Maximizing Mammography Participation

Mammography offers the best protection from breast cancer mortality for women aged 50 years and older. Mammography screening among women in this age group reduces breast cancer mortality by 40% when 85% of a population obtains examinations regularly. Despite an overall increase in mammography use and decrease in breast cancer mortality over the past decade, mammography remains underused by older women. A common method of reminding women of their need for a mammogram is a letter from their physician or health maintenance organization. Motivational and reminder telephone calls may also be an effective strategy to boost the rate of adherence to mammography screening guidelines.

Maximizing Mammography Participation uses a reminder postcard, a reminder telephone call, or a motivational telephone call to encourage women to schedule and keep mammography appointments. The reminder postcard and reminder call serve as a means for inviting women to schedule a mammogram. The motivational call represents a more elaborate health care system intervention based on the principle of motivational interviewing. The motivational call provides an opportunity for women to ask questions and discuss concerns about the mammography exam with a knowledgeable person. The motivational call focuses on understanding the patient's decision-making process and assists them in obtaining a mammogram by discussing the pros and cons of the exam, beliefs, feelings, and logistics in a non-confrontational and empathetic way.

The time required varied among the three types of intervention used during the study. The reminder postcard required minimal time to send; the reminder call took 3 minutes to complete; and the motivational call was completed in 9 minutes. The motivational call also included a two-day training and a one hour weekly meeting with program staff to review taped sessions and reinforce program protocols.

Participants who tested this program were women between 50 and 79 years of age from Seattle, Washington. Participants had no history of breast cancer and were due to receive a mammogram. Eighty-nine percent of the women were White; 72% had had a prior mammogram.  Other populations involved in the study were: Alaskan Native, American Indian, Asian, Black, Hispanic, and Pacific Islander.

The intervention is suitable for implementation in a physician's office, or a health plan.

The reminder postcard is available. The reminder call requires calling instructions, caller documentation descriptions, caller documentation sheets, a call script, and the ability to place a woman on the radiology schedule at the time of the call. The motivational call requires a telephone counseling manual which includes detailed protocols, training on motivational interviewing, baseline and 12-month surveys, and examples of resource guides and information pamphlets. It also assumes the ability to schedule the woman at the time of the call. Cost-effectiveness analyses estimate that the postcard costs $3.95 per scheduled mammogram, the reminder call costs $21.22 per scheduled mammogram, and the motivational call costs $25.99 per scheduled mammogram.

Participants were members of a health maintenance organization (HMO) in Seattle that regularly sent recommendation letters to women when it was time to schedule their mammogram. A total of 1,765 women who did not schedule a mammogram within 2 months of receiving the mailed recommendation were randomly assigned to one of three intervention groups: a reminder postcard (n = 590), a reminder telephone call (n = 585), and a motivational call addressing barriers (n = 590). Women receiving reminder calls were contacted by a female scheduler, who made the appointment through a computer linkage to the radiology center. If concerns arose during a call, the scheduler would refer the woman to the personnel knowledgeable about breast cancer or to her primary care physician. Participants in the motivational call intervention group were contacted by a female masters-level counselor who could also schedule mammography appointments. The women were followed for 1 year to see whether they obtained a mammogram.

Results indicated:

• Women who received a reminder or motivational call were more likely to get a mammogram than women who were sent a postcard. Motivational and reminder calls were equivalent with respect to getting an appointment. Controlling for intervention effect, women with prior mammography were more likely to get a mammogram compared to women with no prior experience.

• The postcard was more cost-effective than either the reminder or the motivational call, but the advantage of the postcard was less significant among women who had never had a mammogram.