Increasing Mammography Screening in Latinas with Diabetes

Institution: Golden Valley Health Centers
Investigator(s): Christine Noguera, M.S. - Stergios Roussos, PhD, MPH -
Award Cycle: 2008 (Cycle 14) Grant #: 14BB-2801 Award: $493,666
Award Type: CRC Full Research Award
Research Priorities
Community Impact of Breast Cancer>Disparities: eliminating the unequal burden of breast cancer

This is a collaboration with: 14BB-2800 -

Initial Award Abstract (2008)
Research shows that Latina women are less likely to get a mammogram when compared to non-Latino women. It is even less likely for Latina women with diabetes to get a mammogram despite more diabetes visits to their healthcare provider than non-diabetic women. Latinas are more likely to be diagnosed with breast cancer at a later stage and less likely to get or ask for a mammogram than non-Latino women. Studies have shown significant differences in mammography screening and greater risk for women with diabetes to develop breast cancer. Low rates of mammography screening among Latinas with diabetes offers an opportunity to medical providers to use the diabetes visits as a way toI increase mammography compliance according to the national recommended guidelines.

This project asks the question can age-appropriate mammography screening be increased for Latinas with diabetes through a systems-integrated intervention that links their diabetes care with methods to promote mammography?

Our hypothesis is that Latina patients ages 40 to 75 with diagnosed diabetes and non-current mammography screening are more likely to complete mammography screening after exposure to a system-integrated intervention that links their diabetes care with methods to promote mammography.

The major specific aim to test our hypothesis is to assess the differential effects on compliance with age-appropriate mammography screening for Latina patients ages 40 to 75 with diabetes before and after exposure to a system-integrated intervention that links regular diabetes care with theory-driven methods to promote mammography screening.

A team of people from different areas of the community will work together to address this underlying issue. The team includes Golden Valley Health Centers, CBEACH, and Women of Courage, who will be implementing the project components created during the pilot phase. With the help of the community advisory group (CAG), this team will test several tasks such as developing, designing and producing intervention components that intend to increase mammography screening among Latinas with diabetes over 40 years of age. The team for Project Perlas will address barriers for mammography screening by the development of a fotonovela, a life-size cutout, a modified diabetes progress note and a behavior assessment tool. Another component includes patient advocate visits by Women of Courage and the CAG to health center staff meetings. Fourteen community health center sites will receive the intervention components in a staggered timeline to prevent sharing across experimental conditions.

Health disparities for mammography for Latinas are correlated with cultural and linguistic factors, such as fear due to the way many women correlate a mammogram with death, lack of trust and poor communication with health care staff and family priorities. With support from the three groups, the project seeks to address several of the psychosocial barriers many Latina women encounter and seeks to increase awareness among health care providers regarding these barriers. Women of Courage, a nonprofit, grassroots group led by breast cancer survivors including GVHC staff, helps Merced County women who may be too young to get a mammogram and have other barriers that prevent them from getting breast cancer screening services. Women of Courage participated in the design of the pilot award components and have been in charge of the community advisory group. The CAG is formed by women who have had breast cancer and diabetes, and who are interested in participating in all the different parts of the full award.

The future for Project Perlas is to continue the collaboration between researchers, community partners and community health centers. It is also expected to ensure that the results and intervention components are shared with other heath centers in order to continue addressing health disparities in underserved communities like Merced County.


Final Report (2011)

Community-Based Participatory Research (CBPR) can contribute to the prevention and control of breast cancer by focusing the individual and synergistic strengths of community-academic teams. Project Perlas was a CBPR project to address disparities in mammography screening among Latina patients with diabetes in community health centers within the Central Valley of California. Latinas with diabetes are less likely to receive age-appropriate mammography despite more health visits (where the complexity of caring for chronic illness is predicted to interfere with mammography). The goal of Perlas was to establish and test the effects of an innovative intervention that takes advantage of a highly prevalent chronic illness among Latinas (diabetes) to prompt for mammography screening, a periodic preventive service. The development of the Perlas intervention and research design to understand its effects were created through close collaboration among the community-academic team including administrative and clinical staff, breast cancer survivors with and without diabetes, and community health researchers. A multi-dimensional intervention was developed which focused on the patient, the provider and the system of health care delivery. Provider intervention components consisted of educating providers about mammography screening and insurance coverage guidelines through group trainings. Patient intervention components consisted of screening prompts and breast health education. Broader service delivery interventions resulted from system improvements to better assess behavioral risk associated with physical activity, nutrition, blood sugar testing, as well as EMR and paper prompts to clinicians to facilitate timely preventive screenings.

A 2-group, pre-post intervention study design was used to examine the effects of Perlas. GVHC sites exposed to Perlas (N=11) with non-Perlas sites (N=12). Data for analysis was retrieved from GVHC patient databases based on variables defined during project design. The primary dependent variable was mammogram status categorized as not current (incomplete or completed 2 or more years from the visit date) and current (completed within 2 years from the visit date). Change in mammogram status was examined with a cohort of patients who completed visits in 2009 (non-intervention year) and 2010 (intervention year) allowing for up to 6-months after a patient visit to complete a mammogram. Patient variables included age, language, payer, and diabetes risk determined by HbA1C level. System variables included the EMR status of the site where the patient received care. A total 2,856 women between the ages of 40-75 completed a medical visit in 2009 and in 2010. Fifty-three percent were between the ages of 50 and 64, 77% were Latino, and 60% spoke Spanish as their primary language. For diabetes risk, 48% of patients were at lower risk, 31% were at moderate risk, and 20% were at higher risk. Compared to non-Latinas, Latinas were more likely to have a moderate (31% vs 28%) and higher risk (21% vs 18%) for diabetes related complications. Approximately 44% of patients were uninsured/self-pay, 47% used government programs, and 9% were insured. The rate of current mammogram status for women in non-Perlas sites increased from 30% to 46% compared to that for women in Perlas sites which increased from 38% to 53%. Thirty-six percent of women in Perlas sites improved from not current to current in their mammogram status compared to 28% of women in non-Perlas sites (P<.01). A similar pattern was seen for Latinas, but Latinas showed a greater improvement than non-Latinas. Multivariate analyses adjusting for all patient and site characteristics found that participation in Perlas was a significant contributor to improvement in mammogram status (not current in 2009 to current in 2010; 95% CI = -.56 to -.002).

While prior studies found that Latinas have lower mammography rates than other ethnicities, our study found the reverse. The highest mammography rate found was for Latinas in Perlas (56%) compared to non-Latinas (43%). This is still below the most currently available (2008) national rate of 61% for Latinas compared to an average of 66% for non-Latina groups. The higher Latina mammography rates in Perlas occurred despite a change in the national mammography screening guidelines, organizational transition to a new EMR, and higher diabetes risk levels for Latinas. The completion of this three-year project illustrates the value of a strong community-academic collaboration, and offers important lessons for addressing mammography disparities among Latinas with diabetes.




Symposium Abstract (2010)

S. Roussos (1, 2), C. Noguera (2), F. Batts (1), M. Bunyard (3), H. Roehlk (3), M. Sigarroa (3), M. Hovell (1)

1-Center for Behavioral Epidemiology and Community Health; 2 Alliance for Community Research and Development; 2-Golden Valley Health Centers; 3-Women of Courage

Community-Based Participatory Research (CBPR) contributes to the prevention and control of breast cancer through the individual and synergistic strengths of community-academic teams. Project Perlas is a CBCPR project addressing disparities in mammography screening among Latina patients in community health centers within the Central Valley of California. Latinas with diabetes are less likely to receive age-appropriate mammography despite more health visits, as the complexity of caring for chronic illness can interfere with preventive services. Perlas is an innovative intervention that takes advantage of a highly prevalent chronic illness among Latinas (diabetes) to prompt for mammography screening, a periodic preventive service.

The development of the Perlas intervention and research design to understand its effects were created through close collaboration by the community-academic team. The community partners include administrative and clinical staff from a network of 25 community health centers and breast cancer survivors with and without diabetes. Community Latino members, breast cancer survivors and clinical members were also represented on the team. The academic team was composed of behavioral epidemiologists and community health researchers specializing in health disparities.

This presentation describes the intervention components and research design elements of this ongoing study. The decisions and negotiations during the design process are presented while illustrating how the team worked to ensure valid research methods, relevance and utility to clinical and community partners, and cultural competency. The final intervention includes patient and provider education and clinical prompts tailored to Latino culture and to the organizational culture of community health centers. The research design includes pre-post intervention repeated measures for mammography and diabetes with process evaluation of project implementation. The adoption of electronic medical records (EMR) during the study allows for an exploration of how EMR may be support intervention and measurement activities.

The summary of lessons learned during the collaborative design and development process will help community-academic teams understand how to balance research goals (e.g., internal validity, theory-driven methods) with organizational goals of caring for undeserved, vulnerable patients given limited resources. Insights are shared about how community and academic partners serve as teachers and students in the process of community-based participatory research. Recommendations are provided for community-academic collaboration in research design and intervention development to address disparities in breast cancer prevention.