Speaking of Health Assessing Health Communication Strategies for Diverse Populations (2002) / Chapter Skim
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127 4 The Mammography Exemplar WHY MAMMOGRAPHY IS A USEFUL EXEMPLAR Strong evidence shows that health communication programs have played an important role in reducing disparities in mammography use among diverse groups. The committee chose mammography as an exemplar for this reason and several others.
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128 SPEAKING OF HEALTH partially because of increases in screening (Wingo, Calle, and McTiernan, 2000)
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The Mammography Exemplar 129 0 10 20 30 40 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Year of Death R at e pe r 1 00 ,0 00 White Black Hispanic Asian/PI Am Ind/AK Nat FIGURE 4-2 Breast cancer mortality rates by race/ethnicity, all ages. SOURCE: National Cancer Institute, 2002.
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130 SPEAKING OF HEALTH phy (e.g., Rimer, 1994; Snell and Buck, 1996; Wagner, 1998; Yabroff and Mandelblatt, 1999; Legler et al., 2002)
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The Mammography Exemplar 131 distributed by age and ethnicity, as can be seen from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) data and mortality data from the National Center for Health Statistics (National Cancer Institute, 2002)
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132 SPEAKING OF HEALTH THE ROLE OF SCREENING MAMMOGRAPHY IN THE EARLY DETECTION OF BREAST CANCER Screening mammography is the most effective method for early detection of breast cancer (National Institutes of Health Consensus Development Panel, 1997)
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The Mammography Exemplar 133 mammography use is now similar nationally for all ethnic groups -- 68 percent for white women; 66 percent for African-American women; and 60 percent for Hispanic women. Increased use of mammography from 1987 to 1998 is also evident for different age groups, with the most striking changes noted among women over 60, whose rates have nearly tripled.
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134 SPEAKING OF HEALTH this age group who do not have a high school education are 20 percent less likely to have had a mammogram in the previous 2 years compared to women with a high school education or higher (Breen et al., 2001)
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The Mammography Exemplar 135 dance with this integrative model. We covered a large number of peer-reviewed articles published between 1985 and 2000, with a focus on identifying variations among diverse groups.
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136 SPEAKING OF HEALTH come, or education, although some regional differences exist. Mammography use is higher among women who understand the purpose of mammography, especially its value in the absence of symptoms, and the recommended age-based intervals (McDonald et al., 1999; Lee et al., 1999; Maxwell, Bastani, and Warda, 1997, 1998a, 1998b; Wismer et al., 1998; Fernandez, Tortolero-Luna, and Gold, 1998; Rimer, 1994)
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The Mammography Exemplar 137 Further evidence of the role of cultural beliefs in women's decisions to have a mammogram has been observed across cultural groups, including a reluctance to use Western health care among Chinese-American women (Facione, Giancarlo, and Chan, 2000) ; cultural beliefs about fate among Filipino Americans (Maxwell, Bastani, and Warda, 1997)
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138 SPEAKING OF HEALTH recommendations than African-American women (55 percent versus 45 percent, odds ratio = 1.49)
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The Mammography Exemplar 139 more likely to have screening mammograms if they perceived that family and friends were also having them and were supportive (Maxwell, Bastani, and Warda, 1997)
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140 SPEAKING OF HEALTH dictor of screening than language and ethnic factors -- indicators of acculturation. Like all women, Hispanic women with access to health care are more likely to be screened than are women without access to health care.
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The Mammography Exemplar 141 tions) , and various combinations of the strategies listed.
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142 SPEAKING OF HEALTH colleagues assessed the presence and quality of the reported needs assessment, intervention, study design, analysis methods, and study outcomes, specifically: • From 1960 to 1997, most studies were system/physician directed, individual directed, and access enhancing. There was one social network intervention, and no policy interventions.
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The Mammography Exemplar 143 The methods for the meta-analysis are described more fully elsewhere (see Meissner et al., 1998, and Legler et al., 2002)
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144 SPEAKING OF HEALTH TABLE 4-1 Estimated Intervention Effects Combined Estimate Difference Combined Estimate Unadjusted Odds Ratio Number (95-percent Adjusted (95-percent Intervention of confidence for confidence Type Studies intervala) Monthsb intervala)
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The Mammography Exemplar 145 Results of Meta-Analysis for Diverse Populations As the preceding sections of this chapter demonstrate, many effective interventions have been developed over the past decade. A substantial body of research has focused on identifying and overcoming women's, physicians', and system barriers to mammography (e.g., Rimer et al., 2000a; Meissner et al., 1998; Calle et al., 1993; Clemow et al., 2000; Fox, Roetzheim, and Kington, 1997; Hiatt and Pasick, 1996; Lane et al., 2000; Rimer, 1994; Vernon, Laville, and Jackson, 1990; Yabroff and Mandelblatt, 1999; Mandelblatt and Yabroff, 1999; Bonfill et al., 2001; Yabroff et al., 2001; Sin and Leger, 1999)
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146 SPEAKING OF HEALTH mography use, with an estimated intervention effect of 18.9 percent (95-percent confidence interval [CI] : 10.4-27.4; 14 studies)
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The Mammography Exemplar 147 Additional analyses were conducted to examine the combined intervention effects for specific diverse populations (see Figures 43 and 4-4)
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148 SPEAKING OF HEALTH FIGURE 4-3 Individual and combined intervention effects for specific subgroups. Estimated intervention effects for individual studies and combined intervention effect estimates for studies with all older women and more than 40 percent with low incomes.
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The Mammography Exemplar 149 interventions (effect size 23.6 percent, 95-percent CI: 16.4-30.1; 2 studies) paralleled Legler's individual-directed interventions (effect size 17.6 percent, 95-percent CI: 11.6-24.0; 15 studies)
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150 SPEAKING OF HEALTH ventions. Theory-based educational strategies delivered interactively increased mammography use by 10.7 percent in inreach settings and 19.9 percent in outreach settings.
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The Mammography Exemplar 151 The results of the meta-analysis of mammography interventions for diverse populations show that the past decade's investment in such interventions has translated into effective interventions for these groups. In general, the interventions for general populations are not so different from those that are effective with diverse populations, with the exception of the importance of access-enhancing interventions.
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152 SPEAKING OF HEALTH health and cancer screening. One frequently ignored aspect of the mammography experience is communication between women and radiologic technologists (Moyer et al., 2001)
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The Mammography Exemplar 153 RECOMMENDATIONS • Theory-based interventions need to be developed, tested, and disseminated to increase screening utilization among women who have never been screened and to facilitate regular screening among all women. Qualitative and quantitative research is needed to identify specific barriers and to develop interventions appropriate for this population.
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