Increasing Breast Cancer Screening in Russian Immigrant Women: Identifying Barriers and Providing On-Site Mammography

Background

Despite increasing improvements in technology and the wide availability of screenings aimed at detecting breast cancer at its earliest stages, women are underusing available resources for cancer screenings. Recently, there have been concerning declines in the use of mammography (American Congress of Obstetricians and Gynecologists [ACOG], 2011; Breen et al., 2007). From 2000 to 2005, mammography screening rates dropped from 70% to 66% (Breen et al., 2007). This is especially true for Russian immigrant women in the United States and across the globe (Andreeva & Pokhrel, 2013; Chukmaitov, Wan, Menachemi, & Cashin, 2007; Remennick, 1999). Brooks et al. (2013) also reported that underusing screening tools such as mammography delays appropriate diagnosis and treatment.

Breast cancer is the second leading cause of cancer-related deaths in women (American Cancer Society [ACS], 2015b). According to the World Health Organization (2015), in resource-poor settings, most women are diagnosed with breast cancer in later stages, decreasing their 5-year survival rates to 10%–40%, compared to 80% in women with early stage breast cancer. Because Russian immigrant women are underusing breast cancer screenings (Andreeva & Pokhrel, 2013), these women are presenting with advanced symptoms (Reminnick, 2006). Structural and organizational barriers are factors in the underusing of mammography in this population.

According to Reminnick (2006), structural barriers to breast cancer screening in Russian immigrant women include lack of health insurance, insufficient health insurance, and distance to medical facilities. Organizational barriers include difficulty interacting with medical staff because of a language barrier and challenges navigating complex health care systems (Reminnick, 2006, 2007; Shpilko, 2006). Other barriers include reduced perceived risk of breast cancer, belief that mammography does not consistently prevent breast cancer deaths, and lack of emphasis on health promotion (Breen et al., 2007). Providing on-site access to breast health education and mammography can reduce or eliminate these barriers (Legler et al., 2002).

Education can help eliminate and overcome barriers to health care. Secginli and Nahcivan (2011) found that health promotion and education increases awareness for health prevention screenings in immigrant women. Along with education, providing access to on-site mammography is an effective, evidence-based tool to reach communities that otherwise would not have access to these screenings (Minnesota Department of Health [MDH], n.d.; Park Nicollet Health Services, 2015). The specific aim for this systems improvement (SI) project was developed to increase breast cancer screenings in Russian immigrant women in a faith-based community through identifying barriers and providing access to screening. Legler et al. (2002) and Brooks et al. (2013) state that the strongest mammography-enhancing intervention is access to mammography. The MDH meets these access-enhancing criteria through the Sage Screening Program, which provides a mobile mammography bus in partnership with a regional clinic and the ACS (MDH, n.d.; Park Nicollet Health Services, 2015). The Sage Screening Program brings mammography directly to women using the mobile mammography unit. In addition to breast cancer screening, the MDH Sage Screening Program provides free cervical and colon cancer screenings to eligible women based on income status.

Setting

The setting for this SI project was a southern, outer ring suburb of Minneapolis. The project site community has approximately 283 homes with Russian-speaking families. Russian is the third most common language spoken in this geographic region (Stratis Health, 2012). The primary location for the project within this community was a Russian faith-based congregation. This congregation has 850 members of which approximately 200 are women older than the age of 40 years (O. Maleshenko, personal communication, May 3, 2015). Women who were members of the church and older than 40 years were invited to participate in the SI project. This project was done with the support of the church scheduler, a Sage representative, a regional clinic representative, and an ACS representative.

Interventions

Methods of Evaluation

Ethics

Ethical principles were applied throughout the project process. The presented information and consents were given within the appropriate language of the Russian faith-based community.

Institutional review board (IRB) approval and exempt status was granted prior to the start of project implementation by the PL’s university. The project site did not require a separate IRB.

The project was introduced and discussed at the beginning of the educational sessions in the native Russian language of the women. The PL spoke the Russian language fluently and was able to communicate with the participants freely. All written information was given in two languages, Russian and English. This was done to reinforce understanding of the project for the participants. Risks of mammography were explained before the women consented to the breast cancer screening. These risks include false-positive results, false-negative results, radiation, and the need for further testing. The participants were also ensured their right to withdraw from the project at any time. They were given contact information for the PL, faculty advisor, and the research subjects advocate line should they have any questions or concerns.

Confidentiality and Health Insurance Portability and Accountability Act (HIPAA) compliance were enforced throughout the project. The patients completed a needs assessment and pre-/postquestionnaires without identifying information. At the request of the participants, phone numbers were given to the PL to make reminder phone calls prior to the mammogram event. The PL ensured patient privacy by only speaking to the participant individually regarding the date and time of the mammogram. No voicemail messages were left. During the mammogram event, the use of professional Russian-speaking certified interpreters protected patient confidentiality and eliminated need for family or community members and/or the PL to interpret. The regional clinic and the Sage Screening Program followed HIPAA regulations with private health information of the participants as ordered by their protocols and policies. No private medical data were given to the PL. Only aggregate deidentified information was provided to the PL from the regional clinic and Sage.

Needs Assessment

The needs assessment was the first questionnaire that was filled out, which consisted of three questions. The first and second question assessed when the last clinical breast exam was done and when the last mammogram was obtained. Of the 27, 5 had a clinical breast exam and a mammogram within the last year, 14 in the last 2–5 years, 3 within the last 10 years, and 5 had never had one done. The third and final question assessed participants’ reasons for not having a clinical breast exam and mammogram in the past 2 years. Of the 27, 22 had not had an annual breast exam and mammogram within the last 2 years. The reasons listed included no insurance, didn’t think it was important, other, and no response (Table 1).

Pre- and Postassessment

The pre- and postassessments were analyzed using the Wilcoxon signed-rank test. The frequency of each response in the figures is shown on the Y axis, and the response options are shown on the X axis (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). In assessing participants’ responses to Question 1 regarding the importance of annual mammography, the results demonstrated that there was a trend toward thinking that getting an annual mammogram was more important in the postintervention period compared to the preintervention period (Figure 1). However, this shift was not statistically significant (p = .05991). For Question 2, which assessed participants’ likelihood of getting an annual mammogram after the intervention, the postintervention questionnaire again corresponded with higher responses (Figure 2). These results illustrated that the women were significantly more likely to agree that they will get a mammogram done every year after the intervention (p = .0024). With Question 3, there also was a trend toward increased responses, moving from disagreeable to agreeable (Figure 3). These results showed that after the intervention, the women were significantly more knowledgeable about where they could go to get a mammogram (p = .0168). Thus, results were statistically significant. For the final question on the pre- and postassessment questionnaires, there were significant improvements in participants’ perceived knowledge of breast cancer risk factors and prevention strategies (p < .0003; Figure 4).

Figure 1.

Pre-/postsurvey Question 1: Importance of annual screening mammography.

The red area shows the distribution of the postintervention responses, and the blue area shows the distribution of the preintervention responses. The purple area is where they overlap.

Figure 2.

Pre-/postsurvey Question 2: Likelihood of getting an annual mammogram.

The red area shows the distribution of the postintervention responses, and the blue area shows the distribution of the preintervention responses. The purple area is where they overlap.

Figure 3.

Pre-/postsurvey Question 3: Knowledge of where to get mammograms.

The red area shows the distribution of the postintervention responses, and the blue area shows the distribution of the preintervention responses. The purple area is where they overlap.

Figure 4.

Pre-/postsurvey Question 4: Knowledge of breast cancer risk factors and prevention.

The red area shows the distribution of the postintervention responses, and the blue area shows the distribution of the preintervention responses. The purple area is where they overlap.

Breast Health Tea and Mammogram Event

Ten women attended the Breast Health Tea event. Seventeen more women attended small group discussions, which resulted in 27 female participants. The age range for the participants was 40–62 years, with an average age of 52 years. Of the 27 women, 19 signed up for the mammogram event. Of the eight who did not sign up, four had a mammogram within the last year, and four women went through their primary care provider for breast cancer screening. The mammography results for the 19 women included 16 normal/benign findings. Three women required follow-up. Of the three, one was positive for breast cancer, one was benign on follow-up, and one went elsewhere for further evaluation.

Thematic Network Analysis

Throughout the discussions/events and on the needs assessment tool, several themes and barriers to breast cancer screening were identified. One of the themes that arose was fear that mammography would cause cancer. Another was distrust toward the medical system, for example, believing that the medical system was “making money off me.” Lack of knowledge about risks for breast cancer and the importance of breast cancer screenings also were identified as a barrier to care. However, the most common barrier identified was the financial burden of not having insurance or being underinsured (Figure 5).

Figure 5.

Barriers to accessing breast cancer screening.

Thematic network analysis illustrating the themes that were depicted from the assessments and discussions.

Limitations

Several limitations were identified in this SI project. First, the sample size was small and was obtained from one faith-based community. For this reason, it is difficult to generalize these results to other communities. It would have been beneficial to include other Russian congregations, or even other immigrant congregations, in the region. The number of women who could be screened in 1 day also limited the sample size. The mobile mammography service could only accommodate 20 participants in 1 day. Having multiple screening dates would have allowed for a greater number of participants. Another limitation was having the educational or tea event only one time. Providing this education on several days and at different times may have increased the reach of this educational intervention. In addition, the questionnaires were not tested for reliability or validity. Finally, no information was gathered after the mammography event to assess participants’ responses to the breast cancer screening.

Having a follow-up survey after the mammogram event to further evaluate the participant’s response to on-site mammography would have provided more useful information for developing future screening programs.

Implications for Practice

Health care providers need to be aware of barriers to cancer screening. It is necessary to take the time to educate immigrant women on the importance of breast cancer screenings, and how to access these screenings. Providers can be proactive and participate by volunteering at cancer screening events. They also can advocate funding these programs at the local, state, and federal level. Providing these services in partnership with communities of underserved women will lead to a shift in earlier detection and treatment of breast cancer.

It is important for health care providers to be aware of the current mammography screening recommendations. When this project was implemented, the recommendations by the ACS and the American Congress of Obstetricians and Gynecology (ACOG) advised that women older than the age of 40 years have annual mammograms. The ACS modified its recommendations in October (ACS, 2015b) to recommend women start annual screening mammograms at age 45–54 years and continue screening biennially after that (Oeffinger et al., 2015). Screenings are advised for as long as the life expectancy is 10 years or longer. The ACS recommended against a clinical breast exam at any age. ACOG (2015) continues to recommend annual mammography for women age 40 years and older and annual clinical breast exam starting at age 19 years. Both the ACS and ACOG recommend that providers partner with their patients to collaborate on the best plan of care regarding the timing of mammography screenings (ACOG, 2015; Oeffinger et al., 2015).