Isabel Del Canto, BS; Kenny Morales, BS; Gianna Ramos, MD, MPH, MSW; Ashkan Moazzez, MD, MPH; Griselda Gutierrez, MD; Carmen Mendez, MD; Junko Ozao-Choy, MD; Christine Dauphine, MD
Identifying barriers to screening mammography use among low-income women in a public hospital setting in Los Angeles
Background: Mammography remains the most effective method for early detection of breast cancer. The Affordable Care Act requires that screening mammography be fully covered without any out-of-pocket expense for all patients. Still, disparities in mammography use persist, with the lowest rates reported for women of Hispanic ethnicity and those with Medicaid-based insurance coverage. The aim of this study was to administer a phone survey to better understand the barriers to mammography use among racially diverse low-income women with Medicaid coverage.
Methods: All female patients age 50 to 74 at our facility that had not had a screening mammogram in the recent 24 months were identified. Data were collected from the electronic medical record (EMR) including race/ethnicity, primary language spoken, having had a PCP visit in the previous 12 months, having had a prior mammogram, history of depression, personal history of breast or other cancer, zip code (to estimate median household income), and marital status. Three attempts were made to contact these patients by phone to administer a phone survey that asked them to (1) state in their own words the primary reason for not getting a mammogram and (2) to complete a survey based on the Health Belief Model (HBM) subcategories: issues with self-efficacy (SE), perceived barriers (PBa), perceived benefits (PBe), perceived susceptibility (PS) and cues to action (CA). Barriers were assessed by race and characteristics collected from the EMR as well as survey responses.
Results: There were 810 women due for mammography screening, 333(41%) of which were Hispanic, 146(18%) Black; 112(14%) Asian, 61(8%) Non-Hispanic White, and 158(20%) listed as ‘Other’. Data were collected from the EMR for all 810 women, and 339 (42%) were reached and agreed to participate in the survey. There were 320(40%) patients that did not speak English as their primary language, 441(54%) had not had a prior mammogram, 177(22%) had never visited a primary care physician in the system, and 237 (29%) had not visited one within the last 12 months. The most common self-stated reason Hispanic patients did not get a mammogram was due to lack of knowledge about insurance coverage of mammography; for Black women it was being busy with work related or personal and family illnesses; for Asian a language barrier; and for White/Non-Hispanic it was occupation with illness. The most commonly identified barrier for all races based off of the additional survey questions was limited mammography hours.
Conclusion: In an underserved, predominantly Hispanic population who has Medicaid coverage, health professionals should better educate Hispanic patients on their insurance coverage, provide educational material that includes Asian languages, and consider that extended hours could help patients of all races find time to schedule a mammogram as efforts to minimize barriers will ultimately serve to decrease racial health disparities in breast cancer outcomes.