Randomized controlled trial of mammography intervention in insured very low-income women.

BACKGROUND: The expectation that insurance coverage mitigates health disparities and equalizes use of healthcare assumes that services are equally accessed; however, the insured low-income target population in this research had a mammography rate of 23.4%, well below the general population. Our objective was to determine the most effective intervention to improve mammography use in low-income women insured by a managed care organization (MCO). METHODS: The study was a randomized controlled trial. Participants were 2,357 women noncompliant with screening mammography randomly assigned to one of three groups: control (n = 786) received usual care; simple intervention (n = 785) received prompt letter from the MCO medical director; and stepwise intervention (n = 786) received the same prompt letter from the MCO; if noncompliant, a second prompt letter from their primary care physician and, if still noncompliant, counseling from lay health workers. Outcome was completion of screening mammography extracted from medical records. RESULTS: Screening rates were 13.4% for the control, 16.1% for the simple intervention, and 27.1% for the stepwise intervention. Compared with the control, the primary care physician letter in the stepwise intervention increased the likelihood of screening by 80% [Relative Risk (RR) = 1.80; P < 0.001], and counseling tripled the likelihood of screening (RR = 3.11; P < 0.001). CONCLUSIONS: Compared with the control and simple intervention, a stepwise intervention to increase mammography is effective in a target population of hard-to-reach, low-income, insured women. IMPACT: The research provides evidence for the impact of stepwise interventions to improve cancer screening in low-income insured populations, although the screening rates remain well below those of the general population.

Breast cancer knowledge and barriers to mammography in a low-income managed care population.

BACKGROUND: Low-income women experience multiple barriers to screening mammography. This study explored cancer knowledge as a point of intervention to reduce overall barriers. METHODS: A survey of breast cancer knowledge and barriers was obtained from 173 low-income female residents of Middle Tennessee, > or =40 years, enrolled in the state managed care organization and nonadherent to mammography. Multiple regression models examined the effect of breast cancer knowledge on mammography screening barriers. RESULTS: Comprehensive breast cancer knowledge, not mere screening awareness, was the strongest contributor towards lower barrier scores. CONCLUSIONS: Strategies to overcome mammography barriers should include comprehensive breast cancer education.

Impact of a two-city community cancer prevention intervention on African Americans.

We report the first multisite, multicomponent community intervention trial to focus on cancer prevention in African Americans. The project explored the potential of historically black medical schools to deliver health information to their local communities and used a community-based participatory research approach. The intervention consisted of culturally sensitive messages at appropriate educational levels delivered over an 18-month period and tested in predominantly black census tracts in Nashville, TN and Atlanta, GA. Chattanooga, TN and Decatur, GA served as comparison cities. Results were evaluated by pre- and postintervention random-digit dial telephone surveys. The intervention cities showed an increase in reported contact with or knowledge of the project. There was little or no effect on knowledge or attitudes in the intervention cities. Compared to Chattanooga, Nashville showed an increase in percentage of women receiving Pap smears. Compared to Decatur, Atlanta showed an increase in percentage of age-appropriate populations receiving digital rectal exams, colorectal cancer screenings and mammograms. The results of this community intervention trial demonstrated modest success and are encouraging for future efforts of longer duration.

Prevalence and correlates of initiation of smoking behavior among preteen black and white children.

This study estimated smoking prevalence and identified factors associated with initiation among preteens in Nashville, TN. An anonymous, self-administrated questionnaire was given to 238 fifth- and sixth-graders in a middle-class neighborhood school. The mean age at initiation was 8.5 years (range 6-11 years). Overall, 10.5% of students had ever smoked; 16.1% of blacks and 9.3% of whites. Eighty-six percent continued to smoke. Black sixth-graders smoked (26.9%) four times the rate of black fifth-graders and 2.5 times that of white sixth-graders. Relatives initiated 78% of blacks while friends initiated 68% of whites. One-quarter of smokers got their cigarettes at home. Regular attendees of religious services had a lower smoking rate (6.9% versus 16.4%; p=0.01). Smoking rates decreased with increased knowledge of risks (p=0.00001). Among smokers, none believed that smoking is a risk factor for heart disease, 96% did not believe that smoking has any short-term health effects or is a risk factor for stroke. Few ever-smokers had a complete understanding of the health risks. Targeted messages and curriculum should be developed to teach preteens about the short- and long-term dangers of smoking. Clinicians can play a major role in educating their clients about the risks of smoking.