Disparities in Receipt of Breast and Cervical Cancer Screening for Rural Women Age 18 to 64 with Disabilities

BackgroundPrevious research has found breast and cervical cancer screening disparities between women with and without disabilities, and between women living in rural versus urban areas. Living in a rural area may add to the barriers women with disabilities experience when attempting to obtain screening for breast and cervical cancer. The purpose of this study was to examine the combination of disability status and rurality in association with receipt of breast and cervical cancer screening among women age 18 to 64 in the United States.MethodsWe conducted cross-sectional analyses of data from the Medical Expenditure Panel Survey, using pooled annual data files from 2002 through 2008. We compared recent receipt of breast and cervical cancer screening among four groups: 1) urban women without disabilities, 2) urban women with disabilities, 3) rural women without disabilities, and 4) rural women with disabilities.FindingsOverall, women with disabilities were less likely to be up to date with mammograms and Pap tests compared with women with no disabilities. Similarly, women in rural areas were less likely to have received breast or cervical cancer screening within recommended timeframes. Women who both had a disability and lived in a rural area were the least likely to be current with screening.ConclusionsOur findings suggest that living in rural regions compounds disparities in receipt of cancer screening among women with disabilities. Increased attention is needed to improve receipt of cancer screening among rural women with disabilities.     

Breast and Cervical Cancer Screening Disparities Associated with Disability Severity

BackgroundPrior research has noted disparities between women with and without disabilities in receipt of timely screening for breast and cervical cancer. Some studies suggest greater disparities for women with more severe disabilities, but the research to date has yielded inconsistent findings. Our purpose was to further examine differences in receipt of breast and cervical cancer screening in relation to severity of disability.MethodsWe analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. Logistic regression analyses examined whether Pap smears and mammograms had been received within the recommended timeframe according to U.S. Preventive Services Task Force Guidelines. We compared four groups of women aged 18 to 64 years, categorized by presence and complexity of disability: 1) No limitations, 2) basic action difficulties only, 3) complex activity limitations only, and 4) both basic and complex activity limitations.FindingsWomen both with and without disabilities fell short of Healthy People 2020 goals for breast and cervical cancer screening. Overall, women with disabilities were less likely to be up to date with both mammograms and Pap tests. The magnitude of disparities was greater for women with complex limitations. Disparities in Pap testing, but not mammography, remained significant when controlling for demographic, geographic, and socioeconomic factors.ConclusionsWomen with more complex or severe disability were less likely to be up to date with breast and cervical cancer screenings. Targeted efforts are needed to reduce barriers to breast and cervical cancer screening for women with significant disabilities, especially those who also experience other socioecological disadvantages.     

Breast cancer knowledge and practices among D/deaf women

BackgroundLimited scientific evidence is available regarding D/deaf women's breast cancer knowledge and early detection practices, as well as about how to increase D/deaf women's breast cancer control practices.Objective/hypothesisTo assess baseline breast cancer knowledge and practices among a sample of D/deaf women recruited into a randomized controlled trial of a breast cancer education program developed for this population.MethodsA written and signed (American Sign Language) survey was administered to a racially/ethnically diverse sample of 209 D/deaf women, 40+ years old, with lower levels of education, recruited in California between October 2008 and May 2009.ResultsThere were misconceptions about breast cancer risk factors, screening, and treatment; only 64.2% of respondents correctly identified the purpose of mammography. Mammography in the prior 2 years was reported by 57.3% of the sample, by 69.8% of White women, and by 43.5% of women from other racial/ethnic groups. Rates also varied by education, having seen a physician in the prior year, and type of insurance.ConclusionsThis study underscores significant gaps in breast cancer screening knowledge and practices, communication issues in health care settings, and unmet needs for tailored health information and materials in this population. Challenges faced in conducting the research needed to develop and test such programs are noted.     

Targeted intervention strategies to increase and maintain mammography utilization among African American women

Objectives. We assessed the impact of a theory-based, culturally relevant intervention designed to increase mammography screening among African American women in 8 underserved counties in Alabama.Methods. Using principles derived from the Stages of Change, Community Health Advisor, and Community Empowerment models, we developed strategies to increase mammography screening. Trained volunteers (N = 143) provided tailored messages to encourage adoption and maintenance of mammography screening. We collected baseline and follow-up data on 1513 women in the communities targeted for the intervention. Our goal was to decrease the number of women in stage 1 (never screened) while increasing the number of women in stage 2 (infrequently screened) and stage 3 (regularly screened).Results. At baseline, 14% (n = 211) of the women were in stage 1, 16% (n = 247) were in stage 2, and 70% (n = 1055) were in stage 3. After the 2-year intervention, 4% (n = 61) of the women remained in stage 1, 20% (n = 306) were in stage 2, and 76% (n = 1146) were in stage 3.Conclusions. Tailored motivational messages and peer support can increase mammography screening rates for African American women.For most cancers in the United States, African Americans have the highest death rate and shortest survival of any racial/ethnic group.^1,2 The most common cancer among African American women is breast cancer. Despite African American women having a lower incidence of breast cancer than White women have (117.6 vs 130.6 per 100 000), African American women have a higher breast cancer mortality rate than that of their White counterparts (33.5 vs 24.4/100 000).² From 2001 to 2005, African American women''s breast cancer mortality rate was 37% higher than that of White women. For breast cancer diagnosed from 1996 through 2004, the 5-year relative survival rate among African American women was 77%, compared with 90% among White women.²One reason for this poorer survival outcome is the stage of cancer at detection. Of all breast cancers diagnosed among African American women, 52% are diagnosed at a local stage (an invasive cancer confined entirely to the organ), compared with 62% of breast cancers among White women.² Barriers to screening, such as fear, lack of awareness, limited financial resources, limited access to care, differences in tumor biology, and social prejudices,^3–6 have been documented among African American women.To create a model that addresses these barriers, in 1999 the Centers for Disease Control and Prevention (CDC) launched the Racial and Ethnic Approaches to Community Health (REACH 2010) demonstration project in response to Healthy People 2010’s national goal of eliminating health disparities.⁷ The CDC established cooperative agreements with more than 40 communities across the United States to close the health disparity gap among minority populations by reducing disparities in 6 health priority areas, including breast and cervical cancer screening and management.⁸To ensure a long-lasting impact in minority communities, the CDC funded proposals that integrated coalition-building activities, empowerment principles, and participatory, community-based approaches. The Alabama REACH 2010 Breast and Cervical Cancer Control Coalition, a diverse coalition founded with the goal of eliminating breast and cervical cancer disparities, applied these activities, principles, and approaches to build trust and establish partnerships between academic institutions and community organizations, engage community members in the design and conduct of the project, and demonstrate that the use of participatory and empowerment models can improve health outcomes.^9,10The Alabama REACH 2010 project was a multilevel intervention with activities directed at the individual, community, and organizational and policy levels.^11,12 We assessed the effectiveness of individual-level intervention activities implemented to encourage and support mammography screening among African American women.     

Racial and Geographic Differences in Mammography Screening in St. Louis City: A Multilevel Study

To examine racial differences in mammography use and its determinants in the City of St. Louis, MO, USA, we recruited women age 40 or older using random-digit dialing to (1) examine the difference in mammography use between white women and African American women and (2) identify individual- and census-tract-level risk factors of nonadherence to mammography. During telephone interviews, we inquired about mammography use and several demographic, psychosocial, and health behavior variables. We determined the residential census tracts of study subjects using a geographic information system. The rate of mammography use was 68.0% among white women and 74.7% among African American women (P = 0.022). African American women were more likely to have mammograms than white woman (adjusted odds ratio [OR] = 1.71; 95% confidence interval [CI] = 1.09-2.69). System-level barriers to mammography and heavy smoking were associated with lower mammography use among both white and African American women. Personal-experience barriers to mammography and no physician recommendation also were independently associated with mammography use among white women. White women residing within a historic geographic cluster area of late-stage breast cancer were less likely to have mammograms (adjusted OR = 0.42, 95% CI = 0.22-0.80), while African American women residing within a historic geographic cluster area of late-stage breast cancer were equally likely to have mammograms (adjusted OR = 0.79, 95% CI = 0.28-2.24). Neither individual- nor census-tract-level socioeconomic status was associated with mammography screening. These findings suggest that there may be a greater need for increasing mammography use among white women, especially in the historic cluster area of late-stage breast cancer in St. Louis.     

Travel distance to screening facilities and completion of abnormal mammographic follow-up among disadvantaged women

PurposeAlthough many studies have examined factors in predicting incomplete and delay in abnormal mammogram follow-up, few have used geospatial methods to examine these factors. Consequently, the purpose of this study was to examine the relationship between travel distance to health facilities and completion of abnormal mammogram follow-up among disadvantaged women in South Carolina.MethodsWomen participating in South Carolina's Best Chance Network between 1996 and 2009 with abnormal mammogram were included in the study. Kaplan–Meier survival was used to describe the probability of work-up completion after abnormal mammogram among different distance categories, and Cox proportional hazards model was used to further assess the relationship between work-up completion and travel distance to the screening provider and mammography facility.ResultsAmong 1,073 women, there was significant difference in time to completion of abnormal mammogram work-up by race; African American women had longer time to completion compared to European American women. Accounting for race, age, previous mammograms, income, and insurance status, women who lived closest to their diagnosing mammography facility were more likely to complete their work-up compared to those who lived the farthest (HR = 1.41; 95% CI = 1.00–1.80).ConclusionsDistance to the diagnosing mammography facility may play a role on the completion of abnormal mammogram work-up.     

Cost as a barrier to screening mammography among underserved women

Background. Breast cancer is a troublesome health problem, particularly among underserved and minority women. Early detection through screening mammography can reduce the impact of this disease, yet it remains underused.

Objective. We examined cost as a barrier to screening mammography and studied the accuracy of women's perceptions of the cost of a mammogram among a rural, low-income, tri-racial (white, Native American and African American) population in need of a mammogram.

Design. We interviewed 897 women age 40 and older, asking about cost as a barrier to mammography and perceptions about the actual costs of a screening mammogram. Face-to-face interviews were conducted between 1998 and 2000 among women participating in a randomized, controlled study to evaluate a health education intervention to improve mammography screening rates in an underserved population. All data used in these analyses were from the baseline interviews.

Results. Cost acted as a barrier to screening mammography for a majority of the participants (53%). More than half of these women (52%), however, overestimated the cost of a screening mammogram, and overestimation of the cost was significantly related to mentioning cost as a barrier (OR 1.56, 95% CI 1.04–2.33). Higher estimates of out-of-pocket costs were associated with reporting cost as a barrier to mammography (OR 2.25, 95% CI 1.43–3.52 for $1–50 and OR 12.64, 95% CI 6.61–24.17 for >$50). Factors such as race, income and employment status were not related to reporting cost as a barrier to screening mammography.

Conclusions. Among a group of tri-racial, low-income, rural women who were in need of a mammogram, cost was a common barrier. Overestimating the cost, however, was significantly and positively associated with reporting cost as a barrier. Providing information about the actual cost women have to pay for mammograms may lessen the role of cost as a barrier to mammography screening, especially for underserved women, potentially improving utilization rates.     

Sexual and behavioral health disparities among African American sexual minority men and women

ABSTRACT

Introduction: Sexual and behavioral health disparities have been consistently demonstrated between African American and White adults and between sexual minority and heterosexual communities in the United States; however, few studies using nationally representative samples have examined disparities between sexual minority and heterosexual adults within African American populations. The purpose of this study was to examine the prevalence of sexual and behavioral health outcomes between sexual minority and heterosexual African American adults and to examine whether there were different patterns of disparities for African American sexual minority men and women, respectively.

Methods: We analyzed data from 4502 African American adults who participated in the 2001–2015 waves of the National Health and Nutrition Examination Survey. Using multivariable analyses, we examined differences in HIV, sexually transmitted infections, mental health, and substance use among African American sexual minority and heterosexual men and women.

Results: After adjusting for sociodemographic variables, African American sexual minority men had significantly higher odds of HIV, sexually transmitted infections, and poor mental health compared to their heterosexual male counterparts, whereas African American sexual minority women had significantly higher odds of Hepatitis C, poor mental health, and substance use compared to their heterosexual female counterparts.

Conclusions: These findings demonstrate notable sexual orientation disparities among African American adults. Disparities persisted beyond the role of sociodemographic factors, suggesting that further research utilizing an intersectional approach is warranted to understand the social determinants of adverse health outcomes among African American sexual minority men and women.     

Validation of recall of breast and cervical cancer screening by women in an ethnically diverse population

BACKGROUND: Screening mammogram and Pap smear rates are lower for women in underserved racial and ethnic groups, yet may be overestimated due to reliance on patients' self-reports. The purpose of this study was to determine accuracy of self-reports of mammograms and Pap smears in a multiethnic, multilingual population of African American, Latina, Chinese, Filipina, and White women residing in low-income census tracts of Alameda County, California. METHODS: Following a baseline telephone survey of 1,464 women regarding receipt of mammograms and Pap smears, we examined computerized and written medical records to validate the dates and locations of tests reported by women. RESULTS: Of 1,464 subjects, 94.9% reported having had a Pap smear, and 87% reported having had a mammogram. For Pap smears, in a subsample of 448 cases, we validated only 69.4% of the women's self-reports, and for mammography, in a subsample of 846 women, we validated only 75.4% of the self-reports. Validation rates differed significantly by ethnicity and site of care for both Pap smears and mammograms. CONCLUSIONS: Population estimates of breast and cervical cancer screening rates based upon patient self-reports need to be adjusted downward, by as much as one-quarter to one-third, for low-income, ethnic women.     

False-positive mammography and mammography screening intentions among black women: the influence of emotions and coping strategies*

ABSTRACT

Introduction: Abnormal mammograms confirmed as benign are known as false-positive mammography (FPM) results. Research indicates that a history of FPM results may be linked to diagnostic delays in Black women, yet much of the research on FPM has focused on White women.

Objectives: The purpose of this study was to examine: 1) The influence of FPM on breast cancer (BrCa) screening beliefs and intentions among Black women and 2) Whether emotional states, personality traits or coping behaviors altered the previously described relationships.

Design: BrCa-free, Black women, aged 40 and older who completed screening mammograms in 2016 were recruited for a case–control study from 2016 to 2017. Women with FPM results were cases, and women with normal results served as matched controls. Print surveys assessing demographics, personality traits, emotions, BrCa screening history, BrCa beliefs, and africentric coping behaviors were mailed to participants. The final sample consisted of 118 respondents (55 cases, 63 controls). Ordinary least squares (OLS) models were constructed. Personality traits and emotions were tested as mediators and coping behaviors as moderators of the relationship between FPM results and BrCa beliefs.

Results: FPM status was associated with a higher perception of barriers to mammography, and an elevated perception of barriers was associated with lower intentions to complete mammography. Collective coping behaviors functioned as a moderator and were associated with a decreased perception of mammography barriers in women with FPM results.

Conclusions: FPM status had a detrimental impact on mammography intention indirectly through the perception of mammography barriers, but the use of africentric coping behaviors moderated the relationship between FPM status and perceived barriers to mammography. Culturally specific research focused on Black women is needed to explore influences on BrCa screening beliefs and mammography completion in this population.     

Pap,Mammography, and Clinical Breast Examination Screening Among Women with Disabilities: A Systematic Review

BackgroundResearch has found some disparities between U.S. women with and without disabilities in receiving clinical preventive services. Substantial differences may also exist within the population of women with disabilities. The current study examined published research on Pap smears, mammography, and clinical breast examinations across disability severity levels among women with disabilities.MethodsInformed by an expert panel, we followed guidelines for systematic literature reviews and searched MEDLINE, PsycINFO, and Cinahl databases. We also reviewed in-depth four disability- or preventive service-relevant journals. Two reviewers independently extracted data from all selected articles.FindingsFive of 74 reviewed publications of met all our inclusion criteria and all five reported data on Pap smears, mammography, and clinical breast examination. Articles classified disability severity groups by functional and/or activity levels. Associations between disability severity and Pap smear use were inconsistent across the publications. Mammography screening fell as disability level increased according to three of the five studies. Results demonstrated modestly lower screening, but also were inconsistent for clinical breast examinations across studies.ConclusionEvidence is inconsistent concerning disparities in these important cancer screening services with increasing disability levels. Published studies used differing methods and definitions, adding to concerns about the evidence for screening disparities rising along with increasing disability. More focused research is required to determine whether significant disparities exist in cancer screening among women with differing disability levels. This information is essential for national and local public health and health care organizations to target interventions to improve care for women with disabilities.     

Community-based breast cancer intervention program for older African American women in beauty salons.

African American women are at high risk for morbidity and mortality from breast cancer. African American women ages 50 and older have been a difficult group to reach through conventional breast cancer intervention programs. Cultural and health beliefs that differ from mainstream society are reported to be factors contributing to the low rates of breast screening among this group. In addition to these attitudinal factors, older African American women are disproportionately represented among uninsured and under-insured Americans. As a result, cost becomes a barrier to mammography screening for many of these women. This project proposes to increase breast cancer screening awareness and provide a referral or free breast screening, or both, for African American women ages 50 and older. This information will be offered in the culturally familiar setting of local beauty salons. The culturally sensitive educational pamphlets developed by the National Cancer Institute (NCI) and video developed by the NCI-funded project, Cancer Prevention Research Unit, will be used to promote mammography, clinical breast examinations, and breast self-examination. Providers staffing a mobile mammography van provided by Dr. Anitha Mitchell of the Association of Black Women Physicians through a grant from the Breast and Cervical Cancer Control Program, funded by the Centers for Disease Control and Prevention, will perform mammograms for women on site during scheduled intervals. A followup telephone survey will be conducted.     

Understanding barriers to participation in mammography by women with disabilities

PURPOSE: The study purpose was to identify barriers to mammography screening among women with different disabilities and to suggest interventions to address barriers. METHODS: Forty-two women with self-reported disabilities, ages 40 to 69 years participated. They resided in 24 Connecticut towns, and most had a prior mammogram. Data were collected through six disability-specific focus groups from women with sensory, physical, psychiatric, and cognitive/intellectual impairments. Facilitator-conducted groups used a semistructured guide. Qualitative analysis applied an iterative coding process to generate themes and categories. RESULTS: We identified four themes (i.e., access, beliefs, social support, and comfort/ accommodations) and nine subthemes that characterized barriers. In all focus groups, women mentioned physical access and physical comfort/accommodations as types of barriers. Other major subthemes were communication and professional support. Women also described mammography facilitators. CONCLUSION: Despite frequent use of health care and personal strategies to facilitate mammography screening, women with disabilities reported barriers to getting mammograms. Findings suggest a multifaceted approach to address these barriers.     

Understanding the use of breast cancer screening services by women with intellectual disabilities

Objectives: The uptake of mammography for breast cancer screening is considerably lower among women with intellectual disability than for women in the general population. The purpose of the present study was to investigate carer perceptions of barriers and enablers to mammography use by these women.Methods: To determine the reasons why women with intellectual disability are not utilising screening services, a series of focus groups were held with social trainers working in accommodation provided for people with intellectual disability.     

Using Medicare data to estimate the prevalence of breast cancer screening in older women: comparison of different methods to identify screening mammograms

OBJECTIVES: To compare different methods for defining screening mammograms with Medicare claims and their impact on estimates of breast cancer screening rates. METHODS: Medicare outpatient facility and physician claims for 61,962 women in 1993 and 59,652 women in 1998 were reviewed for evidence of receipt of screening mammography. We compared the estimates of screening mammography use derived from CPT (Current Procedure Terminology) codes to categorize mammograms as screening or diagnostic versus using an algorithm that uses CPT codes plus breast-related diagnoses in the prior two years. We also compared estimates obtained from review of physician claims alone, facility claims alone, or the combination of the two sources of claims. RESULTS: Use of physician claims alone produced estimates of screening rates similar to rates calculated from use of both physician and outpatient (facility) claims. In 1993, the CPT code for screening mammography underestimated the rate of screening compared to estimates generated by using the algorithm (8.3 percent versus 18.0 percent prevalence, p<0.001). By 1998, the screening prevalence rate generated from using the CPT code for screening mammography more closely approximated the rate generated by the algorithm (23.0 percent versus 25.1 percent). By all methods of estimating screening mammography with Medicare claims, its prevalence increased substantially between 1993 and 1998. CONCLUSION: Providers increased their use of the screening mammography code in their charges to Medicare during the 1990s. This has improved the claims' ability to distinguish screening from diagnostic mammograms, but screening rates computed with claims continue to fall below those generated from self-reports of mammography use among general populations of older women.     

Continuing social disparities despite upward trends in sexual and reproductive health service use among young women in the United States

BackgroundBuilding upon previous work describing declining rates and socioeconomic disparities in sexual and reproductive health (SRH) service use among young women in the United States, we reexamined patterns and determinants of SRH service use in 2006–2010.Study DesignWe used the latest data from the National Survey of Family Growth to evaluate SRH service use including contraceptive, sexually transmitted infection (STI) and other gynecological exam services among 3780 women ages 15–24 years. We compared proportions of service use across survey years and employed multiple logistic regression to estimate the influence of time and women's sociodemographic characteristics on the likelihood of SRH service use.ResultsThe proportion of women using SRH services increased from 50% (2006–2007) to 54% (2007–2008) and 57% (2008–2010) [all year odds ratios (ORs) 1.4, p values<.03]. Among sexually experienced women, the proportions using SRH and contraceptive services were unchanged, while STI service use increased from 22% (2006–2007) to 33% (2008–2009) (OR 1.7, confidence interval 1.1–2.4, p=.009). Differentials in service use existed across sociodemographic groups, largely with lower proportions of service use among women of social disadvantage.ConclusionsOur results suggest a reversal of negative trends but continuing social disparities in young women's use of SRH services in the United States.     

Sociodemographic differences in use of preventive services by women enrolled in Medicare+Choice plans

BACKGROUND: We examined the effect of sociodemographic factors on the receipt of mammography, colorectal cancer screening, and influenza vaccinations by women enrolled in two Medicare+Choice health plans. METHODS: Administrative and survey data for 2,698 female health plan members was analyzed using multivariate logistic and ordinal logistic regression to assess the effects of enrollee characteristics on use of preventive services. RESULTS: Age, race and wealth were associated with the receipt of one or more preventive services. Older women were less likely to receive mammograms, wealthier women were more likely to receive mammograms and CRC screening, and Black women were more likely to receive CRC screening but less likely to receive influenza vaccinations. Wealthier women received a greater number of preventive services, other things equal, while older women received fewer preventive services. CONCLUSIONS: Race and wealth continue to be important factors in the receipt of preventive services by elderly women, though not always consistent with historical trends. Medicare+Choice plans should consider strategies to further reduce racial and wealth disparities in the use of preventive services.     

Medical mistrust and patient satisfaction with mammography: the mediating effects of perceived self‐efficacy among navigated African American women

BackgroundMedical mistrust is salient among African American women, given historic and contemporary racism within medical settings. Mistrust may influence satisfaction among navigated women by affecting women''s perceptions of their health‐care self‐efficacy and their providers'' roles in follow‐up of abnormal test results.ObjectivesTo (i) examine whether general medical mistrust and health‐care self‐efficacy predict satisfaction with mammography services and (ii) test the mediating effects of health‐related self‐efficacy.DesignThe current study is a part of a randomized controlled patient navigation trial for medically underserved women who had received a physician referral to obtain a mammogram in three community hospitals in Chicago, IL. After consent, 671 African American women with no history of cancer completed questionnaires concerning medical mistrust and received navigation services. After their mammography appointment, women completed health‐care self‐efficacy and patient satisfaction questionnaires.ResultsWomen with lower medical mistrust and greater perceived self‐efficacy reported greater satisfaction with care. Medical mistrust was directly and indirectly related to patient satisfaction through self‐efficacy.ConclusionsPreliminary findings suggest future programmes designed to increase health‐care self‐efficacy may improve patient satisfaction among African American women with high levels of medical mistrust. Our findings add to a growing body of literature indicating the importance of self‐efficacy and active participation in health care, especially among the underserved.