Targeted Mailing: Increasing Mammogram Screening Among the Elderly

Older women have the highest breast cancer rates, but are underscreened relative to their risk. Rates of breast cancer continue to rise throughout a woman's life span and do not level off until a woman is over the age of 75 years. One-half of the new cases of breast cancer are diagnosed in women 65 years and older. Racial/ethnic minority women have especially low rates of screening, often because of financial constraints. Although the Health Care Financing Administration's (HCFA) Medicare program began to partially cover the cost of biennial screening for mammograms for all Medicare-eligible women in 1991, under use of this benefit continues to be a national problem.

The program uses a targeted mail intervention to increase awareness about the Medicare mammography reimbursement benefit and other low-cost screening options for diverse racial/ethnic groups of elderly women. The program seeks to address the question of whether elderly women will increase their use of screening mammography when made aware that its costs are offset by the Medicare program.

The intervention can be implemented in the home through a one-time mailing.

Study participants were White, Black and Hispanic female Medicare enrollees aged 65 years and older, from three sites in southern California. Eligible women were non-institutionalized with no history of breast cancer.

This intervention is suitable for implementation by mail.

Required resources include a 2-page bilingual mailing describing Medicare screening benefits, low-cost screening alternatives, and risk factors related to age. A mammography facility guide is also required to indicate where woman can obtain a low-cost mammogram in their community. Costs associated with the program's implementation are not provided.

The intervention, based on the Health Belief Model, aimed to increase women's awareness of vulnerability (to breast cancer), lowering screening barriers, and providing cues to action (where to get breast cancer screening). Women were assigned to either the intervention group (mailing) or the control group (no intervention). Intervention group participants received a mailing describing the new Medicare benefit and low cost screening options. Women were informed about their risk status and the prevalence of the disease for their age group. Women also received a facility guide indicating where they could obtain a low-cost screening mammogram in their community. The intervention was evaluated through telephone and mail interviews before and after the mailing.

Results indicated that mammogram use increased significantly among minorities receiving the intervention:

• Among Black women, those receiving the mailing were twice as likely as those in the control group to have had a mammogram in the 2-year period after intervention.
• Among Hispanic women, those who received the mailing were more than twice as likely as the control group to have had a mammogram in the 2-year period after intervention.
• White women in the intervention community reported an increase in their mammography use (57% to 69%) as did Black women in the intervention community (57% to 60%). Although Hispanic women in the intervention community reported a decrease from 50% to 44% this decline was more pronounced for Hispanic women in the control condition (51% to 42%).
• Respondent awareness that Medicare subsidized the cost of regular screening mammograms significantly increased the likelihood of having had a mammogram.