Mammography utilization in Canadian women aged 50 to 69: identification of factors that predict initiation and adherence

Determinants of mammography screening participation-a cross-sectional analysis of the German population-based Gutenberg Health Study (GHS)

PURPOSE

We investigated the association between social inequality and participation in a mammography screening program (MSP). Since the German government offers mammography screening free of charge, any effect of social inequality on participation should be due to educational status and not due to the financial burden.

METHODS

The 'Gutenberg Health Study' is a cohort study in the Rhine-Main-region, Germany. A health check-up was performed, and questions about medical history, health behavior, including secondary prevention such as use of mammography, and social status are included. Two indicators of social inequality (equivalence income and educational status), an interaction term of these two, and different covariables were used to explore an association in different logistic regression models.

RESULTS

A total of 4,681 women meeting the inclusion criteria were included. Only 6.2% never participated in the MSP. A higher income was associated with higher chances of ever participating in a mammography screening (odds ratios (OR): 1.67 per €1000; 95%CI:1.26-2.25, model 3, adjusted for age, education and an interaction term of income and education). Compared to women with a low educational status, the odds ratios for ever participating in the MSP was lower for the intermediate educational status group (OR = 0.64, 95%CI:0.45-0.91) and for the high educational status group (0.53, 95%CI:0.37-0.76). Results persisted also after controlling for relevant confounders.

CONCLUSIONS

Despite the absence of financial barriers for participation in the MSP, socioeconomic inequalities still influence participation. It would be interesting to examine whether the educational effect is due to an informed decision.

Self-selection for mammography screening according to use of hormone replacement therapy: A systematic literature review

Mammography screening participation may be influenced by the awareness of an increase in breast cancer risk due to hormone replacement therapy (HRT), which received particular attention upon publication of the Women's Health Initiative (WHI) trial results in 2002. Our aim was to synthesize evidence on a potential self-selection for mammography screening according to HRT use. We systematically searched the literature (MEDLINE, EMBASE, CINAHL) for studies reporting on the association between HRT use and mammography screening participation. Data were extracted independently by two reviewers. Overall, 2018 studies were identified. Of these, 32 studies from nine countries, predominantly from North America (50%) and Europe (28%), were included. In studies from all countries and 94% of all studies, higher mammography screening uptake among HRT users compared to non-users was reported. In all 21 studies reporting an odds ratio, the association was positive, and in about 70% of these studies, this association was ≥2. This also held true for studies exclusively using data collected before publication of the WHI findings in 2002 (63% of all studies). The association was not restricted to certain types of screening (organized vs. opportunistic) or certain types of HRT (combined vs. estrogen-only). We found a consistent and relevant association between mammography screening uptake and HRT use. This is of considerable relevance for the design and interpretation of studies investigating risk factors or evaluating preventive measures for breast cancer.

Examining screening mammography participation among women aged 40 to 74

OBJECTIVE

To examine participation in screening mammography among women aged 40 to 74 and identify which factors are associated with those women who participate in screening.

DESIGN

Secondary analysis of the cross-sectional 2012 Canadian Community Health Survey.

SETTING

Canada.

PARTICIPANTS

A population-based national sample of 18 312 women aged 40 to 74.

MAIN OUTCOME MEASURES

Women's participation in screening mammography in the 2 years preceding the 2012 Canadian Community Health Survey; women's preventive health activities (ie, having a regular doctor, a recent physical checkup, and a Papanicolaou test), which were adjusted for sociodemographic factors.

RESULTS

Participation in recent screening mammography was highest among women aged 60 to 69 (70.3%), followed by those aged 50 to 59 (63.4%) and those aged 70 to 74 (58.4%). Almost one-third (31.4%) of women aged 40 to 49 had had a screening mammogram in the past 2 years. Having a regular doctor (odds ratio [OR] = 3.30, 95% CI 2.90 to 3.73), a physical checkup in the past year (OR = 3.06, 95% CI 2.30 to 4.08), or a Pap test in the past 3 years (OR = 3.47, 95% CI 3.18 to 3.79) more than tripled the odds that women had had a recent screening mammogram.

CONCLUSION

Aside from age being a factor associated with women's participation in screening mammography, factors related to women's health care use (having a regular doctor, a recent physical checkup, and a recent Pap test) demonstrated a stronger association with women aged 40 to 74 having had recent mammograms. The association between women's participation in screening and their preventive health activities implies that the doctor's office is an appropriate venue for conversations regarding the potential benefits and harms of screening mammography.

Participation and retention in the breast cancer screening program in New Brunswick Canada

New Brunswick (NB) Canada uses its breast cancer screening service program to assess the extent to which eligible NB women are complying with mammography guidelines. While many studies have investigated factors associated with participation in periodic breast cancer screening in Canada and elsewhere, most work has relied on self-reported surveys or smaller scale primary data collection. Using a longitudinal administrative dataset for NB over the period 1996-2011 of 255,789 eligible women aged 45-69, this study examined demographic, socioeconomic and geographic factors associated with initial participation in regular screening at age 50 and ongoing retention in the program. Logistic regression was used to examine correlates of initial screening, while rescreening participation was estimated using survival analysis accounting for rescreening episodes. Initial screening participation was lower for women born outside of NB, many women living farther away from screening centers, women in rural areas, and higher for married women. In contrast, retention was higher for rural women and women recently arrived in NB. For both participation and retention, regional disparities across health zone persisted after controlling for observable personal and locational factors. The analysis highlights important characteristics to be targeted to increase screening but also that how health zones operate their screening programs exerts a very significant effect on the use of screening services by eligible women. This offers lessons for the design and evaluation of any cancer screening program.

Correlates of clinical breast examination among lesbian, gay, bisexual, and queer women

OBJECTIVES

Lesbian, gay, bisexual, and queer (LGBQ) women have increased risk of breast cancer yet lower use of early detection screening than heterosexual women. This lower use may be due in part to sexual stigma. The study purpose was to explore correlates of past two-year clinical breast examination (CBE) among LGBQ women to better understand screening disparities, particularly among gender non-conforming LGBQ women.

METHODS

A cross-sectional Internet-based survey was conducted with LGBQ women in 2011-2012. We conducted multivariate logistic regression to assess the associations between individual, social/structural and health care factors and past two-year CBE among LGBQ women (n = 414), including a subsample of gender non-conforming LGBQ women (n = 148).

RESULTS

In multivariate analyses, significant correlates of past two-year CBE among the full sample included sexually transmitted infection knowledge (OR: 1.12, 95% CI: 1.05, 1.19), sexual risk practices (OR: 0.92, 95% CI: 0.87, 0.98), past two-year Papanicolaou test (OR: 8.36, 95% CI: 4.24, 16.45), having a regular source of health care (OR: 4.84, 95% CI: 2.60, 9.01), and health care provider knowing one's sexual orientation (OR: 3.60, 95% CI: 2.29, 5.81). Among gender non-conforming LGBQ women, perceived gender non-conformity stigma (OR: 0.85, 95% CI: 0.74, 0.99) and belief that one's health care provider is uncomfortable with one's sexual orientation (OR: 0.33, 95% CI: 0.11, 1.00) were also associated with lower screening.

CONCLUSION

These findings enhance understanding of individual, social/structural, and health care factors correlated with CBE among LGBQ women. More research is needed to understand the complex interplay of these factors to inform multi-level interventions to address screening disparities for diverse LGBQ women.

Access to medical care: how do women in Canada and the United States compare?

OBJECTIVES

The purpose of this study is to determine if access to medical care and utilization of cancer screenings differs between women in the United States and Canada. This study examined this question by comparing women in Canada to women in the United States who have insurance coverage and those who do not.

METHOD

This study used data from the 2002/03 Joint Canada United States Survey of Health and examined access to medical care and cancer screenings. A binary probit model was used to address several measures of access to medical care and cancer screening utilization.

RESULTS

This study finds five significant differences between insured American and Canadian women. Canadian women are better off in terms of ever having a mammogram, having a regular doctor, and having access to needed medicine, but fare worse in terms of having had a recent mammogram and having perceived unmet healthcare needs. With the exception of having recent mammograms, there is no statistical difference between uninsured and insured American women.

CONCLUSION

Although this study does not show that one group is strictly better off, it does show that there are significant differences between the two groups of women.

Sociodemographic determinants of nonattendance in a population-based mammography screening program in the city of Manisa, Turkey

Objectives. Community based breast cancer screening has decreased breast cancer mortality in women. This study examined the predictors of nonattendence for invitational breast cancer screening in relation to socioeconomic status in the city of Manisa, in western Turkey. Study Design. For the evaluation of the reasons for refusing to participate in the study, two districts were selected. 446 women aged between 50 and 69 years were selected from the program database by systematic random sampling. Methods. The questionnaire consisted of sociodemographic variables and the adapted version of Champion's Health Belief Model Scale. Univariete and multivariete logistic regression analysis were performed throughout the data analysis. Results. Being from an urban district and being from the western region were the risk factors for not participating in the screening program (P = 0.014, P = 0.023). A statistical significance was found between mammography-benefit, mammography-barrier and program participation (P = 0.044, P = 0.006). Although there were many more barriers for not participating in the screening program for the women of the slum district, the attendence rate of the slum district was higher than that of the urban district. Conclusions. Increased attendance may be achieved through enhancement of breast cancer awareness and by reducing some of the modifiable barriers.

Adherence to a breast cancer screening program and its predictors in underserved women in southern Brazil

BACKGROUND

Adherence to breast cancer screening is a key element to ensure effectiveness of programs aiming at downstaging of breast cancer. In this study, we evaluated adherence to a screening program and its predictors in underserved women in southern Brazil.

METHODS

Attendance to the program, which is based on yearly mammogram and clinical examination, was evaluated prospectively. Mean time frames between visits were calculated. Possible predictors of adherence (defined as mean intervals ≤18 mo), such as socioeconomic indicators and health/lifestyle behaviors, were investigated.

RESULTS

A total of 3,749 women (age 51 ± 8 y, illiteracy rate of 6.8%, 57.4% with parity ≥3) were analyzed. Median time between screening rounds was 16.5 months (interquartile range, 13.1-25.7), and median number of rounds attended was 3 (interquartile range, 2-4); 57.6% had mean intervals ≤18, and 71% ≤24 months. The most important independent predictors of adherence were high genetic risk [relative risk (RR), 1.25; 95% confidence interval (95% CI), 1.11-1.40], illiteracy (RR, 0.77; 95% CI, 0.67-0.90), parity ≥5 (RR, 0.89; 95% CI, 0.83-0.96), and smoking (RR, 0.82; 95% CI, 0.77-0.88).

CONCLUSIONS

Although the proposed screening interval was 1 year, compliance to biannual screening (accepted in several international programs) was high, especially when considering the low socioeconomic level of the sample.

IMPACT

This project aims to test a breast cancer screening model for underserved populations in limited-resource countries where adherence is an issue. The identification of worst adherence predictors can point to interventions to improve outcomes of similar public health screening strategies.

Adherence to cancer screening guidelines across Canadian provinces: an observational study

BACKGROUND

Cancer screening guidelines reflect the costs and benefits of population-based screening based on evidence from clinical trials. While most of the existing literature on compliance with cancer screening guidelines only measures raw screening rates in the target age groups, we used a novel approach to estimate degree of guideline compliance across Canadian provinces for breast, colorectal and prostate cancer screening. Measuring compliance as the change in age-specific screening rates at the guideline-recommended initiation age (50), we generally found screening patterns across Canadian provinces that were not consistent with guideline compliance.

METHODS

We calculated age-cancer-specific screening rates for ages 40-60 using the Canadian Community Health Survey (2003 and 2005), a cross-sectional, nationally representative survey of health status, health care utilization and health determinants in the Canadian population. We estimated the degree of compliance using logistic regression to measure the change in adjusted screening rates at the guideline-recommended initiation age for each province in the sample.

RESULTS

For breast cancer, after adjusting for age trends and other covariates, being above age 50 in Quebec increased the probability of being screened by 19 percentage points, from an average screening rate of 24% among 40-49 year olds. None of the other regions exhibited a statistically significant change in screening rates at age 50. Additional analyses indicated that these patterns reflect asymptomatic screening and that Quebec's breast cancer screening program enhanced the degree of guideline compliance in that province. Colorectal cancer screening practice was consistent with guidelines only in Saskatchewan, as screening rates increased at age 50 by 12 percentage points, from an average rate of 6% among 40-49 year olds. For prostate cancer, the regions examined here are not compliant with Canadian guidelines since screening rates were quite high, and there was not a discrete increase at any particular age.

CONCLUSIONS

Screening practice for breast, colorectal and prostate cancer was generally not consistent with Canadian clinical guidelines. Quebec (breast) and Saskatchewan (colorectal) were exceptions to this, and the impact of Quebec's breast cancer screening program suggests a role for policy in improving screening guideline compliance.

The effect of major depression on participation in preventive health care activities

BACKGROUND

The objective of this study was to determine whether major depressive episodes (MDE) contribute to a lower rate of participation in three prevention activities: blood pressure checks, mammograms and Pap tests.

METHODS

The data source for this study was the Canadian National Population Health Survey (NPHS), a longitudinal study that started in 1994 and has subsequently re-interviewed its participants every two years. The NPHS included a short form version of the Composite International Diagnostic Interview (CIDI-SF) to assess past year MDE and also collected data on participation in preventive activities. Initially, we examined whether respondents with MDE in a particular year were less likely to participate in screening during that same year. In order to assess whether MDE negatively altered the pattern of participation, those successfully screened at the baseline interview in 1994 were identified and divided into cohorts depending on their MDE status. Proportional hazard models were used to quantify the effect of MDE on subsequent participation in screening.

RESULTS

No effect of MDE on participation in the three preventive activities was identified either in the cross-sectional or longitudinal analysis. Adjustment for a set of relevant covariates did not alter this result.

CONCLUSION

Whereas MDE might be expected to reduce the frequency of participation in screening activities, no evidence for this was found in the current analysis. Since people with MDE may contact the health system more frequently, this may offset any tendency of the illness itself to reduce participation in screening.

Determinants of non attendance to mammography program in a region with high voluntary health insurance coverage

Background

High participation rates are needed to ensure that breast cancer screening programs effectively reduce mortality. We identified the determinants of non-participation in a public breast cancer screening program.

Methods

In this case-control study, 274 women aged 50 to 64 years included in a population-based mammography screening program were personally interviewed. Socio-demographic characteristics, health beliefs, health service utilization, insurance coverage, prior mammography and other preventive activities were examined.

Results

Of the 192 cases and 194 controls contacted, 101 and 173, respectively, were subsequently interviewed. Factors related to non-participation in the breast cancer screening program included higher education (odds ratio [OR] = 5.28; 95% confidence interval [CI95%] = 1.57–17.68), annual dental checks-ups (OR = 1.81; CI95%1.08–3.03), prior mammography at a private health center (OR = 7.27; CI95% 3.97–13.32), gynecologist recommendation of mammography (OR = 2.2; CI95%1.3–3.8), number of visits to a gynecologist (median visits by cases = 1.2, versus controls = 0.92, P = 0.001), and supplemental private insurance (OR = 5.62; CI95% = 3.28–9.6). Among women who had not received a prior mammogram or who had done so at a public center, perceived barriers were the main factors related to non-participation. Among women who had previously received mammograms at a private center, supplemental private health insurance also influenced non-participation. Benign breast symptoms increased the likelihood of participation.

Conclusion

Our data indicate that factors related to the type of insurance coverage (such as prior mammography at a private health center and supplemental private insurance) influenced non-participation in the screening program.

Socio-demographic determinants of participation in mammography screening

Our objective was to use individual data on socio-demographic characteristics to identify predictors of participation in mammography screening and control to what extent they can explain the regional difference. We used data from mammography screening programmes in Copenhagen, 1991-1999, and Funen, 1993-2001, Denmark. Target groups were identified from the Population Register, screening data came from the health authority, and socio-demographic data from Statistics Denmark. Included were women eligible for at least 3 screens. The crude RR of never use versus always use was 3.21 (95%CI, 3.07-3.35) for Copenhagen versus Funen, and the adjusted RR was 2.55 (95%CI, 2.43-2.67). The adjusted RR for never use among women without contact to a primary care physician was 2.50 (95% CI, 2.31-2.71) and 2.89 (95% CI, 2.66-3.14), and for women without dental care 2.94 (95% CI, 2.77-3.12) and 2.88 (95% CI, 2.68-3.10) for Copenhagen and Funen, respectively. Other important predictive factors for nonparticipation were not being married and not being Danish. In conclusion, to enhance participation in mammography screening programmes special attention needs to be given to women not using other primary health care services. All women in Copenhagen, irrespective of their socio-demographic characteristics, had low participation. Screening programmes have to find ways to handle this urbanity factor.

The distribution and predictive validity of the stages of change for mammography adoption among Canadian women

OBJECTIVE

To examine the predictive validity of the transtheoretical model (TTM) stages of change for mammography participation in Canadian women.

METHOD

We examined the association between baseline TTM stage of mammography adoption and subsequent mammography participation in a representative sample of 3,125 Canadian women aged 40 and older from the longitudinal Canadian National Population Health Survey.

RESULTS

The likelihood of having a mammogram at follow-up (1998/1999) increased with progressive stages of change at baseline (1996/1997) even after adjusting for potential confounders. Relative to women in maintenance, women in precontemplation, relapse, contemplation, relapse risk, and action were significantly less likely to report a recent mammogram during follow-up (adjusted RR of 0.41, 0.50, 0.63, 0.75, and 0.92, respectively; P(trend) < 0.01). This pattern held for women within and outside of the 50-69 target age range, and for urban and to a lesser degree rural-dwelling women.

CONCLUSION

Our findings support the predictive validity of the TTM stages of mammography adoption construct and the inclusion of both relapse and relapse risk categories to improve the sensitivity of the predictive model. Interventions to promote the eventual maintenance of mammography screening should also benefit from further research that aims to understand the variables that promote progressive movement through the stages.