Beauty parlor promotions, bingo nights, and breast cancer screening: An odd combination of activities, but an effective way to encourage women to make mammography a part of their preventive healthcare regimen. And the impact appears greater in locations that lack female physicians.
In a study appearing in the April 2000 issue of the American Journal of Preventive Medicine, researchers from the Fred Hutchinson Cancer Research Center in Seattle assessed the effectiveness of mammography promotion by community volunteer groups in rural areas of Washington. By getting the word out through phone calls, in-person visits, and special events, the researchers found they were able to break through barriers that made many women dismiss breast cancer screening as low priority.
"A lot reported that they just didn't get around to it, that they'd forgotten or had to postpone an appointment," said lead author Dr. M. Robyn Andersen. "They didn't seem to be particularly suspicious of mammography. They were more likely to report that since they weren't at high risk, they didn't feel it was important for them."
Andersen and her team tested three intervention methods: individual counseling, community activities, and a combination of both. About 6,600 women from 40 communities participated in the study between February and June 1994. Based on a series of questions, they were divided into regular users (more than one mammogram in the past five years) and under-users. Women initially categorized as under-users who had undergone screening at follow-up were labeled as new users.
Using the first approach, volunteer counselors provided information to the study population by telephone. The second approach built awareness of mammography through community events, promotions, and newsletters distributed at libraries, clubs, and stores. The third method used both community activity and telephone solicitation.
Analysis of follow-up interviews three years later revealed that mammography use increased by 2.6% in the group of women tagged as under-users. Breast screening went up by 2.9% among those who were regular users.
"The (community activity) intervention appears to have significantly reduced rates of relapse at follow-up by regular users at baseline," the authors said. "Although the effects of study interventions among under-users were small, these small effects are consistent with those observed in other community trials involving low-intensity intervention techniques" (Am J Prev Med, April 2000, Vol.18:3, pp.199-207).
A 'female voice'
One result of the study that Andersen said she found particularly interesting was that intervention worked best in areas where there were no female physicians.
"I think the idea of having a female voice promote mammography was important to these women," she said. "Our guess is that female physicians are more effective promoters."
Such was the case at the Kaweah Delta Health Care District in Visalia, CA, when the Community Breast Center (CBC) was established in the late '90s. At the time, the hospital's imaging center had reached the maximum capacity for mammography, performing 250 screenings a month in the semi-rural community.
As a result, women had to wait up to three months to get an appointment, wrote Roberta Edge, a radiologic technologist who co-authored an article in Radiology Management on the development of the CBC. Edge also is the director of medical imaging for the hospital. But when the CBC project was met with opposition from the local doctors' groups, assistance came in the form of a female physician.
"Fortunately, a female radiologist, a specialist in mammography with prior experience starting and coordinating breast centers, became the coordinator of this project. She spent time talking one-on-one with other physicians about what the addition of a breast center would mean to their individual practices," the authors said (Radiol Manage, May-June 1999, Vol.21:3, pp.38-43).
The CBC is now made up of two clinics and one mobile unit in an area with a high migrant population. The center's community outreach program includes advertising on local television stations and in a newspaper that specifically serves a rural farming community. The center also is part of the Breast Cancer Early Detection Program, in which advocates are recruited from an immigrant population to educate their community, Edge said.
Reaching out around the world
The problem of reaching women in rural communities is an international one. Researchers from Tel Aviv University in Israel reported the results of a one-year program during which family practitioners were encouraged to remind their patients to undergo breast cancer screening (Family Practice, Feb. 2000, Vol.17:1, pp.42-45).
The records of primary care physicians were then audited and the patient population was divided into two groups: those who had received a mammography based on their doctor's recommendation (the intervention group) and those who were not encouraged to do so by their physician. A third control group of patients who initiated breast screening appointments on their own also was established.
Of those patients in the intervention group, 32% reported that they had started to undergo regular breast examinations. The majority of these women -- 85% -- said they did so on the advice of their physician. In comparison, only 13% of the group that did not receive intervention sought out breast screening of their own volition.
A French team from the Institut Bergonie in Bordeaux looked at the anthropological reasons why women in rural communities in their country did not respond to breast screening campaigns. The researchers presented their findings at the European Congress of Radiology in Vienna in March.
Based on 25 interviews, the group pinpointed a variety of reasons why these women avoided mammography, including a lack of understanding as to how a screening worked, as well as a fear of breast cancer and the therapies involved in treating it. However, encouragement from a family physician and information through such outlets as women's magazines did help alleviate some of those fears, said Dr. Béatrice Barreau, the study's lead author.
Andersen said she hopes to have two papers published in the near future on how to recruit and train community volunteers, as well as the cost-effectiveness of implementing such promotional programs.
By Shalmali Pal
AuntMinnie.com staff writer
April 17, 2000
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