- Email: [email protected]
Beliefs Regarding Mammography Screening Among Women Visiting the Emergency Department for Nonurgent Care
RESEARCH
BELIEFS REGARDING MAMMOGRAPHY SCREENING AMONG WOMEN VISITING THE EMERGENCY DEPARTMENT FOR NONURGENT CARE Authors: Jennifer Hatcher-Keller, PhD, MPH, RN, Mary Kay Rayens, PhD, Mark Dignan, PhD, MPH, Nancy Schoenberg, PhD, and Penne Allison, RN, Lexington, KY Introduction: One in 8 US women will develop invasive
breast cancer in their lifetime. Despite evidence that mammography is an effective method of early detection, certain vulnerable groups, such as those using the emergency department as a medical home, do not adhere to mammography screening guidelines, and suffer disparate mortality from breast cancer. The purpose of this study was to investigate differences in beliefs regarding mammography screening among women attending the emergency department for nonurgent care and ultimately to develop interventions that promote mammography for this vulnerable population. Methods: We explored the relationship between stage of
readiness to adopt mammography behavior and barriers, benefits, and perceived susceptibility by administering scales for risk, benefits, and barriers to a sample of 110 women who had presented to the emergency department of a public hospital for nonurgent complaints or were seated in the ED waiting room. We also collected sociodemographic information and stage of readiness. Results: Mammography adherence was about 60%. Most women who were not compliant with current guidelines were
Jennifer Hatcher-Keller is Associate Professor, University of Kentucky College of Nursing, Lexington, KY. Mary Kay Rayens is Professor, University of Kentucky College of Nursing, Lexington, KY. Mark Dignan is Professor, Internal Medicine Department, University of Kentucky Chandler Medical Center, Lexington, KY. Nancy Schoenberg is Marion Pearsall endowed Professor, University of Kentucky Behavioral Sciences, Lexington, KY. Penne Allison, Member, Bluegrass Chapter ENA, is Director of Emergency Services, University of Kentucky HealthCare Hospitals, Lexington, KY. For correspondence, write: Jennifer Hatcher-Keller, PhD, MPH, RN, 3024 Blackford Parkway, Lexington, KY 40509; E-mail: [email protected]. J Emerg Nurs 2014;40:e27-e35. Available online 9 March 2013. 0099-1767/$36.00 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.01.015
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contemplators. Those who were not contemplating being screened were significantly less likely to perceive themselves to be at risk of getting breast cancer. Women who had more barriers to mammography perceived less benefit from having a mammogram. African American women perceived less benefit from having a mammogram. Discussion: Mammography promotion is appropriately placed in the ED waiting room given the suboptimal rate at which this population is being screened. Beliefs regarding mammography differ for women in various stages of mammography adoption and for minority women. Understanding these differences will allow intervention in this setting to be tailored to the population. ED nurses are an important and sometimes sole point of health care contact for patients who routinely visit the emergency department. As such, they have a valuable opportunity to provide cancer screening promotion messages. It is critical that nurses in this setting understand the complexities of delivering this information and the need to do so. Key words: Mammography; Nonurgent care; Cancer control;
Stages of change
nvasive breast cancer will develop in 1 in 8 women in the United States during their lifetime. The American Cancer Society (ACS) estimates that more than 40,000 women will die from breast cancer in 2013, making it the second leading cause of cancer death among American women, exceeded only by lung cancer. 1–3 Screening mammography is the single most effective method of early detection of breast cancer and can identify cancer several years before physical symptoms occur. 4 Early detection by mammography generally leads to a greater range of treatment 5 options, including less-aggressive surgeries and therapies. Women aged 50 to 69 years and 40 to 49 years who are regularly screened may experience a reduction in mortality by 4 as much as 20% to 35% and 20%, respectively. Healthy People 2020 set a national standard for mammography utilization of 81% for women older than 40 years to be screened every other year. 6 Despite increasing
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adherence to screening recommendations and improvements in breast cancer treatments, certain vulnerable populations have not realized decreased mortality rates documented in the population at large. 7 Such women may not receive health care providers' recommendations for screening, the strongest predictor of adopting screening. 8,9 Among the women most vulnerable to inadequate screening are women who lack a regular source of care, including those who visit emergency departments. Women who visit the emergency department for nonurgent care have had demonstrably lower mammography screening rates than the U.S. average, establishing the need for mammography-promoting programs aimed at this population 10,11 and delivered in this setting. Overall, 1 in 5 Americans visits the emergency department each year. 12 Many of these visits are made by the most vulnerable members of society and are for nonurgent complaints. Older adults are more likely to have had at least one ED visit in a 12-month period than are people in younger age groups. Non-Hispanic black persons are more likely to have had one or more ED visits in a 12-month period than are non-Hispanic white or Hispanic persons. As family income decreases, the likelihood of having one or more ED visits in the past year increases. 12 These persons are the same ones who are likely not to have been screened in a timely and regular manner for breast cancer. This pattern of ED visits by these vulnerable persons may present an opportunity, because the emergency department may be the sole point of contact with the health care system for many of them. 13 A “teachable moment” may occur when the patient is ready to accept new information. 14 Patients are more likely to become motivated to make health behavior changes when they are approached during key times when their attention is focused on their health, such as while they are in the emergency department. Their attention to their health care needs is heightened at that time. This heightened attention of patients and family during ED visits may provide an important opportunity for patient education. 15 The purpose of this study was to investigate differences in beliefs regarding mammography screening among women attending the emergency department for nonurgent care. To develop interventions that promote mammography for this vulnerable population, it is important to understand the beliefs that may influence the decision to obtain a mammogram. Although the emergency department presents unique challenges to health promotion activity, it also may provide one of the few opportunities for intervention with a population that may likely be rarely or never screened for
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breast cancer and is at high risk of increased mortality because of late-stage diagnosis. Mammography Promotion in the Emergency Department
Despite the suggestion that the emergency department is a location where preventive health care would be feasible and welcomed, 10 few interventions to promote mammography screening in this setting have been implemented. Most notable have been the studies conducted in the Harlem emergency department by Mandelblatt and colleagues 16 and the work in the Boston Medical Center ED by Bernstein and colleagues. 17 Mandelblatt and colleagues 16 offered screening for cancers of the breast and cervix to women with nonemergency problems who presented to the emergency department of a large, urban public hospital. They concluded that it was indeed feasible to screen for breast and cervical cancer in the emergency department. They also concluded that a key barrier to this intervention was the involvement of the ED staff. The triage nurse and other staff members were busy with other patient care needs and did not screen all eligible patients. This study highlighted the need for interventions that involved others, such as lay health workers, who have been shown to be effective in similar settings. 18,19 Bernstein and colleagues 17 conducted a similar study in the emergency department of Boston Medical Center that was designed to test a lay health worker-delivered intervention to increase the regularity of mammography in a diverse population of inner-city women, primarily older African American women. Although 65% of the 90 women had never had a mammogram, 60% of the women reported having a mammogram sometime in the 3 months after the intervention. The researchers concluded that the success of the intervention was attributable to the interactive format and the interchange that took place between peers. They suggested that more research, including a randomized controlled trial of several types of interventions, including lay health worker-delivered and negotiated interviews, be undertaken to establish comparative efficacy in this setting. One important way to increase the efficacy of these interventions is to deepen our understanding of the variables related to mammography decision making for this population. 20 This study provides a foundation for designing mammography promotion interventions that are more tailored to the specific needs of the population served in the emergency department for nonurgent care by examining key beliefs regarding screening that may influence their screening decisions.
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Theoretical Framework
To understand the stages women may progress through when adopting behavior change and to account for perceived disease threats and barriers and benefits to a particular behavior, we used the Transtheoretical Model and the Health Belief Model (HBM), respectively. 21,22 The fundamental concept of the Transtheoretical Model is that people progress through a series of progressively more committed stages as they progress toward adopting a healthrelated behavior such as mammography. 21 The HBM addresses an individual's perception of the threat posed by a problem (eg, susceptibility and severity), the benefits of avoiding the threat, and the factors that influence the decision to act (ie, barriers and benefits). 22 With this theoretical backdrop, we explored the relationship between stage of readiness to adopt mammography behavior and barriers, benefits, and perceived susceptibility for women who are using the emergency department for nonurgent care. Specifically, the aims of this study were to investigate differences in beliefs regarding mammography screening, including perceived susceptibility and perceived benefits and barriers, among women attending the emergency department for nonurgent care; to determine if those beliefs differ by stage of screening adoption; and to determine the demographic and personal factors that predict perceived susceptibility, benefits, and barriers of mammography.
which allowed the ED staff to screen for the urgency of the patients’ complaints and to examine demographic criteria commonly collected at triage. The research assistant also approached women who were seated in the waiting area and appeared to fit study criteria, and asked if they would be willing to participate in the study. She then screened the women for age eligibility. Women who agreed to participate in the study were interviewed in a private room of the emergency department. Recruitment flyers were placed in the emergency department to encourage women who visited when the research assistant was not present to call in if they met the listed eligibility criteria and were interested in participating in the study. Women were also recruited using a snowball technique. Those who had previously participated in the study were mailed letters of appreciation with several recruitment flyers included. They were invited to recommend friends who had been seen in the emergency department in the past 6 months for the study and to give the flyers to any friends they thought might be eligible. They were given a phone number to call to suggest women for the study. The women recruited using this method either called study personnel or were contacted by phone, using the information supplied by the previous participants. Eligibility for the study was determined by phone, and the interviews were conducted in person at a location convenient to the participant. We recruited 110 participants to the study; each was given a $20 cash incentive after survey completion.
Methods
INSTRUMENTS
SAMPLE
Demographic and Personal Items
Data for this study were collected from a convenience sample of 110 women who had presented to the emergency department of a public hospital with nonurgent complaints within the past 6 months or those who were seated in the waiting area of the emergency department. We enrolled English-speaking women who met the age eligibility guidelines for mammography from the ACS: annual mammograms for women aged 40 years and older. 2 All protocols were approved by the University's Institutional Review Board.
Demographic information was collected on age, race/ ethnicity, years of education, marital status, whether the woman had access to a primary care provider, and health insurance status.
RECRUITMENT
We used several recruitment strategies for this study. Women who were visiting the emergency department were contacted by a trained research assistant stationed in the emergency department during various shifts. The research assistants used a variety of methods to recruit women in the emergency department. These methods included inquiring at triage if eligible women were present in treatment rooms,
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Mammography Stage Women were asked if they had a mammogram in the past year or ever had one, based on the guidelines of the ACS, which recommends mammograms every year for women older than 40 years. 3 If they had not had a mammogram in the past year or had never had one, they were asked how likely they were to have one in the next 6 months, with options of “I will certainly get a mammogram in the next 6 months,” “it is somewhat likely,” “it is not very likely,” “I will definitely will not get a mammogram in the next 6 months,” and “don't know.” 23 Using their responses to how recently they had a mammogram and the likelihood they would get one in the next 6 months, each participant was
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classified into one of the 3 stages; precontemplation, contemplation, or action. Women who said, “It is not very likely that I will get a mammogram in the next 6 months,” “I definitely will not get a mammogram in the next 6 months,” or “don't know” were classified as precontemplators, whereas those who responded “I will certainly get a mammogram in the next 6 months” or “It is somewhat likely” were considered contemplators. Women who had had a mammogram in the past year were classified in the “action” stage of readiness. Perceived Susceptibility Based on the HBM, perceived susceptibility is a measure of the threat a person feels that a disease poses to their health. Theoretically, before health-promoting behaviors will occur, a threat must be recognized, which was measured using a 5item scale. 23 These items were previously tested for validity and reliability. 23 Items measured the perceived general likelihood of getting breast cancer, chances of getting breast cancer “sometime during my life,” and other like questions. The scale used a 5-point Likert format with possible responses ranging from 1 = “strongly disagree” to 5 = “strongly agree.” The range of possible total scores was 5 to 20, with higher scores indicating greater perceived susceptibility. The scale had a reliability of 0.84 in this sample. Perceived Benefits and Barriers The benefits of and barriers to mammography were measured by scales based on the HBM constructs of benefits and barriers. Perceived benefits in this context are defined as those related to the perceived positive outcomes of obtaining a mammogram, such as increased chances of early detection, better treatment options, and increased chance of survival. 24 Perceived barriers of mammography are defined as emotional, physical, or structural concerns related to mammography behaviors, including pain, fear of radiation, and cost. 24 These scales also have been previously tested for validity and reliability. 25 Both scales used a 5point Likert format from 1 = “strongly disagree” to 5 = “strongly agree”. The 4 benefits of mammography items assessed help in finding breast lumps early, decreased need for extensive treatment, perceived best way to find small lumps, and decreased chances of dying from breast cancer. Reliability for the scale was 0.64 for this sample, and the range of possible scores was from 4 to 16, with higher scores indicating greater rating of the benefits of mammography. The 13-item barriers to mammography scale assessed fear, lack of understanding, embarrassment, time, pain, and other factors identified in the literature as potential barriers to mammography. The reliability of the barriers subscale in
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this sample was 0.89, and the potential total score ranged from 13 to 52. DATA ANALYSIS
For the purpose of analysis, race/ethnicity was coded as a binary indicator variable (0 = white; 1 = other racial/ethnic category), as was years of education (0 = less than high school; 1 = at least high school), and marital status (1 = married; 0 = other marital status). The indicator variables for primary care provider status and health care insurance status both had yes/no response options and were coded as 1 = yes and 0 = no. Descriptive statistics, including means and standard deviations or frequency distributions, were calculated. Internal consistency of each of the 3 subscales was determined using Cronbach's α. Pearson's product moment correlation was used to assess linear associations among the 3 subscales of susceptibility, benefits, and barriers. One-way analysis of variance was used to compare means for susceptibility, benefits, and barriers among the 3 stages of readiness for mammography (precontemplation, contemplation, and action); post-hoc testing for significant overall F tests was based on Fisher's least significant difference procedure for pairwise comparisons. Personal and demographic predictors of susceptibility, benefits, and barriers were determined using multiple linear regression models. The three-level ordinal variable measuring mammography readiness was converted to two binary indicators to be used in the regression analysis. The first indictor was coded as 1 for contemplation and 0 for other stages; the second indicator was coded as 1 for action and 0 for other stages. Variance inflation factors were considered as a test for multicollinearity in each regression. An α level of 0.05 was used throughout.
Results
The average age of the women in the sample was 55.9 years (SD = 9.8; range, 40 to 86). More than half of the participants belonged to a minority racial/ethnic group (see Table 1). Of the 54 women in this category, 53 were black and one was Native American. Most participants had at least a high school diploma or General Educational Development (GED), and the majority were not married (including never married, divorced, widowed, or separated). Most of the women did have health insurance and access to a primary care provider. The majority of participants reported currently being adherent to mammography guidelines according to ACS (i.e., action stage; see
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TABLE 1
Demographic and personal characteristics of sample (N = 110) Demographic/personal characteristic
Race/ethnicity White Other racial/ethnic category Education b High school education At least high school/General Education Development (GED) Marital status Married Not married Access to primary health care provider Yes No Health insurance Yes No
n (%)
43 (44.3) 54 (55.6) 15 (15.6) 81 (84.4)
45 (46.4) 52 (53.6) 93 (86.9) 14 (13.1) 95 (87.2) 14 (12.8)
Table 2). The next most prevalent category was contemplation, followed by precontemplation. As shown in Table 3, out of a potential maximum score for Perceived Susceptibility of 20 (higher scores indicate higher perceived susceptibility), the average score was 12.3, and scores ranged from 5 to 20. With a maximum possible score of 16, the average for Benefits (higher scores indicate greater rating of benefits of mammography) was 13.5, and the range was 8 to 16. The mean Barriers score was 22.3, out of a possible 52, and the range was 13 to 51 (higher scores indicate more perceived barriers). Perceived susceptibility was not correlated with either benefits or barriers, but benefits and barriers were negatively correlated: women
who perceived a greater benefit from mammography also perceived lower barriers, and vice versa. The comparisons of scores for perceived susceptibility, benefits, and barriers by stage of readiness are shown in Table 4. Of the 3 one-way analysis of variance models, only perceived susceptibility demonstrated a significant group difference. Post-hoc analysis of this group comparison indicated that those in the precontemplation stage perceived significantly lower susceptibility to breast cancer compared with those in the contemplation or action stages; there was no difference in perceived susceptibility between contemplators or actors. The other 2 scales, benefits and barriers, did not demonstrate a group effect by stage of readiness; there were no significant differences in the means for these 2 scales by readiness stage, and thus post-hoc analysis was not considered. Multiple regression analysis was used to assess predictors of scores for perceived susceptibility, benefits, and barriers. Regressors included in each model were age, the binary indicators for minority status, high school graduate status, marital status, and the binary indicators for access to primary care and health insurance status. In addition, the two binary indicator variables for contemplation and action mammography stages also were included. The models for perceived susceptibility and barriers were not significant overall, and thus they are not presented here. The model with benefits as the dependent variable is displayed in Table 5. The overall model was significant (R 2 = 0.18; F8,77 = 2.1; P = .04). Benefits score was significantly predicted by minority status and health insurance status. Persons who belonged to a minority racial/ethnic group had significantly lower benefits scores than did persons who did not belong to a minority racial/ethnic group, and persons with health insurance had significantly lower benefits scores than did persons without insurance, controlling for other demographic and personal characteristics. The standardized β values for these two predictors suggest that both influence benefits at an equal level. The variance inflation factors
TABLE 2
Mammography stages: definitions and percentages in the sample (n = 104) Mammography stage
Definition for stage
% of participants in stage
Precontemplation
Never had a mammogram OR had one more than 12 mo ago AND not thinking about having one in the next 6 mo Never had a mammogram OR had one more than 12 mo ago AND thinking about having one in the next 6 mo5 Had a mammogram in the past 12 mo
12
Contemplation Action
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TABLE 3
Descriptive statistics for perceived susceptibility, benefits, and barriers and correlations among scales (N = 110) Scale
Perceived susceptibility Benefits Barriers
No. of items
5 4 13
Mean
SD
12.3 13.5 22.3
3.5 2.2 7.2
Range
Pearson's product moment correlation (P value)
5-20 8-16 13-51
Correlation with benefits
Correlation with barriers
0.13 (.2) — —
0.16 (.09) –0.23 (.01) —
mammography utilization of 81% for women older than 40 years to be screened every other year. 6 Other studies have found even lower rates of mammography screening for women who visit the emergency department for nonurgent care, establishing the need for mammography-promoting programs aimed at this population 10,11 and delivered in this setting. This study also documents several interesting and important factors regarding the decisions by this population to adopt screening mammography. In this sample, women who have significant barriers to mammography seem unable to recognize or identify the benefits of having a mammogram. For the participants, the relationship between perceived barriers and benefits is negatively correlated, suggesting that the perceptions are related. As barriers increased, the perception that having a mammogram would be beneficial decreased. This finding is consistent with other research documenting barriers to and benefits of cancer screening. Champion and Springston 23 examined barriers and benefits to mammography in a sample of low-income African American women and found that the women who were either screened or about to be screened perceived the most benefits to screening. The women who had the most barriers did not fully recognize the benefits of screening and were far less likely to be ready to get screened. This finding suggests that interventions that focus exclusively on removing barriers might actually tip the decisional balance and result in women being more open to considering the benefits of mammography. This finding
were small and suggest that multicollinearity is likely not distorting regression parameters. Discussion
Attention to women's readiness to screen and beliefs about screening may play an important role in developing interventions that decrease unnecessary burdens from breast cancer. One place these interventions may be useful is in the emergency department, where these women may be being treated for nonurgent conditions. In order to develop these interventions, it is important to understand the beliefs that may influence the women's decision to obtain a mammogram. The study gives important insight into the risk: benefit ratio for women in this population, as well as perceptions of lack of susceptibility to breast cancer. Several important findings emerged from this study. First, the low mammography rates among the target population lend support to using the emergency department as a potential site for mammography promotion. Mammography adherence for this group of women was 63%, slightly less than the national average of 67%. 26 Although this difference is small, regular visitors to the emergency department are typically older, minorities, and underinsured or uninsured. 12 These groups have experienced disparate mortality rates from breast cancer, and this lower mammography rate, when combined with other risk factors, places them at increased risk for late-stage diagnosis. In fact, Healthy People 2020 set a national standard for TABLE 4
Average scores for perceived susceptibility, benefits, and barriers by readiness stage, with group comparisons (n = 104) Scale
Perceived susceptibility Benefits Barriers a
Action
12.6 13.5 21.7
a
Contemplation
12.8 13.9 22.9
a
Precontemplation
F (P value)
10.1 12.9 22.0
3.3 (.04) 0.3 (.8) 0.9 (.4)
Post-hoc testing only conducted for perceived susceptibility; means with the same letter were not significantly different.
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TABLE 5
Multiple regression model to assess predictors of benefits score (n = 86) Predictor
Parameter estimate (standard error)
Standardized β (P value)
Variance inflation factor
Age Minority High school graduate Married Have access to primary care Have health insurance Readiness (precontemplation is reference) Readiness in Action Stage Readiness in Contemplation Stage
0.0084 –1.11 0.61 0.33 0.40 –1.76
.03 –.25 .10 .08 .06 –.28
1.1 1.1 1.1 1.1 1.5 1.5
0.98 (0.69) 1.20 (0.73)
also suggests that educational interventions that focus primarily on highlighting the benefits of mammography such as early detection and less devastating treatment may only be effective in the context of consideration of specific barriers being faced. The barriers of poverty among older women who struggle with access to quality care may outweigh the benefits they perceive. This result should be considered in the design of specific interventions to meet the needs of this population. Further research that elucidates the specific barriers to mammography for women who use the emergency department for nonurgent treatment is critical for the design of effective interventions for this group. This research will allow us to target the barriers that are most salient to this vulnerable population, allowing them to consider the benefits that screening may provide. Specifically, nurses who are aware of the most common barriers to mammography for this population may provide resources and referrals as appropriate. Such resources and referrals may include social services and/or information regarding appropriate programs such as free and reduced-price mammograms offered by local health departments. Removing or reducing barriers appears to be a more appropriate approach than simply awareness raising, given our finding that many women out of compliance had experienced at least one mammogram. These “one-time” mammogram users may be aware and even convinced of the need to screen, but their lack of current compliance with guidelines underscores the importance of addressing specific barriers. Another important finding from this study is the view of precontemplators regarding their perceived risk of breast cancer. Precontemplators, that is, women who are not considering having a mammogram in the near future, were significantly less likely than those at other stages to believe that
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(0.025) (0.47) (0.66) (0.47) (0.78) (0.79)
(.7) (.02) (.4) (.5) (.6) (.03)
.22 (.2) .25 (.1)
2.4 2.2
they were susceptible to developing breast cancer. This finding reinforces the theoretical premise that precontemplation is the stage where women are not fully aware of their risk, and therefore barriers are outweighing benefits. This information is essential in the design of stage-appropriate interventions. In the case of individuals at the precontemplation stage, the perceived benefits of a behavior change should exceed its perceived costs/cons. Therefore the goal of messages for precontemplators should be to capture their attention by emphasizing the benefits of screening while reducing the negative aspects of screening (e.g., mammography finds lumps, possibly resulting in less aggressive treatments). Aligning perceived risk with actual risk in order to increase awareness may be particularly important for women in the precontemplation stage. Aligning perceived risk with actual risk would involve providing factual information regarding risk factors and profiles of the population being targeted. An example of tailoring messages to precontemplators in this manner is the use of a culturally tailored video to promote mammography screening in lowliteracy Latino populations. 27 A similar strategy may be used with other populations of women visiting the emergency department for nonurgent care. These messages should be culturally tailored and can target any number of high-risk populations. One suggestion would be a kiosk that features stage-appropriate mammography promotion messages as women wait for nonurgent care. Kiosks are currently being used in emergency departments in a variety of capacities, including interactive kiosks that feature asthma education and pediatric safety tips. 28,29 Finally, African American women perceived less benefit from having a mammogram than did white women. Given that African American women experience higher mortality rates from breast cancer than do white women (ie, a 5-year
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breast cancer survival rate of only 77% versus 90% for white women), 30 greater attention should be given to increasing African American women's perceived benefits from mammography. Because the ED visit rate for African Americans is double that of other racial/ethnic groups, 31 locating interventions in emergency departments and targeting African American women may be fruitful. The focus of such interventions, according to the results of this study, should involve the identification and reduction of barriers to screening. These interventions could include the use of peer educators, culturally tailored kiosks, and other approaches that are tailored to the population. As perceived and real barriers are reduced or, preferably, eliminated, African American women in this setting will be able to focus on the benefits of having regular mammograms.
mammograms. Understanding the most effective intervention approaches to promoting mammography in this population is critical, because such women are at increased risk for presenting with later stages of breast cancer and therefore are at risk for increased mortality. The emergency department may provide a point of access for nurses and other health care providers to intervene to promote screening among this underserved group. Currently no model exists for this type of nursing intervention in a busy emergency department, and further research into the best way to integrate this intervention into practice will be necessary for this work to move forward. These interventions may necessarily involve the use of lay health educators who work in collaboration with the nurses and community agencies, such as health departments.
LIMITATIONS
REFERENCES
Several limitations to this study are worth noting. The convenience sample may not represent the general population of women older than 40 years who are seeking care in the emergency department. Because we did not collect refusal rates, it is possible that the sample self-selected and the results may not be generalizable. Finally, future studies would benefit from larger sample sizes, particularly within the mammography stage category of precontemplation. IMPLICATIONS FOR EMERGENCY NURSES
Nurses have a valuable opportunity during first contact with patients in the emergency department to provide cancer screening promotion messages. Specific activities that nurses might consider would include screening this vulnerable population for mammography patterns at an appropriate point during the ED visit, providing appropriate referrals to mammography centers and social services, and collaborating with researchers and public health workers to design programs to promote mammograms. This study provides a foundational understanding of the beliefs related to the various stages of mammography adoption for a sample of women who use the emergency department for nonurgent care. It is critical that nurses in these settings understand the complexities of delivering this information and the need to do so.
1. American Cancer Society. What are the key statistics about breast cancer? http://www.cancer.org/cancer/breastcancer/detailedguide/breastcancer-key-statistics. Accessed January 9, 2013. 2. American Cancer Society. Cancer facts & figures. http://www.cancer. org/Research/CancerFactsFigures/CancerFactsFigures/cancer-factsfigures-2011. Accessed August 7, 2011. 3. American Cancer Society. Breast cancer detailed guide: what are the key statistics about breast cancer? http://www.cancer.org/Cancer/ BreastCancer/DetailedGuide/breast-cancer-key-statistics. Accessed August 7, 2011. 4. Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for breast cancer. JAMA. 2005;293:1245-56. 5. Michaelson J, Satija S, Moore R, et al. The pattern of breast cancer screening utilization and its consequences. Cancer. 2002;94:37-43. 6. U.S. Department of Health and Human Services. Healthy People 2020 topics and objectives: cancerU.S. Department of Health and Human Services; 2011. 7. Rust G, Ye J, Baltrus P, Daniels E, Adesunloye B, Fryer GE. Practical barriers to timely primary care access: impact on adult use of emergency department services. Arch Intern Med. 2008;168:1705-10. 8. Stockwell DH, Woo P, Jacobson BC, et al. Determinants of colorectal cancer screening in women undergoing mammography. Am J Gastroenterol. 2003;98:1875-80. 9. Tinley ST, Houfek J, Watson P, et al. Screening adherence in BRCA1/2 families is associated with primary physicians’ behavior. Am J Med Genet. 2003;125A:5-11. 10. Hatcher J, Rayens MK, Schoenberg NE. Mammography promotion in the emergency department: a pilot study. Public Health Nurs. 2010;27:520-7.
Conclusions
This study is the first to examine mammography-related beliefs in a sample of women who are visiting the emergency department for nonurgent care. This group has impeded access to recommendations for preventive care, including
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11. Llovera I, Ward MF, Ryan JG, LaTouche T, Sama A. A survey of the emergency department population and their interest in preventive health education. Acad Emerg Med. 2003;10:155-60. 12. Garcia TC, Bernstein AB, Bush MA. Emergency department visitors and visits: who used the emergency room in 2007?National Center for Health Statistics; 2010.
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13. Rhodes KV, Gordon JA, Lowe RA. The Society of Academic Emergency Medicine Public Health and Education Task Force. Preventive Care in the emergency department, part I: clinical preventive services-are they relevant to emergency medicine? Acad Emerg Med. 2000;7:1036-41. 14. Wei HG, Camargo CA Jr. Patient education in the emergency department. Acad Emerg Med. 2000;7:710-7. 15. Cohen DJ, Clark EC, Lawson PJ, Casucci BA, Flocke SA . Identifying teachable moments for health behavior counseling in primary care. Patient Educ Couns. 2011;85:e8-e15. 16. Mandelblatt J, Freeman H, Winczewski D, et al. Implementation of a breast and cervical cancer screening program in a public hospital emergency department. Cancer Control Center of Harlem. Ann Emerg Med. 1996;28:493-8. 17. Bernstein J, Mutschler P, Bernstein E. Keeping mammography referral appointments: motivation, health beliefs, and access barriers experienced by older minority women. J Midwifery Womens Health. 2000;45:308-13. 18. Malchodi CS, Oncken C, Dornelas EA, Caramanica L, Gregonis E, Curry SL. The effects of peer counseling on smoking cessation and reduction. Obstet Gynecol. 2003;101:504-10. 19. Anderson AK, Damio G, Young S, Chapman DJ, Perez-Escamilla R. A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community. Arch Pediatr Adolesc Med. 2005;159:836-41. 20. Merchant RC, Gee EM, Bock BC, Becker BM, Clark MA. Correlates of women's cancer screening and contraceptive knowledge among female emergency department patients. BMC Womens Health. 2007;7:7. 21. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992;47: 1102-14.
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22. U.S. Department of Health and Human Services. Theory at a glance: a guide for health promotion practice Washington, DC: National Institutes of, Health; 2005:12-26. 23. Champion VL, Springston J. Mammography adherence and beliefs in a sample of low-income African American women. Int J Behav Med. 1999;6:228-40. 24. Vadaparampil ST, Champion VL, Miller TK, Menon U, Sugg Skinner C. Using the Health Belief Model to examine differences in adherence to mammography among African-American and Caucasian women. J Psychosoc Oncol. 2003;21:59-79. 25. Champion VL. Revised susceptibility, benefits, and barriers scale for mammography screening. Res Nurs Health. 1999;22:341-8. 26. Centers for Disease Control and Prevention. Health, United States, 2010: with special feature on death and dying (p. 295). Hyattsville, MD: U.S. Government Printing Office; 2011. 27. Borrayo EA. Where's Maria? A video to increase awareness about breast cancer and mammography screening among low-literacy Latinas Prev Med. 2004;39:99-110. 28. Joshi A, Weng W, Lichenstein R, Arora M, Sears A Prospective tracking of a pediatric emergency department e-kiosk to deliver asthma education. Health Informatics J. 2009;15:282-95. 29. Gielen AC, McKenzie LB, McDonald EM, et al. Using a computer kiosk to promote child safety: results of a randomized, controlled trial in an urban pediatric emergency department. Pediatrics. 2007;120:330-9. 30. Howlader N, Noone AM, Krapcho M, et al. SEER cancer statistics review, 1975-2008. National Cancer Institute; 2010. 31. Pitts S, Niska R, Xu J, Burt C. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. National Health Statistics Reports; no 7 National Center for Health Statistics; 2008.
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BELIEFS REGARDING MAMMOGRAPHY SCREENING AMONG WOMEN VISITING THE EMERGENCY DEPARTMENT FOR NONURGENT CARE Authors: Jennifer Hatcher-Keller, PhD, MPH, RN, Mary Kay Rayens, PhD, Mark Dignan, PhD, MPH, Nancy Schoenberg, PhD, and Penne Allison, RN, Lexington, KY Introduction: One in 8 US women will develop invasive
breast cancer in their lifetime. Despite evidence that mammography is an effective method of early detection, certain vulnerable groups, such as those using the emergency department as a medical home, do not adhere to mammography screening guidelines, and suffer disparate mortality from breast cancer. The purpose of this study was to investigate differences in beliefs regarding mammography screening among women attending the emergency department for nonurgent care and ultimately to develop interventions that promote mammography for this vulnerable population. Methods: We explored the relationship between stage of
readiness to adopt mammography behavior and barriers, benefits, and perceived susceptibility by administering scales for risk, benefits, and barriers to a sample of 110 women who had presented to the emergency department of a public hospital for nonurgent complaints or were seated in the ED waiting room. We also collected sociodemographic information and stage of readiness. Results: Mammography adherence was about 60%. Most women who were not compliant with current guidelines were
Jennifer Hatcher-Keller is Associate Professor, University of Kentucky College of Nursing, Lexington, KY. Mary Kay Rayens is Professor, University of Kentucky College of Nursing, Lexington, KY. Mark Dignan is Professor, Internal Medicine Department, University of Kentucky Chandler Medical Center, Lexington, KY. Nancy Schoenberg is Marion Pearsall endowed Professor, University of Kentucky Behavioral Sciences, Lexington, KY. Penne Allison, Member, Bluegrass Chapter ENA, is Director of Emergency Services, University of Kentucky HealthCare Hospitals, Lexington, KY. For correspondence, write: Jennifer Hatcher-Keller, PhD, MPH, RN, 3024 Blackford Parkway, Lexington, KY 40509; E-mail: [email protected]. J Emerg Nurs 2014;40:e27-e35. Available online 9 March 2013. 0099-1767/$36.00 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2013.01.015
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contemplators. Those who were not contemplating being screened were significantly less likely to perceive themselves to be at risk of getting breast cancer. Women who had more barriers to mammography perceived less benefit from having a mammogram. African American women perceived less benefit from having a mammogram. Discussion: Mammography promotion is appropriately placed in the ED waiting room given the suboptimal rate at which this population is being screened. Beliefs regarding mammography differ for women in various stages of mammography adoption and for minority women. Understanding these differences will allow intervention in this setting to be tailored to the population. ED nurses are an important and sometimes sole point of health care contact for patients who routinely visit the emergency department. As such, they have a valuable opportunity to provide cancer screening promotion messages. It is critical that nurses in this setting understand the complexities of delivering this information and the need to do so. Key words: Mammography; Nonurgent care; Cancer control;
Stages of change
nvasive breast cancer will develop in 1 in 8 women in the United States during their lifetime. The American Cancer Society (ACS) estimates that more than 40,000 women will die from breast cancer in 2013, making it the second leading cause of cancer death among American women, exceeded only by lung cancer. 1–3 Screening mammography is the single most effective method of early detection of breast cancer and can identify cancer several years before physical symptoms occur. 4 Early detection by mammography generally leads to a greater range of treatment 5 options, including less-aggressive surgeries and therapies. Women aged 50 to 69 years and 40 to 49 years who are regularly screened may experience a reduction in mortality by 4 as much as 20% to 35% and 20%, respectively. Healthy People 2020 set a national standard for mammography utilization of 81% for women older than 40 years to be screened every other year. 6 Despite increasing
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adherence to screening recommendations and improvements in breast cancer treatments, certain vulnerable populations have not realized decreased mortality rates documented in the population at large. 7 Such women may not receive health care providers' recommendations for screening, the strongest predictor of adopting screening. 8,9 Among the women most vulnerable to inadequate screening are women who lack a regular source of care, including those who visit emergency departments. Women who visit the emergency department for nonurgent care have had demonstrably lower mammography screening rates than the U.S. average, establishing the need for mammography-promoting programs aimed at this population 10,11 and delivered in this setting. Overall, 1 in 5 Americans visits the emergency department each year. 12 Many of these visits are made by the most vulnerable members of society and are for nonurgent complaints. Older adults are more likely to have had at least one ED visit in a 12-month period than are people in younger age groups. Non-Hispanic black persons are more likely to have had one or more ED visits in a 12-month period than are non-Hispanic white or Hispanic persons. As family income decreases, the likelihood of having one or more ED visits in the past year increases. 12 These persons are the same ones who are likely not to have been screened in a timely and regular manner for breast cancer. This pattern of ED visits by these vulnerable persons may present an opportunity, because the emergency department may be the sole point of contact with the health care system for many of them. 13 A “teachable moment” may occur when the patient is ready to accept new information. 14 Patients are more likely to become motivated to make health behavior changes when they are approached during key times when their attention is focused on their health, such as while they are in the emergency department. Their attention to their health care needs is heightened at that time. This heightened attention of patients and family during ED visits may provide an important opportunity for patient education. 15 The purpose of this study was to investigate differences in beliefs regarding mammography screening among women attending the emergency department for nonurgent care. To develop interventions that promote mammography for this vulnerable population, it is important to understand the beliefs that may influence the decision to obtain a mammogram. Although the emergency department presents unique challenges to health promotion activity, it also may provide one of the few opportunities for intervention with a population that may likely be rarely or never screened for
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breast cancer and is at high risk of increased mortality because of late-stage diagnosis. Mammography Promotion in the Emergency Department
Despite the suggestion that the emergency department is a location where preventive health care would be feasible and welcomed, 10 few interventions to promote mammography screening in this setting have been implemented. Most notable have been the studies conducted in the Harlem emergency department by Mandelblatt and colleagues 16 and the work in the Boston Medical Center ED by Bernstein and colleagues. 17 Mandelblatt and colleagues 16 offered screening for cancers of the breast and cervix to women with nonemergency problems who presented to the emergency department of a large, urban public hospital. They concluded that it was indeed feasible to screen for breast and cervical cancer in the emergency department. They also concluded that a key barrier to this intervention was the involvement of the ED staff. The triage nurse and other staff members were busy with other patient care needs and did not screen all eligible patients. This study highlighted the need for interventions that involved others, such as lay health workers, who have been shown to be effective in similar settings. 18,19 Bernstein and colleagues 17 conducted a similar study in the emergency department of Boston Medical Center that was designed to test a lay health worker-delivered intervention to increase the regularity of mammography in a diverse population of inner-city women, primarily older African American women. Although 65% of the 90 women had never had a mammogram, 60% of the women reported having a mammogram sometime in the 3 months after the intervention. The researchers concluded that the success of the intervention was attributable to the interactive format and the interchange that took place between peers. They suggested that more research, including a randomized controlled trial of several types of interventions, including lay health worker-delivered and negotiated interviews, be undertaken to establish comparative efficacy in this setting. One important way to increase the efficacy of these interventions is to deepen our understanding of the variables related to mammography decision making for this population. 20 This study provides a foundation for designing mammography promotion interventions that are more tailored to the specific needs of the population served in the emergency department for nonurgent care by examining key beliefs regarding screening that may influence their screening decisions.
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Theoretical Framework
To understand the stages women may progress through when adopting behavior change and to account for perceived disease threats and barriers and benefits to a particular behavior, we used the Transtheoretical Model and the Health Belief Model (HBM), respectively. 21,22 The fundamental concept of the Transtheoretical Model is that people progress through a series of progressively more committed stages as they progress toward adopting a healthrelated behavior such as mammography. 21 The HBM addresses an individual's perception of the threat posed by a problem (eg, susceptibility and severity), the benefits of avoiding the threat, and the factors that influence the decision to act (ie, barriers and benefits). 22 With this theoretical backdrop, we explored the relationship between stage of readiness to adopt mammography behavior and barriers, benefits, and perceived susceptibility for women who are using the emergency department for nonurgent care. Specifically, the aims of this study were to investigate differences in beliefs regarding mammography screening, including perceived susceptibility and perceived benefits and barriers, among women attending the emergency department for nonurgent care; to determine if those beliefs differ by stage of screening adoption; and to determine the demographic and personal factors that predict perceived susceptibility, benefits, and barriers of mammography.
which allowed the ED staff to screen for the urgency of the patients’ complaints and to examine demographic criteria commonly collected at triage. The research assistant also approached women who were seated in the waiting area and appeared to fit study criteria, and asked if they would be willing to participate in the study. She then screened the women for age eligibility. Women who agreed to participate in the study were interviewed in a private room of the emergency department. Recruitment flyers were placed in the emergency department to encourage women who visited when the research assistant was not present to call in if they met the listed eligibility criteria and were interested in participating in the study. Women were also recruited using a snowball technique. Those who had previously participated in the study were mailed letters of appreciation with several recruitment flyers included. They were invited to recommend friends who had been seen in the emergency department in the past 6 months for the study and to give the flyers to any friends they thought might be eligible. They were given a phone number to call to suggest women for the study. The women recruited using this method either called study personnel or were contacted by phone, using the information supplied by the previous participants. Eligibility for the study was determined by phone, and the interviews were conducted in person at a location convenient to the participant. We recruited 110 participants to the study; each was given a $20 cash incentive after survey completion.
Methods
INSTRUMENTS
SAMPLE
Demographic and Personal Items
Data for this study were collected from a convenience sample of 110 women who had presented to the emergency department of a public hospital with nonurgent complaints within the past 6 months or those who were seated in the waiting area of the emergency department. We enrolled English-speaking women who met the age eligibility guidelines for mammography from the ACS: annual mammograms for women aged 40 years and older. 2 All protocols were approved by the University's Institutional Review Board.
Demographic information was collected on age, race/ ethnicity, years of education, marital status, whether the woman had access to a primary care provider, and health insurance status.
RECRUITMENT
We used several recruitment strategies for this study. Women who were visiting the emergency department were contacted by a trained research assistant stationed in the emergency department during various shifts. The research assistants used a variety of methods to recruit women in the emergency department. These methods included inquiring at triage if eligible women were present in treatment rooms,
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Mammography Stage Women were asked if they had a mammogram in the past year or ever had one, based on the guidelines of the ACS, which recommends mammograms every year for women older than 40 years. 3 If they had not had a mammogram in the past year or had never had one, they were asked how likely they were to have one in the next 6 months, with options of “I will certainly get a mammogram in the next 6 months,” “it is somewhat likely,” “it is not very likely,” “I will definitely will not get a mammogram in the next 6 months,” and “don't know.” 23 Using their responses to how recently they had a mammogram and the likelihood they would get one in the next 6 months, each participant was
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classified into one of the 3 stages; precontemplation, contemplation, or action. Women who said, “It is not very likely that I will get a mammogram in the next 6 months,” “I definitely will not get a mammogram in the next 6 months,” or “don't know” were classified as precontemplators, whereas those who responded “I will certainly get a mammogram in the next 6 months” or “It is somewhat likely” were considered contemplators. Women who had had a mammogram in the past year were classified in the “action” stage of readiness. Perceived Susceptibility Based on the HBM, perceived susceptibility is a measure of the threat a person feels that a disease poses to their health. Theoretically, before health-promoting behaviors will occur, a threat must be recognized, which was measured using a 5item scale. 23 These items were previously tested for validity and reliability. 23 Items measured the perceived general likelihood of getting breast cancer, chances of getting breast cancer “sometime during my life,” and other like questions. The scale used a 5-point Likert format with possible responses ranging from 1 = “strongly disagree” to 5 = “strongly agree.” The range of possible total scores was 5 to 20, with higher scores indicating greater perceived susceptibility. The scale had a reliability of 0.84 in this sample. Perceived Benefits and Barriers The benefits of and barriers to mammography were measured by scales based on the HBM constructs of benefits and barriers. Perceived benefits in this context are defined as those related to the perceived positive outcomes of obtaining a mammogram, such as increased chances of early detection, better treatment options, and increased chance of survival. 24 Perceived barriers of mammography are defined as emotional, physical, or structural concerns related to mammography behaviors, including pain, fear of radiation, and cost. 24 These scales also have been previously tested for validity and reliability. 25 Both scales used a 5point Likert format from 1 = “strongly disagree” to 5 = “strongly agree”. The 4 benefits of mammography items assessed help in finding breast lumps early, decreased need for extensive treatment, perceived best way to find small lumps, and decreased chances of dying from breast cancer. Reliability for the scale was 0.64 for this sample, and the range of possible scores was from 4 to 16, with higher scores indicating greater rating of the benefits of mammography. The 13-item barriers to mammography scale assessed fear, lack of understanding, embarrassment, time, pain, and other factors identified in the literature as potential barriers to mammography. The reliability of the barriers subscale in
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this sample was 0.89, and the potential total score ranged from 13 to 52. DATA ANALYSIS
For the purpose of analysis, race/ethnicity was coded as a binary indicator variable (0 = white; 1 = other racial/ethnic category), as was years of education (0 = less than high school; 1 = at least high school), and marital status (1 = married; 0 = other marital status). The indicator variables for primary care provider status and health care insurance status both had yes/no response options and were coded as 1 = yes and 0 = no. Descriptive statistics, including means and standard deviations or frequency distributions, were calculated. Internal consistency of each of the 3 subscales was determined using Cronbach's α. Pearson's product moment correlation was used to assess linear associations among the 3 subscales of susceptibility, benefits, and barriers. One-way analysis of variance was used to compare means for susceptibility, benefits, and barriers among the 3 stages of readiness for mammography (precontemplation, contemplation, and action); post-hoc testing for significant overall F tests was based on Fisher's least significant difference procedure for pairwise comparisons. Personal and demographic predictors of susceptibility, benefits, and barriers were determined using multiple linear regression models. The three-level ordinal variable measuring mammography readiness was converted to two binary indicators to be used in the regression analysis. The first indictor was coded as 1 for contemplation and 0 for other stages; the second indicator was coded as 1 for action and 0 for other stages. Variance inflation factors were considered as a test for multicollinearity in each regression. An α level of 0.05 was used throughout.
Results
The average age of the women in the sample was 55.9 years (SD = 9.8; range, 40 to 86). More than half of the participants belonged to a minority racial/ethnic group (see Table 1). Of the 54 women in this category, 53 were black and one was Native American. Most participants had at least a high school diploma or General Educational Development (GED), and the majority were not married (including never married, divorced, widowed, or separated). Most of the women did have health insurance and access to a primary care provider. The majority of participants reported currently being adherent to mammography guidelines according to ACS (i.e., action stage; see
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TABLE 1
Demographic and personal characteristics of sample (N = 110) Demographic/personal characteristic
Race/ethnicity White Other racial/ethnic category Education b High school education At least high school/General Education Development (GED) Marital status Married Not married Access to primary health care provider Yes No Health insurance Yes No
n (%)
43 (44.3) 54 (55.6) 15 (15.6) 81 (84.4)
45 (46.4) 52 (53.6) 93 (86.9) 14 (13.1) 95 (87.2) 14 (12.8)
Table 2). The next most prevalent category was contemplation, followed by precontemplation. As shown in Table 3, out of a potential maximum score for Perceived Susceptibility of 20 (higher scores indicate higher perceived susceptibility), the average score was 12.3, and scores ranged from 5 to 20. With a maximum possible score of 16, the average for Benefits (higher scores indicate greater rating of benefits of mammography) was 13.5, and the range was 8 to 16. The mean Barriers score was 22.3, out of a possible 52, and the range was 13 to 51 (higher scores indicate more perceived barriers). Perceived susceptibility was not correlated with either benefits or barriers, but benefits and barriers were negatively correlated: women
who perceived a greater benefit from mammography also perceived lower barriers, and vice versa. The comparisons of scores for perceived susceptibility, benefits, and barriers by stage of readiness are shown in Table 4. Of the 3 one-way analysis of variance models, only perceived susceptibility demonstrated a significant group difference. Post-hoc analysis of this group comparison indicated that those in the precontemplation stage perceived significantly lower susceptibility to breast cancer compared with those in the contemplation or action stages; there was no difference in perceived susceptibility between contemplators or actors. The other 2 scales, benefits and barriers, did not demonstrate a group effect by stage of readiness; there were no significant differences in the means for these 2 scales by readiness stage, and thus post-hoc analysis was not considered. Multiple regression analysis was used to assess predictors of scores for perceived susceptibility, benefits, and barriers. Regressors included in each model were age, the binary indicators for minority status, high school graduate status, marital status, and the binary indicators for access to primary care and health insurance status. In addition, the two binary indicator variables for contemplation and action mammography stages also were included. The models for perceived susceptibility and barriers were not significant overall, and thus they are not presented here. The model with benefits as the dependent variable is displayed in Table 5. The overall model was significant (R 2 = 0.18; F8,77 = 2.1; P = .04). Benefits score was significantly predicted by minority status and health insurance status. Persons who belonged to a minority racial/ethnic group had significantly lower benefits scores than did persons who did not belong to a minority racial/ethnic group, and persons with health insurance had significantly lower benefits scores than did persons without insurance, controlling for other demographic and personal characteristics. The standardized β values for these two predictors suggest that both influence benefits at an equal level. The variance inflation factors
TABLE 2
Mammography stages: definitions and percentages in the sample (n = 104) Mammography stage
Definition for stage
% of participants in stage
Precontemplation
Never had a mammogram OR had one more than 12 mo ago AND not thinking about having one in the next 6 mo Never had a mammogram OR had one more than 12 mo ago AND thinking about having one in the next 6 mo5 Had a mammogram in the past 12 mo
12
Contemplation Action
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TABLE 3
Descriptive statistics for perceived susceptibility, benefits, and barriers and correlations among scales (N = 110) Scale
Perceived susceptibility Benefits Barriers
No. of items
5 4 13
Mean
SD
12.3 13.5 22.3
3.5 2.2 7.2
Range
Pearson's product moment correlation (P value)
5-20 8-16 13-51
Correlation with benefits
Correlation with barriers
0.13 (.2) — —
0.16 (.09) –0.23 (.01) —
mammography utilization of 81% for women older than 40 years to be screened every other year. 6 Other studies have found even lower rates of mammography screening for women who visit the emergency department for nonurgent care, establishing the need for mammography-promoting programs aimed at this population 10,11 and delivered in this setting. This study also documents several interesting and important factors regarding the decisions by this population to adopt screening mammography. In this sample, women who have significant barriers to mammography seem unable to recognize or identify the benefits of having a mammogram. For the participants, the relationship between perceived barriers and benefits is negatively correlated, suggesting that the perceptions are related. As barriers increased, the perception that having a mammogram would be beneficial decreased. This finding is consistent with other research documenting barriers to and benefits of cancer screening. Champion and Springston 23 examined barriers and benefits to mammography in a sample of low-income African American women and found that the women who were either screened or about to be screened perceived the most benefits to screening. The women who had the most barriers did not fully recognize the benefits of screening and were far less likely to be ready to get screened. This finding suggests that interventions that focus exclusively on removing barriers might actually tip the decisional balance and result in women being more open to considering the benefits of mammography. This finding
were small and suggest that multicollinearity is likely not distorting regression parameters. Discussion
Attention to women's readiness to screen and beliefs about screening may play an important role in developing interventions that decrease unnecessary burdens from breast cancer. One place these interventions may be useful is in the emergency department, where these women may be being treated for nonurgent conditions. In order to develop these interventions, it is important to understand the beliefs that may influence the women's decision to obtain a mammogram. The study gives important insight into the risk: benefit ratio for women in this population, as well as perceptions of lack of susceptibility to breast cancer. Several important findings emerged from this study. First, the low mammography rates among the target population lend support to using the emergency department as a potential site for mammography promotion. Mammography adherence for this group of women was 63%, slightly less than the national average of 67%. 26 Although this difference is small, regular visitors to the emergency department are typically older, minorities, and underinsured or uninsured. 12 These groups have experienced disparate mortality rates from breast cancer, and this lower mammography rate, when combined with other risk factors, places them at increased risk for late-stage diagnosis. In fact, Healthy People 2020 set a national standard for TABLE 4
Average scores for perceived susceptibility, benefits, and barriers by readiness stage, with group comparisons (n = 104) Scale
Perceived susceptibility Benefits Barriers a
Action
12.6 13.5 21.7
a
Contemplation
12.8 13.9 22.9
a
Precontemplation
F (P value)
10.1 12.9 22.0
3.3 (.04) 0.3 (.8) 0.9 (.4)
Post-hoc testing only conducted for perceived susceptibility; means with the same letter were not significantly different.
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TABLE 5
Multiple regression model to assess predictors of benefits score (n = 86) Predictor
Parameter estimate (standard error)
Standardized β (P value)
Variance inflation factor
Age Minority High school graduate Married Have access to primary care Have health insurance Readiness (precontemplation is reference) Readiness in Action Stage Readiness in Contemplation Stage
0.0084 –1.11 0.61 0.33 0.40 –1.76
.03 –.25 .10 .08 .06 –.28
1.1 1.1 1.1 1.1 1.5 1.5
0.98 (0.69) 1.20 (0.73)
also suggests that educational interventions that focus primarily on highlighting the benefits of mammography such as early detection and less devastating treatment may only be effective in the context of consideration of specific barriers being faced. The barriers of poverty among older women who struggle with access to quality care may outweigh the benefits they perceive. This result should be considered in the design of specific interventions to meet the needs of this population. Further research that elucidates the specific barriers to mammography for women who use the emergency department for nonurgent treatment is critical for the design of effective interventions for this group. This research will allow us to target the barriers that are most salient to this vulnerable population, allowing them to consider the benefits that screening may provide. Specifically, nurses who are aware of the most common barriers to mammography for this population may provide resources and referrals as appropriate. Such resources and referrals may include social services and/or information regarding appropriate programs such as free and reduced-price mammograms offered by local health departments. Removing or reducing barriers appears to be a more appropriate approach than simply awareness raising, given our finding that many women out of compliance had experienced at least one mammogram. These “one-time” mammogram users may be aware and even convinced of the need to screen, but their lack of current compliance with guidelines underscores the importance of addressing specific barriers. Another important finding from this study is the view of precontemplators regarding their perceived risk of breast cancer. Precontemplators, that is, women who are not considering having a mammogram in the near future, were significantly less likely than those at other stages to believe that
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(0.025) (0.47) (0.66) (0.47) (0.78) (0.79)
(.7) (.02) (.4) (.5) (.6) (.03)
.22 (.2) .25 (.1)
2.4 2.2
they were susceptible to developing breast cancer. This finding reinforces the theoretical premise that precontemplation is the stage where women are not fully aware of their risk, and therefore barriers are outweighing benefits. This information is essential in the design of stage-appropriate interventions. In the case of individuals at the precontemplation stage, the perceived benefits of a behavior change should exceed its perceived costs/cons. Therefore the goal of messages for precontemplators should be to capture their attention by emphasizing the benefits of screening while reducing the negative aspects of screening (e.g., mammography finds lumps, possibly resulting in less aggressive treatments). Aligning perceived risk with actual risk in order to increase awareness may be particularly important for women in the precontemplation stage. Aligning perceived risk with actual risk would involve providing factual information regarding risk factors and profiles of the population being targeted. An example of tailoring messages to precontemplators in this manner is the use of a culturally tailored video to promote mammography screening in lowliteracy Latino populations. 27 A similar strategy may be used with other populations of women visiting the emergency department for nonurgent care. These messages should be culturally tailored and can target any number of high-risk populations. One suggestion would be a kiosk that features stage-appropriate mammography promotion messages as women wait for nonurgent care. Kiosks are currently being used in emergency departments in a variety of capacities, including interactive kiosks that feature asthma education and pediatric safety tips. 28,29 Finally, African American women perceived less benefit from having a mammogram than did white women. Given that African American women experience higher mortality rates from breast cancer than do white women (ie, a 5-year
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breast cancer survival rate of only 77% versus 90% for white women), 30 greater attention should be given to increasing African American women's perceived benefits from mammography. Because the ED visit rate for African Americans is double that of other racial/ethnic groups, 31 locating interventions in emergency departments and targeting African American women may be fruitful. The focus of such interventions, according to the results of this study, should involve the identification and reduction of barriers to screening. These interventions could include the use of peer educators, culturally tailored kiosks, and other approaches that are tailored to the population. As perceived and real barriers are reduced or, preferably, eliminated, African American women in this setting will be able to focus on the benefits of having regular mammograms.
mammograms. Understanding the most effective intervention approaches to promoting mammography in this population is critical, because such women are at increased risk for presenting with later stages of breast cancer and therefore are at risk for increased mortality. The emergency department may provide a point of access for nurses and other health care providers to intervene to promote screening among this underserved group. Currently no model exists for this type of nursing intervention in a busy emergency department, and further research into the best way to integrate this intervention into practice will be necessary for this work to move forward. These interventions may necessarily involve the use of lay health educators who work in collaboration with the nurses and community agencies, such as health departments.
LIMITATIONS
REFERENCES
Several limitations to this study are worth noting. The convenience sample may not represent the general population of women older than 40 years who are seeking care in the emergency department. Because we did not collect refusal rates, it is possible that the sample self-selected and the results may not be generalizable. Finally, future studies would benefit from larger sample sizes, particularly within the mammography stage category of precontemplation. IMPLICATIONS FOR EMERGENCY NURSES
Nurses have a valuable opportunity during first contact with patients in the emergency department to provide cancer screening promotion messages. Specific activities that nurses might consider would include screening this vulnerable population for mammography patterns at an appropriate point during the ED visit, providing appropriate referrals to mammography centers and social services, and collaborating with researchers and public health workers to design programs to promote mammograms. This study provides a foundational understanding of the beliefs related to the various stages of mammography adoption for a sample of women who use the emergency department for nonurgent care. It is critical that nurses in these settings understand the complexities of delivering this information and the need to do so.
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Conclusions
This study is the first to examine mammography-related beliefs in a sample of women who are visiting the emergency department for nonurgent care. This group has impeded access to recommendations for preventive care, including
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