelling, pantomime, which is visually effective in conveying the story of how to perform breast self-examination (BSE). Pantomime offers a powerful message of the importance of regular BSE.

esearch has shown that African American women have a higher breast cancer mortality rate than their Caucasian counterparts, which is largely attributed to disproportionate rates of late-stage disease at diagnosis because of inadequate screening (Clegg, Li, Hankey, Chu, & Edwards, 2002; Li, Malone, & Darling, 2003). Although the incidence rate for breast cancer is about 12% lower in African American women than in Caucasian women, during 20002003, the mortality rate was 36% higher (American Cancer Society [ACS], 2007). The reported percentages of Caucasian and African American women aged 40 years and older who received mammograms from 20032005 were both 70%; however, only 54% of African American women reported having had a mammogram in accordance with ACS (2006) screening guidelines. African American women are no more likely to have large, advanced stage tumors than Caucasian women with the same screening history (Smith-Bindman et al., 2006). The disparity in stage and progression of disease declines when women pursue regular breast screening. Clinicians and researchers clearly should continue to pursue strategies to improve African American womens adherence to breast cancer screening. Numerous factors inuence why African American women do not adhere to regular breast screening guidelines. Historically, barriers to participation in breast cancer screening have included limited nances, problems with transportation and other access-related factors, inconvenience, lack of time, lack of physician recommendation, lack of social support, low health literacy, lack of knowledge about breast cancer, and psychological factors such as fear and fatalism (Farmer, Reddick, DAgostino, & Jackson, 2007; Lukwago et al., 2003). As for fear and fatalism, African American women often are afraid mammograms are painful and doubt the benets of screening (Russel, Champion, & Skinner, 2006). The women worry about what will happen if cancer indeed is diagnosed and believe that death is an inevi-

At a Glance Research has shown that knowledge of breast cancer is associated with improved adherence to breast cancer screening guidelines.

Storytelling is a rich cultural tradition that provides a forum

for African American women to share important health messages.

A mime presentation on how to perform breast self-examination (BSE) is a powerful means for simplifying how to perform BSE correctly.

table consequence of breast cancer (Phillips, Cohen, & Moses, 1999; Sensiba & Stewart, 1995). In a study by Sadler et al. (2007) involving more than 1,000 African American women with breast cancer, knowledge of breast cancer was associated with improved adherence to breast cancer screening guidelines; however, although women recognized the serious health threat posed by breast cancer, only 30% reported feeling well informed about the disease. Many of the women in the study demonstrated a lack of basic knowledge about breast cancer. Researchers have attempted to improve African American womens adherence to breast screening through

Michelle Nickerson, AD, is a project coordinator for the Witness Project and Patricia Potter, RN, PhD, FAAN, is a research scientist, both at Siteman Cancer Center at Barnes-Jewish Hospital and the School of Medicine at Washington University in St. Louis, MO. (Submitted July 2008. Accepted for publication October 22, 2008.)
Digital Object Identier:10.1188/09.CJON.301-304 301

Clinical Journal of Oncology Nursing Volume 13, Number 3 Teaching Breast Self-Examination Through Pantomime

various educational approaches, including videotaped presentations, culturally sensitive teaching materials, and storytelling (Grindel, Brown, Caplan, & Blumenthal, 2004; Williams-Brown, Baldwin, & Bakos, 2002). Studies that are successful in improving screening practices consider the cultural context and belief systems of the targeted population.

Storytelling to Convey Messages

Studies have shown advantages to adapting messages about health promotion to culturally relevant norms that support or inhibit change and other cultural characteristics that make a message more or less appealing (Kreuter & McClure, 2004). The approach is part of a popular healthcare initiative, integrative health care, that involves a partnership of patient and practitioner within which conventional and alternative modalities are used to stimulate the bodys innate healing potential (Boon, Verhoef, OHara, Findlay, & Majid, 2004). Communication through narrative storytelling is one alternative modality, offering a culturally rich message format that can help change and strengthen individuals beliefs and ideas about health promotion. Storytelling has been effective in promoting health behavior change among Latinos (Larkey & Gonzalez, 2007) and in reducing anxiety among patients with cancer (Crogan, Evans, & Bendel, 2008). Leeman, Skelly, Burns, Carlson, and Soward (2008) successfully tailored an individualized storytelling format to instruct African American women about diabetes management, which resulted in improved diabetes self-care practices. African American women rarely acquire new knowledge in isolation, but instead, gain knowledge through dialogues with other members of their community (Hill-Collins, 1991). Storytelling is a rich cultural tradition and a means for sharing health messages with African American women. Storytelling has been shown to be a successful forum in which African American women can teach one another through personal testimony, specically about breast health (Williams-Brown et al., 2002). Storytelling engages people socially and helps to embed guidelines for behavior. Culturally appropriate educational interventions like storytelling increase knowledge about breast cancer and screening guidelines and hold promise in improving African American womens adherence to breast self-examination (BSE) and mammography (Farmer et al., 2007).

womens survival from breast cancer (Hurd, Muti, Erwin, & Womack, 2003). The project relies on lay volunteers, many of whom are cancer survivors, to tell their stories and offer an educational approach that empowers women to increase their awareness of BSE, clinical breast examination, and screening mammography to improve their use rates of breast cancer screening. The volunteer role models employ a grassroots outreach approach by presenting in community sites such as churches, businesses, and neighborhood health centers. Both the message and the messenger volunteers incorporate spiritual and faith components that are essential to the lives of African American women (Erwin, 2002). Through witnessing, the role models demonstrate that cancer does not have to be a death sentence and that African American women can survive cancer. The Witness Project of St. Louis targets women who are at high risk for breast cancer, including older adults, uninsured or underinsured, women who have lower levels of education or income, and women who do not have a usual source of health care (OMalley et al., 2002). The Witness Project programs generally begin with the role models opening with a hymn or a prayer followed by a reading of biblical quotations and statements of faith. The spiritual and faith-based nature of the Witness Project is inherent in the program presentation and message, not simply within the environment of the presentation (Hurd et al., 2003).

The Use of Pantomime

The outreach coordinator of the Witness Project decided in 2006 to expand the scope of program activities by seeking an innovative approach for communicating with African American women. Although the Witness Project was reaching members of the African American community successfully, the coordinator desired to make an even greater impact. Her idea took shape while she was attending a church Christmas program where a group of children pantomimed a gospel song. She thought pantomime could be used to demonstrate breast self-examination.

The Witness Project

The Witness Project of St. Louis is a faith- and communitybased, culturally-competent breast education outreach program modeled after the original Witness Project at the University of Arkansas (Winthrop P. Rockefeller Cancer Institute, n.d.). The program is funded by the St. Louis afliate of the Susan B. Komen for the Cure Foundation. Witnessing is a process whereby individuals share their personal experiences, in this case about having cancer, and answer questions about their concerns, fears, and what they learned. The Witness Project programs are delivered by African American women role models who stress the importance of early detection and screening to improve
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Figure 1. Pantomime Showing Demarcation of Breast Self-Examination

Note. Photo courtesy of Barnes-Jewish Hospital. Used with permission.

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Pantomime originated as a Greek and Roman form of dramatic entertainment whereby actors represented scenes from life solely by means of body movement without use of words. In pantomime, the artist tells a story using realistic and symbolic gestures. The use of pantomime as a tool to tell women the story of the importance of BSE made sense. The Witness coordinator met with the churchs director of mime ministry and shared the purpose of the Witness Project. The two discussed the Witness Projects approach for presenting information about BSE through the use of prompt cards. The cards help the lay volunteers communicate their message. The coordinator and director collaborated and created a format for a pantomime BSE presentation. The rst step was to determine if the lay volunteers would feel comfortable in presenting pantomime and if they believed it would be a useful educational tool for African American women. Eight Witness Project volunteers attended the initial presentation of the pantomime and were impressed with its purpose and potential. This group of eight was the rst to agree to become a part of the Witness Project Breast Self-Exam Mime Ministry. The pantomime presentation involves a group of four to ve volunteers who dress in all black attire, wear pink gloves, and don white face makeup. A narrator, dressed in a black suit with a pink blouse and prompt cards, introduces the mime artists to women in the audience and reads the instructions on how to perform BSE. The mime presentation lasts approximately 510 minutes. The volunteers act out, without the use of words, the methods for conducting BSE, the location where tumors typically appear, common signs of breast cancer, and the importance for all women to perform monthly BSE. The mime artists creatively use their hands, assume certain postures, and display body movements to provide a clear visual of how to perform BSE. The mime also allows the artists to communicate the key points to remember in performing BSE correctly. For example, the artists explain how to divide the chest into four quadrants for BSE by using their hands to show how a breast is divided from top of the collar bone, to bottom of bra line, from center of chest, to under the armpit. The demarcations for BSE are shown with the vertical and horizontal use of the hands against the chest wall (see Figure 1). The narrator explains how to palpate each breast, with the artists showing the ngertip motion over their own breasts (see Figure 2). The mime artists demonstrate to women the type of breast changes to look for by miming lumps (extending their arms out to the left and grasping as though a lump is there), swelling (blowing out their jaws and extending their arms out), and puckering (making a puckering sound and using a hand signal). Women are reminded by the narrator to not forget the nipple as the artists show how to gently squeeze the nipple area.

Figure 2. Pantomime Showing How to Palpate Each Breast During Breast Self-Examination

Note. Photo courtesy of Barnes-Jewish Hospital. Used with permission.

pantomime presentation. Many women who have attended the pantomime presentation comment that the approach offers a visual outlook that is easy to remember along with an ideal of the signs and symptoms to look for. Some of the comments from women who have attended the presentation include, They made self breast exam seem so simple, I never would have thought you could mime a breast exam, Beautiful . . . it touched my heart, Reinforced what I should be doing, and Seeing the demonstration was very powerful. The Witness Project coordinator currently is working with her volunteer group to develop a new pantomime presentation that will depict the experience of having a mammogram. Mammography often is associated with fear of pain and pantomime may help in minimizing such fears and encouraging women to pursue mammography on a regular basis. Pantomime is a unique approach to convey the message of the importance of BSE and routine mammography. Responses of African American women to pantomime has been very favorable. Plans for a more thorough evaluation of pantomime presentations are underway to provide more evidence for the value and relevance of this educational approach. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No nancial relationships relevant to the content of this article have been disclosed by the authors, planners, independent peer reviewers, or editorial staff. Author Contact: Patricia Potter, RN, PhD, FAAN, can be reached at pap1212@bjc.org, with copy to editor at CJONEditor@ons.org.

Summary
The pantomime presentation provides a complete narrative and full visual picture on how to perform BSE and what to look for to detect an abnormality. The pantomime presentation is a powerful means for simplifying how to perform BSE correctly. When a presentation is completed, the women have an opportunity to ask questions of the volunteer staff. To date, more than 2,500 women have attended the Witness Project of St. Louis

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