Breast Cancer Detection Rural Women

¶ … Breast Cancer Detection

Rural women are predominantly at a greater risk of dying from breast cancer, because they are not afforded the advantage of screening procedures that are readily available to their urban counterparts. The purpose of this study is to develop an intervention model is to explore the characteristics of rural women who attended a free breast health program that included self breast examination education and free mammography in order to determine how to better improve intervention strategies to strengthen breast health in rural women (Lane and Martin, 2005). The organizing conceptual framework will be the Precede/Proceed Model.

The Precede-Proceed model offers a comprehensive configuration for assessing health and quality-of-life needs and for designing, implementing, and evaluating health promotion and other public health programs in order to meet these needs. "PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) outlines a diagnostic planning process to assist in the development of targeted and focused public health programs. PROCEED (Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) guides the implementation and evaluation of the programs designed using Precede" (Green and Mercer, 2002).

The precede section is made up of five steps or phases. Phase one entails determining the quality of life or social problems and needs of a given group of people. Phase two consists of identifying the health determinants of these problems and needs that they bring. Phase three involves looking at the behavioral and environmental determinants of the health problems. In phase four, the factors that incline to reinforce and enable the behaviors and lifestyles are acknowledged. Phase five involves establishing which health promotion, health education and policy-related interventions is best be apt to encourage the desired changes in the behaviors or environments and in the factors that support those behaviors and environments (Green and Mercer, 2002).

Proceed is made up of four additional phases. During phase six, the things identified in phase five are put into practice. Phase seven involves process assessment of those interventions. Phase eight consists of looking at the impact of the interventions on the factors supporting behavior as well as on the behavior itself. The ninth and last phase looks at outcome evaluation and establishes the final effects of the interventions on the health and quality of life of the population (Green and Mercer, 2002).

Planning and implementing any sort of population health program or environmental intervention should follow a basic agenda of enhancing the quality of life and health status by doing what is necessary to prevent illness and injury. These types of programs usually operate at one or a combination of stages of prevention. The primary stage consists of health enhancement and prevention through environmental controls. The secondary stage is early detection and treatment of known risk factors. The tertiary stage is made up of therapy in order to prevent recurrence. Most population health interventions operate at the primary stage, focused on improving or enhancing the health of the community (Environmental Intervention Planning 101, 206).

The framework of the Precede-Proceed model is useful for grouping together factors that are likely to be used to bring about the desired program outcomes. The three broad groupings are predisposing factors, enabling factors, and reinforcing factors. Predisposing factors are those that include personal attributes such as a person's knowledge, attitudes, beliefs, values, and perceptions that can promote or hinder motivation for change. Enabling factors are those skills, resources, and barriers that encourage or hinder the desired change. Enabling factors are mainly societal forces or systems. Oftentimes enabling factors include availability of personal and community resources, accessibility, referrals, laws or statutes, personal skills, services, and facilities. Reinforcing factors are the behaviors and attitudes or those around the person such as the rewards and incentives received or the feedback that is received from peers, parents, family, employers and social groups for adopting the desired outcome (Lane and Martin, 2005).

The objectives of the Precede-Proceed Model are to explain health-related behaviors and provide a foundation for developing and testing interventions that influence both behaviors and environmental conditions that affect these behaviors. The Precede component of the model is the diagnostic phase that is useful for identifying the predisposing, enabling, and reinforcing constructs associated with the phenomenon and the Proceed component is the development phase outlining the policy, regulatory, and organizational constructs. The Precede structure directs attention to what must precede the desired outcome, in this case, a woman getting a mammogram. In order to determine what causes the desired outcome, the factors important to that outcome must be diagnosed before intervention strategies can be designed. Without an adequate diagnosis of the important factors, the investigator runs the risk of designing ineffective intervention strategies (Lane and Martin, 2005).

Two fundamental propositions that are emphasized in the Precede/Proceed Model include that fact that health and health risks are caused by multiple factors and that, because of this proposition, efforts to effect behavioral, environmental and social change must be multidimensional or multi-sectoral. The Precede component of this model is useful as a framework for this intervention model development because it will provide direction and focus for future investigation of the factors that affect the ability of rural women to adopt breast health behaviors (Lane and Martin, 2005).

The first step that needs to be done is an analysis of why rural women do not take advantage of screening procedures that are readily available to them. The research team would need to develop a survey to elicit information related to characteristics of rural women seeking mammography. The survey would consist of a self-administered questionnaire comprised of fixed choice and open-ended questions regarding respondents' demographic and breast health behaviors. Some of the items will focus on predisposing factors such as personal knowledge, attitude, values, and beliefs regarding breast cancer and early detection. Some questions will focus on enabling factors such as family income and availability of insurance. Some questions will be reflective of reinforcing factors such as incentives or feedback from others regarding healthy behaviors. Face and content validity of the survey would be assessed by a panel of experts consisting of a mobile mammography unit director, registered nurse practicing in a breast center, local public health nurse, and researcher with expertise in breast health (Lane and Martin, 2005).

The target population for this study will consist of women age 35 years and older, who speak and understand English, live in one of four rural, medically underserved counties in the Midwest and were appropriate for screening mammography. Age recommendations for screening mammography will be based on American Cancer Society Guidelines (2002). Additional guidelines for screening mammography will be based on the criteria set down by the contracted mobile van. These include: no breast discharge or pain, no new lumps or dimpling, no biopsy since last mammogram, no current pregnancy or breast feeding, and no breast augmentation. Only screening mammographies will be provided by the mobile unit (Lane and Martin, 2005). Many deaths from breast cancers occur disproportionately among women who are uninsured or underinsured. The thinking is that this could be avoided by increasing cancer screening rates among all women at risk. Mammograms are underused by women who have less than a high school education, are older, live below the poverty level, or are members of certain racial and ethnic minority groups (The National Breast and Cervical Cancer Early Detection Program, 2010).

Once the data has been collected from the survey this information will be used to help determine an intervention strategy that will help reach the goal of increasing the number of rural women who get early breast cancer screening detection. The hope is that the findings from this study will support that women in this rural regions only seek mammography when mobile mammography units are brought into their communities and services are provided at no charge. Research has shown that the most effective patient-targeted strategies to increase mammography use are access enhancing efforts such as mobile vans, transportation services and reduced cost mammograms. Distance has been stated as a barrier to mammography screening in past studies. Distance within the rural community converts to two primary issues: time and money. Fuel prices are also thought to be an issue regarding access to a facility and may increase use of the mobile mammography (Lane and Martin, 2005).

The key is to eliminate as many of the barriers as possible that hamper these women getting early detection screening done. The National Breast and Cervical Cancer Early Detection Program has been set up to help low-income, uninsured, and underserved women gain access to lifesaving early detection screening programs for breast and cervical cancers. This program is working to improve health care for underserved women through outreach, public and professional education, improved access to services, diagnostic evaluation, case management, treatment services, and quality assurance measures (The National Breast and Cervical Cancer Early Detection Program, 2010). It would be important to base any intervention program on these same goals and efforts in order to be successful.

A good intervention program must help women overcome barriers to screening, including fear of a cancer diagnosis, lack of transportation and child care, linguistic and cultural differences, and lack of physician referral. In this particular instance the place to start would be to launch an education program aimed at both patients and providers as to the importance of early detection screening for breast cancer. The goal would be to implement outreach strategies to improve access to screening for women who have rarely or never been screened. A second thing that would need to be done would be that of developing a transportation and child care program that could be utilized by these women in order to help them to seek services. The hope would be that by raising awareness about the importance of early detection and providing access to screening services that a larger percentage of rural women would obtain screening procedures.

Another barrier that would need to be addressed would be that of insurance availability. For those women who have access to insurance the reason for not seeking screening may be one of the aforementioned reasons of lack of transportation and child care, but for some women their reasons include either no insurance or insurance that still leaves them with a high out of pocket cost. For this group there would need to be put into place some sort of reduced cost programs at which these women could seek care at a reasonable rate that they could afford.