Recruiting Rural, Underserved Women to Screening Mammography through Food Pantries:A Multi-Community, Dissemination Research Study

October 8, 2008Eugene 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 IncidenceRural 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 MammographyIs 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

LowIncome

Barriers to Mammography Commonly Reported in the Literature

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 Systematically examine the translation of evidence-based

procedures and programs into real-world settings Why

Assess the generalizabilty of the knowledge Determine the limitations of the original study Apply the findings to additional populations

Characteristics 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’sTell A Friend ® Program

Intent Increase screening mammography among unscreened women

aged 40 years and older. Basis

Observational Learning (modeling) of Social Cognitive Theory Method

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 Theorybehavior is affected by social relationships and ties

Social Cognitive Theorybehavior 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

2. Increase demand with small media and one-on-one education

Baron RC, Rimer BK, Coates RJ, et al (USPSTF).

Am J Prev Medicine 2008

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, non-intervention 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

Food Pantry ProgramNumber of Screenings

in FY 08-09

Intervention County

Measure Change in Number of Screenings

Number of Screenings in FY 07-08

Number of Screenings in FY 08-09

Matched Comparison County

Measure Change in Number of Screenings

Number of Screenings in FY 07-08

Measure Difference between Intervention and Comparison Counties

Measure of Difference

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

Mammogram in Past 12 Months

>= Age 40High Risk

< Age 40

Women in Food Pantry

Not High Risk

Already Scheduled for Next 12 Months

Not Scheduled for Next 12 Months

Eligible for BCCEDP

No Mammogram in Past 12 Months

Mammogram in Past 12 Months

Eligible for Komen Voucher

Not Eligible for Komen Voucher

Not Eligible for BCCEDP

Ineligible for Mammography/Food Pantry

Program

Underserved Barriers Questions

Solicitation and Review of Applications to Deliver the Food Pantry Intervention Funding for cancer coalitions – 2007/2008

PA Division of the American Cancer Society Tartan Terrors

Request for Proposals – May/June 2008 Responses to RFP

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 NY PA US

Population, 2006 estimate 135,357 33,179 40,432 28,093 19,306,183 12,440,621 299,398,484

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%

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%

Median Household Income, 2004 $34,734 $40,482 $32,551 $39,883 $45,343 $43,714 $44,334

Persons below poverty, (%), 2004 14.90% 8.8% 15.7% 10.30% 14.5% 11.2% 12.7%

Breast Cancer FactsIncidence and mortality (2001-2004):

County State US

Chautauqua 141.4 125Elk 109.7

Greene 102.7

Wyoming 135.3* per 100,000

Source: Cancer Control PLANET

County State US Healthy People 2010

Chautauqua 30.7 26.2Elk 25Greene 29Wyoming 25.1* per 100,000

Source: Cancer Control PLANET

23.3

123.9

27.525.5

Breast Cancer Mortality Rate*

Breast Cancer Incidence Rate*

126.1

County State US

Chautauqua 141.4 125Elk 109.7

Greene 102.7

Wyoming 135.3* per 100,000

Source: Cancer Control PLANET

County State US Healthy People 2010

Chautauqua 30.7 26.2Elk 25Greene 29Wyoming 25.1* per 100,000

Source: Cancer Control PLANET

23.3

123.9

27.525.5

Breast Cancer Mortality Rate*

Breast Cancer Incidence Rate*

126.1

Breast Cancer ScreeningRural Appalachia disparity #1Less likely to receive screening tests that can detect cancer early

Elk Greene Wyoming PA

Percentage of women having a mammogram in the past year, Age 40+, 2002-2004

54% 55% 59% 60%

Source: PA DOH

Behavioral Risk Factors

Chautauqua* NY

Percentage of women having a mammogram in past 2 years, all races, female, Age 40+, 2003

72.1% 77.6

*Percentage also includes Cattaraugas County

Source: NYS DOH

Primary CareRural Appalachia disparity #2

Shortage of primary care physicians and screening facilities

Counties MUA/P* HPSA** # of Hospitals# of Cancer

Centers

Chautauqua 6 towns17 towns and 1 city

4 0

Elk None 1 township 1 0

Greene

17 townships

and 6 boroughs

20 townships

and 6 boroughs

1 0

Wyoming 8 townships 0 1 0

*Medically Underserved Areas/Populations** Health Professional Shortage Areas

Rural Population and Distance to CareRural Appalachia disparity #3Travel long distances to be screened or consult with specialistsRural Communities have limited or non-existent transportation systems.

Chautauqua Elk Greene Wyoming NY PA US

41.9% 47.8% 68.7% 85.0% 14.5% 23.0% 21%

Percentage Rural Population

Intervention Timeline

Awards to Intervention Counties August, 2008

Planning September, 2008 – October, 2008

Implementation November, 2008 – February, 2009

Evaluation and Reporting March, 2009 – August, 2009

EvaluationAim 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 Alan Adelman Regina Allen Betsy Aumiller Marcy Bencivenga Bill Curry Bethany Hess Chris Hollenbeak Brenda Kluhsman Sam Lesko Diane Sheehan

Community cancer coalitions 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 Committee13 Community Representatives

Marcia Anderson, Lawrence County Cancer Coalition (PA)

Mary Day, Coalition for People Against Cancer (PA)

Allison Clark and Nicole Hockenbrock, ACTION Health (PA)

Marlene Coccheto, Wellness Council of the Southern Tier (NY)

Jodie Cooper and Sue McDowell, Crawford County Cancer Coalition (PA)

Jeanne Darling, Delaware County Cancer Coalition (NY)

Paulette Schreiber, CRNP, Elk County SHIP/Cancer and Tobacco Coalition (PA)

Christine Schuyler and Tory Irgang, Chautauqua County Partners for Prevention (NY)

Charlie Shoemaker, Indiana County Cancer Coalition (PA)

Carolyn Wissenbach, Greene County Cancer Coalition (PA)

15 State/Professional Representatives

Julia Bucher, PAC3 Marilyn Corbin, PA Cooperative Extension Lisa Davis, PA Office of Rural Health Linda Fleisher, NCI CIS,Fox Chase Cancer Center Aileen Galley, Mount Nittany Medical Center (PA) Heather LeBlanc, NY DOH Philip Lazarus, PSHCI Christy Widman, NCI CIS, Roswell Park Cancer

Institute Roxanne Parrot, PSU Center for Health and Risk

Communication Candance Sanderson, PA American Cancer

Society Debbie Stefanucci, Highmark Luanne Thorndyke, PSH Professional

Development 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, MS717.531.7178elengerich@psu.edu