Transcript Replication of a Screening Mammography Program to Recruit

Recruiting Rural, Underserved Women
to Screening Mammography through
Food Pantries:
A Multi-Community, Dissemination
Research Study
October 8, 2008
Eugene J. Lengerich, VMD, MS
The Pennsylvania State University
Background
Breast Cancer

#1 diagnosed non-skin cancer - 2008



US: 182,460 (26.4%)
PA: 9,410
#2 cause of cancer-related death - 2008


US: 40,480 (14.9%)
PA: 2,180
Cancer Incidence
Rural Appalachia vs. SEER
Lengerich et al, 2005. Journal of Rural Health
Mammography as a breast cancer
screening method

Early detection provides the best chance of survival

Recommendation


Every year for women age 40 years and over (ACS; USPSTF)
Free mammograms and follow-up for those who are
uninsured and meet income limits


National Breast and Cervical Cancer Early Detection Program
(NBCCEDP)
Mammogram vouchers - Komen Foundation
Reported Drop
in
Mammography
Is This Cause for
Concern?
Breen et al. Cancer
2007
Figure. Recent mammography use
(within 2 years) among women by
age:
• Black - women aged 40+ yrs.
• Blue - women aged 65+ yrs.
• Green - women aged 50-64 yrs.
• Red - women aged 40-49 yrs.
Recent trends in U.S. mammography use from
2000–2006: A population-based analysis
Ryerson et al. Preventive Medicine 2008
Low
Income
Barriers to Mammography Commonly
Reported in the Literature

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Perceived susceptibility
Cost
Fear of finding something
wrong
Pain
Takes too much time
Fear of radiation
Embarrassment
Forget to schedule
appointment
Do not know where to get
one








Do not understand what will
be done
Do not know how to go about
getting one
Do not think screening is
important
To old to need one
Other problems are more
important
Lack of physician
recommendation
Lack of symptoms
Lack of transportation
Additional Barriers to Cancer
Screening in Appalachia

Fewer primary care physicians and screening
facilities in rural areas

Residents are unaware of the location of facilities
and services

Residents must travel long distances through
mountainous areas to be screened or consult with
specialists after screening

Lack of transportation, public or private
Health Communication in
Appalachia

Residents receive health information through social
relationships with family, friends and neighbors:



limited number of healthcare professionals;
effective use of the Internet is reduced because of limited
access, ability, or speed.
Social networks are a culturally-appropriate method
to communicate health information
*Behringer B, Friedell GH. Appalachia: where place matters in health. Prev Chronic Dis [serial online]. 2006;3(10).
www.cdc.gov/pcd/issues/2006/oct/06_0067.htm
*Lyttle NL, Stadelman K. Assessing awareness and knowledge of breast and cervical cancer among Appalachian
women. Prev Chronic Dis [serial online]. 2006;3(10). http://www.cdc.gov/pcd/issues/2006/oct/06_0031.htm.
Dissemination Research

Definition


Why




Assess the generalizabilty of the knowledge
Determine the limitations of the original study
Apply the findings to additional populations
Characteristics




Systematically examine the translation of evidence-based
procedures and programs into real-world settings
Multiple sites, with comparison sites
One protocol, with adaptation to local community
Real-world setting
AHRQ, 2003: “There is insufficient evidence to
conclude that any dissemination strategy is
effective at increasing mammography”
Preliminary Study
American Cancer Society’s
Tell A Friend ® Program

Intent


Basis


Observational Learning (modeling) of Social Cognitive Theory
Method



Increase screening mammography among unscreened women
aged 40 years and older.
Peer-to-peer counseling
Trained volunteers contact friends or acquaintances at three
different times
Objective

Each woman to have either received a mammogram or
scheduled an appointment for one
2002 Evaluation of ACS Tell A
Friend ® Program in Pennsylvania
Results:
 Successful in encouraging women to obtain
mammograms

But not reaching rarely or never screened women


Need to reach minority, low-income, and underserved women
Personal contact - as opposed to phone calls - was more
effective in encouraging mammography
Adapted Tell A Friend ® Program
of Indiana County during 2005

Aim



Increase mammography among unscreened women aged 40
years and older
3-contact intervention
Through a trusted community service
The Local Food Pantry (all 18 sites in Indiana County)
Adapted Program in Indiana County
Results:




158 (52%) of 302 age-eligible women were in need of mammography
138 (87%) of 158 women in need of mammography received a mammogram
Increased county-wide screening mammography among low-income and
uninsured women by 28% (n=46)
Detected three asymptomatic breast cancers
Advantages:



Individual, population, and system levels
Multiple-contacts
One-on-one contact - cited as most rewarding by recruitment volunteers
J Rural
Health
2008
Theoretical Basis

Social Network/Social Support Theory
behavior is affected by social relationships and
ties

Social Cognitive Theory
behavior is affected by the dynamic interaction
between environment, personal characteristics,
and the behavior

Health Belief Theory
behavior is affected by one’s beliefs and
perceptions
Frameworks Recommended for Breast
Cancer Screening by USTFCPS in 2008
1. Increase access by reducing out-of-pocket costs
Baron RC, Rimer
BK, Coates RJ,
et al (USPSTF).
Am J Prev
Medicine 2008
2. Increase demand with small media and one-on-one education
Study Design
Quasi-experimental, multi-site
behavioral intervention with matched
non-intervention counties for
comparison

Hypotheses:


The change in mammography utilization by
underserved women in intervention counties will be
significantly larger than it will be in matched, nonintervention counties
Characteristics of the intervention coalitions will affect
the implementation of the program
Specific Aims

To increase mammography screening among
underserved women in intervention counties

To characterize barriers to mammography for
eligible women in food pantries

To develop and evaluate the process for
dissemination of an adaptation of the food pantry
program
Measure of Difference
Intervention County
Number of Screenings
in FY 07-08
Food Pantry Program
Number of Screenings
in FY 08-09
Measure Change in Number of
Screenings
Measure Difference between Intervention and Comparison Counties
Measure Change in Number of
Screenings
Number of Screenings
in FY 07-08
Number of Screenings
in FY 08-09
Matched Comparison County
Selection of Comparison Counties

First phase:


Selected demographics (population size, density, poverty, age
distribution) - Community Health Status Indicators of the Public
Health Foundation
Second phase:



Similar characteristics of food pantries in county
Similar FY 07-08 and FY 08-09 funding for NBCCEDP screening
No food pantry intervention
Eligibility Flow Chart
Women in Food
Pantry
< Age 40
Not High Risk
Mammogram in Past
12 Months
Already Scheduled for
Next 12 Months
High Risk
No Mammogram in
Past 12 Months
Underserved
Mammogram in Past
12 Months
Not Scheduled for
Next 12 Months
Eligible for BCCEDP
Ineligible for
Mammography/Food Pantry
Program
>= Age 40
Eligible for Komen
Voucher
Not Eligible for BCCEDP
Not Eligible for Komen
Voucher
Barriers Questions
Solicitation and Review of Applications
to Deliver the Food Pantry Intervention

Funding for cancer coalitions – 2007/2008




Request for Proposals – May/June 2008
Responses to RFP

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PA Division of the American Cancer Society
Tartan Terrors
Elk County, PA
Greene County, PA
Wyoming County, PA
(Chautauqua County, NY)
Review of Proposals – June/July 2008

NACN Advisory Committee

Representatives of the community and academia
Intervention and Matched
Comparison Counties in
Pennsylvania
Also, Chautauqua
County and its
comparison.
Demographics
VARIABLES
Chautauqua
Elk
Greene
Wyoming
135,357
33,179
40,432
28,093
Female persons,(%)
2006
50.9%
50.2%
47.8%
50.0%
51.5%
51.4%
50.7%
White persons, (%),
2006
95.3%
98.8%
94.4%
98.1%
73.7%
85.7%
80.1%
Black persons, (%),
2006
2.5%
0.2%
4.5%
0.7%
17.4%
10.7%
12.8%
American Indian and
Alaska Native
persons, (%), 2006
0.6%
0.1%
0.2%
0.2%
0.5%
0.2%
1.0%
Asian persons, (%),
2006
0.5%
0.5%
0.3%
0.4%
6.9%
2.4%
4.4%
Persons of Hispanic
or Latino origin, (%),
2006
4.7%
0.5%
1.0%
1.2%
16.3%
4.2%
14.8%
Population, 2006
estimate
NY
PA
19,306,183 12,440,621
US
299,398,484
Demographics, continued
VARIABLES
Chautauqua
Elk
Greene
Wyoming
NY
PA
US
Age 45 + (%), 2000
38.9%
40.6%
39.2%
38.4%
35.2%
38.7%
31.8%
Education, less than
H.S. Diploma, Age
25+, (%) 2000
18.8%
17.3%
24.3%
16.3%
20.9%
18.1%
19.6%
Rural Population (%),
2000
41.9%
47.8%
68.7%
85.0%
14.5%
23.0%
21%
$40,482 $32,551 $39,883
$45,343
$43,714
$44,334
14.5%
11.2%
12.7%
Median Household
Income, 2004
$34,734
Persons below
poverty, (%), 2004
14.90%
8.8%
15.7%
10.30%
Breast Cancer Facts
Incidence and mortality (2001-2004):
Breast Cancer Incidence Rate*
County
State
Chautauqua
Elk
141.4
109.7
125
Greene
102.7
126.1
Wyoming
135.3
US
123.9
* per 100,000
Source: Cancer Control PLANET
Breast Cancer Mortality Rate*
Chautauqua
Elk
Greene
Wyoming
County
State
30.7
25
29
25.1
26.2
* per 100,000
Source: Cancer Control PLANET
27.5
US
Healthy People 2010
25.5
23.3
Breast Cancer Screening
Rural Appalachia disparity #1
Less likely to receive screening tests that can detect cancer early
Behavioral Risk Factors
Percentage of women
having a mammogram in
the past year, Age 40+,
2002-2004
Elk
Greene
Wyoming
PA
54%
55%
59%
60%
Source: PA DOH
Percentage of women
having a mammogram in
past 2 years, all races,
female, Age 40+, 2003
Chautauqua*
NY
72.1%
77.6
*Percentage also includes Cattaraugas County
Source: NYS DOH
Primary Care
Rural Appalachia disparity #2
Shortage of primary care physicians and screening facilities
Counties
MUA/P*
HPSA**
# of Hospitals
# of Cancer
Centers
Chautauqua
6 towns
17 towns
and 1 city
4
0
Elk
None
1 township
1
0
17
20
townships townships
and 6
and
boroughs 6 boroughs
1
0
1
0
Greene
Wyoming
8 townships
0
*Medically Underserved Areas/Populations
** Health Professional Shortage Areas
Rural Population and
Distance to Care
Rural Appalachia disparity #3
Travel long distances to be screened or consult with specialists
Rural Communities have limited or non-existent transportation
systems.
Percentage Rural Population
Chautauqua
41.9%
Elk
47.8%
Greene
68.7%
Wyoming
85.0%
NY
14.5%
PA
23.0%
US
21%
Intervention Timeline

Awards to Intervention Counties


Planning


September, 2008 – October, 2008
Implementation


August, 2008
November, 2008 – February, 2009
Evaluation and Reporting

March, 2009 – August, 2009
Evaluation
Aim 1: Increase screening mammography among
underserved women


Measure receipt of breast cancer screening in FY07-08 and FY
08-09 for intervention and comparison counties through National
Breast and Cervical Cancer Early Detection Program
Compare change between intervention and comparison counties
Aim 2: Characterize barriers to mammography for eligible
women in food pantries

Administer questionnaire to women in food pantries


Susceptibility, Benefits, and Barriers for Mammography Screening
Champion VL. Res Nurs Health. 1999;22:341-348
Appalachia-specific questions
Aim 3: Monitor the process, barriers and cost



Utilize coalition logs
Administer survey to coalitions
Calculate cost-effectiveness of mammography as delivered by the
intervention
Questionnaire





Qualify women for screening eligibility based on:
 age
 history of mammography
 current plans for screening
 insurance status
Ethnicity and race
Education level
Barriers – Mammography
Barriers – Mammography in Appalachia



Transportation
Distance
Knowledge of location
Strengths
Seeks to increase screening mammography
among underserved women in Appalachia
Uses a study design that includes multiple
sites with matching comparison sites
Systematically examines dissemination of an
evidence-informed, culturally-appropriate
program
Acknowledgements

PSU
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Alan Adelman
Regina Allen
Betsy Aumiller
Marcy Bencivenga
Bill Curry
Bethany Hess
Chris Hollenbeak
Brenda Kluhsman
Sam Lesko
Diane Sheehan

Community cancer coalitions

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


Chautauqua County Partners for
Prevention (NY)
Elk County SHIP/Tobacco and Cancer
Coalition (PA)
Greene County Cancer Coalition (PA)
Wyoming County Cancer/Tobacco
Partnership (PA)
Advisory Committee
Advisory Committee
15 State/Professional Representatives
13 Community Representatives


Marcia Anderson, Lawrence County Cancer
Coalition (PA)

Julia Bucher, PAC3

Marilyn Corbin, PA Cooperative Extension
Mary Day, Coalition for People Against Cancer
(PA)

Lisa Davis, PA Office of Rural Health

Linda Fleisher, NCI CIS,Fox Chase Cancer Center

Allison Clark and Nicole Hockenbrock, ACTION
Health (PA)

Aileen Galley, Mount Nittany Medical Center (PA)

Marlene Coccheto, Wellness Council of the
Southern Tier (NY)
Heather LeBlanc, NY DOH


Philip Lazarus, PSHCI

Jodie Cooper and Sue McDowell, Crawford
County Cancer Coalition (PA)

Christy Widman, NCI CIS, Roswell Park Cancer
Institute

Jeanne Darling, Delaware County Cancer
Coalition (NY)

Roxanne Parrot, PSU Center for Health and Risk
Communication

Paulette Schreiber, CRNP, Elk County
SHIP/Cancer and Tobacco Coalition (PA)

Candance Sanderson, PA American Cancer
Society

Christine Schuyler and Tory Irgang, Chautauqua

County Partners for Prevention (NY)

Debbie Stefanucci, Highmark


Luanne Thorndyke, PSH Professional
Development
Charlie Shoemaker, Indiana County Cancer
Coalition (PA)

Carolyn Wissenbach, Greene County Cancer
Coalition (PA)
Lou Ann Weil, Statewide Cancer Screening
Services (PA)

Carol Weisman, PSU Health Services Research
Division

Kathleen Zitka, PA DOH
Bold – Review Committee
Eugene J. Lengerich, VMD, MS
717.531.7178
[email protected]