Health Centers vs Women in the Entire Community

Breast Cancer Screening Practices among Users of County-Funded Health Centers vs Women in the Entire Community... Dorothy S. Lane, MD, MPH, Anthony P. Burg, PhD, MSW Introduction In 1989 the National Cancer Institute (NCI) released a consensus statement about guidelines for mammography screening that was endorsed by 11 national organizations, including the American Cancer Society (ACS) and the American Medical Association. This statement includes a recommendation for annual mammography and breast examination for women aged 50 and older. I The Guide to Clinical Preventive Services, by the US Prevention Services Task Force, also recommends that women aged 50 to 75 have a breast examination annually and mammography annually or every 2 years.2 And in Healthy People: 2000 (1990), the US Department of Health and Human Services set a national goal to increase to at least 60% the proportion of women aged 50 and older who have received a clinical breast examination and a mammogram in the preceding 1 to 2 years (and to increase to at least 80% the proportion who have ever received them).3 Preventive health services are traditionally underused, particularly by the poor, who have competing and more urgent priorities as well as greater problems of access to all health services. And although mammography is a highly effective screening technology for breast cancer, it is not adequately used, particularly by low-income women.34 Yet, despite the higher incidence of breast cancer among women of higher socioeconomic status,5 the need for early detection of breast cancer is most evident among the socioeconomically disadvantaged because they suffer higher mortality due to later-stage diagnosis. This paper assesses differences in breast cancer screening practices between Polednak, PhD, and Mary Ann samples of predominantly low-income women aged 50 to 75 using county-funded health centers and a population-based sample of women in the same age group residing in the towns where the health centers are located. Methods Background This study was part of an NCI-supported project to increase the use of mammography and physical breast examination on a communitywide basis among women 50 years of age and older through public and physician education, as described in detail elsewhere.6 Baseline surveys were done for needs assessment related to planning interventions to improve the use of mammography and physical breast exam, as well as to contribute to the literature currently available about factors associated with use of breast cancer screening among low-income women. The Suffolk (NY) County Department of Health Services provides funding for five health centers that are located in the project's study towns (three centers are in the town of Brookhaven, two are in the town of Islip). Because there is no county hospital, these health centers play an important role in providing ambulatory At the time of the study the authors were with the Department of Preventive Medicine in the School of Medicine, State University of New York at Stony Brook. Requests for reprints should be sent to Dorothy S. Lane, MD, Department of Preventive Medicine, School of Medicine, State University of New York at Stony Brook, Stony Brook, NY 11794. This paper was submitted to the journal May 28, 1991, and accepted with revisions October 1, 1991. American Journal of Public Health 199

Lanet al care services for low-income residents. At the time of the baseline survey, mammography services were not available at the health center sites, nor were they paid for by the county; thus, health center women were referred to private radiologists or hospitals for mammography. Study Samples A telephone surveywas conducted in 1988 on a random sample of women aged 50 to 75, selected from computer files of womenwho hadvisited one or more ofthe five health centers for any reason within the prior year. Random samples were drawn to obtain 400 completed interviews in each of the two intervention towns in which the health centers were located. The sampling was proportionate to the total number of women visiting each health center in that town. Although possible telephone numbers for many women in the sample were obtained from health center records, the interviewers required additional searches. These entailed the use of standard telephone and cross-reference directories, and calls to information operators and to persons with the same surname as sampled patients. The response rate resulting from these procedures was 60.4%. Lack of a known telephone number was the most common reason for nonresponse, and the participation rate among persons with apparently correct telephone numbers was 74%. Because the proportion ofwomen without a telephone number who had moved out of the area was unknown andwewere interested only in women who were still residing in the study towns, 60.4% is an underestimate of the "true" response rate, which lies somewhere between 60% and 74%. The proportion of respondents from each of the five health centers ranged from 13% to 34%. The same surveywas also conducted in 1988 by random-digit dialing to obtain at least 500 interviews of women aged 50 to 75 residing in the entire project intervention area, which included three towns. The estimated response rate was 73.1%. Nonresidential numbers and numbers not in service were excluded. Eligible households were those with one or more women aged 50 to 75 living in the study area. Reasons why eligibility could not be determined include household's refusal to participate prior to screening for eligibility, use ofcontinuous answering machine, and inability to speak one of the four interviewing languages. The proportion of eligibles among those screened was 29.6%. Among households that did not answer after nine attempts, a maximum of 10% of the phone numbers called were estimated to be current residential numbers based on prior experiments conducted by the contractor (Northeast Research in Orono, Me). The proportion of eligibles among those not screened for eligibility was unknown but was estimated to be the same as that among those screened. A methodological article about our community population survey provides a detailed discussion of the response rate calculation.7 Data in this paper cover only the two towns in which the health centers are located Ḃecause only 5% of respondents to the community survey reported a health center as their regular source of care and 87% cited a private physician, there is little overlap between this group and the health center respondents. The two samples, however, may differ in the frequency of recent contact with a physician. The health center sample was restricted to women known to have visited the health center for any reason during the past year, including visits involving physician contacts. Unfortunately, in an effort to limit the length of the survey so it could be completed in 10 minutes, one question that was omitted from the 1988 telephone surveys was whether respondents had visited a physician in the past year. However, in a 1989 survey of women known to havevisited a health center during the past year, 96% reported having seen a physician for any reason that year, compared with 83% in a random sample of community women surveyed by mail. This suggests that there probably was not a large difference between the samples in terms of recent contact with a physician. In the survey, women were asked about their current breast cancer screening practices, their concerns that would influence their participation in screening or having a mammogram, their knowledge and attitudes related to breast cancer risk and the benefits ofscreening, their sources of health care and health insurance, their demographic characteristics, and their personal history of breast cancer. Those with a prior history of breast cancer were excluded from the analysis. Women were asked to rank their level of concern on a scale of 1 to 5, where 1 is "no concem" and 5 is "a great deal of concern." Analysis Chi-square tests were performed using an SAS mainframe program to compare various characteristics of the health center and community survey respondents. Tests with one degree of freedom (df) were continuity corrected. The Pvalues in the tables are reported to three decimal places (as low as P <.001). Because of large sample sizes in some comparisons, the attainment of statistical signifcance may not indicate meaningful differences, and the magnitude of the differences in proportions should be considered. Reml Sociodemographic Characteristics As indicated in Table 1, there were significant differences between the health center and community respondents in all demographic characteristics. The health center respondents were older (43.7% aged 65 to 75 vs 31.2%) and less educated (43.0% had less than a 12th-grade education vs 20.1%); they also had a lower annual household income (52.8% made less than $15 000 vs 19.3%) and had a larger minority population (26.7% Black and Hispanic vs 6.7%). A significantly higher proportion of the health center respondents reported having a regular source of care (96.5%) compared with the community respondents (88.5%), which was statistically significant for these sample sizes (X2 = 28.744, df = 2, P<.001). Knowledge and Attitudes Health center women knew less frequently than community respondents that the lifetime risk ofbreast cancerwas about 1 in 10 (27.0% vs 33.2%; x2 = 4.577, df = 1, P <.05), but their perception of a personal risk of breast cancer was similar to that ofcommunity respondents (likely risk = 25.0% vs 25.3%; x2 = 0.000, df = 1, P=.991). Health center respondents agreed strongly with statements about the benefits of mammography and early detection less frequently than did community respondents, and there was a statistically significant difference in those agreeing that there are other ways to treat breast cancer besides removing the breast and that women live longer if breast cancer is found early (Table 2). The rank order of concerns that would influence their compliance with mammography guidelines were the same for the health center and community respondents (Table 3). A small difference between the two groups in the frequency of reporting the most common concerthe results of the mammography exam (health center = 83% vs community = 200 American Journal of Public Health February 1992, Vol. 82, No. 2

Health Center vs Community Breast Cancer Screening Practices 89%)-reached statistical significance (Table 3). Health center women had greater concem about cost (64%) significantly more often than did community respondents (49%) (Table 3); the level of concern with cost was also significantly higher among health center respondents (36.9% extremely concerned vs 17.1%; x2 = 74.316, df = 4, P <.001). There was no significant difference, however, in the ranking or level of concerns about factors that might influence having a breast exam, with fear of results cited most often, followed by embarrassment. More than 90% of women in both groups had ever heard of a mammogram, and the small difference between community women and health center women in this regard reached statistical significance (Table 4). Screening Behavior Despite their differences in socioeconomic status and in knowledge and attitudes, the health center and community samples differed little when asked if they had ever had a mammogram or breast exam or had had a mammogram in the past year (Table 4). Although there was some variation in mammography use in the past year by individual health centers (ranging from 23% to 41%), there was no health center where mammography use was substantially lower than it was in the community as a whole (29%). Significantly more health center women than community women reported having had a breast exam in the past year (Table 4). Mammography use in the past year was significantly associated with income and education (and there was a trend toward declining use with increasing age) in the community sample, but there was little variation in screening use by income, educational level, or age within the health center sample (Table 5). Mammography use in the past year also did not vary significantly by race/ethnic group within the health center sample (white/non-hispanic 28.7% [163/568], Black/non-Hispanic 28.6% [26/91], Hispanic 33.1% [40/121]; X2 = 0.945, df = 2,P =.623); the numbers of minority persons in the community sample were too small (see Table 1) for a similar analysis. Within the health center group, mammography use in the past year was higher among those with health insurance coverage than among those without it: 32.9% for those with commercial insurance (with orwithout other coverage), 23.9% for those with Medicare and/or Medicaid only, and 22.6% for those without insurance (X2 = 7.658, df = 2,P =.002). Amongwomen February 1992, Vol. 82, No. 2 American Journal of Public Health 201

Lane t al. who had a household income under $15 000, proportionally more than twice as many health center vs community respondents had a mammogram in the past year (x = 8.179, df = 1, P =.004). Variations with demographic characteristics also applied to reports of ever having had a mammogram among the community group but not among the health center group. About half (or more) of the health center respondents had ever had a mammogram within each income, age, and race/ethnic subgroup, whereas among the community respondents this proportion varied significantly with income (X2 = 15.502, df = 3, P =.001) and education (X2 = 20.240, df= 3, P <.001). Among women who had never had a mammogram, the ranking of reasons was similar for both groups of women (Table 6), the most common reason-that it was not necessary or they had no problemwas followed by lack of a doctor's recommendation. More health center women cited cost of the mammogram as a deterrent to mammography, but none of the differences in specific reasons achieved statistical significance. Discussion Despite lower levels of knowledge about mammography and the lifetime risk ofbreast cancer forwomen, less favorable attitudes regarding the value of early detection and mammography, and sociodemographic characteristics more typical of a disadvantaged population, health center registrants who visited a center in the year prior to the survey used breast cancer screening services at levels comparable to those of a random sample ofwomen in the same community. In a 1988 studyofpredominantly Hispanic users of a public health center in Massachusetts, where 59% of the women had ever had a mammogram (compared with 50% for all respondents in our study) and mammography use was similar across age, education, and employment subgroups, there was no comparison group from the general population.8 In our study, income and educational level also did not significantly influence mammography use within the health center population although they were significant factors within the community; this suggests that services were available more equitably to all subgroups using the health centers. Race/ethnicity and age also did not significantly influence mammography use within the health center group. The fact that 15% of community women vs 3% of health center women in the lowest household income category (under $15 000) indicated having no regular source of care did not account for the large difference in mammography use between the two samples of women within 202 American Journal of Public Health February 1992, Vol. 82, No. 2

Health Center vs Community Breast Cancer Screening Practices this income subgroup. None of the 12 community women with household incomes under $15 000 and no regular source of care had a mammogram in the previous year, compared with 14% (2/14) of health center women in the same subgroup. Among those lowest-income women with a regular source of care, however, 31% (127/406) of health center women vs only 17% (11/66) of community women (P =.02) had a mammogram in the pastyear. Thus, having a health center as a source of care was critical. Both health center and community women reported lower mammography use than is recommended in national guidelines, and they cited concerns that would deter them from obtaining such screening. Inadequate use of screening services for breast cancer reflects both patient and physician factors. Our findings suggest that physicians and others should inform women that the purpose of screening is to detect disease early, before there are symptoms, in order to reduce the high frequency of reports of never having had a mammogram because screening is not necessary or there were no "problems." Another common reason for never having had a mammogramwas that the doctor did not recommend it. Research has indicated the importance of physician recommendation for patient compliance with mammography screening.9-12 But although surveys of primary care physicians have shown some improvement in mammography referral rates since the mid 1980s, there is still inadequate physician compliance with national recommendations for mammography screening.13-15 Finally, women's concerns about the results of mammography (Table 3) could possibly be alleviated by highlighting the benefits of screening, such as the high curability of breast cancer ifdetected early and the possibility of lesser surgery. Use of mammography has been shown to decline with decreasing income in other populations.4as expected, cost of mammography was a greater concern among health center than among community respondents. Yet we have shown no difference in mammography use between predominantly low-income health center users and the general population, and significantly higher use within low-income health center users. These findings maybe explained, in part, by differences in health care use factors-for example, all of the health center sample had visited the health center in the past year, which often included physician contact, and almost all of them considered the health center to be their regular source of care. Other features of the health center, however, may also have been important and may require examination-for example, physician behavior, such as higher referral rates of low-income women for mammography by health center providers than by other physicians. Recent legislation that provides some coverage for screening mammography should help increase mammography use in both the community and the health centers. This includes a New York State law effective January 1989 requiring private insurance companies to provide some coverage for screening mammography, and provisions in the Medicare legislation effective in 1991 for Medicare recipients to receive coverage for a screening mammogram every other year. The results of this study suggest an important role for health centers in accomplishing preventive medicine goals for early detection ofbreast cancer among the socioeconomically disadvantaged. They also show the potential for achieving equity in behavioral objectives despite lower educational levels and lower levels of understanding about screening, and they provide an example of the importance of community health centers in improving primary and preventive health care in the population served.16 E Acknowledgments This research was supported by grant irol CA 4503401 from the National Cancer Institute. This paper was presented in part at the annual meeting of the American Public Health Association in October 1989. The authors thank David Kovenock, Ph.D., of Northeast Research (Orono, Me) for assistance in revising the telephone surveys, which were conducted by contract with Northeast Research; and Leijin Chao for assistance in computer data analysis. We are indebted to Drs. David Harris, William Steibel, Judith Feldman, and Clare Bradley of the Suffolk County (NY) Department of Health Services for providing access to the health centers and their registrants, and also to the community advisory boards of the five health centers for approving our survey of the health center population. References 1. Vanchieri C. Medical groups' message to women: if 40 or older get regular mammograms. J Natl Cancer Inst. 1989;81:1126-1128. 2. US Preventive Services Task Force. Guide to ClinicalPreventive Serices:AnAssessment ofthe Effectiveness of 169 Interventions. Baltimore, Md: Williams and Wilkins; 1989;chap 6:39-62. 3. US Dept of Health and Human Services. Healthy people 2000: National health promotion and disease prevention objectives. Washington DC: USDHHS; 1990. 4. National Cancer Institute Breast Cancer Consortium. Screening mammography-a missed clinical opportunity? Results of the NCI Breast Cancer Screening Consortium and National Health Interview survey studies. JAMA. 1990;284:54-59. 5. Freeman HP. Cancer and the socioeconomically disadvantaged. CA. 1989;39: 266-288. 6. Lane DS, Polednak AP, Burg MA. Measuring the impact ofvaried interventions on community-wide breast cancer screening. In: Anderson PN, Engstrom B, Mortonson LE, eds. Advances in Cancer Control VI. New York, NY: Alan Liss Inc; 1989:103-114. 7. Polednak AP, Lane DS, Burg MA. Mail versus telephone surveys on mammography utilization among women 50-75 years old. Med Care. 1991;29:243-250. 8. Zapka JG, Stoddard A, Barth R, et al. Breast cancer screening utilization by Latina community health center clients. Health Educ Res. 1989;4:461-468. 9. Lane DS. Compliance with referrals from a cancer-screening project. J Fam Pract. 1983;17:811-817. 10. Burg MA, Lane DS, Polednak AP. Age group differences in the use of breast cancer screening tests: the effect of health care utilization and socioeconomic variables. J AgigHealth. 1990;2:514-530. 11. Fox SA, Murata PJ, Stein JA. The impact of physician compliance on screening mammography for older women. Arch Intern Medt 1990;151:50-56. 12. Zapka JG, Stoddard A, Costanza M, Greene H. Breast cancer screening by mammography: utilization and associated factors.amjpubi,c Health. 1989;79:1499-1502. 13. Lane DS, Burg MA. Breast cancer screening: changing physician practices and specialty variation. NYState JMed 1990;90: 288-292. 14. American Cancer Society. A survey of physicians' attitudes and practices in early detection. CA 1985;35:197-213. 15. American Cancer Society. 1989 survey of physicians' attitudes and practices in early cancer detection. C4. 1990;40:77-101. 16. Sardell A. The US Exfment in Social Medicine: The Commnunity Health Center Program, 1965-1986. Pittsburgh, Pa: University of Pittsburgh Press; 1988. February 1992, Vol. 82, No. 2 American Journal of Public Health 203