Engaging diverse underserved communities to bridge the mammography divide

The need to study rural cancer outcome disparities at the local level: a retrospective cohort study in Kansas and Missouri

Background

Rural residence is commonly thought to be a risk factor for poor cancer outcomes. However, a number of studies have reported seemingly conflicting information regarding cancer outcome disparities with respect to rural residence, with some suggesting that the disparity is not present and others providing inconsistent evidence that either urban or rural residence is associated with poorer outcomes. We suggest a simple explanation for these seeming contradictions: namely that rural cancer outcome disparities are related to factors that occur differentially at a local level, such as environmental exposures, lack of access to care or screening, and socioeconomic factors, which differ by type of cancer.

Methods

We conducted a retrospective cohort study examining ten cancers treated at the University of Kansas Medical Center from 2011 to 2018, with individuals from either rural or urban residences. We defined urban residences as those in a county with a U.S. Department of Agriculture Urban Influence Code (UIC) of 1 or 2, with all other residences defines a rural. Inverse probability of treatment weighting was used to create a pseudo-sample balanced for covariates deemed likely to affect the outcomes modeled with cumulative link and weighted Cox-proportional hazards models.

Results

We found that rural residence is not a simple risk factor but rather appears to play a complex role in cancer outcome disparities. Specifically, rural residence is associated with higher stage at diagnosis and increased survival hazards for colon cancer but decreased risk for lung cancer compared to urban residence.

Conclusion

Many cancers are affected by unique social and environmental factors that may vary between rural and urban residents, such as access to care, diet, and lifestyle. Our results show that rurality can increase or decrease risk, depending on cancer site, which suggests the need to consider the factors connected to rurality that influence this complex pattern. Thus, we argue that such disparities must be studied at the local level to identify and design appropriate interventions to improve cancer outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12190-w.

Building on existing tools to improve chronic disease prevention and screening in public health: a cluster randomized trial

BACKGROUND

The BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) intervention was designed to integrate the approach to chronic disease prevention and screening in primary care and demonstrated effective in a previous randomized trial.

METHODS

We tested the effectiveness of the BETTER HEALTH intervention, a public health adaptation of BETTER, at improving participation in chronic disease prevention and screening actions for residents of low-income neighbourhoods in a cluster randomized trial, with ten low-income neighbourhoods in Durham Region Ontario randomized to immediate intervention vs. wait-list. The unit of analysis was the individual, and eligible participants were adults age 40-64 years residing in the neighbourhoods. Public health nurses trained as "prevention practitioners" held one prevention-focused visit with each participant. They provided participants with a tailored prevention prescription and supported them to set health-related goals. The primary outcome was a composite index: the number of evidence-based actions achieved at six months as a proportion of those for which participants were eligible at baseline.

RESULTS

Of 126 participants (60 in immediate arm; 66 in wait-list arm), 125 were included in analyses (1 participant withdrew consent). In both arms, participants were eligible for a mean of 8.6 actions at baseline. At follow-up, participants in the immediate intervention arm met 64.5% of actions for which they were eligible versus 42.1% in the wait-list arm (rate ratio 1.53 [95% confidence interval 1.22-1.84]).

CONCLUSION

Public health nurses using the BETTER HEALTH intervention led to a higher proportion of identified evidence-based prevention and screening actions achieved at six months for people living with socioeconomic disadvantage.

TRIAL REGISTRATION

NCT03052959 , registered February 10, 2017.

How do reproductive age women perceive breast cancer screening in Ethiopia? A qualitative study

Background

Breast cancer remains one of the deadliest non-communicable diseases in the world. In Ethiopia, breast cancer accounts for 33.4% of total cancer diagnosis in women.

Objective

This study aims to explore perception about breast screening behavior among reproductive age women.

Methods

This qualitative study was conducted as a baseline to identify gaps to design interventions that will enhance breast screening uptake among reproductive age women. Six focus group discussions and 9 in-depth interviews were conducted with women and health workers respectively. Semi-structured questions were used. Data analysis was analyzed by Atlas.ti. 7 and the ideas were put in direct quotation and narration.

Results

Lack of awareness is the preceding problem for self-susceptibility to breast cancer as well as for having breast screening. Majority of women thought that the cause of breast cancer was a sin (supernatural power). Self-efficacy and cues to action were the most important correlates of the perception owing to fear of socio-cultural stigma and discrimination.

Conclusion

All health belief model constructs identified a critical problem for adaptation of behavior. Therefore, this gives the opportunity to design and develop community-based intervention and explore new intervention mechanism with an accurate method.

A systematic review of health promotion interventions to increase breast cancer screening uptake: from the last 12 years

Background

The outcome of breast cancer treatment largely depends on the timing of detection. The health promotion interventions have an immense contribution to early detection and improved survival. Therefore, this review aimed to provide evidence on the efficacy of the health promotion interventions to increase the uptake of breast cancer screening and to develop effective interventions targeting women.

Methods

Online databases (PubMed/MEDLINE/PubMed Central, Ovid/MEDILINE, EMBASE, Web of Science and Google Scholar) were searched for studies published between January 2005 and January 2017. A quality coding system was assessed using Cochrane checklists for randomized controlled trial (RCT) and Downs and Black checklists for non-RCT. The score was rated for the included articles by each researcher independently and the average score is given accordingly. This study was registered in PROSPERO as [PROSPERO 2017: CRD42017060488].

Results

The review dovetailed 22 studies. Thirteen studies (59.10%) were conducted in the Unite States, 4 in Iran (18.18%), 2 in India (9.09%) and 1 each in Turkey, Saudi Arabia and Israel. The interventions were classified as ‘individual-based’, ‘community-based’, ‘group-based teachings and training’ and ‘behavioral model based’. The majority of the studies showed favorable outcomes after health promotion interventions, including improvements in women’s view of breast screening, breast self-examination and knowledge of breast screening.

Conclusion

The review confirmed that most of the health promotion interventions targeting women boosted the breast screening in one or another way. However, the limited quality of the included studies showed that further research is needed to improve the trials in the next future.

A narrative synthesis scoping review of life course domains within health service utilisation frameworks

Background: Current thinking in health recognises the influence of early life experiences (health and otherwise) on later life outcomes. The life course approach has been embedded in the work of the World Health Organisation since the Ageing and Health programme was established in 1995. Yet there has been limited debate on the relevancy of a life course lens to understanding health service utilisation. Aim: The aim of the review was twofold. Firstly, identify existing healthcare utilisation frameworks other than the dominant Andersen's behavioural model currently in use. Secondly, to identify if current frameworks incorporate the advocated life course perspective in understanding health service utilisation.     Methods: A scoping review of PubMed, Cinahl Plus, Emerald, PsycINFO, Web of Knowledge and Scopus was conducted. Data extraction used a framework approach with meta-synthesis guided by the four domains of the life course proposed by Elder (1979): human agency, location, temporality and relationships, and interdependencies. Results: A total of 551 papers were identified, with 70 unique frameworks (other than Andersen's Behavioural Model) meeting the inclusion criteria and included in the review. Conclusion: To date there has been limited explicit discussion of health service utilisation from a life course perspective. The current review highlights a range of frameworks that draw on aspects of the life course, but have been used with this perspective in mind. The life course approach highlights important gaps in understanding and assessing health service utilisation (HSU), such as utilisation over time. HSU is a complex phenomenon and applying a structured framework from a life course perspective would be of benefit to researchers, practitioners and policy makers.

Increasing Breast and Cervical Cancer Screening in Rural and Border Texas with Friend to Friend Plus Patient Navigation

The Friend to Friend plus Patient Navigation Program (FTF+PN) aims to build an effective, sustainable infrastructure to increase breast and cervical screening rates for underserved women in rural Texas. The objective of this paper is to identify factors that (1) distinguish participants who chose patient navigation (PN) services from those who did not (non-PN) and (2) were associated with receiving a mammogram or Papanicolaou (Pap) test. This prospective study analyzed data collected from 2689 FTF+PN participants aged 18-99 years from March 1, 2012 to February 28, 2015 who self-identified as African American (AA), Latina, and non-Hispanic white (NHW). Women who were younger, AA or Latina, had less than some college education, attended a FTF+PN event because of the cost of screening or were told they needed a screening, and who reported a barrier to screening had higher odds of being a PN participant. Women who were PN participants and had more contacts with program staff had greater odds of receiving a mammogram and a Pap compared with their reference groups. Latina English-speaking women had lower odds of receiving a mammogram and a Pap compared with NHW women and Latina Spanish-speaking women had higher odds of receiving a Pap test compared with NHW women. Women with greater need chose PN services, and PN participants had higher odds of getting a screening compared with women who did not choose PN services. These results demonstrate the success of PN in screening women in rural Texas but also that racial/ethnic disparities in screening remain.

Healthcare Factors for Obtaining a Mammogram in Latinas With a Variable Mammography History

PURPOSE/OBJECTIVES

To understand the relationship between mammography history and current thoughts about obtaining a mammogram among Latinas and examine the mediation effects of several healthcare factors.
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DESIGN

Cross-sectional survey.
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SETTING

Federally qualified health centers (Sea Mar Community Health Centers) in western Washington.
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SAMPLE

641 Latinas nonadherent and adherent with screening mammography.
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METHODS

Baseline survey data from Latinas with a mammography history of never, not recent (more than two years), or recent (less than two years) were analyzed. Preacher and Hayes methods were used to estimate the mediation effect of healthcare factors.
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MAIN RESEARCH VARIABLES

The survey assessed mammography history, sociodemographic and healthcare factors, and current thoughts about obtaining a mammogram.
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FINDINGS

Latinas' thoughts about obtaining a mammogram were associated with mammography history. Having had a clinical breast examination mediated 70% of differences between Latinas with a never and recent mammography history. Receipt of a provider recommendation mediated 54% of differences between Latinas with and without a recent mammography history.
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CONCLUSIONS

These findings emphasize the importance of the patient-provider relationship during a clinic visit and help inform how nurses may be incorporated into subsequent screening mammography interventions tailored to Latinas.
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IMPLICATIONS FOR NURSING

As providers, health educators, and researchers, nurses have critical roles in encouraging adherence to screening mammography guidelines among Latinas.

Organizational Factors Affecting the Likelihood of Cancer Screening Among VA Patients

BACKGROUND

Preventive service delivery, including cancer screenings, continues to pose a challenge to quality improvement efforts. Although many studies have focused on person-level characteristics associated with screening, less is known about organizational influences on cancer screening.

OBJECTIVES

This study aims to understand the association between organizational factors and adherence to cancer screenings.

METHODS

This study employed a cross-sectional design using organizational-level, patient-level, and area-level data. Dependent variables included breast, cervical, and colorectal cancer screening. Organizational factors describing resource sufficiency were constructed using factor analyses from a survey of 250 Veterans Affairs primary care directors. We conducted random-effects logistic regression analyses, modeling cancer screening as a function of organizational factors, controlling for patient-level and area-level factors.

RESULTS

Overall, 87% of the patients received mammograms, 92% received cervical and 78% had colorectal screening. Quality improvement orientation increased the odds of cervical [odds ratio (OR): 1.27; 95% confidence interval (CI), 1.03-1.57] and colorectal cancer screening (OR: 1.10; 95% CI, 1.00-1.20). Authority in determining primary care components increased the odds of mammography screening (OR: 1.23; 95% CI, 1.03-1.51). Sufficiency in clinical staffing increased the odds of mammography and cervical cancer screenings. Several patient-level factors, serving as control variables, were associated with achievement of screenings.

CONCLUSIONS

Resource sufficiency led to increased odds of screening possibly because they promote excellence in patient care by conveying organizational goals and facilitate goal achievement with resources. Complementary to patient-level factors, our findings identified organizational processes associated with better performance, which offer concrete strategies in which facilities can evaluate their capabilities to implement best practices to foster and sustain a culture of quality care.

Interventions to reach underscreened populations: a narrative review for planning cancer screening initiatives

OBJECTIVES

This review was conducted to support knowledge translation (KT) and implementation of interventions to increase participation in organized cancer screening programs in the province of Ontario, Canada.

METHODS

A rigorously designed literature search yielded over 900 references which were then subjected to exclusion criteria. The remainder was organized according to type of intervention, based on the categories applied in two authoritative systematic reviews and an analysis of the level of evidence. Emerging themes in the literature were then identified to provide a bridge between high-level evidence and on-the-ground practice.

RESULTS

We identify three promising types of KT interventions: community-based health education; lay or peer health education; and targeted or tailored interventions. Each is summarized with illustrative examples and a summary of key themes and considerations.

CONCLUSIONS

The authors conclude with a summary the types and a decision tool designed to help KT and implementation teams select interventions which could be adapted to their own context.

Implementation intentions and colorectal screening: a randomized trial in safety-net clinics

CONTEXT

Low-income and racial/ethnic minority populations experience disproportionate colorectal cancer (CRC) burden and poorer survival. Novel behavioral strategies are needed to improve screening rates in these groups.

BACKGROUND

The study aimed to test a theoretically based "implementation intentions" intervention for improving CRC screening among unscreened adults in urban safety-net clinics.

DESIGN

Randomized controlled trial.

SETTING/PARTICIPANTS

Adults (N=470) aged ≥50 years, due for CRC screening, from urban safety-net clinics were recruited.

INTERVENTION

The intervention (conducted in 2009-2011) was delivered via touchscreen computers that tailored informational messages to decisional stage and screening barriers. The computer then randomized participants to generic health information on diet and exercise (Comparison group) or "implementation intentions" questions and planning (Experimental group) specific to the CRC screening test chosen (fecal immunochemical test or colonoscopy).

MAIN OUTCOME MEASURES

The primary study outcome was completion of CRC screening at 26 weeks based on test reports (analysis conducted in 2012-2013).

RESULTS

The study population had a mean age of 57 years and was 42% non-Hispanic African American, 28% non-Hispanic white, and 27% Hispanic. Those receiving the implementation intentions-based intervention had higher odds (AOR=1.83, 95% CI=1.23, 2.73) of completing CRC screening than the Comparison group. Those with higher self-efficacy for screening (AOR=1.57, 95% CI=1.03, 2.39), history of asthma (AOR=2.20, 95% CI=1.26, 3.84), no history of diabetes (AOR=1.86, 95% CI=1.21, 2.86), and reporting they had never heard that "cutting on cancer" makes it spread (AOR=1.78, 95% CI=1.16, 2.72) were more likely to complete CRC screening.

CONCLUSIONS

The results of this study suggest that programs incorporating an implementation intentions approach can contribute to successful completion of CRC screening even among very low-income and diverse primary care populations. Future initiatives to reduce CRC incidence and mortality disparities may be able to employ implementation intentions in large-scale efforts to encourage screening and prevention behaviors.

Breast cancer screening beliefs and behaviors among American Indian women in Kansas and Missouri: a qualitative inquiry

American Indian women have rising incidence and disproportionate mortality rates due to breast cancer. Using a community-based participatory research approach, we conducted ten focus groups with American Indian women in Kansas and Missouri to understand their barriers to mammography and identify ways to intervene to improve screening rates. Focus groups were stratified by screening status, including women who were up to date with current screening mammography recommendations (mammogram within the last 2 years, N = 7 groups, 66 participants) and women who were not (N = 3 groups, 18 participants). While many similarities were identified across strata, some differences emerged, particularly descriptions of prior negative experiences with the health care system among women who were not up to date with screening recommendations. Primary areas identified by participants for intervention included culturally appropriate educational materials and interventions directed specifically at improving American Indian women's trust in Western medicine and alleviating feelings of discrimination.