Mammography screening and breast self-examination among minority women in public housing projects: the impact of physician recommendation

This exploratory study examined the impact of physician recommendations and other factors on mammography screening and breast-self examination (BSE) among African American and Hispanic women in public housing communities. We surveyed a randomly selected sample of low-income households from three low-income communities (n = 291), which included both African Americans and Hispanic women. Data for this paper are reported only on women who were 40 years and older head of the households (n = 120 women, including 74 Hispanics and 46 African Americans), since they meet the age criterion for mammography screening. Our analyses indicated that only 46% of women obtained mammography in the previous 12 months, with no significant differences between the Hispanic and African American women in mammography rates. Physicians' recommendations were among the most significant and substantial predictors of obtaining a mammogram or performing BSE. Further, odds were also higher for those who had insurance coverage. In addition, our data also indicated that almost one out of four women, aged 40 and older participants in this study, claimed that their health care providers never told them they needed a mammogram or never told them that they should perform BSE, with no significant differences between Hispanic and African Americans. Our analyses points to an urgent need for intervention to inform and motivate the service providers in underserved communities to motivate breast cancer screening (BCS) among minority women. Additionally, our examination points to the need for urgent interventions targeting minority women, particularly women with no medical insurance for breast cancer screening.

Using a nursing protocol to assure equitable delivery of cancer-related prevention services

A nurse-administered, protocol-driven model (NP) for preventive services delivery was compared with a traditional physician reminder (PR) model with nursing back-up among 473 patients attending Internal Medicine and Family Medicine clinics. A total of 240 patients were randomized to the NP group and 233 to the PR group. Demographic characteristics including gender [71% female (NP) and 71% female (PR)], race (78% and 75% African American, respectively) and age (numbers of persons aged 18-54, 55-64 and 65+ years) were similar in each group. In the NP group 244/244 screening tests for breast, cervical and colon cancers and alcohol abuse were initiated or completed by nurses, while in the PR group 110/215 (51%) were initiated or completed by physicians. The NP group received 552/552 counseling services from nurses for tobacco, alcohol, nutrition, exercise and prostate screening, while in the PR group, physicians delivered 10% of the needed services (56/560). Aside from counseling for prostate cancer screening, which was 100% in both the NP and PR groups, all other between-group differences for each service were significant at the level of p<0.001. Results show the feasibility of a nursing protocol for initiating equitable cancer prevention services in a primary care setting.

Predictors of breast cancer screening in a panel study of African American women

PURPOSE

This study examines the predictors of breast cancer screening participation in a panel study of African American women over age 40. We examine the effect of depression, age, beliefs and concerns about breast cancer and its risk, communication with social networks regarding screening, marital status, participation in religious organizations, breast cancer family history, and participation in a breast cancer education program.

METHODS

Participants were recruited from 30 African American churches, two low-income housing projects, and from a health fair at a historically African American University (N = 364). Participants were interviewed upon recruitment, and three months later. Multinomial logistic regression models are estimated to assess the relative impact of covariates on the odds of getting a mammogram while controlling for other factors. We also assess predicted probabilities of screening at specific levels of covariates.

RESULTS

We find that age, marriage, an educational intervention, talking with friends, and believing that early detection can lead to cure had a positive impact on getting a mammogram between T1 and T2. In contrast, depression significantly reduces the odds of getting a mammogram. Family histories of breast cancer and church participation have no effect on rates of mammography net of other factors.

HIV prevention for indigenous people of the Amazon basin

This study identifies theoretically-based predictors of condom use in a sample of 251 sexually active adults recruited from Sao Gabriel da Cachoeira and six indigneous communities of the Upper Rio Negro region of Amazonas Brazil. The information-motivation-behavioral skills (IMB) model of AIDS-preventive behavior was used to describe the roles of HIV/AIDS knowledge, experiences with and attitudes toward condom use, peer influences, perceived vulnerability, monogamy and behavioral skills. A predictive path analytic model revealed significant predictors of more condom use including male gender, greater sexual HIV knowledge, positive experiences and attitudes about condom use, multiple partners, and greater behavioral skills. Results suggest that attention to behavioral skills for negotiating safer sex and instruction in the correct use of condoms are important elements in reducing high risk behaviors. Increasing the specific knowledge level of indigenous people regarding the complexities of sexual transmission of HIV is crucial and should be addressed. Heightening individuals' understanding of the limited protection of serial monogamy, and the need to conduct gender-specific training for behavior change to reduce transmission of HIV should be an additional goal of Brazilian health professionals. Obstacles to the implementation of the IMB HIV prevention program in Amazonas are noted and an alternative Brazilian HIV/AIDS prevention program is discussed.

Depression, service utilization, and treatment costs among Medicare elderly: gender differences

OBJECTIVE

To compare gender differences in mood disorders, service utilization, and health care costs among a random sample of Medicare elderly beneficiaries of Tennessee.

DATA SOURCES

Medicare expenditure data from a 5% random sample of Tennessee Medicare beneficiaries (n = 35,673) were examined for 1991-1993. The physician reimbursement files provided data relative to ICD-9 diagnostic codes, physician visits, and the cost of physician services provided. Other service utilization and cost data were obtained for the sample from the outpatient, home health, skilled nursing, hospice and inpatient files.

STUDY DESIGN

The dependent variables were: (i) patients with ICD-9 diagnosis for a mood disorder (major depression and other depression), (ii) service utilization (number of outpatient visits, skilled nursing visits, home health visits, physician visits, emergency visits, and inpatient days), and (iii) health care costs (dollar amount of physician cost, outpatient cost, inpatient cost, total mental health cost, total health cost, and other cost). The independent variable was gender.

PRINCIPLE FINDINGS

Chi-square tests showed that among the patients with a mood disorder, females had a significantly higher incidence than males of major depression (1.3% vs. .4%, respectively, p < .001) and other depression (1.6% vs. .6%, respectively, p < .001). Further, t-test results indicated that females diagnosed with major depression utilized significantly more outpatient services than males (3.2 vs. 2.6, respectively, p < .04). Total health care costs for those with other depression were significantly higher for males than females ($15,060 vs. $10,240, respectively, p < .002).

CONCLUSIONS

The results indicate that mood disorders, outpatient services, and total mental health costs are higher for females than males; however, total health care costs are higher for males than females.

Black-white inequalities in mortality and life expectancy, 1933-1999: implications for healthy people 2010

OBJECTIVES

Optimistic predictions for the Healthy People 2010 goals of eliminating racial/ethnic disparities in health have been made based on absolute improvements in life expectancy and mortality. This study sought to determine whether there is evidence of relative improvement (a more valid measure of inequality) in life expectancy and mortality, and whether such improvement, if demonstrated, predicts future success in eliminating disparities.

METHODS

Historical data from the National Center for Health Statistics and the Census Bureau were used to predict future trends in relative mortality and life expectancy, employing an Autoregressive Integrated Moving Average (ARIMA) model. Excess mortality and time lags in mortality and life expectancy for blacks relative to whites were also estimated.

RESULTS

Based on data for 1945 to 1999, forecasts for relative black:white age-adjusted, all-cause mortality and white:black life expectancy at birth showed trends toward increasing disparities. From 1979, when the Healthy People initiative began, to 1998, the black:white ratio of age-adjusted, gender-specific mortality increased for all but one of nine causes of death that accounted for 83.4% of all US mortality in 1998. From 1980 to 1998, average numbers of excess deaths per day among American blacks relative to whites increased by 20%. American blacks experienced 4.3 to 4.5 million premature deaths relative to whites in 1940-1999.

CONCLUSIONS

The rationale that underlies the optimistic Healthy People 2010 forecasts, that future success can be built on a foundation of past success, is not supported when relative measures of inequality are used. There has been no sustained decrease in black-white inequalities in age-adjusted mortality or life expectancy at birth at the national level since 1945. Without fundamental changes, most probably related to the ways medical and public health practitioners are trained, evaluated, and compensated for prevention-related activities, as well as further research on translating the findings of prevention studies into clinical practice, it is likely that simply reducing disparities in access to care and/or medical treatment will be insufficient. Millions of premature deaths will continue to occur among African Americans.

Correlates of HIV risk-taking behaviors among African-American college students: the effect of HIV knowledge, motivation, and behavioral skills

This study identifies theoretically based predictors of condom use in a sample of 253 sexually active African-American college students recruited from two historically African-American colleges. The Information-Motivation-Behavioral (IMB) skills model of AIDS-preventive behavior was employed to delineate the roles of HIV/AIDS knowledge, experiences with and attitudes toward condom use, peer influences, perceived vulnerability, monogamy, and behavioral skills. A predictive structural equation model revealed significant predictors of more condom use including: male gender, more sexual HIV knowledge, positive experiences and attitudes about condom use, nonmonogamy, and greater behavioral skills. Results imply that attention to behavioral skills for negotiating safer sex and training in the proper use of condoms are key elements in reducing high risk behaviors. Increasing the specific knowledge level of college students regarding the subtleties of sexual transmission of HIV is important and should be addressed. Heightening students' awareness of the limited protection of serial monogamy, and the need to address gender-specific training regarding required behavior change to reduce transmission of HIV should be an additional goal of college health professionals.

Does public and private religiosity have a moderating effect on depression? A bi-racial study of elders in the American South

Religious activities are shown to correlate with rates of psychological depression symptoms in a sample of 995 African American and white elderly residents of Nashville. The data, collected in face-to-face interviews, included indicators of both public and private religiosity. Levels of religiosity and perceived social support were higher among the African-American respondents than among others, and among female respondents. Separate regression analyses of the racial groupings, which appeared to have distinctive religious subcultures, generally show that perceptions of social support mediate the relationship between levels of religiosity and symptoms of depression.

Predictors of depression among the elderly: racial differences over time

Depressive symptomatology and correlates of depression were compared in 600 white and 600 black elderly people over a period of 18 months. Overall, factors associated with depression were found to be similar for both groups. They included prior depression; social and medical stressors; poor ego; and social networks that were small, with which contact was infrequent, and from which emotional support was lacking. Implications for intervention are offered.

Social density, stressors, and depression: gender differences among the black elderly

This research examined gender differences with regard to the effects of social density and stressors upon depressive symptomatology among 600 Black elderly community residents (aged 55-85 years) of Nashville, Tennessee. The sample had more females than males and fewer married individuals. Approximately half of the males and females lived alone. Regression analyses show that poor ego and chronic medical problems were the common predictors of depression among both the males and females. Gender differences were found with regard to life events in that females tended to become more depressed as the number of events increased and as level of contact with relatives and friends decreased. Further, females with lower levels of social attachment, guidance, and reliability were more depressed. None of these social support dimensions related to depression among the males. These relationships tended to be stronger for those living alone than for those living with others.

An evaluation of a therapeutic health program for the black elderly

This paper evaluates the effectiveness of a therapeutic health program which was offered in 1988 to the black elderly living in subsidized high-rise apartments in Nashville. The pre-program data (of 1987) indicated distinct differences in that the elderly living in the high-rises had significantly more medical problems, higher levels of depression, and smaller social support networks than those living in their own single dwelling homes. The therapeutic program included various modules such as cognitive and grief therapy, reminiscence therapy, social skills and remotivation therapy. Analyses of pre-post measures of selected variables showed that the program was effective in improving the health status of the participants. As compared to a non-treatment control group, the elderly in the experimental group showed significant improvements in depression, social network, and a sense of control over their lives. A discussion of these findings is provided.

Health care behavior among urban black and white women

A cohort of 308 black and white women was followed 6 years to determine health status and preventive health behavior. The women of both races had nearly identical age and education levels. Health care utilization and health state perception was nearly identical, too. White women more frequently were dieters while black women walked for exercise and used prayer for problem solution. Women who exercised initially felt better at the end of the study. The persistence of health activities was stronger for white women but over half never exercised. More women need engagement in consistent preventive health activities

Social class and depressive symptomatology. The role of life change events and locus of control

This paper considers the hypothesis that the relationship between social class and impairment may be accounted for by the greater prevalence of life events among lower-class individuals. This hypothesis was evaluated on data from 713 rural Tennessee adults. The data indicated that, although social class indices were inversely related to psychiatric impairment as expected there was no significant tendency for lower-class individuals to report a greater number of life events. For total number of events, as well as total number report a greater number of life events. For total number of events, as well as total number of undesirable, unexpected, or unpreventable events, middle- and upper-class individuals tended to report more events. Controls for the event indices did not affect the relationship between social class and symptomatology as the stress hypothesis would predict. However, locus of control was positively related to social class and was found to influence the event-impairment relationship. These data raise questions regarding the etiological role of life events in the relationship between social class and psychiatric impairments. The data suggest that observed social class differences in impairment may arise from the coping styles of certain social classes (as measured by locus of control) rather than from the differential prevalence of life events.

Characteristics of life events and psychiatric impairment in rural communities

This household survey of a random sample of 713 rural adults (ages 18 to 60) examined the influence of event characteristics upon the relationship between life change events and impairment. Data were obtained on the occurrence of events, event characteristics, demographic characteristics, and psychiatric impairment (using the General Well-Being Schedule and the Center for Epidemiologic Studies Depression Scale). Analysis indicated that individuals experiencing higher proportions of undesirable, unanticipated, unpreventable, and disruptive events or events having minimal social support manifested higher levels of psychiatric symptomatology. Although total number of events was consistently the best predictor of impairment, it did not diminish the effects of the event characteristics on impairment. The independent effects of these event characteristics are discussed.

Psychiatric impairment in rural communities

This household survey of 713 adults residing in nine rural Middle Tennessee counties was conducted to estimate the prevalence of psychiatric impairment in the rural population, to determine which groups in the population are characterized by higher levels of impairment, and to assess the validity of three indices of psychiatric impairment (HOS, CES-D, and GWB). The data indicate that approximately 12% of the rural population may be impaired and that impairment is most likely among females, the divorced, widowed, or separated, and those in lower socioeconomic strata. While depression was more common among the young, physical and psychosomatic complaints were more common among older respondents. Further, respondents classified as impaired by the indices tended to view themselves as having "substantial" or "major" problems and were likely to feel that they might require professional help. While the GWB appeared to discriminate between users and non-users of services, the other indices were less effective as predictors of service utilization.

Mental health needs and service utilization in a predominantly black community

This study examined social indicators of the Mental Health Demographic Profile System as predictors of both mental health needs and utilization of mental health services in a black community served by a metropolitan CMHC. Over a two-year period, it was found that only four social indicators were significant predictors of the need-utilization relationship in that census tracts that had a higher percentage of nonhusband/wife households, large families, overcrowded housing, and working mothers with preschool children tended to have higher service utilization. Further, census tracts that had higher utilization in the first year remained higher utilizers of services in the second year. Implications of these findings in terms of proximity to the CMHC are discussed.