Applying recursive partitioning to a prospective study of factors associated with adherence to mammography screening guidelines

Although a number of predictors of adherence to mammography screening guidelines have been identified using traditional statistical methods, many women are not screening according to these guidelines. Recursive partitioning may aid in developing novel intervention strategies to promote this screening behavior by identifying subgroups of women that differ on adherence across predictor variables. In a prospective study of 1,229 African-American and White women in Connecticut whose adherence to mammography screening guidelines was ascertained over a 26-month follow-up period from initial screening in 1996-1998, recursive partitioning selected six of 22 candidate predictors and identified subgroups that differed on adherence across predictors by age (40-49 and 50-79 years). Among the five subgroups identified for women aged 50-79 years, the subgroup most adherent to screening guidelines during follow-up included four predictors: a history of adherence, annual family income of 15,000 dollars or more, a belief that mammograms were very useful, and low or moderate perceived breast cancer susceptibility. Among the three subgroups identified for women aged 40-49 years, the most adherent subgroup included only one predictor: receipt of a health-care provider's recommendation to obtain a mammogram. These findings suggest that recursive partitioning may be a useful statistical tool and may aid in developing interventions to promote adherence to mammography screening guidelines.     

It's the amount of thought that counts: when ambivalence contributes to mammography screening delay

PurposeThis study examines whether ambivalence toward mammography screening, as moderated by total amount of thought given to the reasons for and against getting mammograms at recommended intervals, predicts greater delay in obtaining subsequent screening mammograms.MethodsA sample of 3,430 insured women with recent (within the last 8–9 months) screening mammograms completed telephone interviews as part of a 5-year intervention study to achieve sustained adherence to annual-interval mammography. Delay was assessed by the number of days between mammograms.ResultsControlling for demographic factors and perceived screening barriers, days between mammograms increased as ambivalence and thought increased. Thought moderated ambivalence: Among women who were most ambivalent, women obtained mammograms 1 month earlier for each unit increase in thought.ConclusionFuture studies should test innovative ways to resolve ambivalence and increase thought about consequences of getting mammograms as a strategy to promote mammography screening adherence.     

Patterns of breast cancer screening among lesbians at increased risk for breast cancer

BACKGROUND: Women with a family history of breast cancer (i.e., in a mother, sister or daughter) are at increased risk for this disease. Previous data also suggest that lesbians are at increased risk for breast cancer. While the screening behaviors of women with a family history have been described, little is known about factors that influence screening behaviors of lesbians with the same risk factor profile. PURPOSE: The purpose of this study was to characterize the perceptions of susceptibility to breast cancer and describe factors that influence adherence to breast cancer screening guidelines in a sample of lesbians with a first-degree relative with a diagnosis of breast cancer. METHODS: Structured telephone interviews were conducted on a sample of 139 self-identified lesbians who had a first-degree relative with a diagnosis of breast cancer, were between the ages of 35 to 75 and had no previous history of cancer. Cross-sectional data obtained, included socio-demographics, breast cancer risk factors, breast cancer screening patterns, breast cancer perceptions, worries, and knowledge, and barriers and access to health care factors. Individual subject characteristics were examined for their association with adherence to mammography guidelines followed by a multivariate analysis to evaluate the most important combinations of factors. Outcome measures were age-specific adherence to ACS guidelines for both mammography and overall adherence (i.e., mammography, clinical breast examination and breast self-examination). RESULTS: The 139 lesbians interviewed for this study were young (mean age = 43), almost exclusively white (94%), highly educated (78% = college graduate and beyond), and partnered (68%). In the bivariate analysis of individual factors, being employed and reporting breast cancer worries were significantly and positively associated with adherence to mammography guidelines. Higher income and insurance type were significantly associated with mammography adherence. No factors were significantly associated with overall adherence. Multivariate logistic regression analyses revealed that only income level and degree of breast cancer worries were significantly and positively associated with mammography adherence. However, since there was a high correlation between income level and employment status, a regression model with employment status and worry was also significantly related to mammography adherence. CONCLUSIONS: In lesbians who are at an increased risk for breast cancer because of family history, breast cancer worries may motivate, rather than deter, adherence for mammography use. High income levels also appear to enable adherence in this population. IMPLICATIONS: Additional studies are needed to validate these findings, identify the prevalence of lesbians in general samples of women at increased risk for breast cancer, and prospectively test lesbian sensitive educational intervention strategies designed to facilitate adherence to mammography screening guidelines in this population.     

Maintaining mammography adherence through telephone counseling in a church-based trial

OBJECTIVES: This study assessed the effectiveness of telephone counseling in a church-based mammography promotion intervention trial. METHODS: Thirty churches were randomized to telephone counseling and control conditions; telephone interview data were used in assessing intervention effects on mammography adherence. Separate analyses were conducted for baseline-adherent participants (maintaining adherence) and baseline-nonadherent participants (conversion to adherence). RESULTS: Year 1 follow-up data indicated that the telephone counseling intervention maintained mammography adherence among baseline-adherent participants and reduced the nonadherence rate from 23% to 16%. CONCLUSIONS: Partnerships between the public health and faith communities are potentially effective conduits to promote maintenance of widely endorsed health behaviors such as regular cancer screening.     

Colorectal cancer screening behavior in women attending screening mammography: Longitudinal trends and predictors

PURPOSE: Nationally representative surveys demonstrate that the adherence to screening mammography guidelines are associated with increased prevalence of colorectal cancer (CRC) screening; however, the incidence of CRC screening in the screening mammography population is unknown. Our purpose was to describe non-fecal occult blood test (FOBT) CRC screening utilization by women prior to and subsequent to screening mammography at a large academic medical center. MATERIALS AND METHODS: Using the institutional administrative data base, 17,790 women aged 50 and older who underwent screening mammography between 1998 and 2002 were retrospectively identified. We determined that women were current with non-FOBT CRC screening at the time of mammography if they had undergone flexible sigmoidoscopy or double-contrast barium enema in the 5 years or colonoscopy since 1995, the earliest for which data are available. We excluded FOBT as a form of CRC screening because the administrative data base did not adequately capture episodes of FOBT. Women who were not current were considered eligible for non-FOBT CRC screening. We then assessed the number of women who underwent flexible sigmoidoscopy, barium enema, or colonoscopy within 12 months following mammography. Age, insurance status, Breast Imaging Reporting and Data System classification, recommendations after screening mammography and year of mammography were examined as potential predictors of non-FOBT CRC screening completion. RESULTS: At the time of mammography, 13.3% women were current with non-FOBT CRC screening. Of women eligible for non-FOBT CRC screening at the time of mammography, 1.1% completed non-FOBT CRC screening within 12 months after mammography. The rate of non-FOBT CRC screening completion increased over time. After multivariate analysis, being insured by a commercial managed care organization or by Medicaid remained significant predictors of non-FOBT CRC screening. CONCLUSION: The prevalence of non-FOBT CRC screening is low in the population of women undergoing screening mammography, with an incidence of 1.0%. Future studies should examine whether delivering CRC screening interventions at a screening mammography visit increase adherence to non-FOBT CRC screening.     

Factors Influencing Adherence to Mammography Screening Guidelines in Appalachian Women Participating in a Mobile Mammography Program

The objectives of this study were to evaluate the characteristics (demographic, access to care, health-related behavioral, self and family medical history, psychosocial) of women age 40 years and above who participated in a mobile mammography screening program conducted throughout West Virginia (WV) to determine the factors influencing their self-reported adherence to mammography screening guidelines. Data were analyzed using the Andersen Behavioral Model of Healthcare Utilization framework to determine the factors associated with adherence to mammography screening guidelines in these women. Of the 686 women included in the analysis, 46.2% reported having had a mammogram in the past 2 years. Bivariate analyses showed predisposing factors such as older age and unemployed status, visit to a obstetrician/gynecologist (OB/GYN) in the past year (an enabling factor) and need-related factors such as having a family history of breast cancer (BC), having had breast problems in the past, having had breast biopsy in the past, having had a Pap test in past 2 years, and having had all the screenings for cholesterol, blood glucose, bone mineral density and high blood pressure in past 2 years to be significant predictors of self-reported adherence to mammography guidelines. In the final model, being above 50 years (OR = 2.132), being morbidly obese (OR = 2.358), having BC-related events and low knowledge about mammography were significant predictors of self-reported adherence. Breast cancer related events seem to be associated with mammography screening adherence in this rural Appalachian population. Increasing adherence to mammography screening may require targeted, community-based educational interventions that precede and complement visits by the mobile mammography unit.     

Measuring adherence to mammography screening recommendations among low-income women

OBJECTIVES: (1) To describe the accuracy of self-report and administrative claims for measuring mammography adherence among low-income women; (2) to determine whether the accuracy of self-report differed between telephone interview and mailed questionnaire; and (3) to explore whether the method of measuring adherence affected associations between mammography adherence and participant sociodemographic characteristics. DESIGN: Retrospective cohort study of women receiving care from a Philadelphia Medicaid Managed Care Organization (MCO). PARTICIPANTS: Three hundred and ninety-nine low-income women eligible for screening mammography of whom 64% were African American, 14% Caucasian, 13% Hispanic, and 8% Asian American. MEASURES: Self-reported use of mammography screening, administrative mammography claims data, and dates of mammograms from radiology facility records. The "gold standard" categorized women as having undergone screening if they had either a billing claim or facility record for a mammogram in the past 12 months. MAIN RESULTS: Two hundred and eighty-three of the 399 women reported having had a mammogram in the past 12 months. The sensitivity of self-report was 0.93, specificity was 0.54, positive predictive value was 0.70, and negative predictive value was 0.86. One hundred and seventy-nine of the 399 women had a claim for a mammogram in the past 12 months. The sensitivity of claims data was 0.83 with a negative predictive value of 0.84. The sensitivity of self-report was higher with telephone data collection (0.98) than with mailed data collection (0.82), while the specificity was higher with mail (0.64) than telephone (0.50). African American race was associated with adherence to screening recommendations when mammography use was measured by self-report (RR 1.31, P = 0.002) but not when it was measured by claims or facility validation (RR 1.03, P = 0.56, and RR 1.12, P = 0.15, respectively). CONCLUSIONS: Accurate measurement of adherence to mammography screening among low-income women is difficult. Self-report substantially overestimates adherence (particularly when collected through telephone interviews), while also misclassifying some women who underwent screening as not having been screened (particularly when collected through mailed questionnaires). In contrast, administrative claims data substantially underestimates adherence. Inaccurate measurement of mammography adherence can lead to a biased understanding of the factors associated with adherence.     

Factors associated with women''s adherence to mammography screening guidelines.

OBJECTIVE: To examine individual and environmental factors associated with adherence to mammography screening guidelines. DATA SOURCES: A unique data set that combines a national probability sample (1992 National Health Interview Survey); a national probability sample of mammography facility characteristics (1992 National Survey of Mammography Facilities); county-level data on 1990 HMO market share; and county-level data on the supply of primary care providers (1991 Area Resource File). STUDY DESIGN: The design was cross-sectional. DATA EXTRACTION/ANALYSIS: Data sets were linked to create an individual-level sample of women ages 50-74 (weighted n = 2,026). We used multipart, sequential logistic regression models to examine the predictors of having ever had mammography, having had recent mammography, and adherence to guidelines. We categorized women as adherent if they reported a lifetime number of exams appropriate for their age (based on screening every two years) and they reported having had an exam in the past two years. PRINCIPAL FINDINGS: Only 27 percent of women had the age-appropriate number of screening exams (range 16 percent-37 percent), while 59 percent of women had been screened within two years. Women were significantly more likely to adhere to screening guidelines if they reported participating with their doctor in the decision to be screened; were younger; had smaller families, higher education and income, and a recent Pap smear; reported breast problems; and lived in an area with a higher percentage of mammography facilities with reminder systems, no shortage of primary care providers, higher HMO market share, and higher screening charges. CONCLUSIONS: A small percentage of women adhere to screening guidelines, suggesting that adherence needs to become a focus of clinical, programmatic, and policy efforts.     

Identifying Sociocultural Barriers to Mammography Adherence Among Appalachian Kentucky Women

Despite lower breast cancer incidence rates, Appalachian women evidence lower frequency of screening mammography and higher mortality risk for breast cancer compared to non-Appalachian women in Kentucky, and in the United States, overall. Utilizing data from 27 in-depth interviews from women in seven Appalachian Kentucky counties, this study examines how Appalachian women explain sociocultural barriers and facilitators to timely screening mammography, and explores their common narratives about their mammography experiences. The women describe how pain and embarrassment, less personal and less professional mammography experiences, cancer fears, and poor provider communication pose barriers to timely and appropriate mammography schedule adherence and follow-up care. The study also identifies how improving communication strategies in the mammography encounter may improve mammography experiences and adherence to screening guidelines.     

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.     

Intervention to increase screening mammography among women 65 and older

This paper reports the results of a practice-based intervention program to increase mammography screening among women 65 and older who receive their health care in the private sector. Forty-three primary-care practices and 2147 women in central and western North Carolina were enrolled in the study, and 1911 women completed all phases of the study. The intervention was a three-stage educational and counseling program designed to become progressively more intensive at each stage. The interventions included provider education in the form of current information on issues in mammography for older women, simply written educational materials on breast cancer and screening mailed to women, and a brief telephone counseling session for the women. While the analysis revealed no overall effect across all three stages of the intervention program, tests for interaction indicated a significant program effect for women who were 80 or older, had less than 9 years of education, were black, or had no private insurance to supplement Medicare. The results suggested that providing primary-care physicians with information on screening older women and providing the women with useful educational materials can increase participation in screening mammography among subgroups of women currently least likely to receive mammography screening.     

A community-based intervention to increase screening mammography among disadvantaged women at an inner-city drop-in center

PURPOSE: To determine the effectiveness of a community- based intervention to increase the use of screening mammography among disadvantaged women at an inner-city drop-in center. METHODS: This study involved women 50 to 70 years old who were clients of an inner-city drop-in center in Toronto, Canada, during the years 1995-2002 (N = 158 in 1995-2001 and N = 89 in 2002). In 2002, the drop-in center and a nearby hospital initiated a collaborative breast cancer screening project in which a staff member of the drop-in center accompanied small groups of women for mammography visits at a weekly pre-arranged time. Interrupted time series analysis was used to examine the effect of this intervention on the annual rate of screening mammography, as determined by review of medical records. RESULTS: More than half of the women 50 to 70 years old who used the drop-in center in 2002 had been diagnosed with a major mental illness, and one-third were either homeless or living in supportive housing. In the 7 years before the introduction of the intervention, annual mammography rates among women using the drop-in center averaged 4.7%. During the intervention year, 26 (29.2%) of 89 women underwent mammography (p = 0.0001 for the change from pre-to post-intervention). CONCLUSIONS: The introduction of accompanied small-group visits was associated with significantly increased use of mammography in a group of disadvantaged women who were clients of an inner-city drop-in center. This approach may be useful to promote breast cancer screening among women affected by mental illness or homelessness who have contact with community-based agencies.     

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.     

Breast and cervical cancer screening and health beliefs among African American women attending educational programs

This article assessed the relationship between breast and cervical cancer screening rates and health beliefs in African American women participating in Witness Project of Harlem (WPH) education sessions. WPH is a culturally sensitive, faith-based breast and cervical cancer screening education program targeting African American women in medically underserved New York City communities. A questionnaire administered to women participating for the first time in a Witness Project education session collected demographics, adherence to breast and cervical cancer screening, and information about health beliefs related to cancer worry, medical mistrust, and religious faith. Screening adherence guidelines applied were as per the American Cancer Society recommendations. No statistically significant relationship was found between worry about getting breast or cervical cancer and screening adherence, or between screening adherence and agreement with statements about medical mistrust and religious beliefs. The low screening mammography and monthly breast self-exam rates emphasize the utility of programs like WPH that teach the importance of screening mammography and breast self-exam and point to the need for increased access to quality health care and cancer screening in underserved populations.     

Association between CBE,FOBT, and Pap smear adherence and mammography adherence among older low-income women

BACKGROUND: Adherence to regular and timely mammography screening, especially in older low-income women, continues to fall below objectives. The primary aim of this study was to examine whether engaging in other cancer screenings was associated with mammography adherence for older women. METHODS: Women, ages 52 and over, without a self-reported history of breast cancer (N = 862) were selected from a larger sample of women residing in Washington, DC, census tracts with >/=30% of households below 200% of the federal poverty threshold. A computer-assisted telephone survey was used to collect data on health care system factors, demographics, cultural beliefs, clinical breast exam (CBE), Pap smear, fecal occult blood testing (FOBT), and mammography. Adherence was defined as receipt of the last two screening tests within recommended intervals for age. RESULTS: After controlling for other variables, adherence to CBE (OR = 4.15; 95% CI, 2.55-6.73) and Pap smear (OR = 1.82; 95% CI, 1.07-3.12) were highly predictive of mammography adherence. Adherence to FOBT (OR = 1.66; 95% CI, 0.97-2.84) was marginally predictive. CONCLUSIONS: Results of this study indicate that nonadherence to other cancer screenings can help identify women in need of additional interventions to improve mammography adherence.     

The impact of a physician intervention program on older women's mammography use.

The Mammography Optimum Referral Effort (MORE) is a physician office-based intervention program initiated by the Connecticut Peer Review Organization (CPRO) to increase mammography use among older women in Connecticut. Three locales in the state were targeted for the MORE intervention based on identified low mammography rates in women aged 65 years and older. Thirty-seven physicians participated from March 1, 1996, to August 31, 1996. Annual mammography rates were derived by merging Medicare Part B mammography claims with a database from the Connecticut Tumor Registry. This strategy allowed us to exclude women with a prior history of breast cancer from the analysis, in order to estimate screening rates. The MORE intervention was associated with an absolute increase of 5.9%, which represents a relative increase of 15.4%, in annual mammography use. Our findings suggest that a multifaceted physician intervention is capable of increasing mammography use among older women.     

Compliance with mammography guidelines: physician recommendation and patient adherence

BACKGROUND: Guidelines recommend that women ages 50-75 years receive screening mammography every 1-2 years. We related receipt of physician recommendations for mammography and patient adherence to such recommendations to several patient characteristics. METHODS: We retrospectively reviewed medical records of 1,111 women ages 50-75 attending three clinics in an urban university medical center. We ascertained overall compliance with mammography guidelines and two components of compliance: receipt of a physician recommendation and adherence to a recommendation. Outcome measures were the proportion of patients demonstrating each type of compliance and adjusted odds ratios, according to several patient-related characteristics. RESULTS: Overall, 66% of women received a recommendation. Of women receiving a documented recommendation, 75% adhered. Factors showing significant positive associations with receiving a recommendation included being a patient in the general internal medicine clinic, having private insurance, visiting the clinic more often, and having a recent Pap smear. Patient adherence was positively associated with private insurance and Pap smear history, negatively associated with internal medicine, and not associated with visit frequency. CONCLUSIONS: Patient factors influencing physician mammography recommendations may be different from those associated with patient adherence, except for having private health insurance, which was a predictor of both.     

The gradient in mammography screening behavior: a lifestyle marker

The study reports a gradient in adhering to a recommended health behavior-mammography screening. Data were collected on 951 Israeli women, aged 50-74, who were mailed an invitation to a prescheduled mammography screening appointment and were later phone interviewed about their background, their other health behaviors and their health perceptions related to cancer, mammography and self-rated health. The main finding that emerged was a gradient consisting of three groups defined by their adherence to mammography screening: women who declined the invitation to undergo screening (nonattenders, 32%), women who attended a screening upon encouragement (attenders, 45%) and women who initiated the test on their own (self-screenees, 23%). This gradient was shown to be related to structural/background variables (e.g. SES, age, education, ethnicity), other health behaviors and perceptual variables related to health in general and to cancer. For example, self-screenees were of a higher SES, engaged in more health behaviors and were closer to other women who performed a mammography. An analysis carried out to discern where the difference between the three groups lied showed that it was more apparent between the self-screenees and attenders, and that the attenders and nonattenders were more similar to each other. These findings are discussed in terms of health behavior as a discrete phenomenon vs. reflecting a lifestyle. Suggestions for intervention possibilities are presented in light of the finer ranking proposed above (as opposed to the dichotomy of engaging/not engaging in a health behavior).     

Implementation of outreach telephone counseling to promote mammography participation.

To increase mammography participation, the authors implemented an outreach intervention translating concepts from expectancy value theory into a motivational interviewing telephone intervention that included the opportunity to schedule a screening appointment. Process data are presented from 491 women who had not scheduled a mammogram within 2 months of receiving a mailed invitation from a managed care organization's centralized breast cancer screening program. A total of 83% of targeted women accepted the counseling calls. Counselors rated 84% of completed calls as either receptive or neutral in tone. Women with prior mammography experience were more likely to be receptive and to schedule a screening appointment during the calls than were women with no prior experience. Topics discussed during the calls also differed between women with and without prior mammography experience. Implications for dissemination of counseling interventions in health care organizations are discussed.     

Does gender discrimination impact regular mammography screening? Findings from the race differences in screening mammography study

ABSTRACT Objective: To determine if gender discrimination, conceptualized as a negative life stressor, is a deterrent to adherence to mammography screening guidelines. Methods: African American and white women (1451) aged 40-79 years who obtained an index screening mammogram at one of five urban hospitals in Connecticut between October 1996 and January 1998 were enrolled in this study. This logistic regression analysis includes the 1229 women who completed telephone interviews at baseline and follow-up (average 29.4 months later) and for whom the study outcome, nonadherence to age-specific mammography screening guidelines, was determined. Gender discrimination was measured as lifetime experience in seven possible situations. Results: Gender discrimination, reported by nearly 38% of the study population, was significantly associated with nonadherence to mammography guidelines in women with annual family incomes of > or =$50,000 (OR 1.99, 95% CI 1.33, 2.98) and did not differ across racial/ethnic group. Conclusions: Our findings suggest that gender discrimination can adversely influence regular mammography screening in some women. With nearly half of women nonadherent to screening mammography guidelines in this study and with decreasing mammography rates nationwide, it is important to address the complexity of nonadherence across subgroups of women. Life stressors, such as experiences of gender discrimination, may have considerable consequences, potentially influencing health prevention prioritization in women.