North Carolina Breast Cancer Screening Research Articles

Abstract A34: Using a community-based breast health intervention to reduce structural barriers in accessing breast cancer screening services among underserved rural Latina and black women in Eastern North Carolina

Abstract Background: Although breast cancer mortality rates have been steadily decreasing over time, Black and Latina women continue to have the highest death rate and shortest survival of any racial and ethnic groups in the United States for breast cancers. Most scholars agree, however, that the major cause of this disparity is more likely to be diagnosed with late (vs. early) stage breast cancers that are less responsive to treatment. This disparity in cancer-stage-at-diagnosis reflects Black and Latina women's lower prevalence of breast cancer screening that could detect cancers at earlier, curable stages. Pitt and Edgecombe Counties, located in a rural disadvantaged part of Eastern North Carolina (ENC), maintain breast cancer disparities among its minority women as compared to their white counterparts. Breast cancer incidence among minority women is lower compared to white women for both counties, however the mortality rate for minority women is twice as high compared to their white counterparts (42.4 vs. 21.9 respectively) in Pitt county and slightly higher in Edgecombe county (37.3 vs. 36.7 respectively). Pitt County also has the highest breast cancer mortality rate among minority women and Edgecombe has the fifth highest in Eastern NC. Furthermore, minority women are diagnosed at later stages of the disease, with the rate of diagnosis at stage 4 being almost three times higher than white women in Pitt County and significantly higher in Edgecombe County. This community-based breast health intervention (The Pitt County Breast Wellness Initiative-Education) works to reduce these health disparities in breast cancer mortality through provision of education and navigation to early detection and access to screening for uninsured and underinsured Black and Latina women in Edgecombe and Pitt Counties in NC. Methods: The Pitt County Breast Wellness Initiative-Education provides culturally tailored breast cancer education and navigation to age-appropriate screening services for uninsured/underinsured Black and Latina women age 25 and older in Pitt and Edgecombe Counties, North Carolina. Using a lay health model (adapted from North Carolina Breast Cancer Screening Program Training Curriculum), we trained eight community members on breast health, breast cancer, and being an effective breast health educator. The education component includes a brief 10-minute presentation on breast health, breast cancer, and guidelines for age-appropriate breast cancer screening services. The navigation component includes assistance with the following: (1) Breast Health Assessment Tool and BCCCP applications, (2) scheduling appointments/accessing age-appropriate breast screening services, (3) interpretation, and (4) transportation. Since our program initiation in April 2015, we have educated 85 women and navigated 47 to age-appropriate breast cancer screening services in Pitt and Edgecombe counties. Results: Among the 47 navigated women to age-appropriate screening, 78% (n=37) were 40 years of age or older, 82% (n=39) reported being uninsured, 32% (n=15) reported no previous clinical breast exam, and 38% (n=18) reported no previous mammogram. Among those who reported a having a previous mammogram, many were 2 years or more over due for their yearly mammogram. We use pre-/post-surveys to determine an increase in knowledge and awareness regarding breast health, breast cancer, and guidelines for age-appropriate breast cancer screening services. Up-to-date results from program participants will be reported during the presentation. Conclusion: Specifically, using a LHA community-based model allows this program to serve as a cultural mediation between underserved communities in Pitt and Edgecombe counties and health care service systems and reduces structural barriers in accessing screening services and diagnostic follow-up. Strong collaborative community partnerships will streamline the process of accessing care in an effort to ensure seamless transition within the continuum of breast cancer care. Citation Format: Essie T. Torres, Alice R. Richman. Using a community-based breast health intervention to reduce structural barriers in accessing breast cancer screening services among underserved rural Latina and black women in Eastern North Carolina. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A34.

A Community-Academic Partnership to Plan and Implement an Evidence-Based Lay Health Advisor Program for Promoting Breast Cancer Screening

Despite a growing body of evidence concerning effective approaches to increasing breast cancer screening, the gap between research and practice continues. The North Carolina Breast Cancer Screening Program (NC-BCSP) is an example of an evidence-based intervention that uses trained lay health advisors (LHA) to promote breast cancer screening. Partnerships that link academic researchers knowledgeable about specific evidence-based programs with community-based practitioners offer a model for increasing their use. This article describes a partnership between CrossWorks, Inc., a community-based organization, and the UNC-CH Lineberger Comprehensive Cancer Center in planning and implementing an evidence-based program for promoting breast cancer screening among older African American women in rural eastern North Carolina communities. We used in-depth interviews to explore the relationship of the partnership to the activities that were undertaken to launch the evidence-based program.

Taking the Transtheoretical Model Into the Field: A Curriculum for Lay Health Advisors

The transtheoretical model (TTM) is a commonly applied theoretical perspective for understanding mammography behaviors and improving the effectiveness of one-on-one counseling. The North Carolina Breast Cancer Screening Program (NC-BCSP) developed a training curriculum to incorporate TTM into the advising practices of lay health advisors (LHAs). The TTM helped "natural helper" LHAs understand that women in their rural North Carolina communities were likely to be in different stages for mammography screening and hence required different messages. NC-BCSP staff believed that by combining an understanding of TTM with LHAs' natural helping abilities we potentially increased the effectiveness of LHA advising. Our limited evaluation, based on LHA feedback, suggests the curriculum is a useful training tool, even for those unfamiliar with behavior change models. Our TTM curriculum serves as an example of a health behavior theory successfully operationalized outside academia for use in the field by lay people.

Baseline predictors of initiation vs. maintenance of regular mammography use among rural women

Background Predictors of regular mammography screening over many years have not often been examined prospectively. We used data from baseline (1993–1994), first (1996–1997), and second follow-up (2000) interviews with 336 White and 314 African-American rural women in the North Carolina Breast Cancer Screening Program to evaluate baseline factors predictive of regular mammography use over 7 years. Methods We defined regular mammography use as a recent mammogram (past 2 years) at all three interviews. Using binomial and logistic regression models adjusted for age, we examined factors associated with initiation (for women without prior regular use) and maintenance (for women with prior regular use) of mammography. Results Younger age and White race were predictive of initiation of regular mammography use. Physician recommendation was the strongest predictor of both initiation and maintenance of regular mammography use. Positive mammography attitudes and fewer personal barriers were strongly associated with initiation but not with maintenance. Conclusions Increased contact with providers and greater support for screening mammograms by providers could have an important impact on rural women initiating and maintaining regular mammography screening. Special efforts are needed to prompt rural African-American women and those over age 65 to initiate screening, since once they start they are likely to continue.

Relation Between Intervention Exposures, Changes in Attitudes, and Mammography Use in the North Carolina Breast Cancer Screening Program

Abstract Objective: Many past interventions have been based on the assumption that improving attitudes about mammography can increase mammography use. We studied changes in breast cancer and mammography attitudes over time in mediating the effect of intervention exposures on mammography use in the North Carolina Breast Cancer Screening Program. Data came from interviews with a cohort of 331 black women who said they had heard of mammography at baseline interview. Methods: We created scores and score changes for mammography (7 items) and breast cancer (11 items) attitudes at baseline (1993–1994) and follow-up interviews (1996–1997). We modeled intervention exposures, attitude changes, and mammography use in linear risk and logistic regression. Intervention exposures were defined for mammography discussion with a project lay health advisor (“LHA advice”), mammography discussion with anyone besides a doctor or nurse, and project awareness. Results: Positive change in mammography attitudes was associated with intervention exposures and mammography use and appeared to account for a large percentage (34–98%) of the effect of mammography discussion variables on increased mammography use. Greatest effect of attitude improvement was found for women without a recent mammogram at baseline and with the least positive baseline attitude scores. Conclusion: Using cohort data enabled us to examine the role of attitude change over time on mammography use. Breast cancer screening programs should target women with the most negative mammography attitudes and the least mammography use to start with and concentrate their messages on improving attitudes specific to mammography rather than improving attitudes about breast cancer risk.

Implementing a Natural Helper Lay Health Advisor Program: Lessons Learned from Unplanned Events

Programs that train natural helpers, or members of the community to whom others naturally turn for help, to be lay health advisors (LHAs) have proliferated throughout the United States; evaluations of these programs, however, are uncommon. The goal of this exploratory study was to understand how the natural helper LHA approach, as operationalized by the North Carolina Breast Cancer Screening Program (NC-BCSP), was translated from idea into practice. Data from document review and in-depth interviews with 24 LHAs and four of their coordinators were used to compare theory-based program plans with actual practice. Results suggest that although in large part the natural helper model was followed, program implementation departed from program plans in several unanticipated ways in the areas of (a) recruitment, (b) program direction, and (c) LHA activities. Differences illustrate the tensions between theory and practice and between community and program planners that may be inherent in a natural helper program, and highlight the need to include community members and program participants in all aspects of planning.

Expanding the Role of Mammographers: A Training Strategy to Enhance Mammographer-Patient Interaction

The use of routine mammography screening is associated with earlier breast cancer detection and decreased mortality. Several researchers have identified mammographers as potentially effective agents for encouraging patients to engage in routine screening. Mammographers are particularly well situated within the health care system to address patients' knowledge, psychological, and cultural barriers to routine screening. Few opportunities exist, however, for mammographers to acquire skills in providing culturally-sensitive patient education and emotional assessment to help women overcome such barriers. In 1997 the North Carolina Breast Cancer Screening Program (NC-BCSP) developed and implemented an innovative, two-hour training program to help mammographers address the educational and psychosocial needs of rural, African American women in eastern North Carolina. NC-BCSP's extensive survey data (n=2000), as well as qualitative data from 25 focus groups conducted with more than 200 rural African American women, were used to develop a curriculum titled Expanding the Role of Mammographers. It was the first American Society of Radiologic Technologists (ASRT) accredited training program for mammographers in North Carolina that solely addressed psychosocial topics. The curriculum emphasized mammographers' potential impact on women's attitudes and behavioral intentions, and taught communication strategies to enhance mammographer-patient interaction. It included supplemental learning materials, skill-building exercises, and patient education materials to assist participants in applying new skills and knowledge. Of the 33 mammographers invited to the training, 19 attended. A structured evaluation form, completed by 18 participants, conveyed positive reactions to the intervention. This training workshop was conducted as part of NC-BCSP's much larger, community-based intervention; as such, it was not independently evaluated. NC-BCSP's broader intervention appears to be associated, however, with positive population-level changes in breast cancer awareness and mammography use.

The role of physician recommendation in women's mammography use: is it a 2-stage process?

To explore the use of a 2-stage model in explaining the role of physician recommendation in women's use of mammography screening and to provide an integrated framework for understanding the mammography-use process. Data on 1,301 women aged > or =52 years from the North Carolina Breast Cancer Screening Program (NC-BCSP) questionnaire were combined with information from 91 of their physicians from the North Carolina Medical Board. A 2-stage system of equations using women's characteristics (demographic, health, access), physicians' characteristics (demographic, practice), women's beliefs, and women's report of a physician recommendation was created and statistically tested. The model was estimated using 2-stage logistic and probit estimation. The 2-stage approach produced different results compared with the single pooled model. In the second-stage mammography-use model, younger age, family history of breast cancer, and a woman's having ever requested a mammogram retained significance (P < or = 0.05) in addition to the predicted value of physician recommendation obtained from the first stage. Women's characteristics significantly associated with physician recommendation in the first stage included some access, health risk, and demographic variables as well as physician age and race (P < or = 0.05). A 2-stage model for estimating mammography use among women with regular physicians may be more informative than a single model. These results imply that programs designed to increase mammography rates should focus on ensuring appropriate physician recommendations in addition to encouraging women to request screening. Future research should consider using an integrated framework for evaluating utilization of mammography and other preventive services.

Counseled women's perspectives on their interactions with lay health advisors: a feasibility study.

Although the use of lay health advisors (LHAs) has become a popular intervention in public health promotion projects, few programs have conducted evaluations demonstrating program impact by interviewing people actually counseled by LHAs. This study used semistructured, in-person interviews with 29 older, black women to elicit their perceptions of their interactions with the North Carolina Breast Cancer Screening Program's LHAs, and the ways in which these interactions affected their mammography attitudes and behavior. Interview data indicate that a majority of the respondents felt that LHAs had helped them in some way; most said that talking to advisors made them think more positively about mammograms and/or consider getting one. LHAs influenced the women they counseled because the women knew the advisors well, felt comfortable talking to advisors about private issues, considered advisors to be credible sources of information about mammography and because advisors offered women support with respect to their mammography behavior. These results elucidate some of the mechanisms through which LHAs affect the attitudes and behavior of individuals in their social networks.

What lay health advisors do: An evaluation of advisors' activities.

Since the 1970s, health promotion and disease prevention programs that rely on lay health advisors have proliferated, making it important to ascertain the levels and types of activity that can reasonably be expected from such advisors. This report describes the activities of lay health advisors participating in a program to increase mammography screening by older African American women and shares lessons that the authors learned about evaluating advisors' activities. Between September 1994 and January 1996, 144 lay health advisors, associated with the North Carolina Breast Cancer Screening Program, were asked to complete, on a periodic basis, a standardized, self-administered activity report that asked about group presentations in the past 3 months and one-on-one contacts in the past week. Eighty-five advisors submitted one or more reports. The authors tabulated responses for lay health advisors overall, for those turning in one or more reports, and for those reporting a specific type of activity. The responses showed that North Carolina Breast Cancer Screening Program lay health advisors made approximately one group presentation every 3 months and had one to three individual contacts per week. Group presentations were commonly in churches and homes, and focused on who needs a mammogram, how then, and where to get one. During one-on-one encounters, advisors primarily encouraged women to get mammograms or discussed fears about mammograms. Information about lay health advisor activities serves several important purposes. Such information allows programs to identify the types of messages that lay health advisors transmit and the number of contacts they make, while also identifying the groups that are more and less difficult to reach, and the topics and locations favored by advisors and the women they contact. Activity data may indicate what resources or other support the advisors need, whether in-service training is necessary, and how to enhance the recruitment and training of additional lay health advisors.

Bringing Down the Barriers to Mammography: A Review of Current Research and Interventions

Although mammography screening is effective in reducing breast cancer mortality, major challenges still remain in increasing rates of initial mammography and in improving subsequent adherence to mammography screening. Behavioral science theories offer insights into the potential for individual, organizational, community, and population-level interventions to address these challenges. In this review, we draw on social ecological approaches to health promotion to suggest a conceptual framework for such interventions. After discussing theories of who is and is not screened regularly, and why, we consider selected barriers to mammography and corresponding interventions to overcome them. We conclude with an illustration of the North Carolina Breast Cancer Screening Program (NC-BCSP), a series of interventions informed by the social ecological perspective.

Promoting breast cancer screening in rural, African American communities: the "science and art" of community health promotion.

Implementing community health promotion programs can be a daunting task for social workers. Aside from the practical skills necessary for engaging diverse groups, it requires an understanding of the complex interplay of several theoretical constructs. Using an eight-year breast cancer prevention project, the North Carolina Breast Cancer Screening Program, as a case study, this article describes both the "science and art" of community health promotion. The article provides examples illustrating the "art" of generating participation by both lay and professional communities and concludes with guidelines for social workers who plan to conduct their own community health promotion programs.

Lay health advisors: a strategy for getting the word out about breast cancer.

Transforming natural helpers into lay health advisors (LHAs) is a complex undertaking. Using the North Carolina Breast Cancer Screening Program (NC-BCSP) as a case study, this article describes the steps involved in developing, implementing, and evaluating an LHA intervention, considering factors that make the LHA approach appropriate for the NC-BCSP's population, setting, and health focus. The authors review five phases of implementation (start-up, training, LHA activities, follow-up, resource mobilization) and discuss the NC-BCSP's evaluation strategies and tools in light of difficulties involved in assessing natural helping processes and impact. Program challenges related to resource needs, identification of natural helpers, and LHA monitoring and support also are considered. The authors describe ways in which one large group of older, rural, African American LHAs are helping establish countywide partnerships between health care providers, agencies, and local communities that support and sustain individual changes in health behavior.

The North Carolina Breast Cancer Screening Program: foundations and design of a model for reaching older, minority, rural women.

Breast cancer screening programs do not reach all women at the same rate. Screening mammography use varies according to sociodemographic characteristics; mammography utilization is highest among women in their fifties but then decreases with age. In North Carolina, breast cancer is a particular burden for Black and lower-income women. Black women are more likely to be diagnosed with late stage disease, and their rate of breast cancer mortality is higher than it is for White women even though the incidence in White women is greater. Older, Black, and low-income women are less likely to obtain screening by mammography and clinical breast examination. The Black-White gap is even more pronounced among rural women, in part because they are more likely to be poor. The North Carolina Breast Cancer Screening Program (NC-BCSP) was established to increase the rate of regular mammography screening by an absolute 20% in 3 years among older Black women ages 50 and older in five rural counties in the eastern part of the state. In this paper, we describe the genesis of this comprehensive community intervention model, highlighting the behavioral science constructs, health education principles, and theories of behavioral and organizational change that form its conceptual foundation. NC-BCSP's theoretical foundations include the social ecological perspective, the PRECEDE model of health promotion, the Health Belief Model of individual change, and the "stages of change" transtheoretical model. We also review the experiences and lessons learned from two previous outreach initiatives in North Carolina that provided valuable "lessons" in the development of the NC-BCSP intervention model. In the second half of the paper, we describe the actual NC-BCSP interventions, activities, and evaluation tools, citing specific examples of how the underlying theories are implemented. NC-BCSP's goal goes beyond individual behavior change to raise low mammography screening rates among Black women in rural North Carolina. Its ultimate objective is to create linkages across agencies, and between agencies and communities, that will endure after the research project ends.