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W V Med J. Author manuscript; available in PMC 2016 June 07. Published in final edited form as: W V Med J. 2014 ; 110(2): 20–26.
Predictors of Self-reported Adherence to Mammography Screening Guidelines in West Virginia Women Visiting a Stationary Facility
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Ami Vyas, MS, Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV Suresh Madhavan, PhD, Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV Kimberly Kelly, PhD, Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV. Mary Babb Randolph Cancer Center, West Virginia University, Morgantown, WV Aaron Metzger, PhD, Department of Psychology, West Virginia University, Morgantown, WV
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Judith Schreiman, MD, and Department of Radiology, School of Medicine, West Virginia University, Morgantown, WV Scott Remick, MD Mary Babb Randolph Cancer Center, West Virginia University, Morgantown, WV
Abstract
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The objectives of this study are to describe the characteristics of women age 40 years and above who utilize a stationary mammography facility and to determine the predictors of self-reported adherence to mammography screening guidelines. Data were analyzed using the expanded version of Andersen Behavioral Model of Healthcare Utilization. Of the 1,104 women included in the analysis, 1,019 women (92.3%) reported having had a mammogram in the past two years. In logistic regression after adjusting for all the variables, older age, having health insurance, not having delayed medical care due to transportation problem, being adherent to clinical breast exam (CBE), Pap test and other routine screenings and having positive views about mammography screening significantly predicted adherence to mammography screening. Adherence to mammography screening was very high in this sample, and enabling and need-related factors and positive views about mammography screening predicted adherence to mammography screening guidelines.
Corresponding Author: Ami Vyas, WVU, School of Pharmacy, RCBHSC (North), Dept. of Pharmaceuticals Systems & Policy, P.O. Box 9510, Morgantown, WV 26506-9510; ; Email: [email protected]
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Introduction
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West Virginia (WV) is the only state that lies completely within Appalachia and 34 out of its 1 55 counties are classified as rural. ,2 Appalachia is a largely rural, medically underserved region in the country with high levels of poverty, low levels of education, high rates of 3 6 chronic disease, and poor health behaviors. – WV has a lower incidence but higher rates of 2 11 advanced and unstaged breast cancer (BC). ,7– This discrepancy has been attributed to low 2 mammography screening rates among WV women. ,12 A study on BC screening in WV using Behavioral Risk Factor and Surveillance System (BRFSS) reported that as compared to the national estimate of 76.6%, 74.5% of WV women had a mammogram in the previous 12 two years. Another recent study indicated that less than 40% of WV Medicaid fee-forservice women had a mammogram related billing in 2007–2008 within the previous two 13 years although mammography screening is covered by WV Medicaid. The authors of this study suggested that there may be factors other than insurance coverage and financial constraints, such as lack of knowledge about mammography, views and attitudes about mammography screening, lack of physician recommendation, lack of transportation, which 13 may influence screening rates in the WV Medicaid population. Thus, there is a vital need to determine the predictors of adherence to mammography screening guidelines in WV women who routinely utilize stationary mammography facilities to get mammograms. Hence, the objectives of this research study are to describe the characteristics of women age 40 years and above who utilize a stationary mammography facility and to determine the predictors of self-reported adherence to mammography screening guidelines by comparing women who are adherent with those who are not.
Conceptual Framework Author Manuscript
The ‘expanded’ version of Andersen Behavioral Model for Health Services Utilization 14 (Andersen model) was utilized as the conceptual model for this study (Figure-1). This model includes psychosocial factors to the basic Andersen model comprising of predisposing, enabling and need-related factors. Previous studies have reported that psychosocial factors have a strong influence on health prevention and maintenance behaviors 15 and are widely studied in the cancer screening behavior. ,16 Hence, the ‘expanded’ version of Andersen model which includes psychosocial factors, was utilized for the study as it provided a strong theoretical framework to identify the factors that influence adherence to mammography screening guidelines in WV women.
Methods Author Manuscript
Mammography screening stationary facility There are 70 mammography screening centers in WV of which the Betty Puskar Breast Care Center (BPBCC, a stationary facility) is the largest mammography screening stationary facility in WV and hence is selected as the representative stationary facility. The center screens approximately 10,000–12,000 women each year from 35 out of 55 WV counties such as Monongalia, Doddridge, Calhoun, Pocahontas, Greenbrier, Harrison, and southern counties such as Raleigh and Wyoming, to name a few.
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Participants
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Participants for this research study comprised of women who had mammography screening at the BPBCC at least once in the past ten years and completed the ‘Mammography Screening and Preventive Care Survey’. Out of 16,687 women age 40 years and above who utilized the BPBCC to get a screening mammogram at least once in the past ten years (from August 2001 to July 2011), 2,255 women were randomly selected and were mailed the survey. 1,104 women (48.96%) completed and returned the survey. Survey Instrument, Survey Administration & Data Collection
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Data were collected via the West Virginia University Institutional Review Board approved Mammography Screening and Preventive Care Survey. The survey has several sections including personal health history, menstrual and pregnancy history, family history of cancer, cancer risk assessment and screening history, views on BC screening, BC awareness, preventive care and wellness history, and demographics. The details about the survey 17 development are explained elsewhere. A survey, a cover letter and a prepaid business reply envelope were mailed to the 2,255 randomly selected women who had mammography screening at the BPBCC at least once in the past ten years. Two rounds of the survey were sent to these women at three-week intervals to maximize the response rate. A $5 gift-card was mailed to all women who completed and returned the survey to acknowledge their participation and time. Dependent variable - Self-reported on-schedule adherence to mammography screening guidelines
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The main outcome of interest was self-reported on-schedule adherence to mammography 18 screening guidelines, defined as having had a mammogram in the past one to two years. The dependent variable was dichotomized into adherent and non-adherent groups. For this study, the United States Preventive Services Task Force (USPSTF) 2002 recommendations were utilized which advocates mammography screening every one to two years for women 19 age 40 years and above. ,20 This is also in general agreement with the current recommendations from various professional organizations such as the Centers for Disease Control & Prevention, Healthy People 2010 & 2020 objectives, and National Cancer Institute. Independent variables
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Table 1 provides the independent variables included in the study. These include predisposing factors such as age, education level, and employment status, body mass index (BMI), smoking status, and alcohol consumption; enabling factors such as marital status, household income, health insurance, visit to physician and OB/GYN in the past year, and delay in medical care due to transportation. Need-related factors included were self-reported health status, family history of BC, breast problems in the past, breast biopsy in the past, adherence to clinical breast exam (CBE), adherence to Pap test, having had any cancer, and a composite score of having had other screening tests such as blood glucose test, bone mineral density test, cholesterol test, high blood pressure test (possible scores 0, 1, 2, 3, or 4). The composite score was grouped into two groups, those with scores 0–3 and those with the W V Med J. Author manuscript; available in PMC 2016 June 07.
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score 4. A woman who had all the four screening tests in previous two years was given a score of 4 while a woman who did not have any of these screening tests in the previous two years was given a score of 0. A woman was considered adherent to CBE if she had CBE in the previous one year as per recommended guidelines and adherent to Pap test if she had Pap 21 test within the previous two years as per recommended guidelines. Perceived five-year risk and perceived lifetime risk of developing BC (lower, similar, higher), views towards mammography screening, and knowledge about BC and mammography screening comprised the psychosocial factors. The details of the assessment of positive and negative views towards mammography screening, knowledge about BC and mammography screening 17 are described elsewhere. Non-response bias assessment
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Women who did not participate in the study may be different from those who participated, and hence non-response bias was assessed. The details of the non-response bias assessment 22 are described elsewhere. Non-respondents were significantly more likely to be unemployed, and had less than college-level education. Statistical Analyses
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Descriptive statistics were used to describe the characteristics of the study sample. Chisquare tests for categorical variables and t-tests for continuous variables were used to determine significant differences between self-reported adherent and non-adherent groups. Logistic regression was performed to analyze the relationship between self-reported adherence with all the constructs of the Andersen model, after controlling for predisposing, enabling, need-related and psychosocial factors. ‘Non-adherent group’ was the reference group for the dependent variable. Resulting odds ratios and their corresponding 95% confidence intervals were examined. The findings that were significant with p-values less than 0.05 levels are discussed. SAS 9.2 software was used for the statistical analyses.
Results Characteristics of the study cohort
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Table 1 describes the characteristics of 1,104 women age 40 years and above who had at least one mammogram at the stationary mammography facility in the past ten years. A majority (57%) of the women were in the 50–64 age group, 23% were 65 and above and 20% were 40–49 years old. A majority were married or partnered (77%), had at least some college level education (62%), were employed (58%), overweight to morbidly obese (68%), had a household income more than $50,000 (55%), and were insured (95%). Seventy-three percent of women had visited a doctor in the past year, while 53% had visited an OB/GYN in the past year. Twenty percent of women reported a family history of BC, 73% had a Pap test in the past two years, and 63% had a CBE in the past year. A majority (62%) had moderate knowledge while 31% showed higher knowledge about BC and mammography screening. The mean score was 1.975 for the positive views statements and 5.822 for the negative views statements (on the scale of 1 = Strongly agree and 7 = Strongly disagree). Out of 1,104 women, 1,019 women (92.3%) reported adherence to mammography screening guidelines.
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Results of Bivariate Analyses
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Self-reported adherence to mammography screening guidelines was higher in women who had at least some college-level education, were never smokers, were married/partnered, had higher household income, had health insurance, had visited a doctor and/or OB/GYN in the past year, had a breast biopsy in the past, were adherent to CBE and Pap test, perceived their lifetime risk of developing BC as higher, reported higher knowledge of BC and mammography screening and strongly agreed with the positive views, and strongly disagreed with the negative views about mammography screening (data not shown). Results of Multivariate Analyses for the stationary facility study sample
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Table 2 describes the adjusted odds ratio of self-reported adherence to mammography screening guidelines in women aged 40 years and above who utilized a stationary mammography facility, after controlling for all the predisposing, enabling, need-related and psychosocial factors (only significant variables are presented). Among predisposing factors, being older (age 65 and above) was a significant predictor of adherence to mammography screening guidelines (AOR = 2.803, 95% CI = 1.055–7.451). Among enabling factors, women who did not have health insurance remained significantly less likely to be adherent to mammography screening guidelines (AOR = 0.208, 95% CI = 0.087–0.499). Those who reported delayed medical care due to transportation problem were 73% less likely to be adherent to mammography screening guidelines (AOR = 0.274, 95% CI = 0.084–0.894). Furthermore, among need-related factors, women were not adherent to CBE and Pap test, and who did not have all the four screenings in the past two years were significantly less likely to be adherent to mammography screening guidelines. The AORs were 0.253 (95% CI = 0.124–0.514), 0.179 (95% CI = 0.094–0.342) and 0.349 (95% CI = 0.146–0.833), respectively. In addition, women whose level of agreement towards positive views about mammography screening reduced by one point on the agreement scale, were 31% less likely to be adherent to mammography screening guidelines (AOR = 0.691, 95% CI = 0.567– 0.841).
Discussion
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In this study, the characteristics of women age 40 years and above who utilized a stationary mammography facility and the predictors of self-reported adherence to mammography screening guidelines were examined. Overall, 92.3% of women in the study sample were adherent to mammography screening guidelines. This rate is substantially above the national 23 Healthy People 2010 goals for mammography screening, and the national screening rate of 24 12 75.4% in 2010. This finding is also in contrast to a previous study on WV women and a 13 recent study on WV Medicaid fee-for-service women. The high mammography screening rate among women who utilized stationary facility suggests that these women never have had or have already overcome the majority of the barriers to mammography screening. In addition, the screening facility is located in a university town which may introduce some bias in the selection of the sample which may have ultimately resulted in higher screening rates. The sample was more affluent and educated as compared to national averages which may have resulted in higher screening rates.
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Among predisposing factors, older age (65 and above) was associated with adherence to 25 30 mammography screening guidelines, which is consistent with previous studies. – As Medicare covers mammograms, women age 65 years and above may have regular access to screening services and hence are more likely to be adherent to mammography screening guidelines. Among enabling factors, having insurance was a significant predictor of 25 adherence to mammography screening, which is consistent with the previous studies. ,30,31 This suggests that health insurance coverage is a very important access factor which supports women’s utilization of mammography screening services. Also, women who reported delay in medical care due to transportation problems were more likely to be nonadherent to mammography screening, suggesting that transportation problem is one of the key issues associated with non-adherence in the geographically challenging state of WV. Hence, although women have higher education levels and higher income levels, insurance coverage and transportation problems pose threats to their screening behaviors.
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Among need-related factors, adherence to the CBE, Pap test and other tests for blood glucose, blood cholesterol, bone mineral density, and blood pressure strongly predicted adherence to mammography screening guidelines. This is consistent with a previous study which indicates that women who follow such preventative behaviors are sufficiently knowledgeable about the importance of preventive healthcare to overcome any barriers that 28 they may encounter to screening. Among psychosocial factors, having strong positive views about mammography screening was associated with adherence to mammography 32 screening. This finding is consistent with the previous study by Magai C et. al. Hence, the findings of this study are consistent with the previous studies which also indicated that lack of insurance, lack of transportation, younger age, and views about mammography screening 13 restricted women from adhering to mammography screening guidelines. ,31 These findings may be helpful in developing interventions for women under 65 years of age, without health insurance coverage and who have transportation problems, and who are not adherent to other preventive behaviors, in order to increase screening rates in women who are not adherent to mammography screening guidelines.
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There are several limitations of the study. One limitation is the response rate; 51% of women who utilized a stationary mammography facility did not respond to the surveys. A nonrespondents analysis indicated that non-respondents were significantly more likely to be unemployed and with lower levels of education. Hence, these should be taken into consideration while extrapolating the findings of the study. Moreover, data is collected from only one stationary screening facility which is assumed to represent stationary screening facilities in WV. BPBCC is located in a university town from which a part of the sample was drawn. This may incorporate some selection bias. However, the area outside the 5-miles radius of the town is very rural and underserved and is considered to be a medically underserved area. Another limitation is that survey data is self-reported which may differ from mammography screening information obtained from medical records of healthcare providers. In addition, the findings of this study may not be generalized to women residing outside of WV.
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Conclusion Adherence to mammography screening was very high in women age 40 years and above who utilized a university town stationary mammography screening facility. Enabling and need-related factors and positive views about mammography screening predicted adherence to mammography screening guidelines in these women.
Acknowledgments This research study is partially funded by Susan G. Komen For the Cure, Claude Worthington Benedum Foundation, and AHRQ grant # R24HS018622-02. The authors acknowledge the PhD students, Amit Raval, Parul Agarwal, Tricia Lee Wilkins, Traci LeMasters and Elvonna Atkins from the Department of Pharmaceutical Systems & Policy, West Virginia University, for helping in mailing out the surveys for the study.
References Author Manuscript Author Manuscript Author Manuscript
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15. Allen J, Sorensen G, Stoddard A, Peterson K, Colditz G. The relationship between social network characteristics and breast cancer screening practices among employed women. Annals of Behavioral Medicine. 1999; 21:193–200. [PubMed: 10626024] 16. Suarez L, Ramirez A, Villarreal R, et al. Social networks and cancer screening in four US Hispanic groups. American Journal of Preventive Medicine. 2000; 19:47–52. [PubMed: 10865163] 17. Vyas A, Madhavan S, Lemasters T, et al. Factors influencing adherence to mammography screening guidelines in Appalachian Women participating in a mobile mammography program. J Comm Health. 2012; 37(3):632–646. 18. Gierisch JM, Reiter PL, Rimer BK, Brewer NT. Standard definitions of Adherence for infrequent yet repeated health behaviors. Am J Health Behav. 2010; 34(6):669–679. [PubMed: 20604693] 19. U S. Preventive Services Task Force. Screening for breast cancer: recommendations and rationale. Ann Intern Med. 2002; 137(5):344–346. [PubMed: 12204019] 20. Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002; 137(5 part 1):347– 360. [PubMed: 12204020] 21. Smith RA, Cokkinides V, Brawley O. Cancer screening in the United States, 2012: A review of current American Cancer Society Guidelines and current issues in cancer screening. CA:A Cancer Journal for Clinicians. 2012; 62:129–142. [PubMed: 22261986] 22. Vyas A, Madhavan S, Kelly KM, et al. Do Appalachian women attending a mobile mammography program differ from those visiting a stationary mammography facility? Journal of Community Health. 2013 Accepted for publication, February 2013. 23. United States Department of Health and Human Services. Healthy people 2010: Understanding and improving health. Washington DC: US department of Health and Human Services; 2010. 24. National Cancer Institute. [Accessed March 5, 2013] State cancer profiles screening and risk factors report 2010, 2010. 2010. http://progressreport.cancer.gov/doc_detail.asp? pid=1&did=2009&chid=92&coid=916&mid= 25. Rahman SMM, Digman MB, Shelton BJ. Factors influencing adherence to guidelines for screening mammography among women aged 40 years and older. Ethn Disp. 2003; 13(4):477–484. 26. Gierisch JM, Earp JA, Brewer NT, Rimer BK. Longitudinal predictors of non-adherence to maintenance of mammography. Cancer Epidemiol Biomarkers Prev. 2010; 19(4):1103–1111. [PubMed: 20354125] 27. Meissner HI, Breen N, Taubman ML, Vernon SW, Graubard BU. Which women aren’t getting mammograms and why? (United States). Cancer Causes Control. 2007; 18:61–70. [PubMed: 17186422] 28. Coughlin SS, Uhler RJ, Hall I, Briss PA. Non adherence to Breast and Cervical cancer screening: What are the linkages to chronic disease risk? Prev Chronic Dis. 2004; 1(1):A04. [PubMed: 15634366] 29. Borrayo EA, Hines L, Byers T, et al. Characteristics associated with mammography screening among both Hispanic and non-hispanic white women. J Womens Health. 2009; 18(10):1585–1594. 30. Zapka JG, Stoddard A, Maul L, Costanza ME. Interval adherence to mammography screening guidelines. Medical Care. 1991; 29(8):697–707. [PubMed: 1875738] 31. Rakowski W, Meissner H, Vernon SW, Breen N, Rimer B, Clark MA. Correlates of Repeat and recent mammography for women ages 45 to 75 in the 2002 to 2003 Health Information National Trends Survey (HINTS 2003). Cancer Epidemiol Biomarkers Prev. 2006; 15(11):2093–2101. [PubMed: 17119033] 32. Magai C, Consedine N, Neugut AI, Hershman DL. Common psychosocial factors underlying breast cancer screening and breast cancer treatment adherence: a conceptual review and synthesis. J Womens Health. 2007; 16(1):11–23.
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Figure 1.
Conceptual model illustrating the constructs of expanded version of Andersen Behavioral Model of Healthcare Services Utilization in predicting adherence to screening mammography guidelines.
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Table 1
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Description of the Study Sample of WV Women age 40 and above. Stationary Mammography Facility (Betty Puskar Breast Care Center) Stationary facility N (1,104)
%
40–49
217
19.66
50–64
630
57.07
65 & above
257
23.28
Less than HS
15
1.36
Some HS/HS grad
273
24.73
GED/Tech
135
12.23
Some college/Graduate
681
61.68
Employed
635
57.52
Unemployed
469
42.48
Underweight/Normal weight
351
31.79
Overweight to Morbidly Obese
753
68.21
Never
729
66.03
Former
267
24.18
Current
108
9.78
Yes
526
47.64
No
578
52.36
Married/Partnered
848
76.81
Single
256
23.19
Less than $25,000
232
21.01
$25,000–$50,000
270
24.46
$50,000–$75,000
220
19.93
More than $75,000
382
34.60
Yes
1,048
94.93
No
56
5.07
PREDISPOSING FACTORS Age
Education
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Employment status
Body Mass Index
Smoking status
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Alcohol consumption
ENABLING FACTORS Marital Status
Household Income
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Health Insurance
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Stationary facility
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N (1,104)
%
Yes
805
72.92
No
299
27.08
Yes
582
52.72
No
522
47.28
Visit to doctor in past year
Visit to OB/GYN in past year
Delayed care due to transportation problem Yes
34
3.08
No
1,070
96.92
Fair/Poor
168
15.22
Excellent/V.good/Good
936
84.78
Yes
216
19.57
No
888
80.43
Yes
259
23.46
No
845
76.54
Yes
368
33.33
No
736
66.67
Yes
692
62.68
No
412
37.32
Yes
774
70.11
No
330
29.89
Yes
150
13.59
No
954
86.41
0–3
753
68.21
4
351
31.79
Lower
391
35.42
Similar
541
49.00
Higher
172
15.58
NEED-RELATED FACTORS
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Self-rated Health Status
Family History of BC
Breast problems
Breast biopsy in past
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Adherence to CBE
Adherence to PAP test
History of Cancer
Total score of screenings
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PSYCHOSOCIAL FACTORS Perceived five-year risk
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Stationary facility
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N (1,104)
%
Lower
337
30.53
Similar
571
51.72
Higher
196
17.75
Perceived Lifetime risk
Knowledge Low
75
6.79
Moderate
683
61.87
High
346
31.34
Views Positive Views
Mean
1.975
Negative Views
Mean
5.822
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HS: high school; V.good: very good, OB/GYN: obstetrician/gynecologist, ADL: activities of daily living; IADL: instrumental activities of daily living. For views, score 1 is equal to strongly agree and score 7 is equal to strongly disagree on the scale of 1 to 7.
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Table 2
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Adjusted Odds Ratios and 95% Confidence Interval from Logistic Regression Of Self-Reported Adherence to Mammography Guidelines Stationary mammography facility AOR
95%CI
p-value
Sig
PREDISPOSING FACTORS Age 40–49
1
50–64
1.918
[0.942, 3.906]
0.0725
65 & above
2.803
[1.055, 7.451]
0.0388
[0.087, 0.499]
0.0004
*
ENABLING FACTORS
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Health Insurance Yes
1
No
0.208
*** *
Delayed care due to transportation problem Yes
0.274
No
1
[0.084, 0.894]
0.0318
[0.124, 0.514]
0.0001
NEED-RELATED FACTORS Adherence to CBE Yes
1
No
0.253
***
Adherence to PAP test
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Yes
1
No
0.179
[0.094, 0.342]
W V Med J. Author manuscript; available in PMC 2016 June 07. Published in final edited form as: W V Med J. 2014 ; 110(2): 20–26.
Predictors of Self-reported Adherence to Mammography Screening Guidelines in West Virginia Women Visiting a Stationary Facility
Author Manuscript
Ami Vyas, MS, Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV Suresh Madhavan, PhD, Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV Kimberly Kelly, PhD, Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV. Mary Babb Randolph Cancer Center, West Virginia University, Morgantown, WV Aaron Metzger, PhD, Department of Psychology, West Virginia University, Morgantown, WV
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Judith Schreiman, MD, and Department of Radiology, School of Medicine, West Virginia University, Morgantown, WV Scott Remick, MD Mary Babb Randolph Cancer Center, West Virginia University, Morgantown, WV
Abstract
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The objectives of this study are to describe the characteristics of women age 40 years and above who utilize a stationary mammography facility and to determine the predictors of self-reported adherence to mammography screening guidelines. Data were analyzed using the expanded version of Andersen Behavioral Model of Healthcare Utilization. Of the 1,104 women included in the analysis, 1,019 women (92.3%) reported having had a mammogram in the past two years. In logistic regression after adjusting for all the variables, older age, having health insurance, not having delayed medical care due to transportation problem, being adherent to clinical breast exam (CBE), Pap test and other routine screenings and having positive views about mammography screening significantly predicted adherence to mammography screening. Adherence to mammography screening was very high in this sample, and enabling and need-related factors and positive views about mammography screening predicted adherence to mammography screening guidelines.
Corresponding Author: Ami Vyas, WVU, School of Pharmacy, RCBHSC (North), Dept. of Pharmaceuticals Systems & Policy, P.O. Box 9510, Morgantown, WV 26506-9510; ; Email: [email protected]
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Introduction
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West Virginia (WV) is the only state that lies completely within Appalachia and 34 out of its 1 55 counties are classified as rural. ,2 Appalachia is a largely rural, medically underserved region in the country with high levels of poverty, low levels of education, high rates of 3 6 chronic disease, and poor health behaviors. – WV has a lower incidence but higher rates of 2 11 advanced and unstaged breast cancer (BC). ,7– This discrepancy has been attributed to low 2 mammography screening rates among WV women. ,12 A study on BC screening in WV using Behavioral Risk Factor and Surveillance System (BRFSS) reported that as compared to the national estimate of 76.6%, 74.5% of WV women had a mammogram in the previous 12 two years. Another recent study indicated that less than 40% of WV Medicaid fee-forservice women had a mammogram related billing in 2007–2008 within the previous two 13 years although mammography screening is covered by WV Medicaid. The authors of this study suggested that there may be factors other than insurance coverage and financial constraints, such as lack of knowledge about mammography, views and attitudes about mammography screening, lack of physician recommendation, lack of transportation, which 13 may influence screening rates in the WV Medicaid population. Thus, there is a vital need to determine the predictors of adherence to mammography screening guidelines in WV women who routinely utilize stationary mammography facilities to get mammograms. Hence, the objectives of this research study are to describe the characteristics of women age 40 years and above who utilize a stationary mammography facility and to determine the predictors of self-reported adherence to mammography screening guidelines by comparing women who are adherent with those who are not.
Conceptual Framework Author Manuscript
The ‘expanded’ version of Andersen Behavioral Model for Health Services Utilization 14 (Andersen model) was utilized as the conceptual model for this study (Figure-1). This model includes psychosocial factors to the basic Andersen model comprising of predisposing, enabling and need-related factors. Previous studies have reported that psychosocial factors have a strong influence on health prevention and maintenance behaviors 15 and are widely studied in the cancer screening behavior. ,16 Hence, the ‘expanded’ version of Andersen model which includes psychosocial factors, was utilized for the study as it provided a strong theoretical framework to identify the factors that influence adherence to mammography screening guidelines in WV women.
Methods Author Manuscript
Mammography screening stationary facility There are 70 mammography screening centers in WV of which the Betty Puskar Breast Care Center (BPBCC, a stationary facility) is the largest mammography screening stationary facility in WV and hence is selected as the representative stationary facility. The center screens approximately 10,000–12,000 women each year from 35 out of 55 WV counties such as Monongalia, Doddridge, Calhoun, Pocahontas, Greenbrier, Harrison, and southern counties such as Raleigh and Wyoming, to name a few.
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Participants
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Participants for this research study comprised of women who had mammography screening at the BPBCC at least once in the past ten years and completed the ‘Mammography Screening and Preventive Care Survey’. Out of 16,687 women age 40 years and above who utilized the BPBCC to get a screening mammogram at least once in the past ten years (from August 2001 to July 2011), 2,255 women were randomly selected and were mailed the survey. 1,104 women (48.96%) completed and returned the survey. Survey Instrument, Survey Administration & Data Collection
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Data were collected via the West Virginia University Institutional Review Board approved Mammography Screening and Preventive Care Survey. The survey has several sections including personal health history, menstrual and pregnancy history, family history of cancer, cancer risk assessment and screening history, views on BC screening, BC awareness, preventive care and wellness history, and demographics. The details about the survey 17 development are explained elsewhere. A survey, a cover letter and a prepaid business reply envelope were mailed to the 2,255 randomly selected women who had mammography screening at the BPBCC at least once in the past ten years. Two rounds of the survey were sent to these women at three-week intervals to maximize the response rate. A $5 gift-card was mailed to all women who completed and returned the survey to acknowledge their participation and time. Dependent variable - Self-reported on-schedule adherence to mammography screening guidelines
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The main outcome of interest was self-reported on-schedule adherence to mammography 18 screening guidelines, defined as having had a mammogram in the past one to two years. The dependent variable was dichotomized into adherent and non-adherent groups. For this study, the United States Preventive Services Task Force (USPSTF) 2002 recommendations were utilized which advocates mammography screening every one to two years for women 19 age 40 years and above. ,20 This is also in general agreement with the current recommendations from various professional organizations such as the Centers for Disease Control & Prevention, Healthy People 2010 & 2020 objectives, and National Cancer Institute. Independent variables
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Table 1 provides the independent variables included in the study. These include predisposing factors such as age, education level, and employment status, body mass index (BMI), smoking status, and alcohol consumption; enabling factors such as marital status, household income, health insurance, visit to physician and OB/GYN in the past year, and delay in medical care due to transportation. Need-related factors included were self-reported health status, family history of BC, breast problems in the past, breast biopsy in the past, adherence to clinical breast exam (CBE), adherence to Pap test, having had any cancer, and a composite score of having had other screening tests such as blood glucose test, bone mineral density test, cholesterol test, high blood pressure test (possible scores 0, 1, 2, 3, or 4). The composite score was grouped into two groups, those with scores 0–3 and those with the W V Med J. Author manuscript; available in PMC 2016 June 07.
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score 4. A woman who had all the four screening tests in previous two years was given a score of 4 while a woman who did not have any of these screening tests in the previous two years was given a score of 0. A woman was considered adherent to CBE if she had CBE in the previous one year as per recommended guidelines and adherent to Pap test if she had Pap 21 test within the previous two years as per recommended guidelines. Perceived five-year risk and perceived lifetime risk of developing BC (lower, similar, higher), views towards mammography screening, and knowledge about BC and mammography screening comprised the psychosocial factors. The details of the assessment of positive and negative views towards mammography screening, knowledge about BC and mammography screening 17 are described elsewhere. Non-response bias assessment
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Women who did not participate in the study may be different from those who participated, and hence non-response bias was assessed. The details of the non-response bias assessment 22 are described elsewhere. Non-respondents were significantly more likely to be unemployed, and had less than college-level education. Statistical Analyses
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Descriptive statistics were used to describe the characteristics of the study sample. Chisquare tests for categorical variables and t-tests for continuous variables were used to determine significant differences between self-reported adherent and non-adherent groups. Logistic regression was performed to analyze the relationship between self-reported adherence with all the constructs of the Andersen model, after controlling for predisposing, enabling, need-related and psychosocial factors. ‘Non-adherent group’ was the reference group for the dependent variable. Resulting odds ratios and their corresponding 95% confidence intervals were examined. The findings that were significant with p-values less than 0.05 levels are discussed. SAS 9.2 software was used for the statistical analyses.
Results Characteristics of the study cohort
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Table 1 describes the characteristics of 1,104 women age 40 years and above who had at least one mammogram at the stationary mammography facility in the past ten years. A majority (57%) of the women were in the 50–64 age group, 23% were 65 and above and 20% were 40–49 years old. A majority were married or partnered (77%), had at least some college level education (62%), were employed (58%), overweight to morbidly obese (68%), had a household income more than $50,000 (55%), and were insured (95%). Seventy-three percent of women had visited a doctor in the past year, while 53% had visited an OB/GYN in the past year. Twenty percent of women reported a family history of BC, 73% had a Pap test in the past two years, and 63% had a CBE in the past year. A majority (62%) had moderate knowledge while 31% showed higher knowledge about BC and mammography screening. The mean score was 1.975 for the positive views statements and 5.822 for the negative views statements (on the scale of 1 = Strongly agree and 7 = Strongly disagree). Out of 1,104 women, 1,019 women (92.3%) reported adherence to mammography screening guidelines.
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Results of Bivariate Analyses
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Self-reported adherence to mammography screening guidelines was higher in women who had at least some college-level education, were never smokers, were married/partnered, had higher household income, had health insurance, had visited a doctor and/or OB/GYN in the past year, had a breast biopsy in the past, were adherent to CBE and Pap test, perceived their lifetime risk of developing BC as higher, reported higher knowledge of BC and mammography screening and strongly agreed with the positive views, and strongly disagreed with the negative views about mammography screening (data not shown). Results of Multivariate Analyses for the stationary facility study sample
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Table 2 describes the adjusted odds ratio of self-reported adherence to mammography screening guidelines in women aged 40 years and above who utilized a stationary mammography facility, after controlling for all the predisposing, enabling, need-related and psychosocial factors (only significant variables are presented). Among predisposing factors, being older (age 65 and above) was a significant predictor of adherence to mammography screening guidelines (AOR = 2.803, 95% CI = 1.055–7.451). Among enabling factors, women who did not have health insurance remained significantly less likely to be adherent to mammography screening guidelines (AOR = 0.208, 95% CI = 0.087–0.499). Those who reported delayed medical care due to transportation problem were 73% less likely to be adherent to mammography screening guidelines (AOR = 0.274, 95% CI = 0.084–0.894). Furthermore, among need-related factors, women were not adherent to CBE and Pap test, and who did not have all the four screenings in the past two years were significantly less likely to be adherent to mammography screening guidelines. The AORs were 0.253 (95% CI = 0.124–0.514), 0.179 (95% CI = 0.094–0.342) and 0.349 (95% CI = 0.146–0.833), respectively. In addition, women whose level of agreement towards positive views about mammography screening reduced by one point on the agreement scale, were 31% less likely to be adherent to mammography screening guidelines (AOR = 0.691, 95% CI = 0.567– 0.841).
Discussion
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In this study, the characteristics of women age 40 years and above who utilized a stationary mammography facility and the predictors of self-reported adherence to mammography screening guidelines were examined. Overall, 92.3% of women in the study sample were adherent to mammography screening guidelines. This rate is substantially above the national 23 Healthy People 2010 goals for mammography screening, and the national screening rate of 24 12 75.4% in 2010. This finding is also in contrast to a previous study on WV women and a 13 recent study on WV Medicaid fee-for-service women. The high mammography screening rate among women who utilized stationary facility suggests that these women never have had or have already overcome the majority of the barriers to mammography screening. In addition, the screening facility is located in a university town which may introduce some bias in the selection of the sample which may have ultimately resulted in higher screening rates. The sample was more affluent and educated as compared to national averages which may have resulted in higher screening rates.
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Among predisposing factors, older age (65 and above) was associated with adherence to 25 30 mammography screening guidelines, which is consistent with previous studies. – As Medicare covers mammograms, women age 65 years and above may have regular access to screening services and hence are more likely to be adherent to mammography screening guidelines. Among enabling factors, having insurance was a significant predictor of 25 adherence to mammography screening, which is consistent with the previous studies. ,30,31 This suggests that health insurance coverage is a very important access factor which supports women’s utilization of mammography screening services. Also, women who reported delay in medical care due to transportation problems were more likely to be nonadherent to mammography screening, suggesting that transportation problem is one of the key issues associated with non-adherence in the geographically challenging state of WV. Hence, although women have higher education levels and higher income levels, insurance coverage and transportation problems pose threats to their screening behaviors.
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Among need-related factors, adherence to the CBE, Pap test and other tests for blood glucose, blood cholesterol, bone mineral density, and blood pressure strongly predicted adherence to mammography screening guidelines. This is consistent with a previous study which indicates that women who follow such preventative behaviors are sufficiently knowledgeable about the importance of preventive healthcare to overcome any barriers that 28 they may encounter to screening. Among psychosocial factors, having strong positive views about mammography screening was associated with adherence to mammography 32 screening. This finding is consistent with the previous study by Magai C et. al. Hence, the findings of this study are consistent with the previous studies which also indicated that lack of insurance, lack of transportation, younger age, and views about mammography screening 13 restricted women from adhering to mammography screening guidelines. ,31 These findings may be helpful in developing interventions for women under 65 years of age, without health insurance coverage and who have transportation problems, and who are not adherent to other preventive behaviors, in order to increase screening rates in women who are not adherent to mammography screening guidelines.
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There are several limitations of the study. One limitation is the response rate; 51% of women who utilized a stationary mammography facility did not respond to the surveys. A nonrespondents analysis indicated that non-respondents were significantly more likely to be unemployed and with lower levels of education. Hence, these should be taken into consideration while extrapolating the findings of the study. Moreover, data is collected from only one stationary screening facility which is assumed to represent stationary screening facilities in WV. BPBCC is located in a university town from which a part of the sample was drawn. This may incorporate some selection bias. However, the area outside the 5-miles radius of the town is very rural and underserved and is considered to be a medically underserved area. Another limitation is that survey data is self-reported which may differ from mammography screening information obtained from medical records of healthcare providers. In addition, the findings of this study may not be generalized to women residing outside of WV.
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Conclusion Adherence to mammography screening was very high in women age 40 years and above who utilized a university town stationary mammography screening facility. Enabling and need-related factors and positive views about mammography screening predicted adherence to mammography screening guidelines in these women.
Acknowledgments This research study is partially funded by Susan G. Komen For the Cure, Claude Worthington Benedum Foundation, and AHRQ grant # R24HS018622-02. The authors acknowledge the PhD students, Amit Raval, Parul Agarwal, Tricia Lee Wilkins, Traci LeMasters and Elvonna Atkins from the Department of Pharmaceutical Systems & Policy, West Virginia University, for helping in mailing out the surveys for the study.
References Author Manuscript Author Manuscript Author Manuscript
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Figure 1.
Conceptual model illustrating the constructs of expanded version of Andersen Behavioral Model of Healthcare Services Utilization in predicting adherence to screening mammography guidelines.
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Table 1
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Description of the Study Sample of WV Women age 40 and above. Stationary Mammography Facility (Betty Puskar Breast Care Center) Stationary facility N (1,104)
%
40–49
217
19.66
50–64
630
57.07
65 & above
257
23.28
Less than HS
15
1.36
Some HS/HS grad
273
24.73
GED/Tech
135
12.23
Some college/Graduate
681
61.68
Employed
635
57.52
Unemployed
469
42.48
Underweight/Normal weight
351
31.79
Overweight to Morbidly Obese
753
68.21
Never
729
66.03
Former
267
24.18
Current
108
9.78
Yes
526
47.64
No
578
52.36
Married/Partnered
848
76.81
Single
256
23.19
Less than $25,000
232
21.01
$25,000–$50,000
270
24.46
$50,000–$75,000
220
19.93
More than $75,000
382
34.60
Yes
1,048
94.93
No
56
5.07
PREDISPOSING FACTORS Age
Education
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Employment status
Body Mass Index
Smoking status
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Alcohol consumption
ENABLING FACTORS Marital Status
Household Income
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Health Insurance
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Stationary facility
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N (1,104)
%
Yes
805
72.92
No
299
27.08
Yes
582
52.72
No
522
47.28
Visit to doctor in past year
Visit to OB/GYN in past year
Delayed care due to transportation problem Yes
34
3.08
No
1,070
96.92
Fair/Poor
168
15.22
Excellent/V.good/Good
936
84.78
Yes
216
19.57
No
888
80.43
Yes
259
23.46
No
845
76.54
Yes
368
33.33
No
736
66.67
Yes
692
62.68
No
412
37.32
Yes
774
70.11
No
330
29.89
Yes
150
13.59
No
954
86.41
0–3
753
68.21
4
351
31.79
Lower
391
35.42
Similar
541
49.00
Higher
172
15.58
NEED-RELATED FACTORS
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Self-rated Health Status
Family History of BC
Breast problems
Breast biopsy in past
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Adherence to CBE
Adherence to PAP test
History of Cancer
Total score of screenings
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PSYCHOSOCIAL FACTORS Perceived five-year risk
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Stationary facility
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N (1,104)
%
Lower
337
30.53
Similar
571
51.72
Higher
196
17.75
Perceived Lifetime risk
Knowledge Low
75
6.79
Moderate
683
61.87
High
346
31.34
Views Positive Views
Mean
1.975
Negative Views
Mean
5.822
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HS: high school; V.good: very good, OB/GYN: obstetrician/gynecologist, ADL: activities of daily living; IADL: instrumental activities of daily living. For views, score 1 is equal to strongly agree and score 7 is equal to strongly disagree on the scale of 1 to 7.
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Table 2
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Adjusted Odds Ratios and 95% Confidence Interval from Logistic Regression Of Self-Reported Adherence to Mammography Guidelines Stationary mammography facility AOR
95%CI
p-value
Sig
PREDISPOSING FACTORS Age 40–49
1
50–64
1.918
[0.942, 3.906]
0.0725
65 & above
2.803
[1.055, 7.451]
0.0388
[0.087, 0.499]
0.0004
*
ENABLING FACTORS
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Health Insurance Yes
1
No
0.208
*** *
Delayed care due to transportation problem Yes
0.274
No
1
[0.084, 0.894]
0.0318
[0.124, 0.514]
0.0001
NEED-RELATED FACTORS Adherence to CBE Yes
1
No
0.253
***
Adherence to PAP test
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Yes
1
No
0.179
[0.094, 0.342]
