Utilization of Early Detection Services: A Recruitment and Screening Program for African American Women

Brief communication 269 UTILIZATION OF EARLY DETECTION SERVICES: A RECRUITMENT AND SCREENING PROGRAM FOR AFRICAN AMERICAN WOMEN Over the past 40 years, increasing numbers of Americans have benefited from breast cancer prevention, early detection, and improved treatment. However, prognosis and survival after the diagnosis of breast cancer are poorer among African American women compared with Caucasian and Hispanic women.1,2 Studies that attempt to explain this disparity have emphasized that African American patients, with the exception of those from upper education/income levels, are more likely to present with a higher stage or more advanced disease.3,4 These patients are also more likely to report some commonly perceived barriers to screening, such as cost and/or lack of medical insurance, lack of access to mammography facilities, the misconception that without symptoms there is no need to be screened, and fewer motivations in their decision to participate. The need for targeting specific populations has been demonstrated in previous studies reporting disparity in the screening rates in women of different socioeconomic levels and cultures.5 Data of mortality by race of all ages show that African American women are more likely to die of breast cancer with a rate of 31.2 per 100,000, compared with a rate of 26.0 per 100,000 for Caucasian women.6 The death rate for breast cancer in American women declined 4.7 percent between 1989 and 1992, but African American women showed an increase in the death rate of 2.6 percent during this same time period.67 Breast cancer awareness and screening are the key factors in the decline. However, to address the disparate rates of breast cancer in our society, enhanced efforts in targeting minority groups are obviously needed. Targeting minorities for screening Previous attempts for recruiting minorities have been approached from different perspectives. Minority-targeted studies have addressed income disparities and found that universal health care coverage does not overcome socioeconomic barriers to screening.8 Katz collected a random sample of women from the Ontario Health Survey and the U.S. National Health Interview Survey for comparing the association of income and education with breast cancer screening. In both countries, higher income and education were positively associated with increased screening. Studies have also targeted minorities by addressing educational level but found that the duration of Journal ofHealth Care for the Poor and Undersenxd · Vol. 10, No. 3 · 1999 270 Utilization of Early Detection Services education does not always equate with the quality of care received and again does not overcome barriers to screening.3,9 Most, if not all, of these studies promoted barrier-free programs with improved access to health care. Mammography utilization was examined from data of the 1990 National Health Interview Survey of Health Promotion and Disease Prevention.10 Both low-income and high-income groups were analyzed. Correlates of screening included recency of Papanicolaou test, of clinical breast exam, and of regular breast self-examination. These factors were associated with screening regardless of income status. Medical care utilization behavior in general does influence medical utilization of many services. The most salient barriers to mammography screening observed across studies included the reported absence of a physician referral and a lack of perceived risk of cancer. These two factors remained the greatest barriers to screening, even in studies in which mammograms were offered at no charge. However, other social factors play a role in the decision to present for cancer screenings. These factors have been shown to differ between racial and socioeconomic groups. A different set of knowledge and belief variables has been identified for minority women compared with Caucasian women. A telephone interview of 1,677 employed women was conducted in 1996 who reported on their use of mammography. Although both groups of women reported similar screening utilization, minority women were more likely to underestimate their cancer risk and to fear radiation.11 The relationship of health belief variables with the behavior of seeking information on breast cancer detection was examined in 1995 by discriminant analysis.12 Pertinent to community women, a factor associated with seeking behavior for media campaigns and for a friend or relative model was cancer in one's social environment , while...