Utilization of screening mammography among middle-aged and older women

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Barriers to routine checkups use among Saudis from the perspective of primary care providers: A qualitative study

OBJECTIVES

To explore the perspectives of primary care providers (PCPs) on the low use of and barriers to routine checkups among Saudi adults.

METHODS

A qualitative phenomenological study design was used. Interviews were carried out between (December 2020 and February 2021) with 19 PCPs working at 5 primary healthcare centers (PHCs) operated by the Ministry of Health (MOH) in Makkah, Saudi Arabia. Descriptive statistics were performed to characterize participants, and a directed content analysis was carried out to examine major themes.

RESULTS

Primary care providers identified a number of barriers that contributed to a low uptake of routine checkup among Saudis. These barriers to routine checkups were classified into 3 main themes: patient-related barriers, provider-related barriers, and healthcare system-related barriers. Lack of knowledge of patients, crowdedness at PHCs, and busy staff at PHCs were the most frequently mentioned barriers that hamper the use of routine checkups.

CONCLUSION

This study presented new insight into the low use of routine checkups by obtaining the perspective of PCPs. Although results point to potential targets for interventions to increase routine checkups, additional research is recommended with a representative sample of PCPs randomly selected from the healthcare system to inform future policy and decision making related to improving use of routine care available through the Saudi Healthcare System.

Breast Cancer in the Elderly: An Observational Study Investigating Compliance of Screening Mammography in an Underserved Community

Background

The incidence of breast cancer increases with age. Individuals living in higher socioeconomic communities also have higher incidence secondary to early detection of breast cancer from increased accessibility to mammograms. This retrospective study studied the percentage of new breast cancer cases in the elderly between 2010 and 2019, and investigated the compliance of screening mammography in some of the medically underserved suburbs of southern Chicago.

Methods

The parameters used to power this study include “age greater than 70” and “2010 to present” at the time the study was first initiated. The final data set contained 381 electronic health records (EMRs) that met the parameters of interest. We specifically looked at method of diagnosis, stage at diagnosis, date of last normal screening mammogram, hormone status, histology, race, and smoking history.

Results

Thirty percent of the breast cancer patients diagnosed at our institution were over 70 years of age between 2010 and 2019. Of the 381 patients included in the overall sample, 45% were diagnosed with breast cancer by screening mammogram, and 52% of individuals in the 70 - 75 age group were diagnosed with breast cancer by screening mammography. Only 40% of individuals in the 75+ age group were diagnosed with breast cancer by screening mammogram (P = 0.0234). Furthermore, in the overall sample, 63% had a normal screening mammogram at some time prior to their breast cancer diagnosis. In the 70 - 75 age group, 76% had a normal screening mammogram at some time prior to their breast cancer diagnosis. In the 75+ age group, only 54% had a normal screening mammogram at some time prior to their breast cancer diagnosis (P < 0.0001). Individuals in both age groups were more likely to have early-stage breast cancers and luminal A hormone expression.

Conclusions

Decreased compliance to screening mammography is observed in the elderly living in underserved communities. Since the elderly are underrepresented in research, organizations do not have sufficient information to recommend screening mammography in the elderly. With increasing life expectancy, observational studies have demonstrated a mortality benefit with screening mammography by early detection of breast cancer, favorable breast cancer characteristics and potentially higher cure rates. Socioeconomic factors also affect screening compliance and likely influenced the results of our study. Future studies should investigate how individual factors influence screening mammography compliance in the elderly in underserved communities.

Knowledge and Practice of Breast Cancer Screening Methods among Female Community Pharmacists in Jordan: A Cross-Sectional Study

Objectives

Our study is aimed at exploring the knowledge and personal practice of breast cancer screening among female community pharmacists in Jordan.

Methods

A cross-sectional survey was carried out using a nonrandom sample selection method for pharmacists in community pharmacies.

Results

A total of 551 female pharmacists completed the questionnaire. The mean age of pharmacists was 29.1 ± 7.3 years (range 21–67), and most have bachelor degrees in pharmacy (89.1%). The mean score of knowledge of breast cancer signs and symptoms was 4.2 ± 1.5 out of 6 points (range 0–6). The mean score of knowledge of risk factors was 7.6 ± 1.9 out of 12 points (ranging from 2–12). The mean score for knowledge of screening guidelines was 2.8 ± 0.9 out of 4 points (range 0–4). Overall, 452 pharmacists (85.8%) had acceptable knowledge while 75 pharmacists (14.2%) had poor knowledge of breast cancer. Pharmacists surveyed were aware of the different screening methods of breast cancer. The percentage of pharmacists who has performed breast self-examination (BSE), clinical breast examination (CBE), and mammography was 46.6%, 16.5%, and 5.4%, respectively. The most common reason for the lack of BSE and CBE performance was the absence of breast symptoms. Not being at the age recommended for mammography was the most common reason for not undergoing this screening method. Knowledge and practice of screening methods were influenced by age, years of experience, geographic region, personal history of breast cancer, and educational level among community pharmacists.

Conclusions

This study revealed some gaps in the knowledge of breast cancer among female community pharmacists. The practice of the different screening methods was suboptimal, and variable reasons were indicated for the low uptake of these screening methods. Community pharmacists need to practice preventive behaviors to a satisfactory level to encourage women in the community to adopt similar behavior.

Association of depression with adherence to breast cancer screening among women aged 50 to 74 years in the United States

RATIONALE, AIMS, AND OBJECTIVES

Previous research has shown inconsistent results regarding the association of depression and screening mammography use behaviours. This study aimed to assess the relationship between women's depression and mammography adherence.

METHODS

This cross-sectional study used data from the 2016 Behavioural Risk Factor Surveillance System and employed the Health Belief Model (HBM). The primary independent variable was the presence of depression. The dependent variable was adherence to biennial screening mammography based on the US Preventive Services Task Force guidelines. Demographic characteristics and HBM constructs were included as covariates. Univariate and multivariate logistic regressions were used.

RESULTS

A total of 139 550 women were included (weighted n = 48 712 531). Among them, 23.1% reported the presence of depression (n = 32 247). The unadjusted odds ratio (OR) for mammography use in women with depression was 0.85 (95% confidence interval [CI], 0.80-0.91, P < .001) compared with women without depression, and the probability of mammography use was significantly lower in women with depression (76.3%; 95% CI, 75.4-77.3) compared with women without depression (79.1%; 95% CI, 78.5-79.6). However, the adjusted OR was not statistically significant when controlling for demographic and HBM characteristics (1.02; 95% CI, 0.93-1.11, P = .698), and the probabilities of mammography use were similar between women with depression (80.1%; 95% CI, 79.0-81.3) and without depression (79.9%; 95% CI, 79.2-80.6).

CONCLUSIONS

Depression itself was related to nonadherence with mammography screening guidelines. However, after controlling for demographic and HBM characteristics, depression was not associated with adherence with mammography screening guidelines.

Addressing perceived economic obstacles to genetic testing as a way to mitigate disparities in family health history for adoptees

In this paper, we ask whether or not we can afford to realize the potential benefits of genetic testing as a screening tool for adoptees. Our method is to provide reasonable cost and savings estimates. We argue that the prospect of cost neutrality should be sufficient to explore the targeted screening for a population who will otherwise suffer an avoidable health disparity in access to inherited disease information. Our goal here is to establish that the investment needed to attain these benefits is not beyond our means.

Comparing Rural and Urban Cervical and Breast Cancer Screening Rates in a Privately Insured Population

Low preventive screening varies by region and contributes to poor outcomes for breast and cervical cancer. Previous comparative urban and rural research on preventive screening has focused on government programs. This study quantified and compared rural and urban preventive cancer screening rates for women who were privately insured. National Quality Forum measures were used to calculate rates for women within rural and urban parts of the same Hospital Referral Region (HRR) using claims data. Mammography screening rates for women age 24 to 69 years were 77.1% in 2011 and 76.1% in 2008. Compared to urban women, mammography screening rates for women visiting rural physicians were lower in 42%, higher in 2% and identical in 56% of HRRs. Cervical cancer screening rates for women age 21 to 64 years were 82.9% in 2011 and 83.5% in 2008. Cervical cancer screening rates among women who saw rural physicians were lower in 55%, higher in 4%, and identical in 42% of HRRs. HRRs where rural areas underperformed urban areas increased between 2008 and 2011 for both screenings. Moderate but notable differences in women's preventive screening rates between rural and urban physicians highlight the need for practical solutions that increase use of screening services and reduce barriers to services in rural areas.

Relative Association of Multi-Level Supportive Environments on Poor Health among Older Adults

Background: The aging of the United States population poses significant challenges to American healthcare and informal caregiving systems. Additional research is needed to understand how health promotion programs and policies based on a socio-ecological perspective impact the health and well-being of older persons. The purpose of this study was to investigate personal characteristics and supportive environments associated with poor health among older individuals aged 65 and over. Methods: This study used a cross-sectional design and was guided by a conceptual framework developed by the authors to depict the relationship between personal characteristics and environments associated with poor health status. Environment types included in this study were family, home, financial, neighborhood, and healthcare. The sample was comprised of 1319 adults aged 65 years and older residing in Central Texas. From a random selection of households, participants were administered a mail-based survey created by a community collaborative effort. Descriptive statistics and three binary logistic regression models were fitted to examine associations with poor health status (i.e., physical, mental, and combined physical/mental). Results: Two personal characteristics (number of chronic conditions and educational level) were consistently related (p < 0.05) to health outcomes. Supportive family, home, financial, neighborhood, and health care environmental factors were shown to be related (p < 0.05) to various aspects of physical or mental health outcomes. Conclusions: Multidimensional factors including personal characteristics and protective environments are related to health status among older individuals. The unique roles of each environment can help inform public health interventions to create and enhance support for older adults to engage in healthful activities and improve their physical and mental health.

Racial Disparities in Screening Mammography in the United States: A Systematic Review and Meta-analysis

PURPOSE

Many studies have suggested that disparities exist in the use of medical screening tests. The purpose of this study was to assess racial disparities in screening mammography in the United States via a systematic review and meta-analysis.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus for comparative studies published between 1946 and 2015 comparing utilization of mammography among various racial groups. Two independent reviewers extracted data and appraised study. Meta-analysis was conducted when appropriate using the random-effects model.

RESULTS

A total of 5,818,380 patients were included across 39 relevant studies; 43.1% of patients were white, 33.3% were black, 17.4% were Hispanic, and 6.2% were Asian/Pacific Islander. Black and Hispanic populations had lower odds of utilizing screening mammography when compared with the white population (odds ratio [OR] = 0.81; 95% confidence interval [CI], 0.72-0.91; I² = 89.4% and OR = 0.83; 95% CI, 0.74-0.93, respectively). For African Americans, these disparities were present in both the 40 to 65 age group and the >65 age group; for Hispanics, these differences were present only in the 40 to 65 age group. There was no difference in mammography utilization between Asians/Pacific Islanders and whites (OR = 1.82; 95% CI, 0.09-38.41).

CONCLUSIONS

Racial disparities in utilization of screening mammography are evident in black and Hispanic populations in the United States. Further studies are needed to understand reasons for disparities, trends over time, and the effectiveness of interventions targeting these disparities.

Changes in breast cancer risk distribution among Vermont women using screening mammography

BACKGROUND

Screening mammography utilization in Vermont has declined since 2009 during a time of changing screening guidelines and increased interest in personalized screening regimens. This study evaluates whether the breast cancer risk distribution of the state's screened population changed during the observed decline.

METHODS

We examined the breast cancer risk distribution among screened women between 2001 and 2012 using data from the Vermont Breast Cancer Surveillance System. We estimated each screened woman's 5-year risk of breast cancer using the Breast Cancer Surveillance Consortium risk calculator. Annual screening counts by risk group were normalized and age-adjusted to the Vermont female population by direct standardization.

RESULTS

The normalized rate of low-risk (5-year breast cancer risk of <1%) women screened increased 8.3% per year (95% confidence interval [CI] = 4.8 to 11.9) between 2003 and 2008 and then declined by -5.4% per year (95% CI = -8.1 to -2.6) until 2012. When stratified by age group, the rate of low-risk women screened declined -4.4% per year (95% CI = -8.8 to 0.1; not statistically significant) for ages 40 to 49 years and declined a statistically significant -7.1% per year (95% CI = -12.1 to -2.0) for ages 50 to 74 years during 2008 to 2012. These declines represented the bulk of overall decreases in screening after 2008, with rates for women categorized in higher risk levels generally exhibiting small annual changes.

CONCLUSIONS

The observed decline in women screened in Vermont in recent years is largely attributable to reductions in screening visits by women who are at low risk of developing breast cancer.

Do breast cancer risk factors differ among those who do and do not undertake mammography screening?

Objectives

There is considerable interest in whether mammography screening leads to over-diagnosis of breast cancer. However self-selection into screening programmes may lead to risk differences that affect estimates of over-diagnosis. This study compares the breast cancer risk profiles of participants and non-participants of population-based mammography screening. Risk profiles are also compared between those who have and have not used private screening services.

Setting

This study involved 1162 women aged 40–84 who participated in the 2012 Health Omnibus, an annual face-to-face interview-based survey of a representative sample of the population in the state of South Australia.

Methods

Data were collected on participation in mammography screening, demographic characteristics and breast cancer risk factors (including reproductive, familial and lifestyle factors). Missing data were multiply imputed. Factors independently associated with ever having been screened were identified using multivariable logistic regression, for population-based and ad hoc, private mammography screening separately.

Results

Compared with non-participants, participants of population-based screening were more likely to have used hormone replacement therapy (odds ratio [OR] = 3.72), experienced breast biopsy or surgery (OR = 2.22), and be overweight or obese (OR = 1.57). They were less likely to be sufficiently active (OR = 0.57) or be born in a non-English speaking country (OR = 0.50) or aged under 50 (OR = 0.09). Women who were screened privately were more likely to have a family history of breast cancer (OR = 1.66) and have experienced breast biopsy or surgery (OR = 3.17) than those who had not.

Conclusions

South Australian women who participated in the population-based mammography screening have a slightly higher prevalence of breast cancer risk factors. This also applies to those who undertook private screening.

Healthcare access and mammography screening in Michigan: a multilevel cross-sectional study

BACKGROUND

Breast cancer screening rates have increased over time in the United States. However actual screening rates appear to be lower among black women compared with white women.

PURPOSE

To assess determinants of breast cancer screening among women in Michigan USA, focusing on individual and neighborhood socio-economic status and healthcare access.

METHODS

Data from 1163 women ages 50-74 years who participated in the 2008 Michigan Special Cancer Behavioral Risk Factor Survey were analyzed. County-level SES and healthcare access were obtained from the Area Resource File. Multilevel logistic regression models were fit using SAS Proc Glimmix to account for clustering of individual observations by county. Separate models were fit for each of the two outcomes of interest; mammography screening and clinical breast examination. For each outcome, two sequential models were fit; a model including individual level covariates and a model including county level covariates.

RESULTS

After adjusting for misclassification bias, overall cancer screening rates were lower than reported by survey respondents; black women had lower mammography screening rates but higher clinical breast examination rates than white women. However, after adjusting for other individual level variables, race was not a significant predictor of screening. Having health insurance or a usual healthcare provider were the most important predictors of cancer screening.

DISCUSSION

Access to healthcare is important to ensuring appropriate cancer screening among women in Michigan.