The Ineffectiveness of Mammography Interventions in Reaching African-American Women in the U.S. – Kate Laporte

The Centers for Disease Control and Prevention (CDC) reported that breast cancer mortality in the U.S. declined by 2.2 percent per year from 1990 until 2004 (1). This is due primarily to widespread use of mammography and early detection of tumors, which leads to a better prognosis than late-presentation cases (2). However, racial disparities in breast cancer mortality have persisted even as the overall incidence rates have dropped. Incidence rates are lower for African-American women compared to white women, but African-American women have higher rates of mortality from the disease (3). African-American women have also been found to have a higher risk of underutilization of mammography, which is a factor in the increased mortality rates (4). Traditional public health approaches to increasing mammography use have focused on raising awareness about the risks of breast cancer and the benefits of mammography through education efforts. The National Breast and Cervical Cancer Early Detection Program of the CDC describes the purpose of their recruitment program as follows: to increase the number of women in priority populations receiving clinical screening services by raising awareness, addressing barriers, and motivating women to use these screening services (5). Intervention strategies to increase the uptake of mammography are focused on three aspects: educational efforts that increase women’s knowledge about breast cancer and mammography, training programs to help physicians increase uptake of mammography by their patients, and increasing access to mammography, typically through mobile mammography clinics and ensuring that women are informed about insurance coverage for mammograms (6). The interventions have failed to reach that goal, especially among African-American women. Researchers at the University of California at San Francisco included over one million women in a recent study of mammography utilization and found that African-American women had a 1.2 odds ratio of not obtaining a mammogram with comparison to white women (4). This study, published in 2006, found that large, advanced-stage tumors and lymph node–involved tumors were more likely to be diagnosed in African-American women than in white women. However, when rates of mammography screening were accounted for, the differences were attenuated or eliminated. Public health interventions to increase mammography use, based largely upon traditional behavioral change models, have had too narrow a focus to be effective in reaching African-American populations. The following arguments, based on the social context theory, the structural influence model and framing theory illuminate the weaknesses of this approach.
Considering the Social Environment
According to social context theory, there are three dimensions of the social environment that should be taken into consideration when modeling social change (7). These are the following: societal structures or shapers (factors external to individuals such as technology, race and social class), social processes (perceptions, attitudes, values) and social realities (common patterns of social behavior). The public health campaigns to promote mammography and evaluations of such programs have been based upon traditional behavioral models that do not include macro-level processes. They have been focused on changing individual women’s attitudes and beliefs toward their susceptibility to breast cancer and the value of mammography without including the larger societal influences that weigh in on behavior. One recent cross-sectional survey of African American women’s knowledge, attitudes and beliefs concerning breast cancer screening was based on the Health Belief Model (8). The Health Belief Model postulates that people will perform a health behavior if the perceived benefits of the behavior outweigh the perceived barriers (9). The researchers found that the women were aware of the value of the screening process and they identified breast cancer as one of the top health concerns for African-American women. This suggests that public health efforts and fund raisers targeted at increasing awareness had been successful. However, actual mammography utilization was drastically lower than recommended standards; less than half of the women reported having had a mammogram in the past year. The solution recommended by the researchers was increased educational campaigns targeted to African-American women. The broader societal forces that impact African American women were not accounted for in this narrow approach. Other evaluations have similar recommendations. According to social context theory, social realities (common patterns of social behavior) impact individual behavior. The folkways and norms that form common patterns of behavior in African-American communities have been reported to contribute to lower rates of mammography (10). For example, African American women have reported that cultural norms prioritize acute care over preventative health care. There is a tendency for women to neglect preventative care when other concerns are pressing. These others concerns were reported to include neighborhood violence, housing issues and substance abuse. None of these concerns are included as barriers to mammography in the traditional public health approach. Social context theory also emphasizes the affects of societal structures (e.g. race, socioeconomic status) on behavior. Since there is a disproportionate amount of African-American women are living in poverty and in unsafe neighborhoods, these societal structures are important determinants of whether a mammography is obtained. Thus, interventions to increase mammography use in this population must take into account the social context in which health behaviors take place. Another example of the impact of community-level beliefs is the integration of other women’s experiences with breast cancer into the folklore and norms of the community. One study found that the shared experiences of the community were found to impact women’s attitudes and beliefs concerning breast cancer screening (10). Negative experiences with mammography or breast cancer were found to impact how women viewed obtaining a mammogram, regardless of whether the information was correct or if it had happened to someone else. Recommendations to obtain mammograms were disregarded due to the integrated beliefs that it was associated with pain and cancer diagnosis. Traditional educational methods do not address community-level norms and beliefs and fail to capture the impact of these negative experiences on other women’s health behavior.
Communication and the Health Care System
The traditional approach has failed to examine the impact of the experiences of African American women with the health care system upon mammography use. Real or perceived negative experiences with the health care system can create a sense of fatalism regarding cancer (10). However, traditional individual-focused approaches to promoting mammography use have not considered the system-level factors of African American women’s experiences with the health care system. For instance, communication difficulties may play a part in discouraging women to obtain a mammography. One study that used focus groups to elicit the ideas and concerns of African-American women regarding mammography reported women’s fears about cancer that arose from a mistrust of the health care system due to negative encounters with health care providers. The negative encounters were largely concerned with communication, such as inadequate explanation of what a mammography entailed or what would be done with the results (10). Another study documented that African-Americans are less likely than whites to have their physicians discuss treatment plans and preventive health care during clinical encounters. This suggests that racial disparities may exist in the amount of information communicated to African-American women about screening mammograms (11). The structural influence model holds that social determinants (e.g. socioeconomic position) and mediating or moderating conditions (socio-demographics of age, gender, and race/ethnicity and social networks of social capital and resources) impact communication outcomes (12). Communication outcomes include information access, information processing and information utilization. A structural level approach to increasing mammography use would recognize that social determinants and mediating conditions influence communication of patients and providers. Race and poverty, in particular, can play mediating roles in the experiences of African-American women with their providers. Since a disproportionate amount of African-Americans are poor, they will encounter the health care system differently. Poverty has a negative impact on the behavior of health care providers and the availability of health services. Those who provide health care for minorities and people in low income areas, for example, are often less informed about preventive care services and are less likely to be board certified (13). This has not been accounted for in traditional provider training programs that have focused largely on increasing physician recommendation for mammography (6). Training that emphasizes increasing recommendations without regard to the other factors that are impacting communication is most likely ineffective. The structural influence model offers a more comprehensive view than the traditional approach of the interaction of African-American women with the health care system and the impact of that communication on mammogram use.
Framing the Issue
Much has been studied about the disparities in breast cancer mortality between African-American women and white women. The disparities have been documented for greater than thirty years (3). Interventions aimed at increasing mammography use have been focused on individual-level behavior and the problem of mammography utilization among African-American women has been thought of as an education and motivation problem. The social determinants of health have not entered the picture of breast cancer health disparities. Framing theory provides the means to readjust the paradigm concerning mammography use as one of a social and systems problem rather than an individual’s failure. A message can frame population health disparities as being caused by internal factors (within control of the individual), external factors (beyond the control of the individual), or some combination of the two (14). Instead of focusing on under utilization of mammography, the shift to a broader perspective of health disparities would take into consideration the underlying social determinants of health. The social determinants of race and the often correlating factor of income level serve little function as descriptions of study group participants. Their impact on women’s experiences with the health care system and the types of barriers faced by women in their everyday lives to preventative health care are critical factors in understanding why disparities have persisted. Investigation into the social determinants of health can lead to policy change that would address the fundamental underlying factors of disparities. Barriers inherent in the health care system such as communication difficulties could then be addressed on a widespread level. The social norms that discourage preventative health care could be addressed within African-American communities. Finally, agencies and organizations that aim to increase mammography uptake could take into account the real-life society-level concerns that African-American women face and design approaches that consider these concerns.
In conclusion, the traditional, educational, public health approach to mammography uptake has failed. Disparities in mammography utilization and related breast cancer mortality in African-American women in the U.S. have persisted despite millions of dollars of educational and awareness programs. Social science theory elucidates the limitations in the traditional approach. A comprehensive picture of the social context of health behavior and the role of the health care system in promoting mammography use offers new perspectives concerning the underlying determinants of health disparities. The new perspective gained can help frame this health disparity in a way that reflects social responsibility.
A novel approach
Through use of the spatial interaction model, Mobley and colleagues describe a comprehensive approach to factors affecting mammography use (15). The model was applied to aggregate pooled information from several heterogeneous states in the U.S. The aim was to demonstrate that pooled data can provide misleading information regarding predictors of health care utilization. The model includes factors that impact mammography use at several different levels, including fundamental/macro factors, intermediate or community factors, interpersonal factors, and individual factors. It draws from different disciplines to create a more comprehensive picture of what impacts health behavior than individual beliefs and perceived risks (Health Belief Model). Each of the levels, from the outermost (fundamental/macro factors) to the innermost (individual factors) impedes on the next level until, ultimately, the cumulative effects weigh in on individual behavior. The model is described below:
Fundamental/Macro factors:
Distribution of wealth, educational opportunities, and political influence; social and economic policies, institutions, regulations, campaigns, topography, climate, water supply
Intermediate or Community:
Social context – neighborhood, workplace, and housing conditions; public infrastructure and investment; police, enforcement services, crime; health care system
Health care system: proximity and density of facilities, physicians; crowding, scheduling and convenience, personal physician, managed care climate, primary care physician shortage; international medical graduate enclave
Physical environment – community capacity and partnership; land use patterns, transportation systems, buildings, public resources, pollution
Interpersonal:
Stressors, social integration and support, psychosocial factors, behavioral settings, social relationships, living conditions, neighborhoods and communities, neighborhood watchfulness, driver courtesy, social or cultural cohesion, population health behaviors or norms
Individual/Population:
enabling/disabling: personal disability, personal resources, type of health coverage, new address, marital status, employment status
predisposing: age, sex, gender; race or ethnicity, educational attainment
need: beliefs, family history, perceived risk, health status
Accounting for social context
The terms that are highlighted were discussed in previous sections as potential mediating factors in African-American women’s mammography rates that were left unaddressed by the traditional approach. The traditional approach does not consider the social context in which African American women live, including social norms particular to their communities. Population health behaviors or norms are integrated into the interpersonal level in the spatial interaction model. Also, concerns that keep African American women from obtaining mammograms such as neighborhood violence and housing conditions are included at both the intermediate and interpersonal levels. The study based on this model found that factors at the intermediate level did, in fact, affect mammography rates differently across states. In particular, the researchers found that in five of the states, the proportion of the workforce who commuted more than sixty minutes each way to work was negatively associated with mammography use. These findings highlight the need to examine specific social contextual factors that traditionally seem unrelated to health care utilization.
Accounting for system level factors
The model also takes into account the characteristics of the health care system that can promote or inhibit mammography utilization. In particular, the availability of primary care physicians may have an impact on mammography use. Physician shortages tend to occur in poorer areas and this factor may have a disparate affect on African American women, since a disproportionate amount of African American women live in poverty. Crowding, scheduling, convenience and the availability of a personal physician may all play a role in determining whether African American women perceive their experiences with the health care system as positive or negative. These types of variables cannot be quantified at the individual level but require a systems perspective. However, valuable qualitative data from women’s experiences can be obtained through focus groups and open-ended questionnaires that can help illuminate the specific areas of concern. Here, the concerns that surfaced through focus groups are included in the model as mediating factors on mammography use.
Reframing the issue
The spatial interaction model includes race/ethnicity as an individual level factor. While this may seem to be akin to the traditional approach, the model accounts for the impact of race/ethnicity as a determinant of health care utilization through multilevel modeling. The macro-level, intermediate and interpersonal factors that are modeled are the same factors that affect people of different racial/ethnic groups differently. Thus, while including race or ethnicity as an individual risk factor, the spatial interaction model also investigates the higher level processes by which people of various races and ethnicities are affected. The authors reframe the issue of disparate mammography use as one of differences in place-specific resources. The issue of place-specific trends is tightly joined to racial health disparities due to the extremely high degree of racial geographic segregation in the US (16). The health disparities that affect one racial or ethnic group, such as African-American women, are reflective of the place-specific resources and conditions acting upon their lives.
Conclusion
The structural and social forces that drive racial inequalities are being recognized gradually in public health research as the underlying, foundational determinants of health disparities. Mammography utilization is particularly important for African American women, whose mortality rates remain high and frequently present with later stage disease than their white counterparts. Education and individual-level interventions have proven ineffective in reducing disparities over the last thirty years. Specific social contextual factors and broader structural determinants must be addressed if this gap in health care utilization is going to be eliminated.

REFERENCES:
1. http://www.cdc.gov/cancer/breast/statistics/trends.htm; accessed on 12/01/08.
2. Feig SA. Effect of service screening mammography on population mortality from breast carcinoma. Cancer 2002; 95:451–457.
3. Newman LA. Breast Cancer in African-American Women. The Oncologist 2005; 10:1-14.
4. Smith-Bindman R. et al. Does Utilization of Screening Mammography Explain Racial and Ethnic Differences in Breast Cancer? Ann Intern Med. 2006; 18:541-53.
5. http://www.cdc.gov/cancer/nbccedp/ accessed on 11/24/08.
6. Wong FL. The Manual of Intervention Strategies to Increase Mammography Rates. The Centers for Disease Control and Prevention. 1997. http://www.cdc.gov/cancer/nbccedp/publications/; accessed on 12/02/08.
7. Earle L and Earle T. Social Context Theory. South Pacific Journal of Psychology. 1999; 11(2).
8. Sadler GR et al. Breast cancer knowledge, attitudes, and screening behaviors among African American women: the Black cosmetologists promoting health program. BMC Public Health 2007; 7(57).
9. Rosenstock IM. Historical origins of the health belief model. Health Educ Monogr. 1974;2:328-335.
10. Peek ME, Sayad JV and Markwardt R. Fear, Fatalism and Breast Cancer Screening in Low-Income African-American Women: The Role of Clinicians and the Health Care System. J Gen Intern Med 2008; 23(11):1847–53.
11. Oliver MN, Goodwin MA, Gotler RS, Gregory PM, Stange KC. Time use in clinical encounters: are African-American patients treated differently? J Natl Med Assoc 2001; 93:380–85.
12. Taylor-Clark K, Koh H and Viswanath K. Perceptions of Environmental Health Risks and Communication Barriers among Low-SEP and Racial/Ethnic Minority Communities. Journal of Health Care for the Poor and Underserved 2007; 18:165–183.
13. Gerend MA and Pai M. Social Determinants of Black-White Disparities in Breast
Cancer Mortality: A Review. Cancer Epidemiol Biomarkers Prev 2008;17(11).
14. Niederdeppe J, BU QL, Borah P, Kindig DA and Robert SA. Message Design Strategies to Raise Public Awareness of Social Determinants of Health and Population Health Disparities. The Milbank Quarterly 2008; 86(3):481–513.
15. Mobley, LR, Kuo T-M M, Driscoll D, Clayton L and Anselin L. Heterogeneity in mammography use across the nation: separating evidence of disparities from the disproportionate effects of geography. International Journal of Health Geographics 2008; 7(132).
16. Williams DR and Collins C. Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health. Public Health Reports 2001; 116: 404-416.