Patterns of breast and cervical cancer screening at three public health centers in an inner-city urban area

A multilevel study of socioeconomic predictors of regular mammography use among African-American women

BACKGROUND

Little is known about the predictors of adherence to mammography guidelines by African-American women. We assessed individual-level and group-level socioeconomic predictors of regular mammography use in a large cohort of African-American women.

METHODS

We included 14,706 participants in the Black Women's Health Study who were 40 to 69 years of age at baseline in 1995. Data were obtained through mail questionnaires at entry and biennially during three 2-year follow-up periods until 2001. We linked the women's addresses to census block (neighborhood) socioeconomic data. With multilevel multivariable regression analysis, we assessed the relation of individual-level and neighborhood socioeconomic factors to "regular" mammography use (use in all three follow-up periods) relative to nonregular use, with control for other predictors.

RESULTS

Most participants had health insurance and almost half had graduated college. Having health insurance was the socioeconomic variable most strongly associated with regular mammography use (odds ratio, 3.59; 95% confidence interval 3.02-4.28); the association was present at all levels of educational attainment, household income, and neighborhood socioeconomic status. Regular mammography use increased with individual household income: odds ratio, 2.00 (95% confidence interval, 1.58-2.53) for household income > USD $100,000 relative to < USD $15,001. Regular mammography use did not vary across level of education. Higher neighborhood socioeconomic status was significantly associated with regular mammography use before, but not after, control for household income.

CONCLUSIONS

Access to health insurance is strongly associated with regular mammography use among African-American women, even at higher levels of educational attainment and socioeconomic status. Neighborhood socioeconomic characteristics do not materially influence regular use.

Loss-framed minimal intervention increases mammography use

INTRODUCTION

Although mammography is the most effective early detection breast cancer screening technology available, it is underutilized. This study was conducted to test the effectiveness of a loss-framed minimal intervention to increase mammography use. Loss-frame refers to a communication strategy in which messages are framed from the perspective of what a person has to lose by not taking a particular behavioral action.

METHODS

Participants were medically un- and underinsured women 50-64 years old who called one of two urban clinics randomly selected based on demographic statistical equivalency. The women who participated telephoned to inquire about a mammogram during the 6-month study period. The group randomly designated as the experimental group received a loss-framed message conveyed by trained staff telephonically. Members of the comparison group received the "usual" communication, also conveyed telephonically. In the experimental group, 31 of 112 (27%) women who inquired received mammograms, whereas 157 of the 992 (16%) comparison group women who inquired received mammograms.

RESULTS

The odds of a mammogram, adjusted for race and breast cancer symptoms, significantly increased for the experimental (odds ratio [OR] = 1.914, chi2 = 7.48, p = .0063, 95% confidence interval [CI] 1.20-3.05) versus comparison group.

CONCLUSIONS

A loss-framed, in-reach, minimal intervention approach holds promise as a mammography promotion strategy.

An evaluation of the integration of non-traditional learning tools into a community based breast and cervical cancer education program: the Witness Project of Buffalo

BACKGROUND

Breast and cervical cancer continue to represent major health challenges for African American women. among Caucasian women. The underlying reasons for this disparity are multifactorial and include lack of education and awareness of screening and early detection. Traditional educational methods have enjoyed varied success in the African American community and spawned development of novel educational approaches. Community based education programs employing a variety of educational models have been introduced. Successful programs must train and provide lay community members with the tools necessary to deliver strong educational programs.

METHODS

The Witness Project is a theory-based, breast and cervical cancer educational program, delivered by African American women, that stresses the importance of early detection and screening to improve survival and teaches women how to perform breast self examination. Implementing this program in the Buffalo Witness Project of Buffalo required several modifications in the curriculum, integration of non-traditional learning tools and focused training in clinical study participation. The educational approaches utilized included repetition, modeling, building comprehension, reinforcement, hands on learning, a social story on breast health for African American women, and role play conversations about breast and cervical health and support.

RESULTS

Incorporating non-traditional educational approaches into the Witness Project training resulted in a 79% improvement in the number of women who mastered the didactic information. A seventy-two percent study participation rate was achieved by educating the community organizations that hosted Witness Project programs about the informed consent process and study participation.

CONCLUSION

Incorporating non-traditional educational approaches into community outreach programs increases training success as well as community participation.

Cancer screening estimates for U.S. metropolitan areas

OBJECTIVES

To provide estimates of breast, cervical, and colorectal cancer screening for metropolitan areas in the United States.

METHODS

Behavioral Risk Factor Surveillance System (BRFSS) data from 1997 to 1999 were reweighted and analyzed for 69 U.S. metropolitan areas for the receipt of a Papanicolaou (Pap) test (ages > or =18 years); mammography (ages > or =40 years); fecal occult blood testing and sigmoidoscopy (ages > or =50 years). Stratified analyses by demographics were performed for 25 metropolitan areas with populations of > or =1.5 million.

RESULTS

Metropolitan estimates ranged from 64.6% to 82.0% for mammography and from 77.2% to 91.7% for Pap tests. There was much greater variability in estimates for colorectal cancer screening, with a 3.6-fold difference in the range of estimates for fecal occult blood testing (9.9% to 35.2%) and a 2.5-fold difference for sigmoidoscopy (17.3% to 43.3%). In the 25 largest areas, prevalence of cancer screening was generally lower for persons with a high school education or less and for those without health insurance. Compared with women aged 50 to 64 years, mammography estimates were lower for women aged 40 to 49 years in 13 of the 25 metropolitan areas. Pap testing was less common among women aged > or =65 years, and colorectal cancer screening was less common for persons aged 50 to 64 years.

CONCLUSIONS

Estimates of cancer screening varied substantially across metropolitan areas. Increased efforts to improve cancer screening are needed in many urban areas, especially for colorectal cancer screening. The BRFSS is a useful, inexpensive, and timely resource for providing metropolitan-area cancer screening estimates and may be used in the future to guide local or county-level screening efforts.

Mammography screening in African American women: evaluating the research

BACKGROUND

Notwithstanding some controversy regarding the benefits of screening mammography, it is generally assumed that the effects are the same for women of all race/ethnic groups. Yet evidence for its efficacy from clinical trial studies comes primarily from the study of white women. It is likely that mammography is equally efficacious in white and African American women when applied under relatively optimal clinical trial conditions, but in actual practice African Americans may not be receiving equal benefit, as reflected in their later stage at diagnosis and greater mortality.

METHODS

Initial searches of Medline using search terms related to screening mammography, race, and other selected topics were supplemented with national data that are routinely published for cancer surveillance. Factors that potentially compromise the benefits of mammography as it is delivered in the current health care system to African American women were examined.

RESULTS

While there have been significant improvements in mammography screening utilization, observational data suggest that African American women may still not be receiving the full benefit. Potential explanatory factors include low use of repeat screening, inadequate followup for abnormal exams, higher prevalence of obesity and, possibly, breast density, and other biologic factors that contribute to younger age at diagnosis.

CONCLUSIONS

Further study of biologic factors that may contribute to limited mammography efficacy and poorer breast cancer outcomes in African American women is needed. In addition, strategies to increase repeat mammography screening and to ensure that women obtain needed followup of abnormal mammograms may increase early detection and improve survival among African Americans. Notwithstanding earlier age at diagnosis for African American women, mammography screening before age 40 years is not recommended, but screening of women aged 40-49 years is particularly critical.

Increasing cervical cancer screening among underserved women in a large urban county health system: can it be done? What does it take?

BACKGROUND

Further reduction in avoidable cervical cancer morbidity and mortality may require system-wide, integrated approaches implemented in the public health facilities serving the nation's indigent and minority women.

OBJECTIVES

Report on the evaluation of a 5-year demonstration project testing a multicomponent (provider, system, and patient) intervention to increase cervical cancer screening among women who receive their health care through the Los Angeles County Department of Health Services, the second largest County Health Department in the nation.

MATERIALS AND METHODS

A longitudinal nonequivalent control group design was utilized. Data were collected during a baseline (no intervention) year and 2.5 years of intervention. A large hospital, one feeder Comprehensive Health Centers (CHC), and three of the health center's feeder Public Health Centers (PHC) received the intervention. Another hospital, CHC and its three feeder PHCs (matched on size, patient characteristics, and range of services provided) served as comparison sites. Independent random samples of patients 18 years and older were drawn annually at each site (n = 18,642). The outcome measure was a receipt of a Papanicolaou smear during a 9-month period.

RESULTS

At the Hospital and CHC levels a statistically significant intervention effect was observed after controlling for baseline screening rates and case mix. No intervention effect was observed at the PHCs.

CONCLUSION

An intensive multicomponent intervention can increase cervical cancer screening in a large, urban, County health system serving a low-income minority population of under screened women. Retention of program elements in the postresearch phase, and the difficulties and importance of conducting this type of research, is described.

The effects of message framing and ethnic targeting on mammography use among low-income women

The authors examined the effects that differently framed and targeted health messages have on persuading low-income women to obtain screening mammograms. The authors recruited 752 women over 40 years of age from community health clinics and public housing developments and assigned the women randomly to view videos that were either gain or loss framed and either targeted specifically to their ethnic groups or multicultural. Loss-framed, multicultural messages were most persuasive. The advantage of loss-framed, multicultural messages was especially apparent for Anglo women and Latinas but not for African American women. These effects were stronger after 6 months than after 12 months.

Differences in breast cancer screening rates: an issue of ethnicity or socioeconomics?

Previous reports suggest that use of preventive measures, such as screening mammography (SM), differs by ethnicity. It is unclear, however, if this is determined directly by ethnicity or indirectly by related socioeconomic factors. We studied self-reported data from 18,245 women aged 40-49 who participated in the Behavioral Risk Factor Surveillance System telephone survey in 1992 and 1993. Of these, 11,509 (63%) reported having obtained mammography within the preceding 2 years for screening purposes only. Using reports of other preventive healthcare behaviors, education level, socioeconomic status, and healthcare access problems as independent variables, bivariate associations were assessed, and a logistic regression model was developed. Models for each ethnic group were developed, with consistent results. Women who engaged in other preventive health measures, such as Pap smear (odds ratio [OR] 8.99, 95% confidence interval [CI] = 7.6-10.7), cholesterol measurement (OR 2.64, 95% CI = 2.3-3.0), and seatbelt use, were more likely to obtain SM. Women with healthcare access or insurance problems (OR 0. 59, 95% CI = 0.5-0.7) and current smokers (OR 0.71, CI = 0.6-0.8) had a lower likelihood of obtaining SM. Ethnicity, alcohol use, marital status, and education level were not significantly associated with women's reports of SM. Although ethnicity apparently does not influence a woman's likelihood of obtaining SM, access to healthcare and insurance and engaging in other healthy behaviors do. Health policy planners should consider the importance of these related factors when developing preventive health programs for women.

Revisiting the effect of the Pap test on cervical cancer

OBJECTIVES

This report documents the effect of not having had a Papanicolaou (Pap) test on survival with uterine cervical squamous carcinoma.

METHODS

Data were derived from Charity Hospital of Louisiana at New Orleans Tumor Registry reports for 1984-1987 and 1996.

RESULTS

During the 5 study years, 101 of 213 women (47%) with invasive carcinoma had not undergone a previous Pap test. From 1984 to 1987, the observed 5-year survival rate for 171 patients with invasive carcinoma was 43%. The observed 5-year rate for 107 patients with carcinoma in situ from 1984 to 1986 was 99%.

CONCLUSIONS

The goal of a yearly Pap test for all women can be approached by a number of different routes, with the use of all health facilities augmented with collection of specimens by trained nonphysician personnel.

Delivery of preventive services to older black patients using neighborhood health centers

OBJECTIVES

Older black patients are at risk for underutilization of preventive services. Our objectives were to assess the delivery of five preventive services in Title 330-funded health centers in low income neighborhoods in Cleveland, Ohio, and to determine the association of health system factors and health status with the delivery of these services.

DESIGN

A cross-sectional study.

SETTING

Four neighborhood health centers in low income neighborhoods of Cleveland, Ohio.

PARTICIPANTS

A total of 683 black men and women, aged 70 and older, who regarded the health center as their primary source of outpatient care.

MEASUREMENTS

Demographic characteristics, independence in basic and instrumental activities of daily living, comorbidity scores, and perceived access were determined by telephone interview. We reviewed charts to determine whether each of five preventive service goals were obtained: influenza vaccination within 1 year; pneumococcal vaccination at any time; mammography within 2 years; Papanicolau screening within 1 year or twice at any time in the past with documentation of normal results; and fecal occult blood testing within 2 years.

RESULTS

The defined goals for influenza vaccination, pneumococcal vaccination, mammography, Papanicolau screening, and fecal occult blood testing were achieved for 59%, 64%, 59%, 51%, and 17% of patients, respectively. Influenza and pneumococcal vaccines were obtained more often in persons with greater comorbidity. Mammography and Papanicolau smear were obtained more often in patients without of ADL or IADL impairments. The four clinical sites varied substantially in the delivery of each preventive service. More frequent office visits were associated with greater delivery of all five preventive services. This relationship persisted in multivariable analyses controlling for health status and clinical site.

CONCLUSIONS

This study shows that Title 330 federally supported neighborhood health center sites providing primary care to older blacks in Cleveland achieved high rates of performance in four of the five recommended preventive services. In addition, preventive services practices were associated with prognostically relevant health status information. The frequency of office visits was related strongly and consistently to the performance of the various preventive services, indicating that more, not fewer, office visits may be necessary to achieve Healthy People 2000 targets. J Am Geriatr Soc 48:124-130, 2000. Key words: preventive services; blacks; access to care; geriatrics; primary care

Delivery of primary care to women. Do women's health centers do it better?

OBJECTIVE

Women's health centers have been increasing in number but remain relatively unstudied. We examined patient expectations and quality of care at a hospital-based women's health center compared with those at a general medicine clinic.

DESIGN

Cross-sectional survey.

SETTING

University hospital-affiliated women's health and general internal medicine clinics.

PARTICIPANTS

An age-stratified random sample of 2,000 women over 18 years of age with at least two visits to either clinic in the prior 24 months. We confined the analysis to 706 women respondents who identified themselves as primary care patients of either clinic.

MEASUREMENTS AND MAIN RESULTS

Personal characteristics, health care utilization, preferences and expectations for care, receipt of preventive services, and satisfaction with provider and clinic were assessed for all respondents. Patients obtaining care at the general internal medicine clinic were older and had more chronic diseases and functional limitations than patients receiving care at the women's health center. Women's health center users (n = 357) were more likely than general medicine clinic users ( n = 349) to prefer a female provider ( 57% vs 32%, p =.0001) and to have sought care at the clinic because of its focus on women's health (49% vs 17%, p =. 0001). After adjusting for age and self-assessed health status, women's health center users were significantly more likely to report having had mammography (odds ratio [OR] 4.0, 95% confidence interval [CI] 1.1, 15.2) and cholesterol screening (OR 1.6, 95% CI 1.0, 2.6) but significantly less likely to report having undergone flexible sigmoidoscopy (OR 0.5, 95% CI 0.3, 0.9). There were no significant differences between the clinics on receipt of counseling about hormone replacement therapy or receipt of Pap smear, or in satisfaction.

CONCLUSIONS

These results suggest that, at least in this setting, women's health centers provide care to younger women and those with fewer chronic medical conditions and may meet a market demand. While the quality of gender-specific preventive care may be modestly better in women's health centers, the quality of general preventive care may be better in general medical clinics.

Knowledge, attitudes, and patterns of cancer screening: a self-report among foreign born Hispanic women utilizing rural migrant health clinics

Hispanics are the fastest growing minority in the United States and are currently Washington state's largest minority, with the highest growth rates found in the rural agricultural areas of eastern Washington state. Because breast and cervical cancer mortality rates are higher in Hispanics than other U.S. women, subgroups of Hispanic women with the lowest cancer screening utilization rates need to be identified and targeted for cancer control intervention to most effectively reduce late-stage cancer diagnoses and mortality. A study was conducted at six migrant health clinics located throughout eastern Washington state to discern age-specific proportions for utilization of mammography, breast self-examination, and Pap smears among Hispanic migrants to the United States. Knowledge and attitudes regarding these procedures also were assessed and face-to-face interviews were completed with 512 women. Among women 20 years or older, 15 percent had never heard of a Pap smear, only 78 percent had ever received a Pap smear, and only 44 percent had received a Pap smear within the prior year. In all, 73 percent of the women had been taught breast self-examination, 62 percent performed breast self-examination, and 41 percent had performed a breast self-examination in the prior month. Among women 40 years or older, only 38 percent had never heard of a mammogram, 38 percent had ever received a mammogram, and only 30 percent had received a mammogram in the prior two years. Cost was reported as a major barrier for screening in this population. Additionally, a substantial proportion of the women perceived Pap smears and mammography as unnecessary or diagnostic procedures, rather than preventive health measures.

A clinic-based mammography intervention targeting inner-city women

OBJECTIVE

The objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women.

DESIGN

A randomized controlled trial employing firm system methodology was conducted.

SETTING

The study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle.

PARTICIPANTS

Women aged 50 to 74 years with at least one routine clinic appointment (when they were due for mammography) during the study period were enrolled in the trial (n = 314).

INTERVENTIONS

The intervention program emphasized nursing involvement and included physician education, provider prompts, use of audiovisual and printed patient education materials, transportation assistance in the form of bus passes, preappointment telephone or postcard reminders, and rescheduling assistance. Control firm women received usual care.

MEASUREMENTS AND MAIN RESULTS

Mammography completion within 8 weeks of clinic visits was significantly higher among intervention (49%) than control (22%) firm women (p < .001). These effects persisted after adjustment for potential confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5; 95% confidence interval 1.9, 6.5). The intervention effect was modified by type of insurance coverage as well as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation.

CONCLUSIONS

A clinic-based program incorporating physician education, provider prompts, patient education materials, and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women.

Nursing research on the health of low-income women

The purpose of this paper is to describe the scope of published nursing research on the health of low-income women. Williams' (1990) model of the relationship between socioeconomic status and health was used as a framework for the analysis. This model includes three major components: Medical Care, Psychosocial Factors, and Health Outcomes. There is a body of published nursing research that addresses a range of health issues of low-income women. Our search of English language literature published between 1989 and 1995 retrieved 49 articles that met the inclusion criteria. Most of the nursing studies examined a portion of Williams' model but did not address multiple components. The most frequently addressed component was Psychosocial Factors, particularly health practices, stress and coping, and social ties. Williams' model was an effective framework to classify nursing research. Results of our analysis suggest that further research is needed on the pathways by which low income influences health and on the effectiveness of nursing interventions.

Inner city primary care providers' breast cancer screening knowledge: implications for intervention

Low income and minority women continue to have relatively low breast cancer screening rates. Since physician recommendation is one of the most important determinants of mammography participation, we aimed to characterize the breast cancer screening knowledge of primary care providers serving a socially disadvantaged population. The study was conducted at the Adult Medicine Clinic of Seattle's county hospital. All attending physicians, resident physicians, and mid-level practitioners were asked to complete a questionnaire in the spring of 1995. Forty-nine of 52 (94%) eligible providers completed the survey. The respondents generally agreed with published guidelines for screening mammography use. In contrast, they had relatively low levels of knowledge about breast cancer risk factors and the effectiveness of other breast cancer screening methods. Additionally, providers tended to over-estimate their breast cancer screening knowledge and skills. For example, 69% believed that they could answer patients' questions about mammography, but only 23% were aware of Medicaid's reimbursement policy for the procedure. For some variables, attending physicians were no more knowledgeable than resident physicians. Our results reinforce the need for increased preventive care training in medical schools and primary care residency programs. Educational programs for providers serving disadvantaged populations might usefully focus on pragmatic issues such as institutional costs and public payer reimbursement policies.

A review of cervical cancer screening intervention research: implications for public health programs and future research

In this paper we review the published literature with respect to cervical cancer screening intervention research. Mass media campaigns appear to work best in promoting cervical cancer screening when multiple media are used, when they promote specific screening programs that eliminate or reduce access barriers, or when they are used in combination with other strategies. Many positive examples of using outreach staff to promote cervical cancer screening, as well as using mobile examination rooms in the community, were found. Substantial evidence that letters mailed to patient populations are efficacious was found, especially in promoting interval screening; however, bulk mailings to nonpatient populations have generally not been successful. Both physician and patient prompts have shown promise as well as opportunistic screenings in both the outpatient and the inpatient settings. In addition, several strategies for reducing loss to follow-up among women with abnormal test results were identified, including telephone follow-up, educational mailouts, audiovisual programs, clinic-based educational presentations and workshops, transportation incentives, and economic vouchers. Of special note is the success of other countries in establishing centralized recall systems to promote interval screening for cervical cancer. Ultimately, such systems could replace the need for opportunistic screening in underserved populations and perhaps many community outreach efforts. It is argued that health departments represent a logical starting point for developing a network of recall systems in the United States for underserved women.

Knowledge, beliefs, attitudes, and cancer screening among inner-city African-American women

Three hundred twenty-one inner-city African-American women were interviewed to determine their knowledge, attitudes, and beliefs regarding cancer and cancer screening, and their cancer screening histories. The women were recruited from a variety of sources in Atlanta and were interviewed in their homes by trained lay health workers. Half of the subjects had an annual household income of < $15,000. About half had received a Pap smear and clinical breast examination within the year preceding the interviews. For women > 35 years old, 35% had received a mammogram within the recommended interval. Younger women and women with higher incomes were more likely than older women and those with lower incomes to have received a Pap test and clinical breast examination within the preceding year, but income was not significantly associated with mammography histories. In general, women who were more knowledgeable about cancer and its prevention were more likely to have been appropriately screened. However, various attitudes and beliefs regarding cancer generally were not associated with screening histories. We conclude that cancer screening programs for inner-city minority women should focus on improving knowledge levels among older women rather than attempting to alter attitudes and beliefs.

Using focus group methodology to develop breast cancer screening programs that recruit African American women

Public communication campaigns are designed to increase the number of women who receive mammograms, breast examinations, and cervical exams. However, these campaigns have failed to recruit sufficient numbers of African American women. Focus group techniques were used to provide data to develop a communication campaign that would increase the knowledge, assess the attitudes, and change behaviors of African American women, aged 40-65, about the aforementioned preventive health practices. The discussions revealed that participants distrusted "clinics" and preferred being examined by "their own" or a private physician. Results further revealed that the personal influence of opinion leaders, combined with interpersonal contacts that encourage preventive care, help influence women to participate in mammography and cervical cancer screening.

Cervical screening of Arabic-speaking women in Australian general practice

OBJECTIVE

To determine recency and predictors of cervical screening among Arabic-speaking women in Sydney, Australia.

METHOD

A consecutive sample of Arabic-speaking women, attending 20 Arabic-speaking general practitioners, was asked to complete a self administered health risk questionnaire available in Arabic or English which included three questions about cervical screening knowledge and behaviour.

RESULTS

Of 756 eligible women, 526 (70%) returned completed questionnaires. Of these, 69 (13%) did not know what a cervical smear was. Sixteen per cent of overseas-born compared with 2% of Australian-born women at risk had not heard of a cervical smear. Women were defined as being at risk of cervical cancer if they had both been married and not had a hysterectomy. Of 318 women at risk for cervical cancer who knew what a cervical smear was, 66% had had a smear in the last two years, a further 7% were attending for one that day while 11% had not had a smear for at least two years, 9% had never had one and 7% did not answer/could not remember. Religion, age, and residence in Australia for more than 10 years were significant and independent predictors of screening after adjustment for other variables in simultaneous logistic regression model (P = 0.002, P = 0.002, and P = 0.040 respectively). Muslim women and older women were more likely to be underscreened, and women with more than 10 years' residence in Australia were more likely to have been screened in the last two years. Acculturation, smoking status, health status, duration of relationship with participating doctor, and chronic disease were not significant predictors of a recent smear.

CONCLUSION

As only 73% of women at risk had been screened in the last two years, including women attending on the day and 9% had never been screened, Arabic-speaking women should be a priority for public campaigns, particularly Muslim and older women. Studies to evaluate the effectiveness and acceptability of reminders by ethnic general practitioners are recommended.

Unsolved problems in early breast cancer detection: focus on the underserved

In the last decade, numerous research and programmatic efforts have attempted to improve cancer screening practices among women from diverse race/ethnic backgrounds on the assumption that observed differences in breast cancer survival were largely due to differences in early detection practices. Recent data from the 1992 National Health Interview Survey and a 1992 survey in San Francisco Bay Area multiethnic communities indicate that rates of self-reported breast cancer screening tests among African American, Hispanic, and white women no longer differ significantly. However, there are large, persistent socioeconomic differences as reflected in educational and income levels, the recency of immigration, and English language proficiency. This emphasizes the continuing need for interventions tailored specifically for the underserved, with the racial, ethnic, and cultural composition of the intended audience informing educational messages and strategies. However, effective research interventions are complex and costly throughout the spectrum of outreach, inreach, and follow-up. Thus the generalizability of these strategies to under-founded providers and agencies in low-income communities may be limited. Therefore, as ongoing research continues to refine strategies, the application of effective community-based intervention should seek out potential partnerships with programs that provide the critical access to services. Cancer control scientists are well positioned to advocate for community-based infrastructures that facilitate translation of research into practice.

Breast cancer screening in older black women

The objective of this study was to report findings about older black women's responses to breast health education and screening. Findings were reported from a community-based intervention designed to improve breast screening services for women in Erie County, New York. A 34-foot mobile screening and education clinic was used to overcome barriers such as accessibility and cost. Results from a sample of 271 older black women showed that they participated in breast health education programs and received clinical breast examinations when these services were offered in their neighborhoods. However, there was low participation in screening mammography offered at a local hospital. Low participation was attributed to structural and functional barriers in the delivery system. This study emphasizes the particular importance of education and screening offered as one unit of service. Further, it emphasizes the need to examine older black women's reported experiences after participation in screening.

Mammography and Pap smear screening of Yaqui Indian women

The Pascua-Yaqui Tribe of Arizona receives its health care services at a local neighborhood health center in Tucson and a satellite clinic located on the reservation. Using a computerized data base from the health center, the authors determined the use rates by Pascua-Yaqui women ages 35-65 of the Papanicolaou smear and mammography screening. Among active users of the health center, 31-36 percent had received a Papanicolaou smear, according to the yearly data bases examined from 1986 to 1990, while 65 percent of the women had received at least one smear test over the entire 5-year period. Regarding mammography screening, 41-43 percent of the women ages 50-65 had received a mammogram in the years studied, and 51-58 percent of the women ages 40-49 had been screened. In all, 67 percent had received at least one mammogram during the 1988-90 period when the center offered mammography. This population of 35-65-year-old American Indian women, for whom financial access is not a barrier, were receiving Papanicolaou smears and mammograms at rates comparable with other segments of the U.S. population but at lower rates than those recommended by the American Cancer Society and National Cancer Institute. The challenge for the health center is to reach those women who are eligible for services but do not use them and to address the nonfinancial barriers to care such as language, transportation, and gender-specific issues.

Breast cancer screening in an urban public hospital. Five-year results

BACKGROUND

This report describes the first 5 years of the Breast Cancer Screening Program (BCSP) at Cook County Hospital (CCH), a hospital that serves a predominantly African-American and low-income population.

METHODS

A retrospective review of hospital cancer registry staging for breast cancers diagnosed between 1984 and 1988 was performed.

RESULTS

Between 1984 and 1988, 499 new breast cancers were diagnosed at CCH, of which 33% were diagnosed after referral from the BCSP. The percentage of early breast cancers, defined as Stages 0 or 1, was 25% in women referred from the BCSP, compared with 6% for women referred from other clinical areas (P < 0.001). During this same period of time, the proportion of women at CCH with localized breast cancer increased from 30% in 1980-1983 to 40% from 1984-1988 (P < 0.05), an increase that can be attributed to the BCSP. Only 21% of the breast cancers detected by the BCSP were found by mammography alone. Of these, 91% were localized.

CONCLUSIONS

The BCSP has had an impact on the proportion of early breast cancer diagnosed at CCH. Despite these efforts, the proportion of early breast cancer diagnosed at CCH (12%) is significantly less than that seen for all African-American women with breast cancer in Illinois (32%; P < 0.001).

Cancer prevention and early detection strategies for reaching underserved urban, low-income black women. Barriers and objectives

To achieve national health goals set for reduction of cancer by the year 2000, populations with higher cancer mortality and lower survival must be reached with proven advances for use in cancer prevention and early detection. This article focuses on one segment of those populations that continues to have a poor cancer experience: urban, low-income black women. Barriers for them to cancer prevention and early detection are identified and discussed from studies conducted in Chicago. Specifically tailored interventions that have been used to bring services to this population are described, and implications from the outcomes of this work are discussed.