Baseline predictors of initiation vs. maintenance of regular mammography use among rural women
Introduction
Since the 1980s, the National Cancer Institute (NCI), the American Cancer Society (ACS), and other groups have recommended regular mammography screening at least once every 2 years for women between 50 and 74 years of age [1], [2]. Mammography use has increased dramatically since the mid-1980s. In 2000, 70% of women age 40 and older reported having a mammogram within the past 2 years, according to the National Health Interview Survey [3]. Although recent use of mammography screening has increased, regular screening, necessary to maximize breast cancer survival, remains low. The reported prevalence of regular screening (generally defined as obtaining two successive mammograms 1–2 years apart) has ranged from 28% to 57% between 1995 and 2001 [4]. Researchers have used a variety of measures of regular screening [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], making it difficult to obtain good estimates of rates of “regular mammography use”.
Most research designs used to examine mammography screening are problematic with respect to analysis of regular mammography use. Many studies employ cross-sectional designs to retrospectively examine factors at interview associated with mammography use [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17]. Cross-sectional designs prohibit disentangling initiation of mammography use from mammography screening maintenance; nor do they allow us to discern the extent to which attitudinal variables at interview either influence or are influenced by previous mammography use. Alternatively, retrospective cohort studies using HMO or other medical record data often lack detailed information on attitudinal or other psychosocial predictors [18], [19], [20]. To date, prospective designs have been limited to examining factors associated with recent rescreening over short intervals (1–2 years), often in the context of an intervention [21], [22], [23], [24], [25], [26], [27], [28]. A prospective cohort design such as that of NC-BCSP is necessary to evaluate, apart from the effect of an intervention, attitudinal and other psychosocial variables at baseline that may be predictive of long-term regular screening. Such a design also allows us to evaluate associations separately for initiation and maintenance of mammography use.
According to the Transtheoretical Model, interventions aimed at getting individuals to initiate a behavior should target removing barriers related to knowledge, attitudes, and beliefs, while interventions aimed at getting individuals to maintain a behavior should focus on supporting and prompting repetition of that behavior [30], [31]. Thus, a comparison of mammography initiation predictors with maintenance predictors may provide specific information on how best to target interventions that encourage women to obtain their first mammogram vs. those interventions designed to reinforce behavior already occurring.
Finally, while many studies have focused on urban women, to date none have examined regular mammography use among rural women; this population may face more access barriers to regular preventive care than do urban women.
We examined mammography use over a 7-year period in a cohort of older rural women from the control group of the North Carolina Breast Cancer Screening Program, as well as factors predictive of initiation and maintenance of regular mammography use by these women. The broad goal of these analyses was to provide information for more effectively developing and targeting future interventions for improving regular mammography use among rural women.
Section snippets
Methods
The North Carolina Breast Cancer Screening Program took place in the 1990s in 10 counties in rural eastern North Carolina with a combined 1990 population of 280,659. During this time period, two-thirds of adults lived in rural areas and the other third in small towns, 37% were minorities, and 12% lived below the poverty line. The Centers for Disease Control and Prevention began funding mammograms for eligible low-income women in these 10 counties as part of the Breast and Cervical Cancer
Demographic characteristics
About half the sample was African-American and the remaining half White; 55% were between age 52 and 64, while 45% were age 65 and above; about half the sample reported having a high school diploma and the same proportion reported an annual family income of $12,000 and above. Nine out of 10 women had insurance and the same proportion had a regular physician at baseline interview; 58% reported ever having received a referral for a mammogram from a doctor. The majority of women (58%) reported a
Discussion
According to the Transtheoretical Model of behavior change, changing screening behavior can be thought of as a multistep process that begins with awareness of the issues (precontemplation/contemplation), followed by initiation of the behavior, and finally its maintenance [31]. We used this model as a general rationale for conducting separate analyses to understand what factors are associated with initiation vs. maintenance of long-term regular mammography use. The decision to initiate a
Conclusion
Despite these limitations, our analysis provides important data for understanding how to target interventions to increase mammography use among rural women. The greatest barrier to the adoption of regular mammography screening in rural women appears to be the initiation of mammography screening in the first place. To have the greatest payoff, therefore, interventions should focus more on helping rural women who are not regular users initiate regular mammography use. To achieve the greatest
Acknowledgments
This research was supported by a training grant from the National Cancer Institute to the University of Illinois at Chicago (#CA 57699-06), UNC Breast Cancer SPORE (#CA58223), and by a grant from the Agency for Health Care Research and Quality (#5K02HS000007-03). The authors thank the more than 60 census workers and interviewers who identified the eligible women and collected the data via personal, in-home interviews, and the many students, fellows, staff, volunteers, community members, and
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Present address: Division of General Medicine, Ann Arbor VAMC, University of Michigan, Ann Arbor, MI 48109, USA.