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LIBRARY
Michigan State
University

 

 

 

This is to certify that the

thesis entitled

The Michigan Breast and
Cervical Cancer Control
Program Rescreening Assessment Study

presented by
David Millward

has been accepted towards fulfillment
of the requirements for

Master's degree in Epidemiology

 

 

G. Marie Swanson

Major professor

 

Date August 23. 1999

0.7639 MS U is an Affirmative Action/Equal Opportunity Institution

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

woo c/Cimmu

 

THE MICHIGAN BREAST AND CERVICAL CANCER CONTROL PROGRAM
RESCREENING ASSESSMENT STUDY

By

David T. G. Millward

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

Department of Epidemiology

1 999

ABSTRACT

THE MICHIGAN BREAST AND CERVICAL CANCER CONTROL PROGRAM
RESCREENING ASSESSMENT STUDY

By

David T. G. Millward

Objective: To better understand local BCCCP factors potentially associated with
the adherence of clients to annual breast and cervical cancer screening.
Methods: Five local BCCC Programs with higher than state average second
year rescreening rates and five with lower than state average rates were selected
as study sites. Data about each program’s structures and processes were
collected using structured telephone interviews with the BCCCP Coordinators at
each site. Results: Programs with higher rescreening rates had more “planned-
for" contacts to remind women to return to the program for rescreening. Staff
reminders, the convenience of rescreening and the use of female health care
practitioners were not different between programs with high and low rates.
Rescreening rates were not associated with assessment of client needs and
subsequent modification of services or with the education component of each
program. Conclusions: The results of this study indicate that client reminder
systems are the most important program factor associated with higher
rescreening rates. Nine of ten program sites specified the importance of the
personal (telephone) contact as the single most important recommendation for

increasing rescreening rates.

ACKNOWLEDGMENTS

The author would like to thank all the members of his thesis committee,
Dr. Marie Swanson, Dr. Michael Rip and Dr. Dorothy Pathak. Thanks are also
due to Dr. May Yassine and Dr. Ruth Mohr from the Michigan Public Health
Institute for their help completing this thesis and for the opportunity to work on
this project. I would also like to thank Lora McAdams for her assistance
throughout my study period at Michigan State University. I would like to thank
my girlfriend Katy Larkin for her support and help along the way. Finally, I would
like to thank my parents for all of their support. I could not have gotten this far

without them.

TABLE OF CONTENTS

LIST OF TABLES ................................................................................................. vi

LIST OF ABBREVIATIONS ............................................................................... vii
INTRODUCTION

I. Incidence, Mortality and Survival for Breast and Cervical Cancer...1

II. Benefits and Possible Disadvantages of Screening Programs ....... 3

III. Results of Breast Cancer Screening Studies .............................. 5

IV. Results of Cervical Cancer Screening Studies ............................ 5

V. Adherence to Rescreening ..................................................... 7

VI. Objectives of this Study ................................................................... 7

CHAPTER 1

I. Brief History of the BCCCP ............................................................. 9

ll. Barriers to Screening ..................................................................... 10

Ill. Review of the Literature Relevant to Specific Study Hypotheses .. 11

A. Convenience Factors ............................................................... 11

8. Matching of the Service Provision Process to Client Needs ..... 12

C. Client Input/Feedback .............................................................. 13

D. Education ................................................................................. 14

a) Education of Women .......................................................... 14

b) Education of Physicians/ Other Clinical Staff ...................... 15

c) Overcoming Barriers to Rescreening through Education....16
d) Characteristics that Distinguish Compliers from Non-

compliers ............................................................................ 1 7
e) Summary ............................................................................ 18
CHAPTER 2
Methods .............................................................................................................. 19
I. Selection of the Study Sites .............................................................. 19
II. Development of the Survey Instrument ............................................. 21
Ill. Pilot Study ......................................................................................... 22
IV. Data Collection .................................................................................. 23
V. Statistical Methods ............................................................................ 24
VI. Study Hypotheses and Questions Related to Each .......................... 25
CHAPTER 3
Results ................................................................................................................ 36
I. Standardized (clearer) Procedures Results ...................................... 36
A. Client Reminder Systems ................................................................ 38
B. Staff Reminders .............................................................................. 39
ll. Matching of the Service Provision Process to Client Needs .............. 40
Ill. Convenience of Screening Arrangements ......................................... 41
IV. Client Needs and Feedback .............................................................. 43
V. Patient Education .............................................................................. 43

VI. Program Demographics .................................................................... 43

CHAPTER 4

Discussion .......................................................................................................... 47
Limitations of the Study ....................................................................................... 49
Conclusion .......................................................................................................... 52
BIBLIOGRAPHY ................................................................................................. 53

LIST OF TABLES

Table 1 - Breast and Cervical Cancer and Age-Specific Incidence Rates, Female
Michigan Residents, 1995 .................................................................................... 1

Table 2 - Breast and Cervical Cancer and Age-Specific Mortality Rates, Female
Michigan Residents, 1997 ..................................................................................... 2

Table 3 - Breast Cancer Five Year Relative Survival Rates by Stage & Race
SEER (1986 - 93) .................................................................................................. 2

Table 4 - Cervical Cancer Five Year Relative Survival Rates by Stage & Race

SEER (1986 - 93) .................................................................................................. 3
Table 5 - Screening Criteria for Cancer Developed by the WHO .......................... 4
Table 6 - Summary of experimental studies of the effect of screening on breast

cancer mortality .................................................................................................... 6
Table 7 - BCCCP Rescreening Rates, April 1998........... .................................... 20
Table 8 - Study Sites Selected and Rescreening Rate, April1998 ...................... 21
Table 9 - Enrollment ............................................................................................ 36
Table 10 - Follow-up Missed Mammography ...................................................... 37
Table 11 - Summary of Client Reminder System ................................................ 39
Table 12 - Number of Client Reminders .............................................................. 39
Table 13 - Staff Reminder Systems .................................................................... 40
Table 14 - Convenience Factors — Have They Changed Over Time or Not ........ 42
Table 15 - Service Delivery Models .................................................................... 45
Table 16 - Previous Models Used ....................................................................... 45
Table 17 - Description of the Area that Caseload is Drawn From ....................... 46

Table 18 - BCCCPs Most Important Recommendation for Increasing
Rescreening Rate ............................................................................................... 46

vi

LIST OF ABBREVIATIONS

BCCCP — Breast and Cervical Cancer Control Program
BPE — breast physical examination

CBE — clinical breast exam

CDC — Centers for Disease Control and Prevention

FL - functional limitation

LMAS - Luce, Mackinac, Alger and Schoolcraft BCCCP
NHIS — National Health Interview Survey

NP — nurse practitioner

WHO — World Health Organization

vii

INTRODUCTION

l. Incidence, Mortality and Survival for Breast and Cervical Cancer
Breast cancer is the second leading cause of cancer in women within

Michigan. In 1995, 6131 cases of breast cancer were diagnosed. 1538 women

died from this disease in 1997.1 The age-specific incidence rate for breast

cancer increases with age, from 30.4 (per 100,000 women age 25-39 years) to

414.5 (per 100,000 women age 65 and over).1 The mortality rate from this

disease also increases with age from 5.4 (per 100,000 women age 25-39 years)

to 130.0 (per 100,000 women age 65 and over).1 Cervical cancer is not as

common as breast cancer as there were 423 incident cases in 1995 and 122

deaths due to this disease in 1997 within Michigan.1 The incidence rate for
cervical cancer remains somewhat constant across age groups however the age-

specific mortality rate increases from 1.6 (per 100,000 women age 25-39 years)

to 6.3 (per 100,000 women age 65 and over).1

Table 1: Breast and Cervical Cancer and Age-Specific Incidence Rates, Female
Michigan Residents, 19951

 

 

 

 

 

 

 

 

 

 

 

Total Female Population
Age Group Cancer Site Number Rate'

All Ages Breast 6,131 105.1
Cervix 423 7.2

25 - 39 Years Breast 350 30.4
Cervix 134 11.6

40 - 49 Years Breast 989 139.6
Cervix 96 13.8

50 - 64 Years Breast 1,889 287.6
Cervix 90 1 3.7

65 and Over Breast 2,894 414.5
Cervix 96 13.7

 

Age-adjusted (Rates per 100,000 female population).

 

Table 2: Breast and Cervical Cancer and Age-Specific Mortality Rates, Female
Michigan Residents, 19971

 

 

 

 

 

 

 

Total Female Population
Age Group Cancer Site Number Rate
All Ages Breast 1,538 24.7
Cervix 122 2.1
25 - 39 Years Breast 62 5.4
Cervix 18 1.6
40 - 49 Years Breast 163 23.0
Cervix 29 4.1
50 - 64 Years Breast 405 61.7
Cervix 31 4.7
65 and Over Breast 908 130.0
Cervix 44 6.3

 

 

 

 

 

 

Age-adjusted rate per 100,000 female population

Many of these deaths were unnecessary, as early detection of breast
cancer by screening has proven to reduce mortality. Fifteen to 30% of deaths

caused by breast cancer in women aged 40 and over could be prevented by

effective routine screening.2 The 5-year survival rate is 97% when the cancer is

diagnosed at a local stage but if diagnoses occur after the cancer has spread,

the 5-year survival rate is 21 %.2

Table 3: Breast Cancer Five Year Relative Survival Rates by Stage & Race
SEER (1986 - 93)1

 

 

 

 

 

 

 

Total (%) White (%) Black (%
All Stages 84.2 85.5 70.0
Localized 96.8 97.4 89.6
Regional 75.9 77.4 61 .2
Distant 20.6 21.2 16.8
Unknown 54.9 56.4 47.1

 

 

 

 

 

Like breast cancer, screening for cervical cancer reduces both morbidity

and mortality from this disease.3 Although not as common, the American Cancer

Society, the National Cancer Institute, the American College of Obstetricians and
Gynecologists, the American Academy of Family Physicians and the American

Medical Association all recommend annual screening beginning at age 18 or

when becoming sexually active.4 After three consecutive negative smears,

screening may be performed less often if a physician chooses to do so, however,

screening every year is appropriate for high-risk women.4 The 5-year survival

rate for cervical cancer is 91% when the cancer is diagnosed at a local stage but

if diagnoses occurs after the cancer has spread, the 5-year survival rate is 9%.1

Table 4: Cervical Cancer Five Year Relative Survival Rates by Stage & Race
SEER (1986 - 93)1

 

 

 

 

 

 

 

 

Total (%) White (%) Black 1%)
All Stages 68.9 71.4 57.1
Localized 91.3 91.9 88.2
Regional 49.4 51 .1 40.9
Distant 9.1 9.8 7.7
Unknown 63.4 64.4 62.7

 

 

 

 

II. Benefits and Possible Disadvantages of Screening Programs

Screening programs for cancer provide many benefits. They allow pre-

neoplastic states to be detected and treated. 5‘7 Existing therapies may be more

effective in reducing mortality when applied to preclinical disease rather then to

the clinically evident.8 Early detection provides the opportunity for less radical

treatments to cure some cancer patients thus leading to resource savings due to
lower treatment costs. 7 Cancer screening is also beneficial because it provides

reassurance to women.7

Unfortunately, there are several disadvantages that one must consider
before undertaking a screening program: longer periods of morbidity as a result
of picking up the disease earlier in those patients whose prognosis would not be
any different without screening, over treatment of borderline abnormalities that
may not have been recognized were screening not in place, false reassurance
for those with a false-negative screening test, unnecessary morbidity for those
with a false-positive screening test which might lead to further unnecessary
diagnostic tests, a hazardous screening test and the utilization of resources for

over treatment of borderline abnormalities and the cost of the screening test

itself.7

Screening programs for any type of cancer need to meet certain criteria.
These include: a test that is both safe and painless, 3' 9 inexpensiveav 10 and
simplistic but still adequately sensitive.1o In addition, an effective intervention

must also be available to treat those who are diagnosed.3v 9 An example of
screening criteria developed by the World Health Organization (WHO) is

presented in Table 5.

Table 5: Screening Criteria for Cancer Developed by the WHO11

 

The condition must have a significant effect on the quality or quantity of life.
Acceptable methods of treatment must be available.

The condition must have an asymptomatic period in which detection and
treatment significantly reduces morbidity and/or mortality

Treatment in the asymptomatic period must yield a superior result to that
obtained by delaying treatment until symptoms appear.

Tests that are acceptable to patients must be available at reasonable cost
to detect the condition in the asymptomatic period.

The incidence of the condition must be sufficient to justify the cost of
screeni_ng.

QWPSPNT‘

III. Results of Breast Cancer Screening Studies

Screening that includes mammography with or without clinical breast
examination has been studied to determine its effectiveness at reducing breast
cancer mortality. Most studies have shown a positive relationship between

screening and a reduction in mortality from breast cancer (17-33% reduction in

breast cancer mortality)"2 The exception is the Malmo trial.13 The Malmo trial
had a smaller study population and 24% of the control group was estimated to
have had mammography within this study. Because nearly a quarter of the

controls had mammography during the study period, the reduction in mortality

rate for the screened relative to the control group was relatively small (4%).12 A

summary of the experimental studies is presented in Table 6.

IV. Results of Cervical Cancer Screening Studies

The mortality rate from cervical cancer in the US has dropped since the

initiation of widespread Pap smear screening.14 Numerous studies have
demonstrated a major decline in the incidence of cervical cancer and mortality
rates when screening was performed. These studies were conducted over a

period of 20 years in eight different countries and produced very strong evidence

in favor of cervical cancer screening.15 They include 5 case control studies, 2
using records from a centrally organized screening program in Aberdeen and
Iceland and 3 more in Geneva, Milan and Toronto.15 Cohort studies have also
been completed in British Columbia, Manitoba, Maribo County, Ostfold County

and Sweden.15

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V. Adherence to Rescreening

Much research has been performed examining factors that are associated
with a women ever having a mammogram, however, much less has been studied
on factors associated with a woman's adherence to screening guidelines.
Understanding these factors may lead to interventions that increase a woman's
compliance to the recommended screening guidelines. Although the vast

majority of women have had initial screening, there is a large drop in the

percentage of women who return for rescreening.23'28 In order for cancer
screening to be effective, women must return for regular screening. Therefore,

rescreening adherence needs to become a focus of clinical, programmatic and

policy efforts. 26 Service providers often are not able to change the individual
characteristics that influence a client's decision to return for services. However,

providers can often influence how their service delivery systems are put together.

VI. Objectives of this Study

The objective of this study is to Ieam what components of Michigan's
Breast and Cervical Cancer Control Program (BCCCP) local systems may work
as enhancers or barriers to women returning for screening in year two and
beyond. This is being done through review of local program rescreening rates

and gathering data on how selected local systems are organized.

For this study we hypothesized that the following differences between the

high and low rescreening programs will be observed:

1.

BCCCPs with higher rescreening rates will have more standard operating
procedures.

BCCCPs with higher rescreening rates will have more client-convenient
screening arrangements.

BCCCPs with higher rescreening rates will have more matching of the service
provision process to client needs.

BCCCPs with higher rescreening rates will have more planned for client input/
feedback.

BCCCPs with higher rescreening rates will have more planned educational

interventions for new and returning program participants

CHAPTER 1

I. Brief History of the BCCCP

The Breast and Cervical Cancer Mortality Prevention Act of 1990 was
passed by Congress. It authorized the Centers for Disease Control and
Prevention (CDC) to provide grant money to states, tribes and territories so that
they could provide breast and cervical cancer screening to underserved women.
Funds were awarded to states on a competitive basis. The Michigan program
was one of the first eight that received funding in the fiscal year 1991. Funding
by the CDC continued to expand during the following years so that by 1997, fifty
states, five territories, the District of Columbia and 13 American Indian/Alaskan
Native organizations were participating.

The American Cancer Society recommends annual screening for women

for breast cancer after the age of 40.29 The Michigan BCCCP follows this
recommendation by serving women 40 years and older with incomes up to 250%
of poverty. Women enrolled in the program are provided with breast and cervical
cancer screening and follow-up care when needed. They are enrolled regardless
of age even though CDC’s administrative guidance requires that priority be given
to women 50 years and older. During the 1993 fiscal year, the CDC required
75% of the women who enroll for their first screening be at least 50 years old. By
the 1998 fiscal year, this proportion had been increased to 90%. State funds are
used to cover the costs of screening more women less than fifty years old than

the CDC will fund.

Upon receiving the CDC's funds, Michigan established the BCCCP. The
BCCCP's task was to set up a comprehensive screening program for breast and
cervical cancer. A decision was made to use the local health departments for the
service delivery portion of the program. There were three main reasons why
local health departments would be used:

1. It was the quickest possible route to making screening services available to
target populations.

2. The public health agencies had much experience serving indigent, high-risk
population groups.

3. The Michigan Department of Community Health (MDCH) wished to develop
an infrastructure related to chronic disease prevention and control within the
public health system.

Michigan is divided into 83 counties. Not every county has its own local
health department. There are 32 counties with their own health department.
There are 16 health departments serving 2-6 counties and the Detroit City Health
Department serves residents of this city. Not every local health department
participates in the Michigan BCCCP as initially there were only 27 participating

program sites.

ll. Barriers to Screening
The Breast and Cervical Cancer Mortality Prevention Act of 1990 was created
to overcome many of the barriers that prevent women from accessing these life-

saving procedures. Barriers include: 1. concern not only about the cost of

10

mammography but also the high cost for diagnostic procedures and treatment for
breast cancer if needed;30 2. some women lack a routine source of care and the
time to receive such care;30 3. many women can not afford to take the time off of

work for breast screening due to lost wages or job insecurityf30 4. a woman's
proximity to the screening site can also influence the likelihood of mammography

as many do not have access to private transportation or the time to travel large

distances.30 The Act passed in 1990 by Congress provided the resources to
help older women, those with low incomes and women of racial and ethnic

minority groups overcome these barriers.

Ill. Review of the Literature Relevant to Speclflc Study Hypotheses
A. Convenience Factors

Access barriers such as inconvenience and distance from facilities effect a

woman's compliance to regular screening.” Many women report that they are

too busy to receive screening and that if mammography were more convenient

and free, they would be more likely to attend.” Campbell reports a similar

finding for cervical cancer screening as many women are not screened because
of inconvenient hours.31 Women living in areas with more mammography

facilities were more likely to adhere to recommendation intervals.26 In addition

to this finding, women living in areas without a shortage of primary care providers
were more likely to comply.26 For some women, a lack of transportation and

local availability of facilities, are barriers to screening.32 BCCC programs with

11

more convenient screening arrangements such as appointment availability and

arranging transportation might have higher rescreening rates.

B. Matching of the Service Provision Process to Client Needs

Programs within the BCCCP with higher rescreening rates may have more
matching of the service provision process to client needs like the desire for a
female service provider, language translation or extra assistance because of a
disability. Studies have shown that women are more likely to undergo cancer

screening such as Pap smears and mammograms if they see a female rather
than a male physician.33'35 Language has also been shown to be a barrier to

women using preventive services.36o 37 Programs that provide assistance to
women who do not understand English as a first language may have better
compliance from these clients then those programs that do not accommodate
this need. Disabilities among Medicare patients have been shown to be risk
factors for not receiving mammograms and Pap smears.38 In 1994-1995, a
disability survey was included as a supplement to the National Health Interview
Survey (NHIS). The NHIS Health Promotion/Disease Prevention Year 2000
Objective Supplement provided data that indicated women with functional
limitations (FLs) were less likely than women without FLs to have had a Pap test
within the previous 3 years.39 Programs which identify their clients’ needs and

match service provision to them, may have higher rescreening rates.

12

C. Client Input/Feedback
Whether or not a woman returns for rescreening has been associated with

past screening experiences. If a woman has had a bad experience in the past
(embarrassing or distressing examinations, 40 painful examinations, 41 unhelpful

clinic staff“) they may be less likely to return for a future appointment.25 In a
study involving rescreening at a mobile mammography facility, women who

expressed more dissatisfaction with a number of aspects of their visit, were less

likely to return.40 Women who have experienced prior breast pain may

experience more discomfort with mammography, an important reason for non-

compliance.25v 41 Women who had a mammography screening and an
abnormal result were found to have lower compliance with repeat screenings.

The anxiety, discomfort and inconvenience resulting from the abnormal finding

might have outweighed the perceived benefit of future screenings.25v 40

Since many women make their decision to not return for rescreening

immediately after their initial examination,“ it is important that the client is
satisfied with her screening appointment. In the event that a client were not
satisfied with her appointment, client feedback should be gathered to improve

service provision for the future. Increasing rescreening rates may be possible by

making improvements to the way service provision is provided.40
Participation by women in the decision to be rescreened was associated

with adherence suggesting that the interaction between a woman and her

provider plays a key role in adherence.26 Health care workers may be able to

easily influence several factors associated with non-compliance including fear of

13

the test, concerns about radiation and difficulty scheduling the test.42 BCCC
programs that have more planned for client input/feedback may be able to
resolve such issues and better convince women to come back for future

screenings.

D. Education

The education component of a BCCC program can have an effect on its
rescreening rate.
a) Education of Women

By educating women about the risk factors for breast cancer, they may
become more motivated to comply with regular screening.27- 4345 Before a
woman can be expected to return for a rescreening appointment, she must first
be aware of the current recommendations. Many women simply do not

understand how prevalent breast cancer is and therefore, they are less likely to

receive mammography“, 45 In a study of those who return for breast cancer

screening, those who come back are more likely to believe in the effectiveness of

determining breast problems at an early and curable stage.40 Acceptance of
breast cancer screening has been shown to be associated with knowledge about

the disease, a belief in the efficacy of mammography and believing in the

possibility of a cure.27

14

b) Education of Physicians] Other Clinical Staff

In many studies reviewed, the most important factor associated with

repeat mammography was a physician recommendation.27v 32- 44- 45 Evidence

has been reported to suggest that the more frequently a physician recommends

mammography, the more often a patient obtains a mammogram.46
Unfortunately, as cited by Rimer, physicians are reluctant to refer asymptomatic
women for mammography based on several concerns: the perceived low yield

from the examination, cost, patient inconvenience, radiation exposure and the

belief that mammography is unnecessary in the absence of symptoms."
Physician participation may be different between program sites with high and low
rescreening rates.

While the relationship between physician recommendation and

mammography use has been well established, a nurse’s role or other staff is not

cleariy understood.7 In a study by Tessaro, it was determined that nurse

practitioners (NPs) in public health need further education and skills training
related to cancer control.48 Other studies have reported NPs possess the

knowledge and the skills to educate women about cancer risk factors.49v 50

Therefore, they play important role in providing breast cancer screening

information to women.49v 51 It is also important that nurses be able to recognize

women’s concerns about radiation and pain with procedures so they can provide

information and support to these women.51 As with physician participation,
nurses and other clinical staff may contribute differently between program sites

with high and low rescreening rates.

15

c) Overcoming Barriers to Rescreening through Education
To increase rescreening rates, physicians and other health care providers

need to take an active role. Physicians often believe that they are offering

preventive services more often then their actual practice. 43 Patient education

together with provider education increased the rate of screening in those women

who were not screened in the past. 43 Patient education alone may not be the

significant factor but instead it may be due to the one-to-one interaction with the

nurse or physician who recommended screening.43 Provider education alone

was less effective in changing physician behavior for either clinical breast exam

(CBE) or mammography. 43
Without a physician recommendation, it is not surprising that many women
are not aware of the need for mammography. Lack of awareness of the

importance of breast cancer screening is an important predictor of non-
compliance for rescreening.45 42: 52 Many women have not thought about
mammography and in the absence of symptoms, feel that it is unnecessary.27s
52 As with breast cancer screening, many women are not aware of the need for
cervical cancer screening.53'55 Some women feel the test is unnecessary or of
no benefit.56 Other women who are not likely to be screened for cervical cancer

consider themselves not to be at risk for the disease.31- 54- 55. 57'63.

Women are also less likely to be screened for cervical cancer because of

the anxiety caused by receiving an abnormal cervical smear result.64‘71 Many

16

women are afraid to be tested for cervical cancer or they are embarrassed to

undergo the procedure.31v 54. 55. 5350: 72 Programs with more extensive
educational components may be able to overcome these barriers and therefore
will have higher rescreening rates. Providing more information about rescreening

has been associated with increased confidence in the service provision73 and

reduced anxiety71- 74

d) Characteristics that Distinguish Compliers from Non-compilers
Several characteristics distinguish women who are more likely to comply
with rescreening guidelines from those that are less likely to be rescreened.

Knowledge that risk increases after the age of fifty, perceived vulnerability to
breast cancer44 and family history of the disease were all associated with
adherence to mammography and BPE.40- 44 Women that thought they were

more vulnerable to the disease were more likely to receive a mammogram.44
Education, smoking status and knowledge that women older than 50 are at risk
for breast cancer differentiated those women who had a repeat mammogram
from those that had one in the past year.27

Weinberg cites it might be helpful to inform women of their personal risk
as women that belong to a high-risk category were more likely to participate
when invited for cancer screening.45 Weinberg also cites that caution must be

used so as not to create excess worry that might interfere with mammography

usage.45

17

d) Summary
Women may overlook screening for a variety of reasons: competing

medical demands, physicians not viewing these patients at risk or a lack of

patients awareness of breast cancer screening recommendation and benefits.433
Through education, women can be made to be less skeptic. Knowledge
and beliefs are significantly associated with ever having a mammogram stressing

the importance of education, guidelines for screening and the efficacy of

mammography.75 Most of the issues discussed could be addressed through
patient education by physicians and/or their office staff and through community
education programs. Health professionals can address fears and

misconceptions either in person or on the phone as both have been shown to

increase attendance.31- 63

18

CHAPTER 2

Methods

I. Selection of The Study Sites

The current study sites were selected based upon an analysis of
rescreening rates available from the local programs April 1998. Ten study sites
were chosen to compare and contrast to determine if there were systematic
differences among BCCC programs that might explain differences in rescreening
rates. Rescreening rates are calculated based upon whether or not a woman
returned for a second screening. To be eligible for a second screening, ten
months must have elapsed since the first screening. Five program sites were
chosen that had a lower rescreening rate than the Michigan state average and
five sites were selected with a higher rate than the state average.

From Table 7, one can see that the five lowest and five highest sites were
not chosen. Delta - Menominee was not included because the study
coordinators thought this site would be similar to Dickinson-Iron and Marquette,
the other two sites from the Upper Peninsula. Wayne and Detroit were not
included within the low rescreening group because these two sites were
undergoing a merger. The program coordinator for the newly created site would
not have the knowledge to answer questions regarding the past of both the
Wayne and Detroit programs. Program management at MDCH advised against
including Oakland within the study because this site was undergoing major

changes at the time. District #4, Northwest, Muskegum, Central Michigan and

19

Barry-Eaton also met the study selection criteria, however, MDCH program
management advised against their inclusion. Management suggested that Kent,
Calhoun, and Washtenaw would be more suitable based on their knowledge of

these programs.

Table 7: BCCCP Rescreening Rates, April 1998

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BCCCP Site 1“ # Eligible for 2"“ %
Screening 2"d Screening Rescreened
Screening

1 . Wayne 886 886 244 27.5
2. Central Michigan 236 215 68 31.6
3. Detroit 4835 4626 1838 39.7
4. Oakland 2925 2857 1 170 41.0
5. Kalamazoo 1841 1659 700 42.2
6. LMAS 1584 1544 659 42.7
7. Northwest 2233 2181 933 42.8
8. Chippewa 714 709 321 45.3
9. District # 4 1559 1501 721 48.0
1 0. Kent 3788 3629 1 744 48.1
1 1 . Calhoun 1085 1037 501 48.3
12. Western UP 821 780 385 49.4
13. Shiawassee 514 492 246 50.0
14. Michigan State Rate 45732 43861 22431 51 .1
1 5. Genessee 1 782 1 707 928 54.4
16. District 2 1650 1579 861 54.5
17. lngham 3913 3703 2061 55.7
18. Huron 2537 2387 1362 57.1
1 9. Lenawee 962 906 524 57.8
20. Washtenaw 1307 1264 732 57.9
21 . Muskegum 1943 1891 1109 58.6
22. Barry - Eaton 1025 990 595 60.1
23. District 10 3372 3243 2024 62.4
24. Marquette 1053 1025 662 64.6
25. St. Clair 1530 1462 960 65.7
26. Delta - Menominee 695 660 434 65.8
27. Dickinson - Iron 942 928 649 69.9

 

20

 

Table 8: Study Sites Selected and Rescreening Rate, April1998*

   

are rescreening rate group are shaded.

1This rescreening rate reported for LMAS was calculated for all clients enrolled in the program.
This rate reflects both the tribal and non-tribal components of the program.

2This rescreening rate reported for LMAS does not include any tribal clients. The tribal
component of this program was not considered when responses were given during the interview
as this information was not available therefore, this is the rate used for the LMAS program in
these analyses. The program coordinator was able to give responses only for the non-tribal
component.

The rescreening rates of the sites included within the study were tested to
see if they were significantly different than the overall Michigan state rate. The
test was done using a one-sample test for a binomial proportion. All rescreening
rates tested were either significantly higher or lower than the Michigan state rate

(p<.001).

II. Development of the Survey Instrument

A survey was designed by the study coordinators to collect data to test the
study hypotheses. The questions covered in the interviews with local program
coordinators were developed based on findings from previous client use of
service studies. A BCCCP coordinator from lngham County Health Department

reviewed an early draft of the survey. Revisions were made based on the

21

coordinator's input. lngham County was chosen because it had a rescreening
rate similar to the Michigan State overall rate and therefore it would not be
included as a study site. This coordinator was chosen as a consultant because
she was very knowledgeable, her BCCCP is a large program, has been in
existence a long period of time (since 1992) and was easily accessible. In
addition, input from all BCCCP Team members from MDCH was gathered and

considered during the development of the survey.

Ill. Pilot Study

A pilot study was conducted in July and August 1998 using two program
sites. During the pilot study, the instrument was evaluated to make sure that
questions were easy to understand and answer. The length of the interview was
monitored and a goal of an upper time limit of two hours was established. This
was done so that the length of the interview was tolerable and because program
coordinators” time is at a premium. Each interview within the pilot study lasted
approximately 2.5 hours. In order to decrease the interview time to less than two
hours, several questions that would not provide information that could be used to
test the study hypotheses were removed. Two interviews were conducted, one at
the Barry-Eaton County Health Department in Charlotte, Michigan and the other
at Genessee County Health Department in Flint, Michigan. The author, using the
survey, completed the interviews. These two sites were selected for several
reasons. They were easily accessible, as the driving time to each location was

less than one hour. These sites would also not be included within the study

22

sample because they had rescreening rates similar to the state average. Based
on the information gathered, revisions were made to the survey so that the data
collected could be easily entered into a SPSS database. Questions were

phrased so that they would be close-ended and coded for easy data entry.

IV. Data Collection

Data for the complete study were collected using the revised survey. The
survey was administered in interviews conducted on the telephone. Initially,
interviews were to be conducted at each program’s site, however, based on cost,
time and winter weather conditions, telephone interviews were performed. Two
research assistants who were trained to the survey instrument by the study's
coordinators administered the interviews. The program coordinators at each
BCCCP site provided almost all information with some additional input from other
staff members at several of the sites. Program coordinators were chosen to
complete the interviews because they oversee the operation of each BCCCP and
are very knowledgeable about all aspects of the local program.

During the last week of December 1998 and the first week of January
1999, one of the study coordinators carried out the first contact to the local
BCCCP coordinators. This contact was made by phone to describe the survey
and interview process and to invite the program to participate. A follow-up letter
was also sent. If the coordinator could not be contacted by phone, a letter was
sent describing the study and then a follow-up call was made. Copies of the

survey were sent to all sites prior to the interviews. Some sites requested a copy

23

of the interview to review prior to making the decision to participate and others
did not. The program coordinators of the ten participating sites were then
contacted by telephone beginning January 20 to schedule appointments to
complete surveys during the next four weeks. Each interview required between
90-120 minutes to complete depending on the individual responses given.

After the last interview was completed, the data collected were entered
into an SPSS database. To double check for entry accuracy, 10% of each BCCC
program site’s data were selected randomly and re-entered. All of the data were

recorded accurately.

V. Statistical Methods

The Likert scale options (to no extent, little extent, some extent, great
extent or very great extent) for answers to each question on the survey, were
collapsed into two categories: little or some extent and great or very great extent.
For the question if number of planned for client contacts differed between the two
rescreening rate groups, the number of allowed for contacts was categorized as
4 or less and 5 or more. Fisher’s exact test for 2x2 tables was used to test for
differences between low and high rescreening rate programs to answer various
questions of interest. A one-tailed test was used given that the study hypotheses
always hypothesized that:

Programs with higher rescreening rates would have:

. more standardized (clearer) procedures

0 more matching of the service provision process to client needs

24

o more client-convenient screening arrangements
. more planned for client input / feedback
. planned educational interventions for new and returning program
participants
Given the small sample size, this study lacked the power to detect many
differences at an alpha of .05. All observed differences at p<.10 level are

reported in the results section.

VI. Study Hypotheses and Questions Related to Each
Each hypothesis and the corresponding questions asked during the study
interviews are listed below.
1. BCCC Programs with higher rescreening rates will have more standardized
(clearer) procedures - Question 8, 10 11, 12.
Question 8. To what extent does your program have in place standard operating
procedures or practices (SOP) for the following client-related interactions:
A. Enrollment
Assisting with completion of enrollment
Assisting with translation when needed
Follow-up of missed clinic appointments
Follow-up of missed mammography appointments
Reporting screening results and recommendations to the client

. Tracking clients with abnormal screening results

IQWWPPW

. Tracking treatment initiation for clients with diagnosis of cancer

25

Patient education
J. Keeping clients out of the bill collection process
K. Reminding women about rescreening appointments

L. Changing client contact information, e.g., phone, address

.3

Arranging transportation to appointments

N. Scheduling rescreening appointments
Interviewees were given five categories from which to choose from: to no extent,
little extent, some extent, great extent or very great extent. Program coordinators
were also asked whether or not the SOPs were written down and the percentage
that each were estimated to be followed.
8b. SOP is written down?
8c. % of time SOP is followed (estimate).
8d. Are the above the same for all screening sites? (This question was asked if
the program was an indirect/subcontracted or a combination service delivery
model).
8e. If no, please briefly describe what you know about the above procedures
across the various service delivery sites in your BCCCP using the above matrix.
Question 10. We are interested in learning about the various systems that may
be in place for reminding clients that they are due to be rescreened. Please
describe in detail how this process works in your BCCCP. Walk through the
process for a hypothetical client from start to finish. For example, include the
type of contact(s) made to the client, who makes the contact(s), when the

contacts occur in relation to the anniversary date, the number of contacts

26

attempted (by phone, by mail, in person), and whether the number of contacts
made is standardized (a specific procedure exists).
Question 10f. Are the above the same for all screening sites? (This question
was asked if the program was an indirect/subcontracted or a combination service
delivery model).
Question 109. If no, please briefly describe what you know about client reminder
systems across the various service delivery sites in your BCCCP.
Question 11. Does your BCCC Program use any of the following systems to
remind local coordinating agency staff when clients are due to be screened?

A. Flow charts or “tickler files” to let local coordinating agency staff know

whether clients are due for rescreening
B. Computerized reports of clients’ due dates to remind local coordinating
agency staff when clients are due for rescreening

C. Other (Please specify)
11d. Are the above the same for all screening sites? (This question was asked if
the program was an indirect/subcontracted or a combination service delivery
model).
116. If no, please briefly describe what you know about staff reminder systems
across the various service delivery sites in your BCCCP. Include such things as
reminders from mammography sites regarding rescreening mammograms.
Question 123. Has your local coordinating agency always used the same type of
rescreening reminder systems? If no, which of the following did you use

previously? Check if used previously but not now:

27

Question 12b. Client Reminder Systems:
A. Letter
B. Postcard
C. Phone
D. Other personal (not phone)
E. Reminder wallet cards
F. Other (please specify
Question 12c. Staff Reminder
A. Flow charts or "tickler files”
B. Computerized reports of clients’ due dates
C. Other (please specify)
Question 12d. Do you know of past differences in reminder systems across the
various screening sites (differences not addressed above)? (This question was
asked if the program was an indirect/subcontracted or a combination service
delivery model).
Question12e. If yes, please describe what used to be used for either client
reminding or staff reminding but is NQI now and which part of your

screening delivery system used it.

2. BCCC Programs with higher rescreening rates will have more client-
convenient screening arrangements - Question 16, 17.
Question 16. In your opinion, to what extent are screening arrangements

convenient for your clients in relation to the following factors?

28

G.

7"?"999’?’

Location of clinical screening

Location of mammography screening
Transportation

Time (amount required to complete services)
Appointment availability (time of day; day of week)
Enrollment process (ease of completing)

Other (Please Specify)

Question 17a. Have any of the convenience factors changed over time for your

clients?

If yes,

Question 17b. What has changed?

Question 17c. When did it change?

3. BCCC Programs with higher rescreening rates will have more matching of the

service provision process to client needs - Question 18, 19.

Question 18. To what extent has your program assessed special client needs

related to the following considerations and modified the process of service

provision to meet any special needs identified?

A.

WPQF’

Older Age
Language
Educational level
Cultural background

Physical disability

29

F. Mental disability

G. Sexual orientation

H. Desire for a female clinical service provider

I. Other (Please Specify)
Interviewees were given five categories from which to choose from: to no extent,
little extent, some extent, great extent or very great extent.
Question 19a. Does your BCCC Program use female physicians, nurses and/or
physician assistants to provide the clinical examination?
Interviewees were given five categories from which to choose from: never, rarely,
sometimes, frequently and always.
Question 19b. Do your Program’s other screening sites use female practitioners
to provide the clinical examination? (This question was asked if the program was
an indirect/subcontracted or a combination service delivery model).
Interviewees were given five categories from which to choose from: never, rarely,
sometimes, frequently and always.
Question 190. Is the situation now, different than in the past?
lfyes,
Question 19d. What has changed? How did it change?

Question 19e. When did it change?

30

4. BCCC Programs with higher rescreening rates will have more planned for

client input / feedback - Question 20, 21, 22.

Question 20a. Has your local BCCCP gathered client input or feedback on

service provision?

Question 20b. If yes:

Methods of soliciting client input & feedback on local BCCCP:

A.

F.

G.

Ongoing gathering of client satisfaction information in a systematic way

(e.g., through surveys, interviews, focus groups)

. Periodic gathering of client satisfaction information in a systematic way

(e.g., through surveys, interviews, focus groups)

. Client satisfaction information has been gathered in the past but

currently there is no standing plan for when this occurs
Involvement of clients &/or representatives from client communities
targeted for outreach in the planning & implementation of recruitment

and promotion efforts

. Client participation on local BCCCP steering committees

Client special needs assessments

Other (Please specify)

Question 20c. When in effect?

Question 21. If your program currently gathers client input or feedback, please

briefly describe how this is carried out.

31

Question 22. If client input / feedback has been gathered by survey, interview,
focus group or other systematic way, how was this information used? (For

example, was service delivery modified?)

5. BCCC Programs will have more planned educational interventions for new
and returning program participants - Question 14, 15.

Question 14. Please discuss objectives of the education component, methods
and materials used, usual amount of time allocated, and professional
backgrounds of staff (paid and volunteer) that plan and I or carry out the
education. If you have a written plan that addresses these aspects, you may
attach it as your response.
Question 15a. Has any aspect of your educational component changed over
time?
Question 15b. If yes to 15a:

A. What used to be done, that isn’t done now?

B. What is done now, that was not done earlier?
Question 150. Do you know of differences in education across the various
screening sites (differences not addressed above)? (This question was asked if
the program was an indirect/subcontracted or a combination service delivery
model).
Question 15d. If yes, please describe what is carried out at the other screening

shes.

32

The following question was included that could be related to any of the
study hypotheses:

Question 34. What is your single most important recommendation for increasing

rescreening rates? (For example, what has been the most successful strategy

for your Program to date in increasing rescreening rates?)

In addition to questions addressing the study hypotheses, several
questions were included to gather demographic information about each program
— Question 4, 5, 6 and 7.

Question 4a. The information provided in the Profiles database indicates that

your BCCC Program uses the following service delivery model for the clinical

office visit. Is this information correct? There are three service delivery models,

Direct/ln-house, Indirect/subcontracted and Combination.

Definitions of Service delivery models:

Direct/ ln-house: all clinical screening services (clinical breast examination, pap
test and pelvic examination) are provided at the local health
department.

Indirect I Subcontracted: no clinical screening services are provided at the local
health department.

Combination: some women receive the clinical screening services from the local
health department and some receive the clinical screening services
from subcontractors.

Question 4b. If no, check the model your program uses.

33

Question 4c. Briefly describe your clinical screening service delivery model, not
using the above terms. Include any other terms that you use to
describe your program’s model for service delivery.

Question 4d. If you use a combination model:

( 1 ) What percent of your caseload receives the clinical screening
services in-house?

( 2 ) What percent of your caseload receives the clinical screening
services from subcontracted providers?

Question 5a. Has the service delivery model that your local program uses ever

changed (e.g., from in-house to subcontracted?)

Question 5b. If yes, what other models have been used?

Question 50. Dates in Effect (General estimate is OK)

Question 6b. If the area is best described as combination:

( 1 ) Approximately what percent of your caseload is urban?
( 2 ) Approximately what percent of your caseload is rural?

Question 7. Since your local BCCC Program began, to what extent has staff

turnover within the following areas been a problem?
A. Program Coordinator

Nurse Practitioner

Other clinical staff

Subcontracted clinical screening providers

Staff responsible for scheduling / enrolling

7"!"39?’

Staff responsible for tracking

34

G. Staff responsible for billing
H. Staff responsible for data entry

I. Staff responsible for case management

35

CHAPTER 3

Results

I. Standardized (clearer) Procedures

A. Standard Operating Procedures - SOPs: Programs with a high rescreening
rate were more likely to have in place a SOP for follow-up of missed
mammography appointments (p=.083) and enrollment (p=.083). The
categories to no extent, little extent, some extent, great extent and very great
extent were collapsed into two categories, to little or some extent and to a
great or very great extent to measure this difference. Because no one

reported to no extent, a third category was not necessary.

Table 9: Enrollment”

0 or
some extent

 

group are shaded.

36

Table 10: Follow-up Missed Mammography‘

c or o a or
some extent extent

 

are group are shaded.

For the remaining SOPs tested:
0 Assisting with completion of enrollment
. Assisting with translation when needed
0 Follow-up of missed clinic appointments
0 Reporting screening results and recommendations to the client
. Tracking clients with abnormal screening results
0 Tracking treatment initiation for clients with diagnosis of cancer
0 Patient education
0 Keeping clients out of the bill collection process
0 Reminding women about rescreening appointments
. Changing client contact information, e.g., phone, address
0 Arranging transportation to appointments
0 Scheduling rescreening appointments
programs with the highest rescreening rates do not look different from those with

the low rescreening rates. Whether the SOP was written down or not, was not

37

different between rescreening groups. The percentage of time each SOP was

followed was also not different between the high and low groups.

B. Client Reminder Systems that include more planned-for contacts (letter,
postcard, reminder wallet card, anniversary calendar, phone call and
confirmation of appointment by letter) from the program to women eligible for
rescreening were associated with higher rescreening rates (p=.024). To test
this difference statistically, the number of planned-for contacts (includes the
total number of contacts allowed for in each program’s client reminder
system) were collapsed into two categories, 4 or less and five or more. This
was also done for personal and non-personal client reminders but a

significant difference between rescreening groups was not found.

38

Table 1 1: Summary of Client Reminder System1

Contacts Allowed Personal Contacts Personal Contacts
For Allowed For Allowed For

    

are group are

2This figure includes an anniversary calendar used during the past two years, but they have
stopped using these calendars this year.

3 District 10 sends out a confirmation of appointment letter that was reported in the Fall, 1998
survey.

‘ Contacted until a response is obtained.

Table 12: Number of Client Reminders”

Of or

 

Programs that are included within the high rescreening rate group are shaded.

C. Staff Reminders includes three different systems used by BCCC Programs to
let local coordinating agency staff know whether clients are due for
rescreening: flow charts or “tickler files", computerized reports of clients' due

dates and flag color code by month and rescreening anniversary. Staff

39

Reminder Systems were not statistically different for programs with low or

high rescreening rates.

Table 13: Staff Reminder Systems1

or
files" to let local reports of clients' due by
coordinating agency dates to remind local Month and
staff know whether coordinating agency Rescreening
clients are due for staff when clients are Anniversary
due for

 

Programs that are included within the high rescreening rate group are shaded.
2 This reminder system is the same for all screening sites within this program.

ll. Matching of the Service Provision Process to Client Needs
A. Programs with high and low rescreening rates did not differ on how they
assessed special client needs related to the following considerations and
modified the process of service provision to meet any special needs
identified:
0 Older age
0 Language
0 Education level

0 Cultural background

40

0 Physical disability
0 Mental disability
. Sexual orientation
0 Desire for a female clinical service provider
B. Use of Female Health Care Practitioners: There were no statistical

differences between programs with high and low rescreening rates.

Ill. Convenience of Screening Arrangements
Program sites with lower rescreening rates appeared more likely to report a
change over time in convenience factors then those with higher rates (p=.083).
With the exception of one site, the changes that occurred resulted in more
convenient screening arrangements. This site reported an increased wait for
mammograms but did report more time allocated for clinics this past year. The
other programs with lower rates reported an increase in at least one of the
following: the number of mammography and screening sites, more time available
at the site, and mammograms scheduled on the same day as a women’s visit to
the BCCCP. Other than this finding, there were no statistical differences with
regard to any of the following rescreening arrangements between the low and
high groups:

. Location of clinical screening

. Location of mammography screening

0 Transportation

. Time (amount required to complete services)

41

. Appointment availability (time of day; day of week)

0 Enrollment process (ease of completing).
Table 14: Convenience Factors — Have They Changed Over Time or Not”

program was a
for 1.5 years when it first began. Since
to subcontracted, the program has
more convenient for women. It has
allowed more screening to be performed
less staff.

, this program began setting up
more consistently so that the
mammography would occur on the
day as the rescreening appointment at
department. The mammography facilities
working more closely with the program to
this.

year
to make an appointment) but more time

clinics has been made available this

from 5 in 1992 to 11 in 1996 to 14 in 1999.
program
and clinical screening at a local
in 1996-97.

 

Programs that are included within the high rescreening rate group are shaded.

42

IV. Client Needs and Feedback

Client Needs and Feedback includes collection of client input or feedback on
service provision and matching of services provided to client need. There are no
apparent differences between programs with higher or lower rescreening rates
related to systematic collection of client feedback, informal feedback,
involvement of clients in recmitment or on steering committees, or with special

needs assessments.

V. Patient Education

Includes a description of content covered, general objectives of the education
component, methods, materials, time allotted and staffing. There were no
differences between the programs surveyed on the educational elements
covered.

The responses to the question asking for the single most important
recommendation for increasing rescreening rates were the same for nine of 10
program sites. The nine program sites emphasized the importance of the
personal (phone) contact as the single most important recommendation for

increasing rescreening rates.
VI. Program Demographics

There was no difference between high and low rescreening groups with

respect to service delivery models. The populations of the areas from which the

43

cases were drawn were also not different between the two rescreening groups.

Staff turnover in the following areas did not differ between rescreening groups:

A.

,Iomrnposn

Program Coordinator

Nurse Practitioner

Other clinical staff

Subcontracted clinical screening providers
Staff responsible for scheduling / enrolling
Staff responsible for tracking

Staff responsible for billing

Staff responsible for data entry

Staff responsible for case management

Programs that were indirect/subcontracted or combination service delivery

models were asked an additional question (Are the above the same for all

screening sites?) in several areas of the survey. For all of these questions, there

were no differences reported for any of the study sites.

Table 15: Service Delivery Models1

Subcontracted

      

are group are
2 Kent was a combination model prior to 1998. This percentage represents women that are seen
in-house, the remaining % receive clinical screening services from subcontracted providers.

3 % of women that are seen in-house, the remaining % receive clinical screening services from
subcontracted providers.

Table 16: Previous Models Used

Earlier Models ln-house Subcontracted
program

 

45

Table 17: Description of the Area that Caseload is Drawn From1

    

are group are
2 % of caseload that is urban. The remaining % is rural caseload.

Table 18: BCCCPs Most Important Recommendation for Increasing Rescreening
Rates*

- see
Bronson do this in the near future as are it.

survivors performing the outreach to demonstrate the importance of
- more
works!

them want to come for

 

46

CHAPTER 4

Discussion

It was hypothesized that programs with more clear standardized operating
procedures would have higher rescreening rates. Fourteen SOPs were tested to
see whether each was associated differently with either the low or high
rescreening groups. Only two of the SOPs tested approached statistical
significance: follow-up of missed mammography appointments and enrollment,
as they were more likely to be in place in programs with high rescreening rates
(p=.083).

Programs with high rescreening rates had significantly more planned-for
client contacts (such as phone call and letter reminders) than programs with low
rescreening rates (p=.024). Personal contacts, as a sub-category, did not differ
significantly between the two rescreening groups. However, the importance of
personal contacts was emphasized by the nearly all sites as the most important
recommendation for increasing rescreening rates. Nine out of the ten study sites
cited personal (phone) contacts as the most effective means of increasing
rescreening rates. In addition, the two programs with the highest rescreening
specifically mentioned the importance of quality care and a positive experience
when identifying the most important recommendations for increasing rescreening
rates.

Compliance with routine screening has been associated with convenience

factors like distance from facilities27 and inconvenient hours.31 Most of the

47

convenience factors examined within this study did not differ between low and
high rescreening groups. Program sites with lower rescreening rates were,
however, more likely to report a change in the convenience of screening
arrangements. For the most part, these changes were positive and occurred
within the past two years. Enough time since the changes may not have past for
an effect to be measureable.

More matching of the service provision process was not found in programs

with higher rescreening rates. Several studies have shown women are more

likely to be screened by a female provider. 33’35 Within this study, all of the
program sites reported using female health care practitioners almost exclusively.
Consequently, a difference between low and high rescreening rates was not
there to be measured relating to a program site’s use of a female health
practitioner.

Previous mammography experiences, whether they be positive or
negative, have been associated with rescreening behavior.25v 40. 41 Programs
with high rescreening rates were hypothesized to have more planned for client
input/feedback as they might be better able to address negative experiences. A
difference between rescreening groups was not found related to client
input/feedback.

Many women are not screened for breast or cervical cancer because they
do not feel that they are at risk. 31- 42. 45. 52- 54: 55. 57'53 Researchers have

reported that by educating women about the risk factors for breast cancer, they

may become more motivated to comply with regular screening.27v 4345 For

48

these reasons, it was hypothesized that programs with higher rescreening rates
would have more planned educational interventions for new and returning
program participants than programs with lower rates. The education components

of the BCCCPs within the study did not differ across rescreening groups.

Limitations of the Study

This study was controlled by conditions of the BCCCP. There were only
so many sites that could be included within the study and from these, a sample
size of nearly 50 percent was chosen. Within the results section, differences
were reported if p-values were <.10. Despite the small sample size, some
significant differences between the low and high rescreening groups were found.
It is not clear whether other differences exist but were not detectable given the
small sample size of this study.

When calculating the rescreening rate, the number of women who have
not returned for a second screening includes some of those who are inactive to
the BCCCP (those who have moved, died or become ineligible). All inactive
clients should be removed to calculate this rate, however, the study coordinators
believe that not all inactive clients are indicated in the BCCCP database.
Consequently, the estimated rescreening rates that have been reported within
this thesis may have slightly underestimated the true program rescreening rates.

lnforrnation regarding the education component of three program sites
was not provided during the study interviews. These three sites, Kent,

Kalamazoo and Washtenaw have subcontracted/indirect service delivery models.

49

Consequently, the program coordinators were uncertain what type of educational
component each of the program’s subcontracted providers had in place. Given
an even smaller number of sites to analyze, it is not surprising that differences
were not found between low and high rescreening sites. Given more time or
possibly in a follow-up study, subcontracted providers could be contacted to
determine the education component in place at each site.

The BCCCP at LMAS has two components, a non-tribal and a tribal. The
program coordinator at LMAS was only able to provide information about the
non-tribal component of this BCCCP. The tribal component of this program was
not considered when responses were given during the interview as this

information was not available.

If this study could be expanded to include all of the sites within the
BCCCP, more statistical power would be available to see what is different about
sites with low and high rates. Adequate power might also be available to test for
trends. Future studies should include sub-contracted service providers to fully
understand what is happening in the sites who use them. It would also be
beneficial to include more questions for program coordinators on what they
thought made a difference in rescreening. In addition to the question asking for
their most important recommendation for increasing rescreening rates, the basis
for their response or the characteristics they chose as being most important
might be useful to ascertain.

In addition to the program factors that this study addresses, personal

characteristics that motivated women to obtain rescreening are currently being

50

studied within Michigan’s BCCCP in a separate study. The preliminary results

from this study indicate that women with the following characteristics were

significantly more likely to return to the program for their second screening:

Age 50-64 years

Higher than high school education

Had at least one mammogram before enrollment in the BCCCP
Had at least one Pap smear test before enrollment in the BCCCP
Heard about the BCCCP from media sources (e.g. Radio, TV)
Heard about the BCCCP from written materials (e.g. brochures)

Heard about the BCCCP from a personal contact (e.g. friend, co-
worker)

Has a regular health care provider

White race group

Former or never-smoker

This study was restricted to the variables that were available within the BCCCP

database. It would be useful to collect more information from the BCCCP clients

regarding the specific factors that motivated them to return for rescreening (e.g.

was it the client reminder system, the education they received or the

convenience of the program).

51

Conclusion

Within this study, a null result was found for many of the hypotheses
tested. Programs with higher rescreening rates, for the most part, did not appear
to have more standardized (clearer) procedures or matching of the service
provision process to client needs. Programs with high rates did not have more
planned for client input/feedback nor did education components appear to be
different.

The main finding of this study indicates that client reminder systems are
the most important program factor associated with higher rescreening rates.
Nine of 10 program sites emphasized the importance of the personal (phone)
contact as the single most important recommendation for increasing rescreening
rates. The data indicate something slightly different as programs that are more
persistent and have implemented more planned-for contacts are better able to
bring women back for rescreening. However, the two of the five programs with
higher rescreening rates not only have more planned-for client contacts, but they
also mentioned the importance of quality care. Perhaps the important factor at
work here is the expression of concern for the participant's well being with each
attempted contact. With adequate resources, all BCCCP local sites can take
this approach which can be expected to yield significant improvement in

rescreening rates across the program.

52

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