1. Recruiting Rural, Underserved Women to Screening Mammography through Food Pantries: A Multi-Community, Dissemination Research Study October 8, 2008 Eugene J. Lengerich, VMD, MS The Pennsylvania State University

2. Background

3. Breast Cancer #1 diagnosed non-skin cancer - 2008 US: 182,460 (26.4%) PA: 9,410 #2 cause of cancer-related death - 2008 US: 40,480 (14.9%) PA: 2,180

4. Cancer Incidence Rural Appalachia vs. SEER Lengerich et al, 2005. Journal of Rural Health

5. Mammography as a breast cancer screening method Early detection provides the best chance of survival Recommendation Every year for women age 40 years and over (ACS; USPSTF) Free mammograms and follow-up for those who are uninsured and meet income limits National Breast and Cervical Cancer Early Detection Program (NBCCEDP) Mammogram vouchers - Komen Foundation

8. Reported Drop in Mammography Is This Cause for Concern? Breen et al. Cancer 2007 Figure. Recent mammography use (within 2 years) among women by age: Black - women aged 40+ yrs. Blue - women aged 65+ yrs. Green - women aged 50-64 yrs. Red - women aged 40-49 yrs.

9. Recent trends in U.S. mammography use from 2000–2006: A population-based analysis Ryerson et al. Preventive Medicine 2008 Low Income

10. Barriers to Mammography Commonly Reported in the Literature Perceived susceptibility Cost Fear of finding something wrong Pain Takes too much time Fear of radiation Embarrassment Forget to schedule appointment Do not know where to get one Do not understand what will be done Do not know how to go about getting one Do not think screening is important To old to need one Other problems are more important Lack of physician recommendation Lack of symptoms Lack of transportation

11. Additional Barriers to Cancer Screening in Appalachia Fewer primary care physicians and screening facilities in rural areas Residents are unaware of the location of facilities and services Residents must travel long distances through mountainous areas to be screened or consult with specialists after screening Lack of transportation, public or private

12. Health Communication in Appalachia Residents receive health information through social relationships with family, friends and neighbors: limited number of healthcare professionals; effective use of the Internet is reduced because of limited access, ability, or speed. Social networks are a culturally-appropriate method to communicate health information *Behringer B, Friedell GH. Appalachia: where place matters in health. Prev Chronic Dis [serial online]. 2006;3(10). www.cdc.gov/pcd/issues/2006/oct/06_0067.htm *Lyttle NL, Stadelman K. Assessing awareness and knowledge of breast and cervical cancer among Appalachian women. Prev Chronic Dis [serial online]. 2006;3(10). http://www.cdc.gov/pcd/issues/2006/oct/06_0031.htm.

13. Dissemination Research Definition Systematically examine the translation of evidence-based procedures and programs into real-world settings Why Assess the generalizabilty of the knowledge Determine the limitations of the original study Apply the findings to additional populations Characteristics Multiple sites, with comparison sites One protocol, with adaptation to local community Real-world setting AHRQ, 2003: “There is insufficient evidence to conclude that any dissemination strategy is effective at increasing mammography”

14. Preliminary Study

15. American Cancer Society’s Tell A Friend ® Program Intent Increase screening mammography among unscreened women aged 40 years and older. Basis Observational Learning (modeling) of Social Cognitive Theory Method Peer-to-peer counseling Trained volunteers contact friends or acquaintances at three different times Objective Each woman to have either received a mammogram or scheduled an appointment for one

16. 2002 Evaluation of ACS Tell A Friend ® Program in Pennsylvania Results: Successful in encouraging women to obtain mammograms But not reaching rarely or never screened women Need to reach minority, low-income, and underserved women Personal contact - as opposed to phone calls - was more effective in encouraging mammography

17. Adapted Tell A Friend ® Program of Indiana County during 2005 Aim Increase mammography among unscreened women aged 40 years and older 3-contact intervention Through a trusted community service The Local Food Pantry (all 18 sites in Indiana County)

18. Adapted Program in Indiana County Results: 158 (52%) of 302 age-eligible women were in need of mammography 138 (87%) of 158 women in need of mammography received a mammogram Increased county-wide screening mammography among low-income and uninsured women by 28% (n=46) Detected three asymptomatic breast cancers Advantages: Individual, population, and system levels Multiple-contacts One-on-one contact - cited as most rewarding by recruitment volunteers J Rural Health 2008

19. Theoretical Basis Social Network/Social Support Theory behavior is affected by social relationships and ties Social Cognitive Theory behavior is affected by the dynamic interaction between environment, personal characteristics, and the behavior Health Belief Theory behavior is affected by one’s beliefs and perceptions

20. Frameworks Recommended for Breast Cancer Screening by USTFCPS in 2008 1. Increase access by reducing out-of-pocket costs 2. Increase demand with small media and one-on-one education Baron RC, Rimer BK, Coates RJ, et al (USPSTF). Am J Prev Medicine 2008

21. Study Design

22. Quasi-experimental, multi-site behavioral intervention with matched non-intervention counties for comparison Hypotheses: The change in mammography utilization by underserved women in intervention counties will be significantly larger than it will be in matched, non- intervention counties Characteristics of the intervention coalitions will affect the implementation of the program

23. Specific Aims To increase mammography screening among underserved women in intervention counties To characterize barriers to mammography for eligible women in food pantries To develop and evaluate the process for dissemination of an adaptation of the food pantry program

24. Food Pantry Program Number of Screenings in FY 08-09 Intervention County Measure Change in Number of Screenings Number of Screenings in FY 07-08 Number of Screenings in FY 08-09 Matched Comparison County Measure Change in Number of Screenings Number of Screenings in FY 07-08 Measure Difference between Intervention and Comparison Counties Measure of Difference

25. Selection of Comparison Counties First phase: Selected demographics (population size, density, poverty, age distribution) - Community Health Status Indicators of the Public Health Foundation Second phase: Similar characteristics of food pantries in county Similar FY 07-08 and FY 08-09 funding for NBCCEDP screening No food pantry intervention

26. Eligibility Flow Chart Mammogram in Past 12 Months >= Age 40High Risk < Age 40 Women in Food Pantry Not High Risk Already Scheduled for Next 12 Months Not Scheduled for Next 12 Months Eligible for BCCEDP No Mammogram in Past 12 Months Mammogram in Past 12 Months Eligible for Komen Voucher Not Eligible for Komen Voucher Not Eligible for BCCEDP Ineligible for Mammography/Food Pantry Program Underserved Barriers Questions

27. Solicitation and Review of Applications to Deliver the Food Pantry Intervention Funding for cancer coalitions – 2007/2008 PA Division of the American Cancer Society Tartan Terrors Request for Proposals – May/June 2008 Responses to RFP Elk County, PA Greene County, PA Wyoming County, PA (Chautauqua County, NY) Review of Proposals – June/July 2008 NACN Advisory Committee Representatives of the community and academia

28. Intervention and Matched Comparison Counties in Pennsylvania Also, Chautauqua County and its comparison.

29. Demographics

30. Demographics, continued

31. Breast Cancer Facts Incidence and mortality (2001-2004):

32. Breast Cancer Screening Rural Appalachia disparity #1 Less likely to receive screening tests that can detect cancer early

33. Primary Care Rural Appalachia disparity #2 Shortage of primary care physicians and screening facilities

34. Rural Population and Distance to Care Rural Appalachia disparity #3 Travel long distances to be screened or consult with specialists Rural Communities have limited or non-existent transportation systems.

35. Intervention Timeline Awards to Intervention Counties August, 2008 Planning September, 2008 – October, 2008 Implementation November, 2008 – February, 2009 Evaluation and Reporting March, 2009 – August, 2009

36. Evaluation Aim 1: Increase screening mammography among underserved women Measure receipt of breast cancer screening in FY07-08 and FY 08-09 for intervention and comparison counties through National Breast and Cervical Cancer Early Detection Program Compare change between intervention and comparison counties Aim 2: Characterize barriers to mammography for eligible women in food pantries Administer questionnaire to women in food pantries Susceptibility, Benefits, and Barriers for Mammography Screening Champion VL. Res Nurs Health. 1999;22:341-348 Appalachia-specific questions Aim 3: Monitor the process, barriers and cost Utilize coalition logs Administer survey to coalitions Calculate cost-effectiveness of mammography as delivered by the intervention

37. Questionnaire Qualify women for screening eligibility based on: age history of mammography current plans for screening insurance status Ethnicity and race Education level Barriers – Mammography Barriers – Mammography in Appalachia Transportation Distance Knowledge of location

38. Strengths Seeks to increase screening mammography among underserved women in Appalachia Uses a study design that includes multiple sites with matching comparison sites Systematically examines dissemination of an evidence-informed, culturally-appropriate program

39. Acknowledgements PSU Alan Adelman Regina Allen Betsy Aumiller Marcy Bencivenga Bill Curry Bethany Hess Chris Hollenbeak Brenda Kluhsman Sam Lesko Diane Sheehan Community cancer coalitions Chautauqua County Partners for Prevention (NY) Elk County SHIP/Tobacco and Cancer Coalition (PA) Greene County Cancer Coalition (PA) Wyoming County Cancer/Tobacco Partnership (PA) Advisory Committee

40. 13 Community Representatives Marcia Anderson, Lawrence County Cancer Coalition (PA) Mary Day, Coalition for People Against Cancer (PA) Allison Clark and Nicole Hockenbrock, ACTION Health (PA) Marlene Coccheto, Wellness Council of the Southern Tier (NY) Jodie Cooper and Sue McDowell, Crawford County Cancer Coalition (PA) Jeanne Darling, Delaware County Cancer Coalition (NY) Paulette Schreiber, CRNP, Elk County SHIP/Cancer and Tobacco Coalition (PA) Christine Schuyler and Tory Irgang, Chautauqua County Partners for Prevention (NY) Charlie Shoemaker, Indiana County Cancer Coalition (PA) Carolyn Wissenbach, Greene County Cancer Coalition (PA) 15 State/Professional Representatives Julia Bucher, PAC3 Marilyn Corbin, PA Cooperative Extension Lisa Davis, PA Office of Rural Health Linda Fleisher, NCI CIS,Fox Chase Cancer Center Aileen Galley, Mount Nittany Medical Center (PA) Heather LeBlanc, NY DOH Philip Lazarus, PSHCI Christy Widman, NCI CIS, Roswell Park Cancer Institute Roxanne Parrot, PSU Center for Health and Risk Communication Candance Sanderson, PA American Cancer Society Debbie Stefanucci, Highmark Luanne Thorndyke, PSH Professional Development Lou Ann Weil, Statewide Cancer Screening Services (PA) Carol Weisman, PSU Health Services Research Division Kathleen Zitka, PA DOH Bold – Review Committee

41. Eugene J. Lengerich, VMD, MS 717.531.7178 elengerich@psu.edu