A two-step intervention of increase mammography among women aged 65 and older.

OBJECTIVES: This study evaluated a two-step intervention for mammography screening among older women. METHODS: Four hundred and sixty women, identified from physician practices, were randomized to a control or a two-step intervention (physician letter and peer counseling call) group. Women in the intervention group who obtained a mammogram received a grocery coupon. RESULTS: Over the 12 months of the study, more women in the intervention group than in the control group obtained mammograms (38% vs 16%). The most dramatic difference was in the higher odds that women in the intervention group would obtain a mammogram within 2 months (odds ratio = 10.5). CONCLUSIONS: The intervention significantly increased screening mammography. Future efforts must be multifaceted and incorporate the unique concerns of older women.     

Using Informal Caregivers to Communicate With Women About Mammography

Only a small proportion of women over age 35 routinely obtain screening mammograms, even though use of the technology appreciably reduces breast cancer mortality, the second leading cause of cancer deaths in women. Using a posttest-only control group design, this study employed hair stylists as lay health educators to increase intention to obtain a mammogram among their clients 35 years or older. Theories of informal network communications, social support, and planned behavior provided the conceptual frameworks for the study. Eight hair stylists at a local salon were trained to give clients in the experimental group information about breast cancer, including the benefits and the risks of mammography, and to encourage them to schedule an appointment for a mammogram if they had not had one recently. Clients in the control group received a hair-stylist message and a pamphlet on nutrition. At 2-week follow-up, significant differences were observed between the two groups of clients in knowledge of breast cancer risk, in belief about the value of mammography for early detection of breast cancer, in perceived behavioral control, and in intention to obtain a mammogram (p =. 0001). At 1-year follow-up, women in the experimental group who responded were twice as likely (44%) to report having had a mammogram during the previous year compared to controls (21%). This low-cost intervention shows potential for activating informal social support systems to reach women at risk with messages designed to increase their utilization of mammography.     

Mammography-facility-based patient reminders and repeat mammograms for Medicare in New York State

BACKGROUND: Women who receive mammograms may fail to regularly return for repeat mammography. Many mammography facilities send annual patient reminders, but there are no large studies of their impact on overall mammography return rates, or by patient population subgroups. METHODS: Medicare claims data were used to identify New York women with claims for mammograms during a baseline and an 18-month follow-up period (1999-2000). Receipt of a second mammogram was examined in relation to whether the facility sends annual reminders, while controlling for other patient factors. RESULTS: Of 97,506 women studied, 76% attended facilities that send annual reminders. Of these women, 74% received a second mammogram within 18 months compared to 67% for other women. The impact of reminders was significant in all subgroups, but was less for women who were younger, minority, in Medicaid, in New York City or who received a diagnostic mammogram. In multivariate analysis, the adjusted odds ratio for return within 18 months if the facility uses reminders was 1.42 (95% CI 1.37-1.47). CONCLUSIONS: Annual patient reminders from mammography facilities are effective in increasing regular repeat mammography in Medicare women, although their impact is smaller in some groups. Facilities that do not currently send reminders should be encouraged to do so.     

Improving mammography screening using best practices and practice enhancement assistants: an Oklahoma Physicians Resource/Research Network (OKPRN) study

PURPOSE: In 2004 only 68% of women in Oklahoma over the age of 40 reported having a mammogram in the past 2 years, compared with 75% nationally. Strategies to improve mammography rates have been numerous but have generally included single strategies, such as physician education, practice audit and feedback, and reminders; flow sheets and results have been mixed. The purpose of this randomized controlled trial was to determine the impact of a practice facilitator and "best practice" interventions on mammography rates in a practice-based research network. METHODS: A total of 16 practices participated; 8 were assigned to intervention and 8 to usual care. Pre- and post-audits of mammography rates were conducted. Intervention practices received feedback with benchmarking, academic detailing, and the assistance of a practice enhancement assistant to help with practice redesign over a 9-month period. RESULTS: The groups differed significantly for both the proportion of mammograms offered to eligible patients (P = .043) and for the proportion of patients with current mammograms (P < .015). For the control group, 38% of eligible women were offered a mammogram and 202 (35% of those eligible) actually did have documentation that a mammogram had been performed. Fifty-three percent of the eligible patients in the intervention group were offered a mammogram and 52% of those eligible (n = 332) did have documentation in the chart that the mammogram had been completed. CONCLUSION: The results suggest that these interventions can improve mammography rates in a range of practice settings. These findings are consistent with other studies that have tested multicomponent interventions.     

Cigarette smoking, alcohol consumption, and screening mammography among women ages 50 and older

BACKGROUND: The associations among cigarette smoking and alcohol consumption with recent screening mammograms were evaluated among women ages 50 years and older. METHODS: The sample included 946 white and African-American women ages 50 years and older from the 1995 Maryland Behavioral Risk Factor Survey. Bivariate and logistic regression analyses were performed to evaluate the associations between current cigarette smoking and alcohol consumption in the past month (none, 1-7 drinks, >7 drinks) with obtaining a screening mammogram in the past 2 years (recent mammogram), controlling for sociodemographic and health variables. RESULTS: Seventy-eight percent of respondents had recent mammograms, 15% smoked cigarettes, 18% reported 1-7 drinks, and 12% reported >7 drinks in the past month. Smokers had lower mammography rates than nonsmokers (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.30-0.75). Women who drank alcoholic beverages had higher mammography rates than nondrinkers (OR = 1.37, 95% CI = 1.03-1.83). Smokers had the lowest mammography rates, regardless of their consumption of alcohol. An interaction was observed among white but not African-American women: nonsmokers who consumed moderate amounts of alcohol (1-7 drinks) had the highest mammography rates in this subgroup. CONCLUSIONS: To reduce breast cancer mortality, it is important to increase screening mammography among all women over age 50 and especially among smokers and the oldest women.     

Mammography screening rates decline: a person-time approach to evaluation

OBJECTIVES: Early detection through mammography can reduce breast cancer mortality. This cohort study evaluated trends in mammography screening, demonstrating a person-time approach. METHODS: Included were women HMO members aged 50-69 from 1999 to 2002 who had not had breast cancer, dysplasia, fibrocystic disease, or implant. The amount of person-time covered by mammography as a percent of the time eligible for mammography screening (the prevention index (PI)) was calculated using electronic data. The denominator was the time during which the guidelines recommended that each participant should have been covered by a mammogram (every 24 months), excluding times when breast mass, abnormal mammogram, galactorrhea, or other breast disorders were under evaluation. The numerator was the time during which she was covered by a mammogram. RESULTS: The number of women who contributed person-time increased from 43,283 to 49,512 and the number of screening mammograms declined from 23,586 to 22,719. The overall PI for screening mammography declined from 67.0 (67% of eligible person-time was appropriately covered by a mammogram) to 62.5, and the proportion of women with no coverage during a given year increased 16%. CONCLUSIONS: This study shows a declining pattern of mammography screening using a person-time approach, a decline greater than that shown by methods that include diagnostic mammograms. The study highlights opportunities for use of the PI and quality improvement initiatives to improve breast cancer outcomes.     

Cost-effectiveness of a tailored intervention designed to increase breast cancer screening among a non-adherent population: a randomized controlled trial

ABSTRACT: BACKGROUND: Although the percentage of women who initiate breast cancer screening is rising, the rate of continued adherence is poor. The purpose of this study was to examine the effectiveness and cost-effectiveness of a tailored print intervention compared with a non-tailored print intervention for increasing the breast cancer screening rate among a non-adherent population. METHODS: In total, 1859 participants aged 51--59 years (except those aged 55 years) were recruited from a Japanese urban community setting. Participants were randomly assigned to receive either a tailored print reminder (tailored intervention group) or non-tailored print reminder (non-tailored intervention group). The primary outcome was improvement in the breast cancer screening rate. The screening rates and cost-effectiveness were examined for each treatment group (tailored vs. non-tailored) and each intervention subgroup during a follow-up period of five months. All analyses followed the intention-to-treat principle. RESULTS: The number of women who underwent a screening mammogram following the reminder was 277 (19.9%) in the tailored reminder group and 27 (5.8%) in the non-tailored reminder group. A logistic regression model revealed that the odds of a woman who received a tailored print reminder undergoing mammography was 4.02 times those of a women who had received a non-tailored print reminder (95% confidence interval, 2.67--6.06). The cost of one mammography screening increase was 2,544 JPY or 30 USD in the tailored intervention group and 4,366 JPY or 52 USD in the non-tailored intervention group. CONCLUSIONS: Providing a tailored print reminder was an effective and cost-effective strategy for improving breast cancer screening rates among non-adherent women.     

Knowledge,attitudes, and behavior of women ages 65 and older on mammography screening and Medicare: results of a national survey

BACKGROUND: Compared to younger women, women 65+ will experience the greatest increase in new breast cancer cases. In 1991, Medicare began offering partial reimbursement for screening mammography every 2 years. METHODS: In 1999, the National Cancer Institute (NCI) conducted a telephone survey on breast cancer, mammography, and Medicare reimbursement with a sample of households containing women ages 65+ using random-digit-dialing. Results were weighted to provide nationally representative estimates of U.S. women 65+. NCI compared 1999 results with similar data from a 1992 AARP survey. RESULTS: Of the 814 women surveyed, 88% had had at least one mammogram in their lifetime; within this group, 80% had received their most recent mammogram 2 years ago or less. Only 57%, however, knew about recommendations to have a mammogram every 1-2 years. Approximately one-third indicated that they were not as concerned about getting breast cancer as when they were younger, and/or that women without risk factors could be less vigilant about mammograms. More than 75% were aware of Medicare coverage, but only 58% had used Medicare to help pay for their last mammogram. Minority women were almost twice as likely to be unaware of Medicare coverage. RECOMMENDATIONS: (1) Highlight that breast cancer risk increases with age (and does not decline in the absence of risk factors) and communicate the correct frequency for having mammograms; (2) expand primary care physicians' roles in promoting mammography screening for women 65+; and (3) provide Medicare coverage information to older women, particularly those not taking advantage of this benefit.     

Promoting breast and cervical cancer screening at the workplace: results from the Woman to Woman Study

OBJECTIVES: This article reports findings from a peer-delivered intervention designed to increase use of breast and cervical cancer screening. METHODS: Twenty-six worksites were randomly assigned to the intervention or comparison group. The 16-month intervention consisted of group discussions, outreach, and educational campaigns. Data were collected from a random sample of women employees stratified by age (baseline n = 2943; final n = 2747). Cross-sectional analyses were conducted to evaluate the impact of the intervention on screening behaviors. RESULTS: Relative to comparison worksites, the intervention group experienced greater increases in the percentage of women who reported a recent mammogram (7.2% vs 5.6%), clinical breast examination (5.8% vs 2.1%), and Papanicolaou (Pap) test (4.7% vs 1.9%). After worksite cluster and age strata were controlled for, the observed increase in Pap tests was significantly greater in the intervention group (odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.01, 1.62); however, differences in mammography screening rates (OR = 1.14; 95% CI = 0.90, 1.44) and clinical breast examination (OR = 1.19; 95% CI = 0.96, 1.49) were not statistically significant. CONCLUSIONS: Intervention activities produced a modest increase in cervical cancer screening, but they did not accelerate breast cancer screening rates above the observed secular trend.     

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.     

Promoting mammography use through progressive interventions: is it effective?

This study evaluated interventions implemented with women in a health maintenance organization who had not utilized their annual free mammogram referral 45 days (step 2) and 95 days (step 3) after its mailing. The step 2 evaluation compared mammography utilization for women randomly assigned to receive a brief reminder letter or no reminder: 42% of the reminder group vs 28% of the control group obtained mammograms. The step 3 evaluation compared utilization for women randomly assigned to receive a second reminder, a letter suggesting a preventive office visit, or telephone counseling: 29% of those who received telephone counseling, 14% of those who received a letter, and 12% of those who received a second reminder obtained mammograms.     

Improving access to mammograms through community-based influenza clinics. A quasi-experimental study

BACKGROUND: It is a national priority to increase breast-cancer screening among women aged > or = 50. Annual influenza clinics may represent an efficient setting in which to promote breast-cancer screening among older women. To our knowledge, this possibility has not previously been explored. OBJECTIVE: To examine whether offering women attending community-based influenza clinics the opportunity to receive a scheduling telephone call from a mammography facility will result in an increase in the number of mammograms performed over a 6-month period. METHODS: We used a quasi-experimental design with 6-month follow-up. A contemporaneous population-based survey provided a further control group for comparison. The sample group consisted of a total of 284 women attending nine community-based influenza clinics in a semirural county in Connecticut. All women were aged > or = 50 and reported no mammogram in the preceding 12 months. All women received informational literature on mammography. Experimental subjects were each asked if a radiology facility chosen by the subject could call her at home to schedule a mammogram. Mammograms performed were determined by hospital record for participants who received a scheduling call from a radiology facility, and by self-report for all other participants. RESULTS: Mammography use following access through influenza clinics was approximately twice that of women attending influenza clinics where access to mammography was not offered. Using three different assumptions regarding participants whose mammography status was unknown, the relative risks ranged between 1.6 and 2.1. For each assumption the results were statistically significant (chi(2)=8.51-12.2; p<0.001). CONCLUSIONS: Linking access to mammography at community-based influenza clinics can significantly increase the use of mammograms among women aged > or = 50. Further studies should seek to confirm these findings and determine the degree to which they can be replicated in a variety of communities. Enhancing preventive health practice through the bundling of services suggests a new strategy to exploit available interventions to improve health.     

Female employee participation in a worksite mammography screening program.

We conducted a survey of 1,184 women 35 years of age or older who were employees of a company in Los Angeles County, California, to determine why some women participated in a worksite mammography screening program whereas others did not. Of the 111 who accepted a mammogram, 90 responded to the survey; of the 1,073 who declined mammography, 620 responded. The women were predominantly white, were well educated, and had health insurance. Of the 111 women who received mammograms, one was diagnosed with carcinoma. Seventy-three percent of the respondents to the survey 40 years of age or older who declined mammograms had already fulfilled American Cancer Society (ACS) guidelines for mammography screening at the time of the program. Women who accepted a mammogram were more likely to have had at least one previous mammogram than were women who had not met ACS guidelines yet who declined screening. We conclude that many female employees who are white, are well educated, and have health insurance may not participate in a worksite mammography screening program because they have been screened elsewhere. Companies providing worksite mammography screening should target education to women who have not met ACS guidelines, especially those who have never had a mammogram.     

Multistrategy health education program to increase mammography use among women ages 65 and older.

Mammography use decreases with age although the risk of breast cancer increases with age. Medicare now provides biennial coverage for screening mammography. This study was designed to simulate the Medicare condition by subsidizing mammography among women in eight retirement communities in the metropolitan Philadelphia area. The study also measured the impact of health education interventions and the presence of a mobile mammography van on increased use of mammography. Retirement communities were assigned randomly to the control (cost subsidy alone) or experimental group (cost subsidy, mammography van, and tailored health education interventions). A total of 412 women ages 65 and older who had not had mammograms in the previous year were surveyed at baseline and 3 months later. Analytic techniques reflected the cluster nature of the randomization. Women in the experimental group were significantly more likely than the control group women to have obtained mammograms. Forty-five percent of the experimental group women compared with 12 percent of the control group women subsequently had mammograms in the 3 months after the baseline interview (P less than .001). Logistic regression analysis for mammography use indicated an odds ratio of 6.1 associated with being in the experimental group. For women in the experimental group, a separate logistic regression for mammography use showed an odds ratio of 7.8 associated with attendance at the educational presentation. The results suggest that Medicare coverage alone will not increase mammography use sufficiently to achieve year 2000 objectives. However, the addition of access enhancing and health education interventions boosts utilization dramatically.     

The impact of mailing psychoeducational materials to women with abnormal mammograms.

A randomized trial was conducted to evaluate the impact of mailed psychoeducational materials on adherence to subsequent annual mammography among women with prior abnormal mammograms. The results showed a 13% increment in adherence among women who received this intervention. This effect was independent of all sociodemographic and medical variables examined. We conclude that mailed psychoeducational materials may be an effective mechanism to improve adherence among women with abnormal mammogram results.     

Test-retest reliability of self-reported mammography in women veterans

BACKGROUND: Mammography self-report is used to monitor screening and evaluate intervention trends; however, few studies have examined reliability. METHODS: Reliability of self-reported lifetime number of mammograms, most recent mammogram date, and predictors of reliability were assessed using data from Project H.O.M.E. The study population was 2,494 women 52 years and over, listed in the U.S. National Registry of Women Veterans, with no history of breast cancer, who completed both baseline (2000-2002) and year 1 (2002-2003) surveys. RESULTS: Reliability of lifetime number of mammograms was 60.9% for exact consistency and 79.9% for consistency within one mammogram. Thirty-five percent was exactly consistent in reporting mammogram date; 55.6% was consistent within 3 months. Completing both surveys by mail and reporting fewer lifetime mammograms at baseline were positively associated with consistency of reporting lifetime number. White race/ethnicity, having a Bachelor's degree, reporting a health care provider's recommendation for a mammogram, having a screening mammogram, completing both surveys by mail, and being in the maintenance or action stages of change were associated with consistency in reporting date. CONCLUSIONS: Reliability varies with the measure of self-reported mammography. Likewise, predictors show different patterns of association with different definitions. Our findings call attention to the need for explicit definitions and measures of mammography use.     

The effect of a stage-matched and tailored intervention on repeat mammography(1).

BACKGROUND: Our objective was to determine whether a tailored, stage-matched educational intervention, guided by the transtheoretical model (TTM), would increase rates of repeat-screening mammography. DESIGN SETTING/PARTICIPANTS: A total of 1324 women (N=1026 after attrition) aged 50 to 74 years were recruited from a staff-model health maintenance organization. Some of the women were not due for mammograms at the time of recruitment.Intervention: Women were randomly assigned to one of three intervention conditions: Group 1, no educational materials (usual care); Group 2, standard materials; and Group 3, stage-matched/tailored materials. Women in Groups 2 and 3 received a mailed education packet after both a baseline and a follow-up telephone interview. All women in Group 2 received the same materials regardless of differences in baseline mammography-related attitudes and behaviors. Each woman in Group 3 received materials based on her stage of adoption for mammography and TTM constructs. MAIN OUTCOME: Using clinical records, repeat screening was defined as receipt of a second mammogram within 14 months after obtaining an initial postbaseline mammogram. RESULTS: Women in Group 3 were more likely to obtain repeat-screening mammograms than women in Group 1 (44.2% vs 35.8%; adjusted rate ratio = 1.29, 95% confidence interval [CI]=1.11-1.46; adjusted rate difference = 0.06, 95% CI=-0.01-0.13). The screening percentage in Group 2 was intermediate (39.3%), and did not differ from either Group 3 or Group 1. CONCLUSIONS: The effect of the stage-matched/tailored intervention was sustained for repeat screening, although no educational materials were delivered to coincide with the timing for a second mammogram. However, the stage-matched/tailored intervention was not sufficient to have a substantial impact on screening beyond the effect of standard educational materials. Future interventions may need to administer "booster" sessions to increase repeat screenings.     

P.O.W. (Protect Our Women): Results of a Breast Cancer Prevention Project Targeted to Older African-American Women

ABSTRACT

Objective: Encourage older African-American women to participate in breast cancer detection. Breast cancer deaths for older African-American women are higher than for Caucasian counterparts. Effective outreach education about mammography and breast exam is one method to reduce the disparity by encouraging women to enter treatment earlier through earlier diagnosis. Traditional outreach strategies have proven ineffective with this cohort.

Method: In this study we utilized the trust placed in known community leaders to recruit older African-American women to participate in breast health education leading to completion of a mammogram. One hundred sixty-two women were identified as participants.

Results: Seventy-nine percent of the women who completed the project obtained mammograms and 9% had mammograms scheduled at 1-month follow-up, whereas 22% of the individuals who received only mailed educational materials completed mammograms and none had scheduled mammograms pending.

Discussion: Health education for difficult-to-reach populations can be effective but requires greater inclusion of community partners to offset issues related to trust, health beliefs, and access.     

Factors associated with repeat mammography in a New York State public health screening program.

Screening mammography is the most effective method for early detection of breast cancer, but repeat mammography rates are not optimal in most populations. Since 1988, New York State has supported a program of breast cancer screening for underserved, uninsured, or underinsured women. The present study was designed to identify sociodemographic and clinical factors associated with failure to return for repeat mammography screening after a negative initial mammogram. Of women initially screened between 1988 and 1991 (N = 9,485), 27 percent obtained repeat mammograms by 1993. The final logistic regression model contained program site, race and ethnicity, family income, and time since last mammogram.