Empowering factors in repeat mammography: insights from the stories of underserved women

Barriers to mammography screening among racial and ethnic minority women

RATIONALE

Breast cancer is the second leading cause of cancer death among women. Disparities in breast cancer mortality rates adversely affect racial/ethnic minority women. Mammography screening is the most effective early detection method and means of reducing mortality rates. Yet, barriers prevent racial/ethnic minority women from participating in regular screening.

OBJECTIVE

This review aimed to summarize self-reported barriers to mammography screening in racial/ethnic minority women in studies using open-ended assessments and closed-ended assessments.

METHOD

Literature searches were conducted in two databases, PsycINFO and PubMed. Barriers were detailed in full by barrier type (psychological/knowledge-related, logistical, cultural/immigration-related, and social/interpersonal) and summarized briefly by race/ethnicity (African American/Black, Asian/Pacific Islander, Hispanic, American Indian/Native American, and Middle Eastern).

RESULTS

Twenty-two open-ended and six closed-ended studies were identified as eligible for this review. Overall, racial/ethnic minority women identified common logistical and psychological/knowledge-related barriers. Additionally, women reported cultural/immigration-related and social/interpersonal barriers that were closely tied to their racial/ethnic identities.

CONCLUSIONS

It was concluded that cultural/immigration-related barriers may be the only barrier type that is unique to racial/ethnic minority women. Thus, designing studies of barriers around race and ethnicity is not always appropriate, and other demographic factors are sometimes a more important focus. The variability in 'barrier' definitions, how data were collected and reported, and the appropriateness of closed-ended measures were also examined. This literature may benefit from detailed and strategically designed studies that allow more clear-cut conclusions and better comparison across studies as well as improving closed-ended measures by incorporating insights from investigations using open-ended inquiry.

Breast Screening Utilization and Cost Sharing Among Employed Insured Women After the Affordable Care Act

OBJECTIVE

To assess changes in screening mammography cost sharing and utilization before and after the Affordable Care Act (ACA) and the revised US Preventive Services Task Force (USPSTF) guidelines. To compare mammography cost sharing between women aged 40 to 49 and those 50 to 74.

METHODS

We used patient-level analytic files between 2004 and 2014 from Clinformatics Data Mart (OptumInsight, Eden Prairie, Minnesota). We included women 40 to 74 years without a history of breast cancer or mastectomy. We conducted an interrupted time series analyses assessing cost sharing and utilization trends before and after the ACA implementation and USPSTF revised guidelines.

RESULTS

We identified 1,763,959 commercially insured women aged 40 to 74 years. Between 2004 and 2014, the proportion of women with zero cost share for screening mammography increased from 81.9% in 2004 to 98.2% in 2014, reaching 93.1% with the 2010 ACA implementation. The adjusted median cost share remained $0 over time. Initially at 36.0% in 2004, screening utilization peaked at 42.2% in 2009 with the USPSTF guidelines change, dropping to 40.0% in 2014. Comparing women aged 40 to 49, 50 to 64, and 65 to 74, the proportion exposed to cost sharing declined over time in all groups.

CONCLUSIONS

A substantial majority of commercially insured women had first-dollar coverage for mammography before the ACA. After ACA, nearly all women had access to zero cost-share mammography. The lack of an increase in mammography use post-ACA can be partially attributed to a USPSTF guideline change, the high proportion of women without cost sharing before the ACA, and the relatively low levels of cost sharing before the policy implementation.

Identifying the Social Determinants of Breast Health Behavior: a Qualitative Content Analysis

Background: Prevention, early diagnosis and reduction of mortality caused by breast cancer are the priorities of the world health systems. The aim of this study was to identify the social factors that affect the women’s breast health behavior based on the social determinants model of the World Health Organization (WHO). Materials and Method: This qualitative study was conducted and analyzed using content analysis approach. The data were collected from 32 participants by semi-structured interviews and focused group discussion. The participants comprised of breast surgeons, radiologists, health care providers and women over 35 years of age in Tehran who were selected through purposeful sampling. The interviews continued until data saturation was reached. Results: Based on the experiences of the participants, three themes were obtained from the data that shaped the women’s breast health behavior, including 1) the context of health policy, 2) socioeconomic status, and 3) cultural, psychological, and behavioral factors. Conclusion: A better understanding of social determinants related to breast health behavior can be effective in designing and applying of appropriate theories and models of education and intervention, so that, by early diagnosis of breast cancer and timely treatment of patients, the disease complications and mortality would be reduced.

A systematic review of barriers and enablers to South Asian women's attendance for asymptomatic screening of breast and cervical cancers in emigrant countries

OBJECTIVES

The aim of this review was to identify the cultural, social, structural and behavioural factors that influence asymptomatic breast and cervical cancer screening attendance in South Asian populations, in order to improve uptake and propose priorities for further research.

DESIGN

A systematic review of the literature for inductive, comparative, prospective and intervention studies. We searched the following databases: MEDLINE/In-Process, Web of Science, EMBASE, SCOPUS, CENTRAL, CDSR, CINAHL, PsycINFO and PsycARTICLES from database inception to 23 January 2018. The review included studies on the cultural, social, structural and behavioural factors that influence asymptomatic breast and cervical cancer screening attendance and cervical smear testing (Papanicolaou test) in South Asian populations and those published in the English language. The framework analysis method was used and themes were drawn out following the thematic analysis method.

SETTINGS

Asymptomatic breast or cervical screening.

PARTICIPANTS

South Asian women, including Bangladeshi, Indian, Pakistani, Sri Lankan, Bhutanese, Maldivian and Nepali populations.

RESULTS

51 included studies were published between 1991 and 2018. Sample sizes ranged from 25 to 38 733 and participants had a mean age of 18 to 83 years. Our review showed that South Asian women generally had lower screening rates than host country women. South Asian women had poorer knowledge of cancer and cancer prevention and experienced more barriers to screening. Cultural practices and assumptions influenced understandings of cancer and prevention, emphasising the importance of host country cultures and healthcare systems.

CONCLUSIONS

High-quality research on screening attendance is required using prospective designs, where objectively validated attendance is predicted from cultural understandings, beliefs, norms and practices, thus informing policy on targeting relevant public health messages to the South Asian communities about screening for cancer.

PROSPERO REGISTRATION NUMBER

CSD 42015025284.

Knowledge, Attitudes, and Beliefs Regarding Breast Cancer Among American Indian Women From the Northern Plains

American Indian women have low screening mammography rates. The authors’ goal was to compare the knowledge, attitudes, and beliefs about breast cancer among Northern Plains Reservation women who had and had not received screening mammography in the previous year. Another goal was to compare response rates achieved with an immediate monetary incentive to those achieved with an incentive after survey completion. Questionnaires were mailed to 234 women who had undergone screening mammography and 266 women who had not. Respondents included 144 (62%) of women who had been screened and 127 (48%) of women who had not. Women who had not received mammography less often were aware that older age increased breast cancer risk compared to women who had had a mammogram in the previous year. Findings suggest that Northern Plains women would benefit from educational efforts and discussions with clinicians about mammography. Immediate monetary incentives appear to increase response rates.

Barriers to cervical cancer screening among middle-aged and older rural Appalachian women

Although cervical cancer rates in the United States have declined sharply in recent decades, certain groups of women remain at elevated risk, including middle-aged and older women in central Appalachia. Cross-sectional baseline data from a community-based randomized controlled trial were examined to identify barriers to cervical cancer screening. Questionnaires assessing barriers were administered to 345 Appalachian women aged 40-64, years when Papanicolaou (Pap) testing declines and cervical cancer rates increase. Consistent with the PRECEDE/PROCEED framework, participants identified barriers included predisposing, enabling, and reinforcing factors. Descriptive and bivariate analyses are reported, identifying (a) the most frequently endorsed barriers to screening, and (b) significant associations of barriers with sociodemographic characteristics in the sample. Recommendations are provided to decrease these barriers and, ultimately, improve rates of Pap tests among this traditionally underserved and disproportionately affected group.

Examining the association of health literacy and health behaviors in African American older adults: does health literacy affect adherence to antihypertensive regimens?

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand the health information needed to make appropriate health decisions. The health behaviors of African American adults with inadequate health literacy skills affect their health outcomes. This study examined the association of health literacy and adherence behaviors in African American older adults (N = 121) with hypertension using a descriptive correlational design. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine survey, and adherence was measured using the Hill-Bone Compliance Scale. Most of the participants were functioning with inadequate health literacy. No statistically significant association was found between health literacy and adherence, but regression analysis showed that age and health status significantly predicted adherence: Those who were younger and reported poor or fair health status were less likely to adhere to treatment.

Barriers to screening mammography

Breast cancer (BRCA) is the second most commonly diagnosed cancer among women in the USA, and mammography is an effective means for the early detection of BRCA. Identifying the barriers to screening mammography can inform research, policy and practice aiming to increase mammography adherence. A literature review was conducted to determine common barriers to screening mammography adherence. PsycINFO and PubMed databases were searched to identify studies published between 2000 and 2012 that examined barriers associated with reduced mammography adherence. Three thematic groups of barriers, based on social ecology, were identified from the literature: healthcare system-level, social and individual-level barriers. Researchers must consider screening behaviour in context and, therefore, should simultaneously consider each level of barriers when attempting to understand screening behaviour and create interventions to increase mammography adherence.

Satisfaction with initial screen and compliance with biennial breast screening at centers with and without nurses

BACKGROUND

A woman's experience during her initial breast screen can influence her participation in subsequent screening.

OBJECTIVE

The purpose of this study was to determine the association between a woman's satisfaction with her initial screening experience and compliance to biennial screening at centers with and without nurses.

METHODS

A stratified random sample of compliers and noncompliers to biennial screening was selected from a cohort of 16 858 eligible women aged 50 to 65 years attending centers with and without nurses for their initial screen at the Ontario Breast Screening Program in 2002. Of these eligible women, 3387 were sent questionnaires, 2640 (77.9%) were contacted, and 1901 (72.0%) were interviewed. The association between satisfaction with initial screen and compliance was estimated separately for centers with and without nurses using logistic regression.

RESULTS

Women attending centers with nurses were significantly less likely to comply with their next screen after their clinical breast examination if they were not completely satisfied with the service they received (odds ratio, 0.21; 95% confidence interval, 0.08-0.57) or agreed that the clinical breast examination caused discomfort to their breasts (odds ratio, 0.65; 95% confidence interval, 0.45-0.94). In addition, women attending centers with or without nurses were significantly less likely to comply if they did not understand why they needed to return for screening.

CONCLUSIONS

: Nurses at screening centers have an opportunity to significantly impact a woman's compliance to biennial breast screening by providing a positive initial screening experience.

IMPLICATIONS FOR PRACTICE

Emphasis should be placed on improving a woman's overall satisfaction with her initial screening experience.

'If I feel something wrong, then I will get a mammogram': understanding barriers and facilitators for mammography screening among Chilean women

BACKGROUND

Breast cancer is the leading cause of cancer among women in Chile and in many Latin American countries. Breast cancer screening is an effective strategy to reduce mortality, but it has a very low compliance among Chilean women.

OBJECTIVE

To understand barriers and facilitators for breast cancer screening in a group of Chilean women aged 50-70.

METHODS

Following the Predisposing, Enabling and Reinforcing (PRECEDE) framework, seven focus groups (N = 48 women) were conducted with women that have had diverse experiences with breast cancer and screening practices. Information was collected using field notes and audio and video recording. Following the grounded theory model, a sequential process of open, axial and selective coding was used for the information analysis. Atlas ti 5.5 software was used for coding and segmenting the data obtained from the interviews.

RESULTS

The presence of symptoms and/or the finding of lumps through breast self-examination (BSE) were the main predisposing factors for getting a mammogram. Secrecy, embarrassment and fatalism about breast cancer were significant cultural factors that influenced the decision to seek mammogram screening. Confidence in medical staff and dignity in the treatment at the clinic were important enabling factors. The main reinforcing factors for getting the test were a sense of fulfilment by doing something good for themselves and getting timely information about the results.

CONCLUSIONS

Primary health care providers should use culturally appropriate strategies to better inform women about the importance of mammography screening and the limitations of BSE for preventing advanced breast cancer.

Screening mammography utilization in Tennessee women: the association with residence

CONTEXT

Approximately 70% of US women over age 40 report mammography screening within 2 years. However, rates are likely to vary by age, income, educational level, and residence.

PURPOSE

To describe the prevalence of screening mammography and associated factors in women living in rural and urban areas of Tennessee.

METHODS

Using pooled data from the Tennessee Behavioral Risk Factor Surveillance System (BRFSS; 2001 and 2003), utilization of screening mammography within a 2-year period was examined for a sample of 1,922 women, 40 years and older. Demographic, behavior, and health-related variables were used to examine associations with utilization.

FINDINGS

The prevalence of screening mammography utilization (71.3% 95% CI 67.4-75.2) in women living in rural areas of Tennessee was significantly lower than utilization among women living in urban areas (78.3% 95% CI 75.9-80.7). Higher utilization was associated with having attained at least a high school education, having health insurance, identifying a personal health care provider, being a nonsmoker, recent use of alcohol, having had a recent clinical breast exam or Papanicolau (Pap) test done, and meeting the Healthy People 2010 (HP 2010) recommendation for physical activity. After controlling for all other factors, rural residence was not associated with utilization. For rural women, identifying a personal health care provider was significantly associated with increased likelihood of utilization.

CONCLUSIONS

Lower income and lower education, each associated with lower screening utilization, were more common in rural Tennessee women. The significance of a personal health care provider for utilization in rural women is meaningful for service providers.

Are women with functional limitations at high risk of underutilization of mammography screening?

OBJECTIVES

Women with functional limitations face obstacles in adhering to established mammography guidelines owing to personal factors and barriers within the health care system. Whereas some studies have focused on either physical or cognitive limitations that correlate with lower rates of cancer screening, this study examined multiple functional limitations (physical, psychological, and sociability) and mammography screening.

METHODS

Data from the 2000 National Health Interview Survey were analyzed for 9,505 women aged > or =40 years. We hypothesized that women with functional limitations (physical, psychological, and/or sociability) are less likely to receive screening mammography. Access variables (insurance coverage and usual source of health care) and utilization variables (physician contact and receipt of clinical breast examination) were included. Using multiple logistic regression (MLR), we estimated the relative contribution of functional limitations on mammography use after accounting for sociodemographic characteristics and confounding variables.

RESULTS

An estimated 34.6% of women had physical limitations, 16.1% sociability limitations, and 8.1% psychological limitations. After controlling for all other variables, MLR analysis indicated that women with moderate or severe sociability limitations were less likely than their unimpaired counterparts to utilize mammography (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.48-0.81). Interestingly, women with severe physical limitations were more likely than physically able women to utilize mammography screening (OR, 1.28; 95% CI, 1.07-1.53). Women with no insurance, no usual care, and no doctor's visit within the past year were substantially less likely to use mammography screening.

CONCLUSIONS

Sociability limitations, lack of access to health care, and limited regular checkups played significant roles in underutilization of screening mammography.

Predisposing factors associated with compliance to biennial breast screening among centers with and without nurses

BACKGROUND

Previous research suggests that predisposing factors such as previous screening experience, participation in preventive health behaviors, and knowledge/beliefs about breast cancer and screening influence a woman's decision to make a timely return for a second screen.

METHODS

A stratified random sample of compliers and noncompliers to biennial screening were selected from a cohort of 51,242 women ages 50 to 65 years who had their initial screen at the Ontario Breast Screening Program. In total, 1,901 women were telephone-interviewed. The associations between predisposing factors and compliance were estimated separately for centers with and without nurses using logistic regression analyses adjusted for demographics and smoking status.

RESULTS

Women screened at nurse centers were less likely to comply if they thought women should stop having mammograms before age 70 years [odds ratio (OR), 0.39; 95% confidence interval (95% CI), 0.19-0.79], did not consider mammograms very likely to find cancer (OR, 0.73; 95% CI, 0.56-0.95), felt their likeliness of getting breast cancer was below average (OR, 0.69; 95% CI, 0.54-0.89), or believed a high-fat diet was not an important risk factor for breast cancer (OR, 0.59; 95% CI, 0.36-0.97). Women attending nurse centers were significantly more likely to comply if they sometimes had thoughts or worries about developing breast cancer (OR, 1.40; 95% CI, 1.10-1.80).

CONCLUSIONS

Nurses at screening centers may reinforce a woman's knowledge or beliefs about breast cancer or screening and as a result increase their compliance to biennial breast screening.

Perceived family history risk and symptomatic diagnosis of prostate cancer: the North Carolina Prostate Cancer Outcomes study

BACKGROUND

Prostate cancer (PrCA) is the most common cancer and the second leading cause of cancer death among US men. African American (AA) men remain at significantly greater risk of PrCA diagnosis and mortality than other men. Many factors contribute to the experienced disparities.

METHODS

Guided by the Health Belief Model, the authors surveyed a population of AA and Caucasian men newly diagnosed with PrCA to describe racial differences in perceived risk of PrCA and to examine whether 1) perceived high risk predicts greater personal responsibility for prostate care; and 2) greater personal responsibility for prostate care predicts earlier, presymptomatic diagnosis. Multivariate general linear modeling was performed.

RESULTS

The authors found that men with a PrCA family history appreciated their increased risk, but AA men with a family history were less likely to appreciate their increased risk. Nevertheless, neither reporting a PrCA family history nor perceived increased risk significantly predicted screening and preventive behaviors. Furthermore, higher physician trust predicted increased likelihood to have regular prostate exams and screening, indicating that the racial differences in seeking prostate care may be mediated through physician trust. Expressed personal responsibility for screening and more frequent preventive behaviors were associated with more frequent screening diagnoses, fewer symptomatic diagnoses, and less frequent advanced cancers.

CONCLUSIONS

Together, these results indicate that appreciating greater risk for PrCA is not sufficient to ensure that men will intend, or be able, to act. Increased trust in physicians may be a useful, central marker that efforts to reduce disparities in access to medical care are succeeding.

Breast cancer disparities and decision-making among U.S. women

OBJECTIVE

The impact of breast cancer is immense for all women, but the literature reveals an even greater impact on women of color and among socially and economically disadvantaged populations. Persistent differences in incidence and outcome are undoubtedly due to multiple factors, but one element in poor outcome may be treatment choice. Those treatments shown to be related to best outcomes are less likely to be chosen by certain groups of women. The effects of economic and cultural factors on breast cancer treatment choice have not been thoroughly explored; these factors must be understood if health care professionals are to intervene effectively to address disparities and improve breast cancer outcomes for all women.

METHODS

A review of the breast cancer literature was conducted in order to: (1) describe breast cancer disparities in the United States; (2) delineate factors that might contribute to those disparities; (3) assess possible mitigating factors for predominant causes; (4) begin to decide how health care interventions might allay the factors that contribute to disparities in breast cancer incidence and mortality.

RESULTS

Breast cancer incidence and outcome disparities in the United States are due to multiple interacting factors. These include information about treatment, different types of treatment, the emotional context of decision-making, and patient preference for level of involvement. Treatment decision-making is complex.

CONCLUSION

Health literacy and level of decision-making involvement, both embedded in social and economic reality, are key components in breast cancer treatment decision-making and may contribute to breast cancer disparities in the United States. Current models of shared decision-making may not be generalizable to all breast cancer patients.

PRACTICE IMPLICATIONS

Optimal breast cancer outcomes for all women depend on culturally and ethnically appropriate professional support.

Risk reduction behaviors and provider communication following genetic counseling and BRCA1 mutation testing in an African American kindred

Little is known about the impact of cancer genetic counseling and testing on health behaviors in racial and ethnic subgroups. This prospective observational study examined use of risk reduction strategies following BRCA1 counseling and testing. Participants were female members of an African American kindred who received genetic education, counseling and testing (n = 40) and completed a 1-year follow-up interview. Mutation carriers were more likely to opt for breast (100%, 7/7) and ovarian (25%; 1 of 4) cancer surveillance than prophylactic surgery. Following genetic counseling, 71% (5/7) of the BRCA1 carriers who opted for surveillance reported having a mammogram within the year following receipt of their genetic test results. Ovarian cancer screening among mutation carriers increased from 0% at baseline to 25% (one of four) at 1 year. Compared to noncarriers (23%, 7/30), carriers (70%, 7/10) were more likely to discuss their BRCA1 test results with their primary health care providers. Surveillance for breast cancer was preferred to prophylactic surgery and chemoprevention as a way to reduce risk for these cancers. Our data indicate that patient-provider communication about BRCA1 test results is suboptimal.

Changes Needed in the Healthcare System

Lay health workers can play a crucial role in connecting the community-in-need to the healthcare system. This article provides insights into how lay health workers, selected from underserved communities, view the issues faced in accessing the healthcare system. A sample of lay health workers responded to a questionnaire used to identify barriers they, themselves, experienced as well as get their perspectives on obstacles faced by their clients. The results demonstrated that lay health workers perceived themselves less affected by barriers as compared with their clients in regard to their provider relationship, getting health information, and their own personal attitudes and beliefs about healthcare. In addition, focus group discussions yielded recommendations and potential solutions to reduce barriers and improve the healthcare system, which included improved access to the facilities, management, scope of services offered, and provider behaviors. These results may benefit the efforts of healthcare professionals and researchers by enhancing their knowledge of, and facility to utilize and deploy, community resources, and, in turn, will assist underserved populations to better negotiate the system and obtain the services they need the most.