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.     

Effects of a mammography decision-making intervention at 12 and 24 months

BACKGROUND: Most women are not getting regular mammograms, and there is confusion about several mammography-related issues, including the age at which women should begin screening. Numerous groups have called for informed decision making about mammography, but few programs have resulted. Our research is intended to fill this gap. METHODS: We conducted a randomized controlled trial, which ran from 1997 to 2000. Women aged 40 to 44 and 50 to 54, who were enrolled in Blue Cross Blue Shield of North Carolina, were randomly assigned to one of three groups: usual care (UC), tailored print (TP) materials, or TP plus tailored telephone counseling (TP+TC). We assessed the impact of tailored interventions on knowledge about breast cancer and mammography, accuracy of breast cancer risk perceptions, and use of mammography at two time points after intervention-12 and 24 months. RESULTS: At 12 and 24 months, women who received TP+TC had significantly greater knowledge and more accurate breast cancer risk perceptions. Compared to UC, they were 40% more likely to have had mammograms (odds ratio=0.9-2.1). The effect was primarily for women in their 50s. TP had significant effects for knowledge and accuracy, but women who received TP were less likely to have had mammography. CONCLUSIONS: Decision-making interventions, comprised of two tailored print interventions (booklet and newsletter), delivered a year apart, with or without two tailored telephone calls, significantly increased knowledge and accuracy of perceived breast cancer risk at 12 and 24 months post-intervention. The effect on mammography use was significant in bivariate relationships but had a much more modest impact in multivariate analyses.     

Methodology for targeting physicians for interventions to improve breast cancer screening

INTRODUCTION: Uneven increases in mammography utilization rates call for methods to efficiently target educational interventions to women who do not regularly use mammography and physicians who do not adhere to national guidelines for breast cancer screening. This paper discusses a method for identifying physicians who are nonadherers to breast cancer screening guidelines or in need of continuing medical education (CME) in this area. METHODS: A 1995 community-based telephone survey of randomly selected women aged 50-80, residing in four Long Island, NY, townships was used to identify women who underuse mammography and their regular physicians. Community-based surveys of physicians permitted identification of nonadherent providers. Nonadherence to breast cancer screening recommendations was the primary criterion, but because of anticipated physician reluctance to self report nonadherence with screening guidelines, additional criteria were developed to identify physicians with educational needs relating to breast cancer screening. These criteria included lack of office reminder systems and knowledge relating to breast cancer screening, and lack of confidence in patient counseling and clinical breast examination skills. RESULTS: Overall response rates were 77% for women's survey, and 66% for the physician survey. 3427 women were classified as underusers (38.5%) and 87% of underusers provided the name and address of their regular physicians. By physician self report, 45% of physicians were classified as nonadherers and 42% were identified as having related educational needs. CONCLUSION: A feasible method for identifying physicians who are nonadherers to breast cancer screening recommendations or in need of CME about this is described, permitting efficient targeting of educational interventions to those with patients who underuse mammography. The method is not dependent on access to a specific provider or patient population.     

Comparison of tailored interventions to increase mammography screening in nonadherent older women

BACKGROUND: Recent increases in mammography use have led to a decrease in mortality from breast cancer. METHODS: Building on the Health Belief Model, the Transtheoretical Model, and past effectiveness of tailored interventions, we conducted a prospective randomized trial (n = 773) to test the efficacy on mammography adherence of tailored interventions delivered by five different methods, i.e., telephone counseling, in-person counseling, physician letter, and combinations of telephone with letter and in-person with letter. RESULTS: All five interventions increased mammography adherence significantly relative to usual care (odds ratios, 1.93 to 3.55) at 6 months post intervention. The combination of in-person with physician letter was significantly more effective than telephone alone or letter alone. Women thinking about getting a mammogram at baseline were more likely to be adherent by 6 months; even those in usual care achieved 48% adherence compared with 50-70% in the intervention groups. In contrast, women not thinking about getting a mammogram needed the interventions to increase their adherence from 13% to over 30%. CONCLUSIONS: All five interventions were effective at increasing mammography adherence. Women not thinking about getting a mammogram were most likely to benefit from these tailored interventions while other women might need less intensive interventions.     

Cost-Effectiveness Analysis of Interventions to Enhance Mammography Compliance Using Computer Modeling (CAN*TROL)

OBJECTIVE: Tailored telephone counseling and physician-based and clinic-based interventions have been shown to be cost-effective in enhancing utilization of mammography among nonadherent women. The objective of this study was to evaluate the costs and benefits of a broad implementation of these interventions from a health payer perspective. METHODS: CAN*TROL computer modeling was employed in the cost-effectiveness analysis of interventions in a 2000 Texas female population. The estimated effects of the various interventions and their related costs derived from the literature were applied to a hypothetical scenario of a broad implementation of these interventions. RESULTS: Seven studies were identified from the literature, six of them employed tailored telephone counseling (TC), whereas two used comprehensive physician-based (PB) or clinic-based (CB) interventions. The estimated intervention cost per women was 43 dollars for TC, 71 dollars for PB, and 151 dollars for CB. CAN*TROL model showed that after 15 years of implementation, TC, PB, and CB could reduce cancer mortality by 6.5, 2.2, and 10.7%, respectively. The cumulative net costs of interventions, mammography screening, and medical care costs were lower for TC (TC vs. PB vs. CB, 1.05 million vs. 1.06 million vs. 1.60 million). Nevertheless, CB resulted in more life-years saved (TC vs. PB vs. CB, 11,413 vs. 8515 vs. 14,559). The incremental cost-effectiveness ratio was more favorable for tailored telephone counseling interventions. One-way sensitivity analysis indicated that compliance rates and intervention costs had the most significant impact on the incremental cost-effectiveness ratio. CONCLUSION: Tailored telephone counseling interventions may be the preferred first-line intervention for getting nonadherent women aged 50 to 79 years on schedule for mammography screening.     

The effect of Medicare reimbursement for screening mammography on utilization and payment. National Cancer Institute Breast Cancer Screening Consortium.

OBJECTIVE: In January 1991, Medicare extended its mammography benefit to reimburse for breast cancer screening mammograms. In 1991 and again in 1993, the National Cancer Institute Breast Cancer Screening Consortium (BCSC) conducted a survey to test the hypothesis that this benefit would increase mammography use among women over the age of 65. METHODS: The authors analyzed data on non-Hispanic white women ages 65 to 74 living in 11 geographic areas targeted by the BCSC for an earlier study--six that had received cancer screening educational interventions and five control subsites--to measure the impact of the newly adopted Medicare benefit on the use of mammography and use of Medicare to reimburse mammography costs. RESULTS: The data show little overall increase between 1991 and 1993 in reported mammography use among respondents to the survey. However, in six intervention and five control subsites there was an increase in the percentage of women who reported using public payment sources to at least partially reimburse the cost of mammograms. In three intervention subsites, the increase from 1991 to 1993 in the percentage of women using public sources of payment was greater than in the corresponding control subsites. CONCLUSIONS: These findings suggest that public health interventions are more likely to succeed when educational promotion accompanies a financial benefit.     

The effectiveness of mammography promotion by volunteers in rural communities

INTRODUCTION: The Community Trial of Mammography Promotion assessed the effectiveness of mammography promotion by community volunteer groups in rural areas. Three interventions were tested. One used an individual counseling strategy, one used a community activities strategy, and a third combined the two strategies. METHODS: The effects of the interventions were tested by randomizing 40 communities either to the study interventions or to a control group. A cohort of 352 women from each community was randomly selected and used to evaluate the interventions' effectiveness. Of these, 6592 women were eligible for screening mammography at baseline and follow-up and were successfully interviewed prior to and after study intervention activities. RESULTS: Although the interventions did not significantly increase women's overall use of mammography, the community activities intervention increased use at follow-up by regular users over baseline by 2.9% (p = 0.01). Intervention appears to have increased the use of mammography among certain groups of women who were not regular users at baseline, including those in communities without female physicians (10% to 16%; p < 0.05), and among women with no health insurance (10% to 23%; p 相似文献   

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.     

A randomized trial of breast cancer risk counseling: the impact on self-reported mammography use.

OBJECTIVES: We evaluated the impact of individualized breast cancer risk counseling on mammography use among women at risk for breast cancer. METHODS: Participants (n = 508) were randomized to the breast cancer risk counseling intervention or a general health education control intervention, and 85% completed follow-up. RESULTS: In multivariate modeling, a significant group-by-education interaction demonstrated that among less-educated participants, breast cancer risk counseling led to reduced mammography use. There was no intervention effect among the more-educated participants. CONCLUSIONS: These results suggest that standard breast cancer risk counseling could have an adverse impact on the health behaviors of less-educated women.     

Church-based telephone mammography counseling with peer counselors

Little is published about step-by-step implementation of telephone counseling interventions to promote community-based health activities. This article describes the authors' experience of implementing a church-based telephone mammography counseling intervention with peer counselors representing three principal racial or ethnic groups: African American, Latino, and Anglo (White). Twenty-six women from 12 churches in the Los Angeles area were recruited and trained to deliver the counseling annually over a two-year period to 570 women participants who were recruited from participating churches (n = 15). The counseling sessions were conducted from church-based telephone centers in key geographic locations in our program area. Training and supervision proved challenging: most of the Latino counselors had fewer than seven years of education and spoke only Spanish, while most of the other counselors had at least some college and spoke only English. Culturally specific and small group interactions, role plays, and a more modular approach to training were the most effective ways to enhance counselors' skills. Latina participants' mammography adherence rates were lowest, and their barriers reflected their low socioeconomic status; as Latina counselors shared basic information about mammograms and where to obtain them at little or no cost, the counseling exchanges tended to be nonconflictive and supportive. Black and White participants were generally more knowledgeable and adherent with screening guidelines than Latinas. We found that it was possible to implement this intervention with diverse groups and conclude with lessons learned that may inform others considering such a strategy.     

Tailored interventions to promote mammography screening: a meta-analytic review

OBJECTIVE: To evaluate the effectiveness of tailored interventions, designed to reach one specific person based on her unique characteristics, for promoting mammography use. METHOD: This systematic review used meta-analytic techniques to aggregate the effect size of 28 studies published from 1997 through 2005. Potential study-level moderators of outcomes (sample, intervention, and methodological characteristics) were also examined. RESULTS: A small but significant aggregate odds ratio effect size of 1.42 indicated that women exposed to tailored interventions were significantly more likely to get a mammogram (p<0.001). The type of population recruited and participants' pre-intervention level of mammography adherence did not significantly influence this effect. Tailored interventions that used the Health Belief Model and included a physician recommendation produced the strongest effects. Interventions delivered in person, by telephone, or in print were similarly effective. Finally, defining adherence as a single recent mammogram as opposed to regular or repeated mammograms yielded higher effect sizes. CONCLUSION: Tailored interventions, particularly those that employ the Health Belief Model and use a physician recommendation, are effective in promoting mammography screening. Future investigations should strive to use more standardized definitions of tailoring and assessments of mammography outcomes.     

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.     

The role of trust in use of preventive services among low-income African-American women

BACKGROUND: This study explored factors that predict higher trust in primary care providers, and examined the role of patient trust on the use of preventive services for low-income African-American women. METHODS: We conducted a cross-sectional, population-based telephone survey of 961 African-American women over age 40 in Washington, DC. Two dimensions of trust were examined: overall trust in one's regular primary care provider, and trust that the regular provider had no financial conflict of interest. Self-reported use of mammography, Pap tests, clinical breast exams, colorectal cancer screening, blood pressure, height and weight measurement, diet counseling, and depression screening, as delivered by one's primary care provider, were assessed. An index summarizing overall use of these interventions was the main outcome variable. RESULTS: More than two-thirds of respondents reported high trust in their physician. Older respondents (>65) were more trusting of their physicians overall than were younger respondents (P < 0.01). Primary care characteristics (continuity of care, accessibility of the practice, coordination of specialty care by one's regular provider) were more strongly associated with having high trust than were sociodemographic, health status, and insurance characteristics. Higher trust was significantly associated with greater use of recommended preventive services (OR: 2.3, 95% CI: 1.3, 4.0), controlling for the effects of insurance status, primary care, and patient characteristics. CONCLUSIONS: Trust is associated with use of recommended preventive services in low-income African-American women. Stronger patient-provider relationships, with high levels of trust, may indirectly lead to better health through adherence to recommended preventive services for low income African-American women.     

Cost-effectiveness comparison of five interventions to increase mammography screening

BACKGROUND: Mammography is the primary method used for breast cancer screening. However, compliance with recommended screening practices is still below acceptable levels. This study examined the cost-effectiveness of five combinations of physician recommendation and telephone or in-person individualized counseling strategies for increasing compliance with mammography. METHODS: There were 808 participants who were randomly assigned to one of six groups. A logistic regression model with compliance as the dependent variable and group as the independent variable was used to test for significant differences and a ratio of cost to improvement in mammogram compliance evaluated the cost-effectiveness. RESULTS: Three of the interventions (in-person, telephone plus letter, and in-person plus letter) had significantly better compliance rates compared with the control, physician letter, or telephone alone. However, when considering costs, only one emerged as the superior strategy. The cost-effectiveness ratios for the five interventions show that telephone-plus-letter is the most cost-effective strategy, achieving a 35.6% mammography compliance at a marginal cost of $0.78 per 1% increase in women screened. CONCLUSIONS: A tailored phone prompt and physician reminder is an effective and economical intervention to increase mammography. Future research should confirm this finding and address its applicability to practice.     

Attitudes, beliefs, and knowledge as predictors of nonattendance in a Swedish population-based mammography screening program

BACKGROUND: The effectiveness of mammography screening could be improved if factors that influence nonattendance were better understood. METHODS: We examined attitudes, beliefs, and knowledge in relation to nonattendance in a population-based mammography screening program, using a case-control design. Data were collected from November 1997 to March 1998 through telephone interviews with 434 nonattenders and 515 attenders identified in a population-based mammography register in central Sweden. The questions asked drew primarily upon the components constituting the Health Belief Model. RESULTS: Multivariate analysis showed that nonattendance was most common among women within the highest quartile of perceived emotional barriers, compared to women within the lowest quartile (OR = 4.81; 95% CI 2.96-7.82). Women who worried most about breast cancer were more likely to attend than those who worried least (OR = 0.09; 95% CI 0.02-0.31). Women with the highest scores of perceived benefits were more likely to attend than women with the lowest ones (OR = 0.35; 95% CI 0.08-0.75). Other factors associated with nonattendance were less knowledge about mammography and breast cancer, lack of advice from a health professional to participate, and very poor trust in health care. CONCLUSIONS: Our findings suggest that increased participation in outreach mammography screening programs can be achieved through enhancement of breast cancer awareness and possibly by reducing some of the modifiable barriers. mammography; mass screening; breast cancer; attitudes; Sweden.     

'It's easier said than done': perspectives on mammography from women with intellectual disabilities

PURPOSE Women with intellectual disabilities (or mental retardation) are living longer, receiving primary care in the community, and have equal rates of breast cancer compared with women in the general population, but they have lower rates of mammography. Although several public campaigns have successfully raised the mammography rate for racial and ethnic minority women, they have not penetrated the community of women with intellectual disabilities. No research to date has explored potential barriers to mammography for these women by involving the women themselves as participants.METHODS We undertook a qualitative study to explore the perceptions and understanding of mammography for women with intellectual disabilities and some of the potential reasons they would or would not have the test. Twenty-seven intellectually disabled women were recruited through a variety of community groups and interviewed using a semistructured interview guide. Data were analyzed using qualitative techniques from grounded theory.RESULTS Participants in this study described being poorly prepared for mammography: they did not understand its purpose and were not prepared for the logistics of the experience. The latter was more upsetting to participants and contributed to their negative perceptions of mammography. Participants reported feeling unprepared and singled out for being unprepared, despite their desire to have at least 1 mammogram, as do other women their age.CONCLUSIONS Women with intellectual disabilities perceive mammography differently than do women who do not have intellectual disabilities, and their perception is informed by inadequate knowledge, anxiety, and inadequate preparation. These themes should be considered when planning cancer prevention interventions with this population and when counseling individual women in the clinical setting.     

Maternal dietary counseling reduces total and LDL cholesterol postpartum

ObjectiveThe aim of this study was to investigate the effects of dietary counseling on blood lipid concentrations during and after pregnancy.MethodsPartcipants (N = 256) were randomized into three study groups: dietary counseling with probiotics or placebo and a control group at first trimester of pregnancy. Diet quality was evaluated from food records by an index of healthy eating and total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol, triglycerides, apolipoproteins A-I and B, and lipoprotein (a) were measured at the first and third trimesters of pregnancy and 1, 6, and 12 mo postpartum.ResultsDuring pregnancy, no differences in lipid values were noted among the groups, but postpartum TC and LDL-C were lower in both dietary counseling groups compared with controls (P = 0.027 and P = 0.012, respectively). Higher points on the healthy eating index, normal weight, and regular exercise were associated with a more favorable lipid profile at 12 mo after delivery.ConclusionMaternal dietary counseling may lower maternal TC and LDL-C levels postpartum. A healthy lifestyle during pregnancy and postpartum may benefit women’s cardiovascular health.     

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.     

Delivering Preventive Health Services for Breast Cancer Control: A Longitudinal View of a Randomized Controlled Trial

Objective. To develop a longitudinal model to characterize the delivery of mammography services using repeated observations of mammography referral rates during a randomized controlled trial (RCT) of physician mammography reminders. Data Sources/Study Setting . Administrative records of a health department and observational data on mammography appointment scheduling. Study Design. The design was a longitudinal study of month‐specific referral rates during a 1‐year RCT. A retrospective case‐control study was used to investigate differences between women with timely and delayed (or absent) mammography referral assessed at the end of the intervention year. Data Collection/Extraction Methods. Month‐specific indicators for referrals and missed clinical opportunities, that is, months when clinic visitors were due for a mammogram and not referred, were constructed using administrative and observational data. Findings. In the unadjusted analysis, the effectiveness of the reminder declined over time. However, in a multivariate analysis that controlled for the number of missed opportunities, the effectiveness was constant over time. On a monthly basis, physician reminders were significantly associated with higher referral rates among clinic visitors newly due for mammography (adjusted OR=2.8, 95 percent CI=1.3, 5.8) or who had one previously missed clinical opportunity (adjusted OR=3.0, 95 percent CI=1.6, 5.3) but were not for those with two or more missed clinical opportunities (adjusted OR=1.2, 95 percent CI=0.7, 2.3). Factors independently associated with delayed referral were age over 65, presence of more than one chronic illness, and the absence of a physician mammography reminder. Conclusions. Longitudinal models that examine rates of referral over time and include information about outcomes on previous visits can enhance our understanding of how intervention strategies work in practice.