The most effective way to increase mammography screening among hard-to-reach, low-income, insured women is a stepwise intervention method or counseling program, according to a study published online June 29 in Cancer Epidemiology, Biomarkers & Prevention. The study found counseling increased screening compliance in the target population by 13.7 percent compared to the control group.

“The expectation that insurance coverage mitigates health disparities and equalizes use of healthcare assumes that services are equally accessed; however, the insured low-income target population in this research had a mammography rate of 23.4 percent, well below the general population,” offered the authors.

The study, which sought to determine the most effective intervention to improve mammography use in low-income women insured by a managed care organization (MCO), was led by Nasar U. Ahmed, PhD, chair of epidemiology and biostatistics at the Robert Stempel College of Public Health and Social Work at Florida International University in Miami.

The randomized controlled trial included 2,357 very low income women enrolled in the Tennessee Coordinated Care Network who had been noncompliant with mammography screening in the past two years. The study population included women who were 40 years of age and older, with an average age of 53. Forty-five percent of the target population was Caucasian, 12 percent were Hispanic and 43 percent consisted of African-American women; average annual household income was $8,447.

The women were randomly assigned to one of three groups. The control cohort consisted of 786 women who received usual care, defined as a recommended annual exam, with no intervention. A simple intervention cohort of 785 women received usual care and one prompt  letter from the MCO medical director if screening was not completed after three months. The stepwise intervention group of 786 received the prompt letter from the MCO and if still noncompliant, a second letter from their primary care physician was administered three months following the MCO letter and, if the woman remained noncompliant three months after this step, outreach workers employed by the MCO provided counseling three months after the second letter.

Outcome was determined by completion of screening mammography extracted from medical records, explained the authors.

In the control group, a screening rate of 13.4 percent was achieved after one year. The simple intervention cohort attained 16.1 percent compliance, and 27.1 percent of women in the stepwise intervention group participated in screening mammography. When compared with women in the control group, women who received the primary care physician letter in the stepwise intervention were 80 percent more likely to undergo screening. In addition, counseling tripled the likelihood of screening, said the researchers.

“The research provides evidence for the impact of stepwise interventions to improve cancer screening in low-income insured populations, although the screening rates remain well below those of the general population,” said Ahmed. Still, the researchers noted that despite the increased screening rates after counseling, the stepwise intervention many not be enough, “particularly for low-income women with many barriers and competing priorities, to obtain a mammogram.

“Additional personal strategies are most likely necessary to increase the use of these services among insured persons not accustomed to or comfortable with using the healthcare system for preventive care,” concluded Ahmed and colleagues.