Article
Factors that Influence Mammography Use for Breast Cancer Screening among African American Women

https://doi.org/10.1016/j.jnma.2020.05.004Get rights and content

Abstract

Objectives

The purpose of this study was to assess factors that influence use of mammography screening among African American women, with a focus on social and cultural influences using Andersen's behavioral model (ABM), and to assess the methodological quality of the included studies.

Methods

A literature review was conducted using PubMed, CINAHL, PSYCINFO, and Web of Science. Search terms included a combination of the following words using Boolean operators: breast cancer screening, mammography, repeat mammography, and African American. Studies that met the following criteria were included in the review: 1) examined factors associated with mammography screening, 2) included African American women as a majority, 3) published in a peer-reviewed English language journal between 2005 and 2017, and 4) conducted in the United States. Literature reviews, commentaries and non-research studies were excluded. Cited references from identified studies were examined for additional, relevant articles. Associated factors were grouped into predisposing, enabling, and need factor domains of ABM. The reviewed studies were rated using a methodological quality score (MQS) ranging from 0 to 20, with higher scores indicating higher methodological quality.

Results

Twenty-four studies met the inclusion criteria. Fifteen factors that affect breast cancer screening in African American women were identified: predisposing (age, education, knowledge, beliefs, mistrust, religiosity, fears and fatalism), enabling (health insurance, access to care, income, health utilization), and need (physician recommendation, family/personal history, pain/discomfort, family responsibilities) factors. The most common factor was insurance status, although cultural issues (e.g., mistrust) were evident. Most of the identified factors are modifiable. The mean MQS was 12.2, indicating that the studies were slightly above average in quality.

Conclusions

Financial and cultural issues were important hindrances to breast cancer screening in African American women. These findings highlight the importance of affordable health care for preventive health services as well as the relevance of culturally embedded issues to health, while the MQS accentuates the need for more rigorous research articles. Breast cancer screening interventions in this population should attend to barriers identified in this review.

Introduction

In the United States, breast cancer is the second leading cause of cancer death among women. The American Cancer Society (ACS) estimates that in 2018, there will be 268,670 new breast cancer cases with a projected death count of 41,400.1 Among African American women, breast cancer is the most commonly diagnosed type of cancer.2 Despite substantial developments in breast cancer prevention and early detection, black women still bear an uneven burden of breast cancer mortality.3 While overall incidence rates are slightly lower among African American women compared to white women, African American women have higher mortality rates than white women. During 2005–2011, the five-year survival rates for breast cancer was lower for African American women (80%) than white women (91%).2

Although African American women present with more aggressive cancers in comparison to white women, survival disparities have been shown to remain even after stage and tumor characteristics are accounted for. This indicates that the inequalities might also be attributable to non-clinical factors.4 Some factors known to contribute to the higher mortality rate among African American women include socioeconomic factors, biological factors, lack of access to care and timely treatment.5 Extant studies that have examined mammography screening decisions in African American women have found that sociodemographic, structural3 and cultural factors6,7 are important. Furthermore, studies have also revealed that delay in care utilization after symptom detection is a significant factor in the higher mortality rate in African American women.8 Attempts to improve breast cancer screening have focused on routine mammography for early detection and timely referral. Routine screening detects breast cancer at a timely and treatable stage and is a key factor in reducing mortality.9 The U.S Preventive Services Task Force (USPSTF) currently recommends biennial screening mammography for women aged 50–74 years,10 while the ACS strongly recommends beginning regular screening at age 45.11 The ACS guidelines for breast cancer screening can be found in Table 1.

Historically, white women have utilized mammography at higher rates compared to black women. In recent years, however, some data show that African American women utilize mammograms at similar rates with white women.12 Seemingly, mammography utilization gaps between African American and white women could be closing. Nevertheless, presentation and outcome differences persist; and the extent of unmet needs among African American women is unknown, hence there is a need to assess mammography screening behaviors and associated factors in this population.

Section snippets

Purpose

Understanding the factors that influence breast cancer early detection and care utilization will help reduce disparities and possibly identify factors that can be modified via interventions. This is also aligned with Healthy People 2020 objectives to reduce breast cancer death rates13 and increase access to health services.14

The purpose of this paper was to synthesize findings from recently published studies that assessed factors associated with breast cancer screening and repeat mammography

Data sources

The core search for this study was conducted in four widely used databases: PubMed, CINAHL, Psych INFO and Web of Science. Search terms included a combination of the following words using Boolean operators: breast cancer screening, mammography, repeat mammography and African American. Lists of cited references from the studies included in the review were also assessed.

Eligibility criteria

To be included in this review, articles had to: a) have examined factors associated with mammography screening; b) include

Study characteristics

Overall, 24 articles met the inclusion/exclusion criteria. Studies were published between 2005 and 2017 with majority appearing between 2005 and 2008. A total of 23 studies were exclusively based on African American women while one study had a sample that was 96% African American. Only one author [namely, Davis et al. (n = 2)] published more than one study on the topic. A total of 11 articles used a theoretical framework, with the most frequent being the Health Belief Model, which is widely

Predisposing factors

A total of seven predisposing factors were identified in this review, with the most frequently identified being beliefs, closely followed by fear and fatalism. The factors education and knowledge had a positive influence on mammography use, while medical mistrust had a negative influence. However, the factors age, beliefs, religiosity and fear and fatalism had both positive and negative influences on mammography use.

Enabling factors

Four enabling factors were identified, which were all facilitators of mammography use. Among the reviewed studies, insurance coverage emerged as the strongest factor associated with mammography use.

Need factors

Four need factors were identified in this review, with physician recommendation being the most common. While the factors physician recommendation and personal and family history facilitated use of mammography screening, the factors pain and discomfort and roles of responsibility were deterrents to mammography screening in the population.

Methodological quality assessment

The raters reached an agreement rate of 85.8%. The methodological quality of the studies varied. The mean MQS was 12.2 (SD = 3.8), showing that the studies were above average in quality. Studies varied within a range of 5–18, with none of the studies having the highest possible score. Almost half of the articles (N = 11) had a theoretical framework guiding the study. A majority of the studies employed a cross-sectional design (N = 20), with only a few studies employing prospective or

Discussion

The purpose of this review was to synthesize evidence from published articles assessing factors that influence breast cancer screening among African American women. Using the ABM, this review identified 15 factors which were grouped as predisposing, enabling and need factors. All of the identified factors, apart from age and personal or family history of breast cancer, are modifiable.

Conclusions

This review pinpoints factors that influence mammography utilization among African American women in the United States. This article extends research by i) using a theoretical framework to organize findings from published studies ii) including social and cultural factors in the synthesis iii) assessing both facilitators and barriers that influence mammography use and iv) assessing the methodological quality of the studies. Our findings show that the influences are multifactorial, which

Declaration of competing interest

The authors declare that they have NO conflicts of interest.

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      In addition, current screening recommendations from major national organizations are based on scientific studies that predominantly focused on non-Hispanic White women and therefore do not take into account the relatively younger age of breast cancer onset in Black, Hispanic, and Asian women [16]. Racial or ethnic minority women reported logistical, knowledge-related barriers to getting screening mammography, as well as cultural and immigration-related and social or financial barriers that were closely tied to their racial or ethnic identities [17,18]. It has been found that adherence to screening mammography in racial or ethnic minority groups can be improved with high levels of primary care physician interaction [19].

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