Mammography interventions for 65- to 74-year-old HMO women. Program effectiveness and predictors of use

Effectiveness of the Theory-Based Educational Interventions on Screening of Breast Cancer in Women: A Systematic Review and Meta-Analysis

Screening plays an essential role in the reduction of mortality and morbidity of breast cancer, which is one of the most common cancers in women worldwide. The aim of this study was to find out whether the use of health education model and theory-based behavioral interventions is effective in women’s breast cancer screening behavior. Applying different search strategies, we searched electronic databases including PubMed, ScienceDirect, Web of Science, and Scopus without time limit from January 12 to March 11, 2017. Keywords included “Breast neoplasm,” Screening,” “Women,” and “Health Education.” First, screening was conducted based on title, abstract, and full text. Then, the studies were screened according to the selection criteria of our study. The relevant and eligible studies were critically appraised by Delphi checklist. In addition, a meta-analysis of eligible studies was conducted with the random-effect approach. Twenty-six of 8,620 initial studies (with sample size of 10,681 in the intervention group and 8,854 in the control group) were included in the final analysis. The results of the meta-analysis showed that the probability of screening behavior in the intervention group is 1.4 times of that in the control group. Furthermore, subgroup analysis by the type of screening behavior indicates that the probabilities of conducting breast self-examination and mammography in the intervention group are 1.9 and 1.4 times of those in the control group. The health education program has a significant impact on breast cancer screening behaviors, particularly breast self-examination. Thus, given the positive effects of the educational screening programs in women, it is suggested that these programs must be continuously pursued with long-term follow-up and increasing rates of screening behaviors should be monitored.

An Analysis of Health Behavior Theories Applied to Breast-Screening Behavior for Relevance With American Indian Women

This article reviews studies of the efficacy of breast-screening interventions and their related theories that have had a positive effect in influencing women to use mammography and assesses the potential of various behavioral models for use with American Indian women. The study involved a search of literature in nursing and other health fields. Both communityand practice-based interventions have incorporated elements of various theoretical models. Because of its adaptability, the modified health behavior model appears most relevant for designing interventions to encourage mammography use among American Indian women.

Effect of direct mail as a population-based strategy to increase mammography use among low-income underinsured women ages 40 to 64 years

Women with inadequate health insurance have lower mammography rates than the general population. Finding successful strategies to enroll eligible women is an ongoing challenge for the National Breast and Cervical Cancer Early Detection Program. To test the effectiveness of a population-based strategy to increase mammography utilization among low-income underinsured women ages 40 to 64 years, a randomized trial was conducted to assess the effect of two mailed interventions on mammography utilization through Sage, the National Breast and Cervical Cancer Early Detection Program in Minnesota. Women (N = 145,467) ages 40 to 63 years [mean (SD), 49.7 (6.8)] with estimated household incomes below 50,000 US dollars (47.9% were < 35,000 US dollars) from a commercial database were randomized to three groups: Mail, Mail Plus Incentive, or Control. Both the Mail and the Mail Plus Incentive groups received two simple mailings prompting them to call a toll-free number to access free mammography services. The Mail Plus Incentive intervention offered a small monetary incentive for a completed mammogram. After 1 year, both intervention groups had significantly higher Sage mammography rates than the Controls, and the Mail Plus Incentive group had a significantly higher rate than the Mail group. The Mail and Mail Plus Incentive interventions were estimated to produce increases in Sage screening rates of 0.23% and 0.75%, respectively, beyond the composite Control rate of 0.83%. Direct mail is an effective strategy for increasing mammography use through Sage. Coupling direct mail with an incentive significantly enhances the intervention's effectiveness. Direct mail should be considered as a strategy to increase mammography use among low-income, medically underserved women.

Understanding why women delay in seeking help for breast cancer symptoms

OBJECTIVE

The aim of this study was to improve our understanding of why women delay their presentation with breast cancer.

METHODS

A review of the evidence for the adverse effect of delayed presentation on survival and the risk factors for delay was conducted. The description and rationale for a model to explain the delay process are presented.

RESULTS

Delays of 3 months or more adversely affect survival. Older age, the nature of the breast symptom, not disclosing the symptom to someone close, negative attitudes towards general practitioner (GP) and fears about cancer treatment are risk factors for delay. Using elements of self-regulation theory, the theory of planned behaviour (TPB) and implementation intentions, a theoretical model is proposed to explain delayed help-seeking. The model incorporates stages of symptom appraisal, attitudes towards help-seeking and translating intentions into behaviour.

CONCLUSIONS

Placing the empirical risk factors for delayed presentation in a theoretically derived model should enable the development of an effective intervention to reduce delay and thereby save lives.

Lay health workers in primary and community health care

BACKGROUND

Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. However, little is known about the effectiveness of LHW interventions.

OBJECTIVES

To assess the effects of LHW interventions in primary and community health care on health care behaviours, patients' health and wellbeing, and patients' satisfaction with care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care and Consumers and Communication specialised registers (to August 2001); the Cochrane Central Register of Controlled Trials (to August 2001); MEDLINE (1966- August 2001); EMBASE (1966-August 2001); Science Citations (to August 2001); CINAHL (1966-June 2001); Healthstar (1975-2000); AMED (1966-August 2001); the Leeds Health Education Effectiveness Database and the reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to promote health, manage illness or provide support to patients. A 'lay health worker' was defined as any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education. There were no restrictions on the types of consumers.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data onto a standard form and assessed study quality. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the results of included studies were combined and an estimate of effect obtained.

MAIN RESULTS

Forty three studies met the inclusion criteria, involving more than 210,110 consumers. These showed considerable diversity in the targeted health issue and the aims, content and outcomes of interventions. Most were conducted in high income countries (n=35), but nearly half of these focused on low income and minority populations (n=15). Study diversity limited meta-analysis to outcomes for five subgroups (n=15 studies) (LHW interventions to promote the uptake of breast cancer screening, immunisation and breastfeeding promotion [before two weeks and between two weeks and six months post partum] and to improve diagnosis and treatment for selected infectious diseases). Promising benefits in comparison with usual care were shown for LHW interventions to promote immunisation uptake in children and adults (RR=1.30 [95% CI 1.14, 1.48] p=0.0001) and LHW interventions to improve outcomes for selected infectious diseases (RR=0.74 [95% CI 0.58, 0.93) p=0.01). LHWs also appear promising for breastfeeding promotion. They appear to have a small effect in promoting breast cancer screening uptake when compared with usual care. For the remaining subgroups (n=29 studies), the outcomes were too diverse to allow statistical pooling. We can therefore draw no general conclusions on the effectiveness of these subgroups of interventions.

AUTHORS' CONCLUSIONS

LHWs show promising benefits in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. For other health issues, evidence is insufficient to justify recommendations for policy and practice. There is also insufficient evidence to assess which LHW training or intervention strategies are likely to be most effective. Further research is needed in these areas.

Patient and Clinical Site Factors Associated With Rescreening Behavior Among Older Multiethnic, Low-Income Women

PURPOSE

Our goal was to identify factors predictive of mammography rescreening within 18 months of baseline screening in multiethnic, low-income older women.

DESIGN AND METHODS

We interviewed a cross-sectional survey of staff of 102 randomly selected clinics that provided screening and diagnostic services. We also surveyed a random sample of 391 older women served by these clinics to retrospectively assess their experiences of the screening process.

RESULTS

We found that 59% of the sample returned for a repeat mammogram. Education level and the belief it is important to get an annual mammogram were significant patient-level predictors of rescreening. Offering pap smears and using hands-on demonstrations with breast models were significant clinic-level variables predictive of rescreening. Of note, among the variables that did not prove significant in the final model were those reflecting ethnicity and income.

IMPLICATIONS

Individual and health-care-delivery-system factors play important roles in the obtaining of regular mammograms by low-income women. These findings highlight the importance of both factors in improving rescreening rates among older women.

Living with the worry of cancer: health perceptions and behaviors of elderly people with self, vicarious, or no history of cancer

Cancer is a major health threat that has a long-term impact on quality of life and health worries. The present study is focused on two major issues: (1) the impact that a history of cancer has on reactions to other diseases, in addition to cancer and general health worries; and, (2) the impact that having lived with someone who had cancer has on health perceptions and behaviors. All 108 participants had osteoarthritis, a symptomatic but benign disease (49 people have had cancer, 22 had lived with a cancer patient, and 37 had not had any close experience with cancer). Cancer and health worries were lowest among the people with vicarious experience, while monitoring for bodily signs was similar and highest in both cancer experience groups. Reactions to arthritis suggest more vigilance among people who have had self or vicarious experience with cancer, while reactions to ambiguous symptoms suggest vigilance especially among those with a personal history of cancer. Overall, the findings suggest that the effects of self-experience with cancer and of close experience with a cancer patient may be long-term and impact upon both health perceptions and behaviors.

Screening HMO women overdue for both mammograms and pap tests

BACKGROUND

Regular screening has the potential to reduce breast and cervical cancer mortality, but despite health plan programs to encourage screening, many women remain unscreened. Tailored communications have been identified as a promising approach to promote mammography and Pap test screening.

METHODS

The study used a four-group randomized design to compare with Usual Care the separate and combined effects of two tailored, motivational interventions to increase screening-a clinical office In-reach intervention and a sequential letter/telephone Outreach intervention. Subjects were 510 female HMO members ages 52-69 who had had no mammogram in the past 2 years and no Pap smear in the past 3 years. Primary outcomes were the percentage of women in each condition who received a mammogram, a Pap smear, or both screening tests during the 14-month study period.

RESULTS

Thirty-two percent of the Combined group, 39% of the Outreach group, and 26% of the In-reach group obtained both services versus 19% of Usual Care participants. Overall, compared with Usual Care, both Outreach (P = 0.006) and Combined (P = 0.05) screened significantly more women. For subjects ages 65-69, Outreach rates were lower than those of Usual Care.

CONCLUSION

A tailored letter-telephone Outreach appears to be more effective at screening women ages 52-64 than a tailored office-based intervention, in large part because most In-reach women did not have clinic visits at which to receive the intervention.

Targeted mailed materials and the Medicare beneficiary: increasing mammogram screening among the elderly

OBJECTIVES

Older women have the highest breast cancer rates but are underscreened relative to their risk. Racial/ethnic minority women especially have low screening rates, often because of financial constraints. In response, Medicare introduced subsidized biennial mammogram benefits in 1991. This study examined the effect on mammography rates of an intervention that informed women about the Medicare benefit.

METHODS

A list frame method of subject selection was used to select random samples of eligible women from the Health Care Financing Administration's master beneficiary file. Women were interviewed by telephone in 1991 (N = 917) before the targeted mailing and in 1993 (N = 922). One control and 2 treatment communities participated.

RESULTS

Mammogram use increased significantly among minorities in the treatment groups. Among minorities who received the intervention, Black women were twice as likely (odds ratio = 1.97) and Hispanic women were more than twice as likely (odds ratio = 2.33) to undergo screening relative to their untreated cohorts.

CONCLUSIONS

A targeted low-cost mailed intervention can help increase screening rates among elderly minority women. The Health Care Financing Administration should promote its benefits aggressively if it expects to reach its target--elderly beneficiaries.

Strategies for increasing women participation in community breast cancer screening

BACKGROUND

Strategies for reducing breast cancer mortality in western countries have focused on screening, at least for women aged 50 to 69 years. One of the requirements of any community screening program is to achieve a high participation rate, which is related to methods of invitation. Therefore, it was decided to systematically review the scientific evidence on the different strategies aimed at improving women's participation in breast cancer screening programs and activities.

OBJECTIVES

To assess the effectiveness of different strategies for increasing the participation rate of women invited to community (population-based) breast cancer screening activities or mammography programs.

SEARCH STRATEGY

MEDLINE (1966-2000), CENTRAL (2000), and EMBASE (1998-1999) searches for 1966 to 1999 were supplemented by reports and letters to the European Screening Breast Cancer Programs (Euref Network).

SELECTION CRITERIA

Both published and unpublished trials were eligible for inclusion, provided the women had been invited to a community breast screening activity or program and had been randomised to an intervention group or a control group with no active intervention.

DATA COLLECTION AND ANALYSIS

We identified 151 articles, which were reviewed independently by two people. The discrepancies were resolved by a third reviewer in order to reach consensus. Thirty-four studies were excluded because they lacked a control group; 58 of the other 117 articles were considered as opportunistic and not community-based; 59 articles, which reported 70 community-based randomised controlled trials or clinical controlled trials, were accepted. In 24 of these, the control group had not been exposed to any active intervention, but 8 of the 24 had to be excluded because the denominator for estimating attendance was unknown. At the end, 16 studies constituted the material for this review, although two studies were further excluded because their groups were not comparable at baseline. Data from all but one study were based on or converted to an intention-to-treat analysis. Attendance in response to the mammogram invitation was the main outcome measure.

MAIN RESULTS

The evidence favoured five active strategies for inviting women into community breast cancer screening services: letter of invitation (OR 1.66, 95% CI 1.43 to 1.92), mailed educational material (OR 2.81, 95% CI 1.96 to 4.02), letter of invitation plus phone call (OR 2.53, 95% CI 2.02 to 3.18), phone call (OR 1.94, 95% CI 1.70 to 2.23), and training activities plus direct reminders for the women (OR 2.46, 95% CI 1.72 to 3.50). Home visits did not prove to be effective (OR 1.06, 95 % CI 0.80 to 1.40) and letters of invitation to multiple examinations plus educational material favoured the control group (OR 0.62, 95 % CI 0.32 to 1.20).

REVIEWER'S CONCLUSIONS

Most active recruitment strategies for breast cancer screening programs examined in this review were more effective than no intervention. Combinations of effective interventions can have an important effect. Some costly strategies, as a home visit and a letter of invitation to multiple screening examinations plus educational material, were not effective. Further reviews comparing the effective interventions and studies that include cost-effectiveness, women's satisfaction and equity issues are needed.

Cancer screening decisions

This review focuses on why people decide to obtain or to avoid screening for cancer. We discuss three topics: (a) physician prompts that may elicit compliant screening behavior, (b) the independent and joint effects of risk perceptions and worry, and (c) the costs and benefits of getting screened. Overall, the data suggest that each of these factors will influence screening. So, for example, people are more likely to seek screening if a physician recommends the behavior, if they feel personally vulnerable and worry a little about cancer, if insurance covers the screening, and if they believe that the test is an effective early detection procedure. Future research needs include studies comparing theories, longitudinal rather than cross-sectional studies, and true experiments. We also need to know more about why physicians are such powerful change agents and the trade-offs of increasing personal risk versus exacerbating worry. Practical recommendations for promoting cancer screening include encouraging physician interventions, explaining risk, and lowering the costs while emphasizing the benefits of screening.

Promoting mammography: results of a randomized trial of telephone counseling and a medical practice intervention

BACKGROUND

Despite widespread promotion of mammography screening, a distinct minority of women have remained underusers of this effective preventive measure. We sought to measure the effects of barrier-specific telephone counseling (BSTC) and a physician-based educational intervention (MD-ED) on mammography utilization among underusers of mammography screening.

DESIGN

This was a randomized controlled trial. Women meeting criteria for mammography underuse at baseline (grouped by practice affiliation) were randomized to a reminder control condition (RC group received annual mailed reminders), BSTC or MD-ED interventions and followed for 3 years. Underuse was defined by failure to get two annual or biannual mammograms over a 2- to 4-year period prior to a baseline survey.

PARTICIPANTS AND SETTING

The study included 1655 female underusers of mammography aged 50-80 years who were members of two health maintenance organizations (HMO) in central Massachusetts.

INTERVENTIONS

BSTC consisted of periodic brief, scripted calls from trained counselors to women who had not had a mammogram in the preceding 15 months. Women could receive up to three annual calls during the study. MD-ED consisted of physician and office staff trainings aimed at improving counseling skills and office reminder systems.

MAIN OUTCOME MEASURE

Self-report of mammography use during the study period was the main outcome measure. Regular use was defined as > or =1 mammogram every 24 months.

RESULTS

Forty-four percent in each intervention group became regular users compared to 42% in the RC group. Among subjects who had prior but not recent mammograms at baseline, BSTC was effective (OR=1.48; 95% CI=1.04; 2. 10), and MD-ED marginally effective (OR=1.28; 95% CI=0.88, 1.85). Most recent users at baseline and few never users became regular users (61% and 17%, respectively) regardless of intervention status.

CONCLUSIONS

Among mammography underusers BSTC modestly increases utilization for former users at a reasonable cost ($726 per additional regular user).

Promoting cancer prevention and screening: the impact of the Cancer Information Service. Part 7

Cancer Information Service (CIS) inquiries about cancer prevention and screening are an important opportunity to educate callers about primary or secondary cancer prevention, facilitate their decision-making, and, where appropriate, encourage action. An evaluation was conducted to assess whether these callers' information needs are being satisfied and to determine if the information provided facilitates decisionmaking and subsequent risk reduction actions. A random sample of 2,489 callers was surveyed during a 5-week period, 3 to 6 weeks after their initial call to CIS; prevention or screening was stated as the main reason for calling by 331 respondents. A series of questions was asked regarding level of satisfaction with CIS's performance and how helpful the information provided was in terms of feeling more knowledgeable, making decisions, and taking action. The vast majority of respondents were satisfied with the information received, found it to be helpful, felt more knowledgeable as a result, and would call CIS again with subsequent questions. Although demand characteristics are a possible source of bias, nearly three-quarters of the respondents reported subsequently discussing the information provided with someone else, and almost half sought additional information recommended by CIS. Nearly two-thirds of primary prevention respondents and about half of secondary prevention respondents indicated that they had taken some risk-reducing action subsequent to their interaction with CIS. The CIS is effectively satisfying the information needs of prevention and screening callers; information it is providing is effectively facilitating decisionmaking and stimulating callers to take action.

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.