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Mammography Use Michele M David, MD, MBA, MPH; Linda Ko, MS, MPH; Nicole Prudent, MD, MPH; Eric H. Green MD, MSc; Michael A. Posner, MS; and Karen M Freund, MD, MPH Boston, Massachusetts
Objectives: The goal of this study was to compare mammography use in Haitian women versus that of other racial/ethnic groups in the same neighborhoods and to identify factors associated with mammography use in subpopulations that are seldom studied. Methods: A community-based, cross-sectional survey sampled a multiethnic group of inner-city women from eastern Massachusetts. Bivariate analyses and logistic regression models were used to predict lifetime and recent (within two years) mammography screening. Results: Self-reported lifetime mammography use was similar for Haitian (82%), Afncan-Amencan (78%), Carbbean (81%) and Latina women (86%) but higher for white women (94%, p=0.008). Mammography use in the past two years was also similar in all groups (66-82%, p=0.41). In multivanate models, African-American (adjusted odds ratio [AOR]; 0.3; 95% Cl 0.1-0.9) and Haitian women (AOR 0.3; 95% Cl 0.1-0.9) had lower odds of lifetime mammography compared to white women. Factors independently related to lifetime and recent mammography included having a regular healthcare provider, greater knowledge of breast cancer screening; higher education, and private health insurance. Conclusions: Haitian women with a regular provider and knowledge of breast cancer screening reported recent mammography use similar to women from other racial/ethnic groups. The racial/ethnic patterns of mammography use in our study do not explain racial/ethnic differences in breast cancer stage or mortality. Key words: Haitian U breast cancer M mammogram a ethnicity © 2005. From the Haitian Health Institute at Boston Medical Center and Women's Health Research Unit, Section of General Internal Medicine and Adolescent Medicine, Evans Department of Medicine, Boston University School of Medicine. Send correspondence and reprint requests for J NatI Med Assoc. 2005;97:253-261 to: Michele David, MD, MPH, MBA, Address: Boston University Medical Center, Women's Health Unit, 720 Harrison Ave., DOB 1108, Boston, MA 02118; phone: (617) 638 8036; fax: (617) 638 8026; e-mail:
[email protected]
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
INTRODUCTION Although Massachusetts leads other states in overall rates of screening mammography for black and white women,1 no associated reduction in the gap of breast cancer deaths between black and white women has been observed.2-5 One explanation for this unexpected concurrence is that the group of women defined as black may contain subpopulations that differ in screening behavior, which could account for continued differences in mortality. Subpopulations with a lower education, low income and recent immigration history, such as Haitian women, may have lower screening rates.6-8 Haitians in the United States represent a sizable and growing population, consisting of more than 500,000 documented9 and 1.2 million undocumented immigrants, according to recent estimates.'0 Reliable data on mammography screening of Haitians living in the United States, however, is not available from large population-based surveys. The dearth of this and other data on Haitians, including reliable and valid health information, exists for a number of reasons. Often, Haitians are classified in studies as "black," or "African-American." Moreover, when surveys targeting Haitians are attempted, difficulties owing to factors associated with language, a reluctance to participate due to prior misrepresentation (stigmatization during the early years of the HIV pandemic), immigration history and recent immigration policies are often reported.'0 There are other reasons to believe that mammography use is low in Haitian populations. In addition to the barriers cited above, some women who originate from rural areas of Haiti may view the role of screening mammography with the health attitudes, beliefs and practices thereof.8" 1-13 For these women, breast cancer screening is likely to be an unfamiliar concept, since only Haitian women of the very highest social stratum have access to screening mammography often obtained in the United States.'4 Preliminary literature suggests that Haitian women do not avail themselves of preventive health testing as compared to women VOL. 97, NO. 2, FEBRUARY 2005 253
MAMMOGRAPHY USE
from other racial/ethnic groups.8'15"16 The main goal of our study was to determine whether or not Haitian women utilize mammography at rates similar to women in their communities. We also sought to determine if the predictors of mammography use in this community sample are similar to those already reported in the literature.
In each block, all housing units were enumerated, and 12 units were randomly selected for interview. Interviewers who visited housing units having Haitian residents also asked them to suggest blocks where other Haitian families were likely to reside.
METHODS Subjects
We developed a survey instrument that included questions on ethnicity, age and education, as well as selected knowledge, attitudes and belief variables in relation to the utilization of cancer screening. Researchers adapted questions from the National Health Interview Survey (NHIS), the NHIS cancer control supplements and the Cancer Control Needs in Multi-Ethnic Communities (CCNMEC) survey conducted in New York City in 1992.17-19 We fieldtested the questionnaire by administering it to 20 community members. We incorporated their critique in the final questionnaire, hired interviewers from the population under study. The questionnaire was translated into Haitian Creole, back-translated into English by a different translator, compared translations and resolved discrepancies. The Institutional Review Board of the Boston Medical Center
Survey Instrument and Data Collection
We conducted a community-based, cross-sectional interviewer-administered survey of women 40 years of age and older who spoke English or Haitian Creole in eastern Massachusetts neighborhoods having a high proportion of Haitian residents. We used an area probability sample to select subjects. After constructing a sampling frame by using the City of Boston and Cambridge Assessing Department's Property Parcel Data for fiscal year 1997, we interviewed Haitian community leaders to identify housing blocks with high concentrations of Haitian families. Blocks estimated by two or more informants to contain 10 Haitian households or at least 20% Haitian households were included in the survey universe.
Table 1. Demographic Characteristics by Ethnicity of Community-Based Sample in Eastern Massachusetts (n=326)
Haitian N=143
White N=80
African-American N=55 N
Age 40-49
Caribbean N=26
Latina N=22
P Value
