The proposed research, submitted by the Fred Hutchinson Cancer Research Center (FHCRC), is part of a larger interactive grant aimed at increasing breast cancer screening among women who have not been receiving regular screening by mammography. The interactive collaborators include the Fox Chase Cancer Center in collaboration with Group Health Association, State University of New York at Stony Brook, University of Massachusetts, and University of California at Los Angeles. The overall aims of the interactive application are to compare the effectiveness of Barrier-Specific Telephone Counseling (BSTC) in five regions of the U.S., and to assess its cost-effectiveness in increasing screening among non-adherent women. BSTC has been shown to be efficacious in improving mammography use among non-adherent women in an HMO setting, but has not been tested in other settings. Each grantee will include a substantial proportion of minority women. The FHCRC will focus on the minority group represented by women living in rural communities. A randomized controlled trial (2x2 factorial design) in 40 rural and suburban communities in Washington State is proposed. The primary aim is to evaluate the individual and joint effectiveness of 1) a stepped Individual Counseling (IC) intervention which addresses individual women's barriers to mammography use, and 2) a Community Activities (CA) intervention which is designed to change social norms and provide social support for mammography use in the community. The IC intervention is based on the BSTC protocol which is being tested collaboratively by the interactive collaborators. The CA intervention is based on a community organization approach which has been piloted in two communities in Washington State. Both interventions are designed to influence the behavior of underusers--women who might otherwise never become regular users of mammography--rather than all women in the community. The interventions will be delivered by volunteers recruited from the target populations of women aged 50 to 80 in the intervention communities. Analysis of intervention effectiveness will take into account that communities rather than individuals are the unit of randomization. Baseline telephone interviews (using items developed collaboratively by the five grantees) will be conducted with 9424 women in Year One to identify and characterize underusers. Approximately 3204 identified underusers will be interviewed again in Year 4 to assess intervention impact. Secondary aims are to evaluate the cost-effectiveness of the interventions, and to assess impact in rural vs suburban communities.
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