Proactive screening mammography counseling within the Cancer Information Service: results from a randomized trial.

In 1987, the Division of Cancer Prevention and Control, National Cancer Institute (NCI), funded a randomized trial of a proactive counseling protocol to promote screening mammography among age-eligible female callers to the Cancer Information Service (CIS). This protocol included interactive counseling by CIS counselors to help callers overcome barriers to screening mammography; this counseling was an extension of usual service and was combined with a 2-week follow-up mailout to reinforce the brief (6-minute) proactive telephone-counseling protocol. The screening-mammography counseling intervention was tested in two regional CIS offices using a randomized two-group design. Callers were randomly assigned to the intervention or control group based on the week of their call to the CIS (n = 1831 eligible female callers). Self-reported adherence to NCI screening-mammography guidelines was assessed from telephone interviews conducted at 12 months' follow-up (87% response rate). Among all CIS callers enrolled in this study, self-reported adherence to screening-mammography guidelines at 12 months' follow-up was 63.5%. The most frequently cited barriers to screening mammography reported by CIS callers were inconvenience/being too busy (52%), cost (36%), lack of physician referral (34%), no symptoms (34%), and fear of radiation (29%). A significant intervention effect on adherence behavior was found but only in one of the two test sites and only among CIS callers reporting total family income of $30,000 or more (odds ratio = 1.38, P = .04). The vast majority (90%) of CIS callers (both intervention and control subjects) endorsed the concept of proactive counseling by the CIS. The implications of these findings for the CIS and future research are discussed.

Cross-sectional versus prospective predictors of screening mammography.

Data from a population-based longitudinal study were used to compare cross-sectional versus prospective predictors of screening mammography. Although the results of the two analyses were not dramatically different, some important differences emerged. More attitudinal variables were related to future behavior compared with past behavior. Using purely cross-sectional data from this study to design an intervention would result in potentially important variables being deemphasized or omitted, which could have a significant impact on the strength of the intervention. Our findings strongly suggest that it may be unwise to generalize cross-sectionally obtained data to a longitudinal situation.

Breast cancer screening and related attitudes among Filipino-American women.

This study assessed mammography screening rates and related attitudes and intervention preferences in Filipino-American women, a group that has been neglected in cancer control research. Face-to-face interviews were conducted in English and Tagalog with a convenience sample of 218 Filipino women 50 years and older residing in Los Angeles. Sixty-six % had ever had a screening mammogram, 42% had had one in the past 12 months, and 54% in the past 2 years. These rates are about 20% lower than those found among African-American and white women in the 1994 California Behavioral Risk Factor Survey. Women who had received a doctor's recommendation to obtain a mammogram, women stating that they were very likely to obtain a mammogram if a physician recommended it, and women who felt very comfortable requesting a mammogram from a physician were more likely to have been screened. Women who had friends and relatives who had obtained mammograms those stating that their friends and relatives would be very supportive of their getting a mammogram, and those who felt that it was very worthwhile to obtain a mammogram were also more likely to have been screened. The following variables were negatively related to the outcome: concern over cost, the attitude that mammograms are only needed in the presence of symptoms, perceived inconvenience of taking the time and difficulties getting to the mammography facility, and embarrassment. Implications for interventions to increase breast cancer screening are discussed.

Breast cancer knowledge, attitudes, and behaviors: a comparison of rural health and non-health workers.

The present study surveyed the current levels of knowledge and the attitudes, beliefs, and behaviors of health workers (mostly nurses) with respect to breast cancer and its early detection. In addition, health workers were compared with non-health workers to determine whether the two groups differed with respect to the above variables. The sample comprised 402 women sampled from work sites in a rural community in the Midwest. The results indicated that health workers (n = 96) scored very high on knowledge, had a very positive attitude toward the notion of early detection, and reported strong intentions concerning future participation in a variety of early detection behaviors. Fifty % performed breast self-examinations once a month or more frequently. A stepwise discriminant analysis found that, compared to non-health workers, health workers saw mammography as less dangerous, believed breast cancer to be less common and its causes less controllable, and were less likely to perceive early detection as being beneficial. On the other hand, health workers scored higher than non-health workers on self-efficacy, breast self-examination frequency, and importance of breasts in determining one's self concept. Health workers also rated breast cancer as being more life-threatening and were more likely to believe that the disease was caused by external as opposed to internal factors.

Initial and repeat mammography screening in a low income multi-ethnic population in Los Angeles.

Low income, older, minority women are at high risk for underutilization of screening mammography. One strategy for increasing utilization is to conduct interventions targeting local and state health departments where a majority of these women seek health care. A prerequisite for conducting effective screening programs is to obtain current and accurate information on baseline screening rates to understand the nature and scope of the problem and to plan appropriate intervention strategies. The sample consisted of 3240 women who were 50+ years of age from 2 hospitals and 2 comprehensive health centers operated by the Los Angeles County Department of Health Services. Reviews of medical records indicated that only 21% of the sample had received a mammogram in the 12 months prior to the clinic visit on which they were sampled and 23% of the sample received a mammogram in the following 9 months. Approximately 5% of the total sample received a repeat mammogram in the 21-month period over which they were tracked. Prospective independent predictors of screening were age, number of visits to primary care clinics, number of visits to specialty care clinics, and history of breast abnormalities. The results underscore the importance of implementing programs to increase mammography implementing programs to increase mammography screening within public facilities serving low income multiethnic women. An important finding is that a large number of older women are seen in specialty clinics, which represents an untapped resource for increasing screening in this population. Innovative interventions targeting such specialty clinics could substantially contribute to increasing screening rates. A comprehensive approach targeting system, physician, and patient barriers is recommended.

Acceptability of mobile mammography among community-dwelling older women.

OBJECTIVE: To test the acceptability of mobile mammography among community-dwelling older women and to identify factors predictive of mobile mammography acceptance. DESIGN: Case series. SETTING: Twelve community meal sites sponsored by the City of Los Angeles Area on Aging. PARTICIPANTS: Two hundred fifty-five volunteers aged 60 to 84 years who attended community meal sites. INTERVENTION: On-site mammography offered to women who had not had a mammogram within the last year. MEASUREMENTS: Mammography acceptance rates, reasons for accepting or declining the mammogram, and breast cancer knowledge, beliefs, and intentions. MAIN RESULTS: One hundred seven of the 255 (42%) women were ineligible because they had received mammograms within the last year. Of the 148 women eligible, 57% accepted the mammograms and 43% declined; moreover, 20 of the 42 (48%) women who had not had a mammogram within the last 5 years or who never had a mammogram also accepted on-site mammography in the mobile van. Variables identified as predictive of mammogram acceptance included Asian American status, not being an HMO member, being married, a reported willingness to accept a screening mammogram if recommended by a physician, and previous mammogram screening history. CONCLUSION: Mobile mammography is acceptable to many older community-dwelling women. Although mobile mammography does not eliminate all barriers that inhibit a woman from receiving a mammogram, it may substantially increase screening for some groups.

Demographic predictors of cancer screening among Filipino and Korean immigrants in the United States.

BACKGROUND: Little is known about cancer-screening practices of various Asian subgroups, and even less is known about factors that may predict screening in these populations. DESIGN: Two independent surveys were conducted with 218 Filipino and 229 Korean female immigrants, aged 50 years and older, residing in Los Angeles. RESULTS: In these convenience samples, 48% of Filipino and 41% of Korean women reported receipt of a Pap smear within the past 2 years; 41% of Filipino and 25% of Korean women reported receipt of a mammogram and a clinical breast exam within the past 2 years; and 25% of Filipino and 38% of Korean women reported colorectal cancer screening (blood stool test within the past 12 months or sigmoidoscopy/colonoscopy within the past 5 years). Only 14% of Filipino and 10% of Korean women were adherent to cancer-screening guidelines for all three sites. These differences in screening rates were statistically significant in multivariate analyses of the combined sample, controlling for all demographic characteristics, including age, percent of lifetime in the United States, education, marital status, health insurance, employment, and ethnicity. The two variables that were most consistently independently associated with adherence to cancer screening in both samples were higher percentage of lifetime spent in the United States and ever having had a checkup when no symptoms were present. CONCLUSIONS: These two variables-percent of lifetime in the United States and ever having had a checkup when no symptoms were present-can alert a physician that cancer-screening tests may be overdue among Korean and Filipino immigrants in the United States. Future research should identify predictors of cancer screening among other Asian immigrant groups and U.S.-born Asian women to assist in targeting intervention efforts.

A randomized trial of a self-help smoking cessation intervention in a nonvolunteer female population: testing the limits of the public health model.

Reaching nonvolunteer female smokers with effective smoking cessation programs is a critical public health challenge. Smokers (N = 2,786) among 15,004 female members of a health maintenance organization who completed a routine needs assessment were invited into the "UCLA Preventive Health Behavior Study," consisting of five telephone interviews over 2 years assessing health practices. Participants (N = 1,396) were randomized into experimental or control conditions of an unsolicited, mailed, self-help smoking cessation program. Subjects were not alerted to the link between the program and the health study. Smoking status was assessed at 1, 6, 12, and 18 months. Across all subjects, point prevalence at 18 months was 18.62, and continuous abstinence was 2.71%. No difference was found between treatment and control groups regarding smoking status or readiness to stop smoking--raising questions about the value of mailing cessation materials to nonvolunteers. Quit rates increased over the 18-month follow-up; those still smoking at 18 months reported increased readiness to quit. Predictors at each follow-up point were examined multivariately.

Prevalence of anal sex among heterosexuals in California and its relationship to other AIDS risk behaviors.

This paper describes the prevalence of anal sex among heterosexual adults in California and investigates the relationship of anal sex to other risk behaviors associated with AIDS and STDs. The study consisted of telephone interviews with a household probability sample of 3,545 California adults undersampling those age 44 and older. Seven percent of the sexually active respondents, 8% of males, and 6% of females reported having anal sex at least once a month during the year prior to the survey. Of these, most engage in this activity one to five times per month, and about 60% report never using condoms. Younger respondents and those who were not married were more likely to report anal intercourse. Respondents who had anal sex were more likely to report standard AIDS risks and lifestyle risks associated with STDs, and to engage in recreational use of drugs and alcohol. Both anal sex and condom use during anal intercourse were poorly predicted by these demographic and risk variables. It is concluded that a non-trivial proportion of California heterosexual adults engages in anal sex regularly, most without condoms, and those who have anal sex are more likely to have other risk behaviors associated with AIDS and STDs. These results suggest that anal sex must be addressed specifically in clinical and educational programs designed to reduce the spread of AIDS.

Knowledge and attitudes toward condom use--do they predict behavior among Filipino Americans?

Face-to-face interviews were conducted with 211 Filipino-American adolescents and young adults residing in Los Angeles County to assess AIDS related knowledge, attitudes and behaviors. Among both sexually active and never sexually active respondents, HIV knowledge and self-efficacy with respect to condom use were generally high, and the majority held peer norms that were supportive of condom use. More than half of sexually active respondents reported condom use at last intercourse. Knowledge of HIV transmission, demographic variables, barriers to condom use, peer norms, and being comfortable asking a steady partner to routinely use condoms were not related to condom use at last intercourse. Higher self-efficacy (odds ratio 2.4, P<.06) and carrying condoms (odds ratio 1.9, P<.08) were the only two variables that approached statistical significance in their relationship to condom use at last intercourse. Findings suggest that variables that are related to AIDS risk behavior among non-Asian populations may not explain condom use among Filipinos. Therefore, future studies should identify determinants of AIDS risk behavior among Filipinos and other Asian American populations as a first step towards developing culturally relevant AIDS prevention programs for these groups.

Misconceptions and mammography use among Filipino-and Korean-American women.

Face-to-face interviews were conducted with a convenience sample of 218 Filipino and 229 Korean women residing in Los Angeles County. This paper describes the women's knowledge and misconceptions regarding breast cancer risk factors, their utilization of traditional and westernized preventive health care, and the relationship of these variables to mammography utilization. Sixty-six percent of Filipino women and 49% of Korean women ever had a mammogram. Both Filipino- and Korean-American women share many of the same misconceptions about breast cancer risk factors. More instructive, however, is that these beliefs do not affect mammography utilization. Acculturation and modesty were associated with mammography utilization in both groups. Use of traditional medicine was negatively related and use of westernized preventive health care was positively related to mammography screening only among Filipino women. Practicing health care professionals should use these findings as they develop culturally sensitive breast cancer control programs.

African-American physicians and smoking cessation counseling.

While African American physicians can play a key role in encouraging black patients who smoke to quit, little is known about the views and activities of these physicians with respect to antitobacco programming. In the process of developing a protocol for encouraging physicians' smoking cessation intervention, 96 African-American physicians completed a survey indicating their knowledge, attitudes, and practices relating to stop smoking counseling. Few physicians reported patient help-seeking behavior and 47.9% cited lack of patient motivation as a key barrier to intervention. Only 46.8% believed that it is possible to accomplish a lot of cessation help in a few minutes time, and 34.4% believed that setting up and maintaining an office protocol would require a great deal of effort. Explaining health risks (71.9%) and enrolling patients in programs (66.6%) were perceived as keys to patient cessation; fewer than half of the physicians surveyed discuss specific strategies for quitting with their patients. Physicians indicated a willingness to offer more counseling in the future and were open to a range of strategies for learning more about effective approaches. Our findings support the need for dissemination of such information, particularly among specialists, to support antitobacco efforts among African-American physicians.

Cancer prevention--behavior changes: the short and the long of it.

BACKGROUND: Behavioral factors play an important role in the adoption and maintenance of nutritional modifications, delivered either through chemopreventive regimens or through dietary adaptation. A body of research supports a protective role of fruits and vegetables, dietary fiber, and eating a low-fat diet in reducing cancer risk. There is only limited knowledge, however, about the cancer-preventing properties of specific micronutrients, apart from beta-carotene; about optimal levels of intake of differing micronutrients; and about patterns of food intake associated with reduced cancer risk. Thus, it would seem preferable, overall, to be able to recommend cancer prevention through dietary modification rather than through the administration of individual agents. METHODS: Studies of dietary adherence in cancer prevention have yielded varying success rates, but are generally quite promising. We have developed a model that encompasses the range of behavioral, psychological, social, and systemic variables thought to influence adherence to nutritional regimens. RESULTS: The model is being utilized to influence the form and content of nutritional regimens and to promote short-term change which can then be sustained as long-term lifestyle modification. The model can also be applied to evaluate adherence to nutritional or other behavioral modifications and to determine the factors predictive of success.

Hospital information system and patterns of cancer screening.

Relative ease, implied accuracy, and unprecedented possibilities of computerized health care information systems, is very tempting for researchers. Attempts at determining the referral patterns for cancer screening at a large county hospital through the use of computerized administrative and clinical files, and some of the problems encountered is reported here. Only 17% of women over 18, and 16% of women over 50 who visited this hospital were referred and received screening for cervical and breast cancer, respectively. Pap testing was concentrated at clinics dealing with reproductive health, and women with higher visit frequencies had a higher referral rate. Major problems encountered were lack of uniformity in capturing information for similar variables in different files, inconsistency in capturing data elements, and partial coverage. To enhance capabilities of computerized health information system, following principles must be incorporated in the designs: complete coverage, uniform collection of data across time and files, and inclusion of linking capabilities.

Screening mammography rates and barriers to use: a Los Angeles County survey.

The use of screening mammography among women 40 years of age and older in Los Angeles County was assessed through a random digit dial telephone interview. The sample of 802 women represents a large urban population with substantial proportions of blacks, Hispanics, and Asians. The survey obtained information regarding adherence to the ACS/NCI screening mammography guidelines, perceived benefits of early detection and mammography, perceived threat of developing breast cancer, and barriers to utilization. The results showed that 71% of the women had had at least one mammogram, with 49% having received a screening mammogram according to the guidelines for their age. Less than half the respondents knew the screening guidelines for their age, with women ages 40-49 years being less knowledgeable than women greater than or equal to 50 years old (29 vs 58% answering correctly). A logistic regression analysis predicting the likelihood of having obtained a screening mammogram according to the guidelines found the following to be predictive: concern over radiation (negative association), age (negative association), family history, knowledge of guidelines, and cost of a mammogram (negative association). Other demographic factors and beliefs were not significantly related to this dependent variable.

AIDS risk behaviours and correlates in teenagers attending sexually transmitted diseases clinics in Los Angeles.

OBJECTIVE: Of all age groups, teenagers have the highest rates of sexually transmitted diseases. Therefore, it is particularly important to target interventions at this group. Teenagers attending STD clinics are at particularly high risk since behaviours that lead to an STD can also result in the transmission of HIV. The goal of this study was to collect information concerning the prevalence and correlates of high-risk behaviours in this population as a first step in the design of an effective intervention programme. METHODOLOGY: Face-to-face interviews were conducted with patients attending five STD clinics operated by the Los Angeles County Department of Health Services. RESULTS: In the exclusively heterosexual teenage subgroup (N = 100, 55% Hispanic, 28% African-American, 10% White), males became sexually active at a younger age than females (14 years vs 14.9 years, p < 0.02), had more partners in the last 12 months (4.1 vs 2.0, p < 0.003), more "steady" partners (2.2 vs 1.4, p < 0.02) and more life time partners (14.1 vs. 4.1, p < 0.001). Only 10.0% of males and 3.8% of females reported consistent condom use with steady partners and 36% of both male and female respondents with non-steady partners. The decision to use condoms during vaginal sex was most likely made by the respondent, whereas the decision not to use condoms was most likely a joint decision. CONCLUSIONS: An intervention aimed at improving sexual communication regarding condom use could increase this behaviour among many adolescents, since only few teenagers in our sample perceived condom use as unpleasant.

Condom use in young blacks and Hispanics in public STD clinics.

BACKGROUND AND OBJECTIVES: Young blacks and Hispanics are an emerging risk group for contracting HIV. The goal of this study was to assess the most salient correlates of condom use for young Hispanics and blacks in Los Angeles county sexually transmitted diseases (STD) clinics as a first step toward designing a short clinic-based intervention. STUDY DESIGN: Face-to-face interviews were conducted with 376 patients younger than the age of 27 years at six STD clinics operated by the Los Angeles County Department of Health Services. Assessment included several attitudinal variables and AIDS risk behaviors. RESULTS: Condom use at last intercourse ranged from 40% among Hispanic females to 48% among black males. Among females, condom users were more likely to report high self-efficacy regarding condom use, peer norms supporting condom use, and more sexual communication than respondents who did not use a condom at last intercourse. Among males, no relationship was found between condom use at last intercourse and these attitudinal variables, except for sexual communication. The most important correlate of condom use among males and females was the frequency of carrying condoms. CONCLUSIONS: Our findings suggest that offering educational group sessions and attractive means for carrying condoms to patients in STD clinics may have the potential to increase condom use. The efficacy of these intervention strategies should be explored in future studies.

PIP: This study identifies the most salient correlates of condom use for young Hispanic and Black patients in Los Angeles county sexually transmitted disease (STD) clinics. A total of 376 patients aged under 27 years were interviewed from April to December 1995 at six STD clinics. The questionnaire used was developed to measure AIDS-related attitudes and behavior and included 1) self-efficacy with respect to condom use; 2) perceived peer norms regarding condom use; 3) sexual communication; 4) expected partner reactions; and 5) barriers to condom use. The study revealed that condom use during last intercourse ranged from 40% among Hispanic females to 48% among Black males. Female condom users were more likely to report high self-efficacy regarding condom use, peer norm supporting condom use, and more sexual communication than respondents who did not use a condom at last intercourse. On the other hand, among males, no relationship was found between condom use at last intercourse and these attitudinal variables, except for sexual communication. The frequency of carrying condoms was the most important correlate of condom use among males and females. This study suggests that offering educational group sessions and attractive means for carrying condoms to patients in STD clinics may increase condom use.

Controversy about mammography screening guidelines and physician practices at a university medical center.

To determine the effect of the 1994 controversy about mammography screening guidelines on physicians' practices, the authors surveyed primary care physicians at a university medical center in 1995. The 44-item survey elicited information about screening practices for women in four age groups, at the time of the study and five years earlier. High screening rates were maintained for the noncontroversial 50+ age group, but baseline mammography was still being ordered for 30-39-year-olds. Women 40-49 years old as well as older women were being screened less often in 1995.

Mammography utilization and related attitudes among Korean-American women.

The purpose of this study was to assess mammography utilization among Korean-American women and to identify their knowledge, attitudes and barriers related to screening. Face-to-face interviews were conducted in the Korean language with a convenience sample of 229 predominantly low-income Korean women 50 years and older residing in Los Angeles. Forty-nine percent had ever had a mammogram, 24% had had a screening mammogram in the past 12 months, and 36% had had one in the past two years. Variables positively related to "ever had a screening mammogram" included: having health insurance; income > or = $25,000; having received a physician's recommendation to obtain a mammogram; holding positive group norms; longer duration of residency in the U.S.; and greater acculturation. Variables negatively related to screening included: concerns about finding cancer; taking time to get a mammogram; transportation; embarrassment; and discomfort requesting the procedure from the physician. Strategies to increase mammography utilization among Korean-American women are discussed.

Evaluation of an intervention to increase mammography screening in Los Angeles.

METHODS. A randomized pretest post-test control group design was used to evaluate the effectiveness of a mail-out intervention for increasing screening mammography rates. A random sample of 802 women, 40+, residing in Los Angeles County, was surveyed by telephone at baseline and again 12 months after the intervention. RESULTS. Fifty percent of the intervention group and 56% of the control group had obtained a screening mammogram during the follow-up period. This difference was not statistically significant, indicating that the low-cost intervention was not successful in influencing screening mammography rates in this sample. In the combined intervention and control group, a stepwise logistic regression analysis revealed four baseline variables to be significant prospective predictors of mammography behavior during the follow-up period: Women who were adherent to the age-specific screening guidelines at baseline and women who had health insurance were more likely to obtain a mammogram during the follow-up, as were older women. Also, women who were greatly concerned about radiation exposure during a mammogram were about two and a half times less likely to obtain a mammogram during the follow-up than women who were less concerned. Self-reported reasons for adherence and nonadherence to screening guidelines are also described.