Never Screened: Understanding Breast Cancer Nonadherence in Puerto Rico

Abstract

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer-related death among women in Puerto Rico (PR). The purpose of this study was to identify factors associated with never screened status among a sample of women nonadherent to the 2013 American Cancer Society guidelines. The inclusion criteria for this study were being a woman (1) aged ≥40 years old and (2) nonadherent to breast cancer screening guidelines. We used baseline data from participants ( N = 300; aged ≥40 years old) enrolled in the intervention trial Cultivando la Salud, implemented in Canóvanas, Puerto Rico, from 2012 to 2014. We used multivariate logistic regression models to identify factors associated with never screening status, adjusting by sociodemographical variables and psychosocial constructs about mammography (self-efficacy, beliefs about mammography pros [benefits] and cons [disadvantages], and subjective norms) as well as by health care insurance, usual source of care, and Pap test adherence. Among nonadherent women, 18.0% reported never having a mammography. Never screened women were significantly younger than previously screened women (adjusted prevalence odds ratio [aPOR] = 7.32, 95% confidence interval (CI): [2.38, 22.50]) and almost four times as likely to have the governmental health plan (GHP; aPOR = 3.78, 95% CI: [1.15, 12.46]). In addition, never screened women perceived more cons (disadvantages) to mammography than previously screened women (aPOR = 1.81, 95% CI: [1.18, 2.78]). We found that women who were younger, had GHP insurance, and had higher levels of beliefs against mammography were more likely to have never been screened. Results from this study can be used to target never screened women with health education messages addressing perceived cons of mammography. Additionally, women with GHP insurance may experience disparities in health care access and should be targeted with policies that facilitate access to mammography screening.

Factors promoting breast, cervical and colorectal cancer screenings participation: A systematic review

“…In particular, embarrassment, shame, discomfort, and fear represent the most cited barriers to screening uptake 39 ,. 46 , 47 , 54 , 56–67 Furthermore, for colorectal cancer screening only, also disgust and worries about completing the faecal occult blood test (FOBt) incorrectly are additional barriers that should be carefully addressed 68 …”

“…Indeed, for all the types of screening, research highlights structural barriers such as high financial costs, 61,97 being underinsured/uninsured, 43,100 and residing in rural areas/with limited access to health care facilities 75 . In particular, the lack of access to care 21,54,61,62,81,82 the large distance between the primary care unit and their own place of residence/work, 37,46,112,113 issues with transportation 58 all represent significant hindrances to screening participation. These structural barriers, exacerbated by the long waiting times and the perceived lack of time 29,39,59,63–65 may represent key determinants of non‐adherence.…”

“…In particular, embarrassment, shame, discomfort, and fear represent the most cited barriers to screening uptake. 39,46,47,54,[56][57][58][59][60][61][62][63][64][65][66][67] Furthermore, for colorectal cancer screening only, also disgust and worries about completing the faecal occult blood test (FOBt) incorrectly are additional barriers that should be carefully addressed. 68 Still considering the factor under the label "fears", some studies highlight those fears related to the screening in itself, namely fears related to the unknown procedure, 62,64 previous negative experiences, 66 test pain, 57,61 perceived mistrust in providers' confidentiality 63 and in the safety of the screening procedure.…”

“…Conversely, people possessing fatalism are more likely to perceive greater barriers for screening and, accordingly, less likely to accomplish health recommendations. 46,82,87 In the same direction, the presence of procrastination, addressed by studies reporting "lack of time", "difficulties in planning appointment", "forgetfulness", and "other priorities" as barriers 24,29,39,58,59,62,64,65,88 is associated with notable low rates of screening participation.…”

“…Nonetheless, research highlights some measures which have been successfully implemented to facilitate access to screening, such as the "health bus" (i.e., a mobile unit providing healthcare services to people who are geographically/economically/socially isolated and face barriers to accessing healthcare facilities) and group visits with language support. 37,38,40,58,88,106 Lack of staff/staff homogeneity…”