Supporting women with intellectual disabilities to access breast cancer screening: a healthcare professional perspective

MCILFATRICK S., TAGGART L. & TRUESDALE‐KENNEDY M. (2011) European Journal of Cancer Care 20 , 412–420
Supporting women with intellectual disabilities to access breast cancer screening: a healthcare professional perspective Cancer prevention has been identified as the most cost‐effective strategy for cancer control. This should extend to all groups including women with intellectual disability, seeking to access breast cancer screening. The purpose of this study was to explore the role of healthcare professionals, such as primary healthcare staff (n= 8) and breast care staff (n= 10), on supporting women with intellectual disability to access breast screening in one region in the UK. A qualitative approach using focus groups and telephone interviews was adopted. Healthcare professionals identified that not only was it important that women with intellectual disability undergo regular breast screening but that they should have the same rights as other women to access breast screening services. While many varied risk factors for breast cancer in women with intellectual disability were noted, the level of cognitive functioning was clearly significant. Barriers to accessing breast screening included literacy problems, consent issues and physical health; practical barriers such as transport and timing of appointment; and barriers attributed to healthcare professionals, including staff attitude and lack of awareness and training. The participants identified the need to raise awareness and health promotion education not only for the women with intellectual disability but also for healthcare professionals, alongside developing more interdisciplinary practice.     

Breast Cancer Screening Disparity among Korean American Immigrant Women in Midwest

Purpose: Using three breast cancer screening methods such as mammogram, Clinical Breast Examination (CBE), and Breast Self-Examination (BSE), this study investigated breast cancer screening rates and its associated factors in Korean American immigrant women. Method: Cross-sectional data were obtained from 168 Korean immigrant women aged 40 and older in Midwest. The Andersen’s Behavioral Model (1995) theoretically guided this study and logistic regression was used to examine factors associated with screening receipt and performance. Results: Study participants reported low screening rates, specifically mammography and CBE uptake. About 71% of the women had a mammography at least once in their lifetime, while about 36% indicating receipt of a mammogram in the last three years. About 59% of the women received a CBE at least once in their lifetime, while about 32% had CBE in the past three years. About 74% of study participants have performed BSE at least once in their life time, while about 69% have done it in the past three years. Knowledge of screening method was consistently correlated with participant’s three breast cancer screening uptake. Additional factors that were positively associated with screening included older age, low barriers to mammograms, and lower educational attainment. Conclusions: Overall, study participants reported low rates of breast cancer screening receipt and performance. It is required to promote screening uptake among Korean immigrant women, especially women with young age, a lower level of education, and lack of health accessibility. A community-based language-appropriate health education program should be developed to increase health care access.     

Understanding Breast Cancer Screening Practices in Taiwan: a Country with Universal Health Care

While the incidence of breast cancer (BC) has been relatively low in Asian countries, it has been rising rapidlyin Taiwan. Within the last decade, it has replaced cervical cancer as the most diagnosed cancer site for women.Nevertheless, there is a paucity of studies reporting the attitudes and practices of breast cancer screening amongChinese women. The aim of this study is to assess Taiwanese women’s knowledge of and attitudes toward BCscreening and to identify potential factors the may influence screening behavior. The study population consistedof a sample of 434 Taiwanese women aged 40 and older. Despite access to universal health care for Taiwanesewomen and the fact that a majority of the women had heard of the breast cancer screening (mammogram, clinicalbreast exams, etc.), the actual utilization of these screening modalities was relatively low. In the current study, themajority of women had never had mammograms or ultrasound in the past 5 years. The number one most reportedbarriers were “no time,” “forgetfulness,” “too cumbersome,” and “laziness,” followed by the perception of noneed to get screened. In addition, the results revealed several areas of misconceptions or incorrect informationperceived by study participants. Based on the results from the regression analysis, significant predictors ofobtaining repeated screening modalities included age, coverage for screening, barriers, self-efficacy, intention,family/friends diagnosed with breast cancer. The findings from the current study provide the potential to buildevidence-based programs to effectively plan and implement policies in order to raise awareness in breast cancerand promote BC screening in order to optimize health outcomes for women affected by this disease.     

Review of the Cervical Cancer Burden and Population-Based Cervical Cancer Screening in China

Cervical cancer continues to be a serious public health problem in the developing world, including China. Because of its large population with geographical and socioeconomic inequities, China has a high burden of cervical cancer and important disparities among different regions. In this review, we first present an overview of the cervical cancer incidence and mortality over time, and focus on diversity and disparity in access to care for various subpopulations across geographical regions and socioeconomic strata in China. Then, we describe population-based cervical cancer screening in China, and in particular implementation of the National Cervical Cancer Screening Program in Rural Areas (NACCSPRA) and the challenges that this program faces. These include low screening coverage, shortage of qualified health care personnel and limited funds. To improve prevention of cervical cancer and obtain better cancer outcomes, the Chinese government needs to urgently consider the following key factors: reducing disparities in health care access, collecting accurate and broadly representative data in cancer registries, expanding target population size and increasing allocation of government funding for training of personnel, improving health education for women, enhancing quality control of screening services and improving a system to increase follow up for women with positive results.     

Relationship between Health Literacy and Adherence to Recommendations to Undergo Cancer Screening and Health-Related Behaviors among Insured Women in Japan

Background: Health literacy serves as a major barrier to effective preventive health behaviors, such as cancerscreening, and this relationship has not been studied among insured women in Japan. We examined the relationshipbetween health literacy and adherence to recommendations to undergo cancer screening, and health-related behaviors,among Japanese women who were insured by a health insurance society. Methods: We conducted a cross-sectionalobservation study of 670 insured Japanese women. For this, we used a self-administered questionnaire to assessenvironments, self-rated health status, cancer screening behavior, health-related behaviors (dietary behavior, exercisefrequency, alcohol consumption and smoking behavior), and health literacy. Results: Among the participants, 206completed the questionnaire (response rate, 30.7%). Fifty-seven had undergone breast and/or cervical cancer screening.The mean health literacy score was 3.44 (standard deviation = 0.68). In logistic regression models adjusted for age,self-rated economic status, and having a primary care physician, there was no statistically significant relationship betweenhealth literacy and adherence to recommendations to undergo cancer screening, and health-related behaviors. However,age and having a primary care physician were significantly associated with cancer screening and health-related behaviors.Health literacy was not found significantly associated with effective preventive health behaviors. Conclusions: Thepresent study found no statistically significant relationship between health literacy and adherence to recommendationsto undergo cancer screening and health-related behaviors. Rather, cancer screening and health-related behaviors werefound related to medical support from physicians and those their own age. Further study is needed for exploring theseassociations among insured women in Japan.     

Evaluating Teaching Techniques in the Hmong Breast and Cervical Cancer Health Awareness Project

Cancer health disparities are a reality for Hmong women who are often diagnosed at a later stage and have low literacy and experienced care that are not culturally appropriate. Lack of attention to cultural appropriateness and literacy levels of cancer screening materials may contribute to disproportionately low levels of cancer screening among Hmong women. The purposes of this study were to evaluate the Hmong Health Awareness Project (HHAP), a program designed to create awareness and acceptance of breast and cervical cancer screening, and to examine participants’ perceptions of the utility of the content of the workshops. Hmong researchers partnered with three Midwestern Hmong community centers to implement six workshops. Three teaching techniques: pictographs, videos, and hands-on activities were utilized to teach Hmong participants about cancer screening. Participants included 150 Hmong (male participants?=?30 and female participants?=?120). Teach-back method was used to assess the participants’ understanding of cancer screening throughout the workshops. Qualitative data were collected in focus groups to assess the feasibility of teaching methods and participants’ perceptions of the utility of the content of the workshops. Directed content analysis was used to analyze participants’ responses. The three teaching techniques were helpful in increasing the Hmong people’s understanding about breast and cervical cancer screening. Nearly, all participants perceived an increased in their understanding, greater acceptance of cancer screening, and increased willingness to be screened. Men expressed support for screening after the workshops. Findings can guide future interventions to improve health communications and screening and reduce diagnostic disparities among Hmong and immigrant populations.     

Health maintenance and screening in breast cancer survivors in the United States

BACKGROUND: The general health maintenance and follow-up of breast cancer survivors has not been well-studied. In a population-based sample we sought to investigate the health practices of breast cancer survivors and to compare rates of screening to women with no history of breast cancer. METHODS: Subjects were participants of the medical expenditure survey in the years 1996 and 1998, years for which information on screening were available. We used a matched cohort design. Breast cancer survivors aged 40 and older were matched (on age and race/ethnicity) to women with no breast cancer history. We performed logistic regression to estimate the odds of receiving appropriate health care services in breast cancer survivors versus women with no breast cancer history. In addition, we examined demographic and socioeconomic differences between breast cancer survivors who reported appropriate screening and survivors who had inadequate screening. RESULTS: A small minority of breast cancer survivors report inadequate mammography (18%) and clinical breast exam (12%) follow-up. A significant portion of breast cancer survivors report inadequate screening for Pap smear (40%), general physical exam (GPE) (30%) and flu shot (33%). The odds of receiving appropriate screening were higher in survivors versus matched women for mammography, clinical breast and cholesterol screening. There were no differences for other screening. Across all health maintenance and screening practices, breast cancer survivors who did not receive appropriate screening were less likely to have private insurance, to be married and to be above the mean income level, though these differences were non-significant. CONCLUSIONS: Although survivors report high levels of screening, a small minority of women report inadequate mammography and clinical breast exam follow-up which is concerning given their risk of recurrence and second primary breast cancer. Additionally, a significant portion of survivors report inadequate screening for general health maintenance issues. Demographic and socioeconomic factors were associated with lower screening rates. However, the deficits in screening among breast cancer survivors appears to be smaller compared to women in the general population.     

Cytology-Based Screening During Antenatal Care as a Method for Preventing Cervical Cancer

Background: Cervical cancer is one of the most serious threats to women’s lives. Therefore, the present study aimed to know the dynamics in the collection of cytologic samples during antenatal care as a method of cervical cancer screening and to identify the factors associated with its performance. Material and Methods: Analytical cross-sectional study carried out with pregnant and postpartum women in Fortaleza, Ceará, Northeastern Brazil. Data were collected using a questionnaire addressing sociodemographic variables, antenatal care, pregnancy and cytology-based screening for cervical cancer during antenatal care. Measures of central tendency were calculated and the Chi-squared test and Fisher’s exact test were used with a significance level of 5%. Results: Participants were 229 pregnant women and 89 postpartum women. Age ranged 18 to 43 years, with a mean of 27.9 years (SD=6.1). Only 35 (11%) participants had Pap smears during antenatal care. A total of 283 women did not have Pap smears during pregnancy; of these, 229 (80.9%) did not have the test because of lack of clear information from the health professional, 25 (8.8%) for fear of bleeding or abortion, and 29 (10.3%) because they had had the test before pregnancy. Undergoing cytology-based screening for cervical cancer was associated with high-risk pregnancy (p=0.002), antenatal care provided by a physician (p=0.003), knowledge about the possibility of having the test during pregnancy (p<0.001) and paid job (p=0.043). Conclusion: The percentage of cytology-based screening for cervical cancer during antenatal care was low. Therefore, health education is suggested to improve this figure. However, receiving antenatal care at MEAC, having consultations with a physician, and knowing that it is possible to have a Pap smear during pregnancy were significant protective factors for undergoing cytology screening during pregnancy.     

Does having insurance affect differences in clinical presentation between Hispanic and non‐Hispanic white women with breast cancer?

BACKGROUND: Hispanic women with breast cancer present differently than do non-Hispanic white (NHW) women. Lack of access to care has been offered as an explanation for these differences. In this study breast cancer presentation was examined in Hispanic women in a comprehensive, equal-access health care system. METHODS: Hispanic and NHW breast cancer cases registered between 1995 and 2004 in the Kaiser Permanente of Colorado Tumor Registry were compared by age at diagnosis, stage, tumor grade, size, and receptor status. Multivariate logistic regression was performed to generate age-adjusted odds ratios by ethnicity and each tumor characteristic. RESULTS: A total of 139 Hispanic women and 2118 NHW women with breast cancer were identified. Hispanic women had a mean average age at diagnosis of 56 years compared with 61 years for NHW women (P < .0001). Use of mammographic screening services in the prior 2 years was similar by ethnicity. Relative to NHW women, Hispanic women had age-adjusted odds ratios of 2.70 (95% confidence interval [CI]: 1.26-5.77) for having stage IV disease, 2.25 (95% CI: 1.39-3.67) for having poorly differentiated tumors, 2.16 (95% CI: 1.26-3.69) for having a tumor greater than 5 cm, and 1.88 (95% CI: 1.24-2.81) for having estrogen receptor-negative tumors. CONCLUSIONS: Despite equal access to health care services, differences persist in the size, stage, and grade of breast cancer for Hispanic women compared with NHW women. The results of the study suggest a biologic/genetic basis for these differences.     

Health‐care providers' perceptions,attitudes towards and recommendation practice of cervical cancer screening

In Libya, cervical cancer is ranked third as the most frequent cancer among women with early diagnosis being shown to reduce morbidity and mortality. Health‐care providers can influence women's screening behaviours, and their lack of recommendations for screening can be one of the barriers that affect women's participation in screening programmes. This study aims to assess the health‐care provider's perception around cervical cancer screening. In‐depth, face‐to‐face interviews were conducted with 16 health‐care providers, from both public and private sectors in Az‐Zawiya city, Libya, between February and July of 2014. The interviews were recorded and transcribed, then analysed using thematic analysis. Our findings suggest that health‐care providers did not provide sufficient information regarding cervical cancer screening for women who attend health‐care facilities. The results highlight the role played by health‐care professionals in motivating women to attend cervical cancer screening programs, and the need for health education of health‐care providers to offer a precious advice regarding the screening. On the other hand, health‐care providers highlighted that implementation of reminding system of cervical cancer screening will support them to improve screening attendance. In addition, health‐care providers stressed the necessity for educational and awareness campaigns of cervical cancer screening among Libyan women.     

Race and differences in breast cancer survival in a managed care population.

BACKGROUND: African-American women with breast cancer have poorer survival than European-American women. After adjustment for socioeconomic variables, survival differences diminish but do not disappear, possibly because of residual differences in health care access, biology, or behavior. This study compared breast cancer survival in African-American and European-American women with similar health care access. METHODS: We measured survival in women with breast cancer who are served by a large medical group and a metropolitan Detroit health maintenance organization where screening, diagnosis, treatment, and follow-up are based on standard practices and mammography is a covered benefit. We abstracted data on African-American and European-American women who had been diagnosed with breast cancer from January 1986 through April 1996 (n = 886) and followed these women for survival through April 1997 (137 deaths). RESULTS: African-American women were diagnosed at a later stage than were European-American women. Median follow-up was 50 months. Five-year survival was 77% for African-American and 84% for European-American women. The crude hazard ratio for African-American women relative to European-American women was 1.6 (95% confidence interval [CI] = 1.1-2.2). Adjusting only for stage, the hazard ratio was 1.3 (95% CI = 0.9-1.9). Adjusting only for sociodemographic factors (age, marital status, and income), the hazard ratio was 1.2 (95% CI = 0.8-1.9). After adjusting for age, marital status, income, and stage, the hazard ratio was 1.0 (95% CI = 0.7-1.5). CONCLUSION: Among women with similar medical care access since before their diagnoses, we found ethnic differences in stage of breast cancer at diagnosis. Adjustment for this difference and for income, age, and marital status resulted in a negligible effect of race on survival.     

Educational level, voluntary private health insurance and opportunistic cancer screening among women in Catalonia (Spain).

Health care services in Catalonia (Spain) are organized in a national health service with universal population coverage and include preventive services such as mammography and Pap tests. In addition to a national health service (NHS) coverage, 22% of the population is enrolled in a voluntary private health insurance (VPHI), leading to a double coverage. This situation offers an opportunity to study the impact of this organizational aspect of health care with regard to cancer screening access. The source of data was the Catalan Health Survey (CHS), a cross-sectional survey conducted in a random sample of non-institutionalized population carried out in 1994. Variables analysed were age, educational level and voluntary private health insurance (VPHI). Women were asked if they had ever had a mammography and Pap test for preventive purposes. Logistic regression was used to study the relationship between these variables and the mammography or Pap test participation. The study sample was 5865 women aged 20 years and older. A Pap test and mammography were carried out on 42% and 25% of women, respectively. Participation had a peak between the ages of 30 and 39 years in Pap test and between 40 and 49 years in mammography; it decreased in older women. The percentage of Pap test practice increases according to a higher educational level than it does in mammography. Women who had a VPHI showed a higher percentage of screening tests than the rest of the population. There is also an increase in the mammography practice related to the educational level in older groups, but this fact is not observed in women younger than 40 years . Multivariate logistic regression analysis showed an increase in the likelihood of ever had a mammography and a Pap test according to age and to educational level, although this situation is less pronounced in older age groups. Both variables (educational level and age) remained significant after introducing the VPHI into the model (women who reported having a VPHI were more likely to have had a Pap test and a mammography than the rest of the women). In conclusion the opportunistic screening is associated with age, educational level and VPHI. Educational level is also associated with participation in both screening tests after adjusting by age. Furthermore, screening for cervical cancer shows a higher educational gradient than for breast cancer screening. The influence of VPHI after adjusting by age and by educational level poses the question about the role of private health insurances with regard to preventive practices in the context of a national health service aimed at promoting equity of health care access.     

Human Papillomavirus and Cervical Cancer Knowledge,Perceptions, and Screening Behavior: A Cross-Sectional Community-Based Survey in Rural Philippines

Background: Cervical cancer is the second most common cancer among women in the Philippines. Cervical cancer screening is an effective method to reduce incidence. However, screening utilization is limited. This study aims to assess human papillomavirus (HPV) and cervical cancer knowledge, perceptions, and screening utilization, and to investigate factors influencing screening utilization among rural women in the Philippines. Methods: This cross-sectional community-based study was conducted among 338 rural women aged 20–50 years, with a child under 5 years old registered in one of four public rural health centers in Tacao Island, Masbate Province in October 2017. A questionnaire administered via face-to-face interviews elicited information about demographic characteristics, knowledge, perceived susceptibility and perceived severity of HPV and cervical cancer, and cervical cancer screening utilization. Results: Mean age of participants was 32.5 years. Only 13.9% of participants had ever had cervical cancer screening. Although most women had heard of cervical cancer screening, their knowledge about the cause, risk factors, and preventive measures of HPV and cervical cancer was limited. Older age and higher education status were significantly associated with screening utilization. However, knowledge and perceived susceptibility and severity showed no association. The main reason for having screening was due to a health professional’s request or recommendation, and the reasons for not having screening were cost, not having symptoms, and fear of pain or discomfort and/or embarrassment during the procedure.  Conclusions: Health education must increase knowledge about HPV and cervical cancer and screening among women, including the nature and progression of cervical cancer, benefits of screening, screening cost, and screening procedure. Health care providers have an important role in educating and motivating women to undergo screening.     

Exploring Effective Contextual Factors for Regular Cervical Cancer Screening in Iranian Women: A Qualitative Study

Background: Adherence to regular screening programs for cervical cancer in Iranian women is not common.The aim of this study was to explore contextual factors influencing behavior and compliance with guidelines.Methods: This qualitative content analysis study was conducted in 2016-2017 in Hamadan city, Iran. Semi-structuredin-depth interviews were conducted with 31 participants who were selected purposefully on referring to health centers.Twenty-three were women with various experiences of cervical cancer screening and 8 were health care providers(4 midwives, 1 gynecologist, 1 general practitioner and 1 family health expert). Guba and Lincoln criteria were usedfor tustworthiness. MAXQDA10 software was employed for data analysis. Results: Four themes were extracted fromthe data: an opportunity maker system, opportunities to become acquainted, concerns for healthy living, and perceptionof cancer. Conclusion: The results showed sensitivity of health care providers and their appropriate performancein relation to regular screening behavior of women is very important. Women’s perception of cancer and its curabilityis another factor with a major effect on screening behavior. Opportunities for people to become acquainted with thePap smear in a variety of ways and concern for healthy living and the need to have a healthy life to ensure qualityof life were also found to be important.     

A multifaceted intervention to increase cervical cancer screening among underserved Korean women.

OBJECTIVE: Despite the proven survival benefits associated with cervical cancer screening, use of the Pap test continues to be suboptimal in some population subgroups, such as among Korean-American women who face considerable barriers to screening. Therefore, we evaluated a multifaceted intervention that combined psychoeducational counseling with patient navigation to address both psychosocial and access barriers to screening. METHOD: Women (n = 102) were recruited from Korean community centers and assigned to the intervention or control condition. The intervention group received cervical cancer education and patient navigation delivered by bilingual Korean health educators. The control group received general health education, including information about cervical cancer and screening. Assessments were obtained at baseline and postintervention. Screening behavior was assessed at 6 months postintervention. RESULTS: At baseline, 17% of participants reported having had a Pap test in the previous year. At 6 months postintervention, 83% of women in the intervention group had obtained screening compared with 22% in the control group, chi2(1) = 41.22, P < 0.001. Multivariate logistic regression analyses indicated that participation in the intervention was associated with screening (P < 0.001). Fewer psychosocial barriers (e.g., discomfort at having a stranger perform Pap) and greater self-efficacy were also associated with screening (P < 0.05). CONCLUSION: A combined modality intervention that delivers education with patient navigation training and assistance resulted in increased screening rates. Multifaceted approaches may be effective in reducing the psychosocial, access, and language barriers that contribute to cancer health disparities in underserved populations.     

依托妇幼卫生服务体系建立乳腺癌筛查机制

目的探讨妇幼卫生服务网络在乳腺癌筛查中的作用。方法采取随机整群抽样的方法,在武汉市中心城区抽取35~59岁妇女33 019名为研究对象,利用妇幼卫生服务网络对筛查工作进行组织管理,采用乳腺临床体检、钼靶X线摄片和彩超检查相结合的筛查方案,所有病变诊断及转归的判定均以组织病理学检查为依据。计算筛查率、复查率和乳腺癌检出率等指标,评价妇幼卫生服务体系对乳腺癌筛查的作用。结果33 019名妇女中,30 478名妇女参与了乳腺癌筛查,筛查率为92.30%;钼靶或彩超的复查率为92.47%。通过临床检查、钼靶和彩超联合检查的乳腺癌或可疑癌患者均接受手术治疗,最终25人确诊为乳腺癌,乳腺癌检出率为82.03/100 000。结论利用妇幼卫生服务网络组织乳腺癌筛查,提高了人群顺应性,技术力量能够得到整合,大大提高乳腺癌筛查的质量。