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Section 1: Foundation of the Study and Literature Review
Introduction
This study was an examination of breast cancer screening access to
mammography among Black and White women, aged 50-74 in Boston, Massachusetts.
The focus population comprises the two most dominant racial-ethnic communities in the
City of Boston Massachusetts, Black and White women. Included in both categories of
the target population are native-born citizens and recent immigrants from Africa and
Europe, respectively. As indicated by Boston Massachusetts Population (2019), these two
groups constitute well over 33 % of the entire health population of the City of Boston
Massachusetts. They encompass all the demographic characteristics of both the center
and periphery of the metropolis. According to Kwok et al., (2016), the incidence of breast
cancer screening access among Black women is lower than among the White women.
Kwok, et al. (2016) cited late detection among African American women as due to non-
participation in mammogram programs as impediments, due to health insurance cost,
among others.
In the segments that follow, I described the problem of the study and the
screening access more fully, as well as the factors pertaining to the resistance to such
screening. The section includes definitions of key terms, a statement of the scope and
delimitations of the study, a discussion of its assumptions and significance, and finally a
summary and some conclusions.
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Problem Statement
This study focused on examining breast cancer screening access to mammography
services of Black and White women, aged 50-74 in Boston, Massachusetts. In this Study,
I evaluated access to healthcare providers, whether cost affected the women’s ability to
see their doctors, and whether they have had mammography within the past 2 years.
Sixty-two percent of most breast cancers are localized, 6 -% of the cases diagnosed have
metastasized, and 70- % of new cases diagnosed are among women 55 and older,
according to Kaiser (2018), who attributed the disparities to the differences at the stage
of diagnosis, in access to mammography, follow -up care, and treatment. The Center for
Disease Control (CDC), (2013) suggested that compared with White women, Black
women have lower rates of getting breast cancer and higher rates of dying from it. Patel
et al, (2014) identified limited access, health insurance coverage, socioeconomic status,
and low levels of education attainment, as hindrances to breast cancer screening among
women.
Nonzee et al., (2014) highlighted concerns over systemic barriers, especially poor
access to primary care physicians, as a major hindrance for women’s mammography
whereas - Coughlin (2014) asserted that Black and White women’s differences in access
to mammography play a role as women who had a regular healthcare provider are likely
to receive a recommendation to mammography. The National Cancer Institute, (NCI)
(2015) suggested that women who have no access to breast cancer screening have a
higher mortality rate than those women who have such access, emphasizing that Black
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women have a higher breast cancer mortality than their White counterparts.
Ramachandran et al. (2015) asserted that women with barriers to breast cancer screening
access, are more likely to be older, Black, and on public or no health insurance, compared
to White women. According, to the Behavioral Risk Factor Surveillance System (BRFSS,
2016), 85% of White women (Non- Hispanic) and 83% (Black) women in the
Commonwealth of Massachusetts, aged 50—74, reported having mammography in the
past 2 years, 92% of White women had healthcare providers who they could see as
needed, whereas 88-% of Black women could not see their provider due to cost.
Physician’s recommendation is one of the strongest predictors of breast cancer screening
access to services for women with continuity care providers. Coughlin (2014), stated that
decreasing disparities and facilitating access to breast cancer screening will begin to close
the gap in such health services.
Purpose of the Study
The purpose of this study was to examine breast cancer screening access to
mammography services of Black and White women, aged 50-74, in Boston,
Massachusetts. The study also evaluated whether correlation exists between breast cancer
screening access and healthcare providers for the target populations, whether cost,
socioeconomic status, and education affected Black and White women’s ability to see
their doctors, and whether they had had mammography within the past 2 years. Ragas et
al. (2014) indicated that women’s voices have remained underrepresented in breast
cancer screening access interventions among low income populations. Ragas et al, cited
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recommendations for improving access to screening mammography among the 60%
Black women, and 25% White women. Ragas et al. further recommended addressing
delays caused by high patient volume—preventive services, insurance coverage and
adjusting screening guidelines, overall these researchers stated that patient engagement is
a facilitator of access to breast cancer screening, and that policy changes regarding breast
cancer screening cost - and health insurance will -facilitate screening access.
The Massachusetts Medical Society (MMS) (2017), has pledged to address
system -wide mechanisms to control the forces responsible for escalating healthcare
costs, particularly in breast cancer screening access and prevention. MMS asserted that
universal access to care services in Massachusetts is consistent with the Commonwealth
cost containment objectives. However, the MMS has suggested that some patients are
still struggling with healthcare costs, that are often rising faster than wages are, adding
that despite high rates of insurance coverage, patients’ cost sharing remained high,
particularly for families with lower incomes.
BRFSS (2016) stated that information gathered from the survey helps in
developing health policy and legislation, and in measuring the effectiveness of programs,
such as breast cancer screening access, towards reaching state and national goals. BRFSS
(2016) survey in Massachusetts identified 86 % of women aged 50-74 having had
mammogram in the previous 2 years, 85 % of White women (non- Hispanic) and 83 %
Black women (non- Hispanic), reported that they had mammography in the past 2 years.
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92 % of White women had healthcare provider who they could see as needed, while 88%
of Black women could not see the doctor due to cost.
The Agency for Healthcare Research and Quality Report (AHRQR) (2018), tried
to address the disparities among the Black and White women, in screening
mammography. AHRQR suggested that interventions that address physical barriers, to
breast cancer screening access should assist patients from priority populations, to
navigate patient-provider relationship and the larger health system and cited these as
important to care services. Strom et al., (2018) emphasized that support from
management and leadership is needed in order to promote interprofessional work in
breast cancer screening access, which will benefit healthcare professions, professionals,
and the patient. To reduce barriers to access for breast cancer screening, the workforce
should liaise with leading community members to spread the word about the availability
of breast cancer screening and its usefulness in saving lives.
Zhao et al., (2018) advocated for breast cancer screening access among women,
and greater efforts to increase screening rates and decrease disparities in breast cancer
screenings. These are important strategies that Zhao et al. asserted will help improve
overall population health. Healthy People (2020) initiative projects three steps to access
towards mammography-: (a) entrance into the healthcare system, (b) obtaining proper
services at the right location, and (c) establishing and maintaining a relationship with
trusted provider with whom the patient can communicate.
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Significance of the Study
This study, which examined breast cancer screening access to mammography
services among Black and White women, aged 50-74, in Massachusetts, is the first of its
kind. Other studies have looked at aspects of breast cancer screening in African American
women alone or other minorities but have not concentrated on the two racial ethnic
communities as in this study. Therefore, the study will contribute to filling this gap and
help policy makers and researchers, among others, to close the disparity gap, as well as
help in the treatment, prevention and recommendations to breast cancer screening access
for the population of this demographics.
This study was also significant because of its evaluation of the target population’s
access to their healthcare providers. Determining whether cost affected the women’s
ability to visit their doctors or even to have mammography within the past 2 years,
contributes to a better understanding of the prevention and treatment of cancer, which
ultimately will save lives and cost. Finally, the results of this study emphasized that there
is a relationship between breast cancer screening access to healthcare providers of the
target populations, their socioeconomic status, and their education. Understanding this
relationship will also play a vital role in researchers’ guidelines and recommendations for
healthcare providers and their patients.
Background to the Study: Brief Overview of Breast Cancer
To obtain breast cancer screening care in the healthcare system in Boston, the
Commonwealth of Massachusetts, Black and White women must first enter into the
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system. They must have access to care. The Agency Healthcare Quality and Disparities
Report (AHQDR) ((2018) stated that breast cancer can be diagnosed at different stages of
development, and when diagnosed early enough before metastasis, it stands a good
chance to treatment and cure. The AHQDR, (2018) also indicated that cancers treated late
with extensive spread, often have a poor prognosis and that mammography remains the
most effective method for detecting breast cancer at its early stages. To facilitate early
screening practices, the administrative staff of the healthcare leadership have the
responsibility of assessing women, who present themselves for breast cancer screening,
to ensure that there are no barriers towards access to screening.
The CDC (2017) suggested that a close interview with the women could establish
whether they have primary care doctors, who will recommend mammography. The staff
should note whether the women have insurance coverage, because lack of insurance
coverage affects access to the service. As Pinn, (2017) suggested, students studying to be
health professionals to vulnerable populations should be exposed to the cultural traditions
and belief systems, of these populations, to prepare them to understand and manage the
challenges they face. Cohen (2019) emphasized the importance of the workforce knowing
how much information their patients have, and whether there are other barriers that could
impede the reception of breast cancer screening, such as psychosocial-fear,
embarrassment and logistics. Cohen further cited communications between the healthcare
professionals and the patients as helping to increase mammography rates. The CDC
emphasized that being culturally sensitive is crucial in this regard, and that personal
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barriers include cultural or religious differences, not knowing what to do or when to seek
care, mistrust or concerns about confidentiality or discrimination.
Cultural sensitivity, lack of knowledge as to when to seek care, and concerns
about confidentiality are critical to gaining access to breast cancer screening, and so the
staff should engage in educating the target population and allaying their fears about what
they consider as the unknown. The CDC (2017) indicated that leadership strategic
planning and interventions, are required to encourage the women, and to improve their
access to participation in breast cancer screening, as well as to increase breast cancer
screening rates. The (BRFSS)(2016) suggested that enough resources for cancer
screening need to be allocated for the benefit of the target population, and that this is
where the service leadership must get involved in policy changes, which could benefit the
women unable to meet the cost, as lack of resources impairs breast cancer screening in
Massachusetts. The CDC -pointed out that using reminders, giving radio or - television
information about programs, highlighting breast cancer screening access, and providing
one-on -one education personally or by telephone, could be effective intervention to
increase breast cancer screening access and rates.
Communities, healthcare leadership can indeed generate numbers of people who
have undertaken breast cancer screening or those who have not due to access difficulties.
Such numbers will be useful in a thorough-going attempt to reach those who for one
reason or another have not presented themselves for screening, and thus provide a clear
understanding of the number of women among the target populations who do not present
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themselves for breast cancer screening. A critical goal is to discover those impediments
that hinder the women’s screening access to mammography and address them
accordingly, to facilitate the reception of such services.
Breast Cancer Screening Access Among Black and White Women in Massachusetts.
BRFSS (2016) indicated that in Massachusetts, historically, the levels of breast
cancer screening remain far below the goals set by Healthy People 2020, and that
disparities occur in breast cancer screening access due to socioeconomic status, access,
race, and ethnicity. BRFSS, (2016) further suggested that disparities in breast cancer
screening are due to a complex of factors, and cited access as the most important. The
most important barrier leading to the paucity of access to breast cancer screening and
disparities among Black and White women in Massachusetts healthcare organizations is
lack of insurance coverage. Massachusetts has been at the frontline of health care reform
through its mandatory state-wide health insurance program – the “Massachusett’s Health
Care Reform” (2006), had been rightly recognized as a precursor of the federal
“Affordable Care Act” by Waldman, (2010). The Accountable Care Act, which is the
Patient Protection and Affordable Care Act- (PPACA, 2010) according to Waldman,
responded by expanding access to healthcare cancer screening practices and diagnosis for
women. Through Medicare and Medicaid respectively, ACA has mandated the provision
of coverage for preventive breast cancer screening and the same service for women with
incomes at or below 138% of the Federal poverty level. This expansion seems to be
somewhat helpful for providing access to breast cancer screening among the women.
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BRFSS (2016) stated that, despite this provision, there are still substantial out- of
– pocket costs for breast cancer screening left for these individuals to offset—20% of the
cost of screening services, copays, and plan deductibles. BRFSS, suggested that new
opportunities for access offered by the ACA dismantled potential cost barriers to
preventive services, and that existing disparities in breast cancer screening may be
expected to widen. At this juncture, the healthcare administration, through the integrated
system must collaborate effectively with all professionals to address the problems of
impediments that create the services disparities among the target populations.
The NHQDR (2018) indicated that cancers treated late with extensive spread, often has
poor prognosis. They also asserted that mammography remains the most effective method
for detecting breast cancer at its early stages before symptoms develop, and that
opportunity for early access to mammography plays an important role in this situation.
Healthcare administrative leadership has the responsibility to ensure that these
populations are positioned for early breast cancer screening practices. Team- work within
the administration is key. Critical evaluation and assessment of internal, external, and
personal factors would unveil to them whether the target populations are able to access
breast cancer screening or not. The CDC (2017) suggested that barriers to the reception
of breast cancer screening, namely, financial, structural, personal, and logistics, need to
be urgently investigated and addressed. In addition, the CDC stated that personal barriers
include cultural or religious differences, language barriers, not knowing what to do or
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when to seek breast cancer screening service, mistrust, or concerns about confidentiality
or discrimination.
Healthcare professionals deal with individuals from various cultural backgrounds. As
Papadopoulos (2016) asserted, the capacity to provide effective and compassionate
healthcare requires consideration of people’s cultural beliefs, behaviors and needs. As a
follow-up, they should find out where the barriers are to ensure that defaulting
individuals are located and directed to where they could have breast cancer screening
access. They can do that through the agency of the stakeholders—community leaders
with personal contacts with members of the community and who are well-known to have
the power to enforce traditional patterns of beneficial interrelationship at the grassroots.
Through such organizations, healthcare leadership can indeed generate numbers of
people that have undertaken breast cancer screening or those that have not. Such numbers
would be useful in a thorough going attempt to reach those who for one reason or another
have not presented themselves for screening and thus give us a better understanding of
the number of women that do not present themselves for breast cancer screening. We can
see this gap in research and the necessity to address it urgently.
The healthcare workforce must connect the women to the primary care providers
who should refer them for mammography screening, the staff should direct them to
mammography department to schedule appointments to be screened for breast cancer. As
advocates, healthcare administrators must liaise with stakeholders and policy makers to
generate policies that will dismantle services disparities among White and Black women
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to receive breast cancer screening. Administration should also inform women about the
CDC’s Prevention Breast Cancer Early Detection Program for free breast cancer
screening if needed.
The World Cancer Research Fund International, (2015) estimated that more than
one-third of breast cancers could be prevented through healthy behaviors and that some
premature cancer deaths could have been avoided by eliminating educational and racial
disparities. It is well known that race and ethnicity tend to come between the individual
and vital health services. This is confirmed by Zimmerman et al., (2014), who stated that
education, economic status, and deficiencies in the health care system are the leading
explanations for the various social determinants by geography, and demographic
characteristics, such as race and ethnicity.
A high percentage of Black women may not have access to the internet resources
with vital information about breast cancer screening and its importance. As suggested by
the American Census Bureau (2017) 25 % of Black women in Boston, have internet use.
The educational disparities between White and Black women in Boston are very deeply
rooted, and there are many psychological and historical factors involved. The educational
disparities between Black and White women in Massachusetts stands at 47.4 % and 86.1
% respectively. The fundamental issue is that historically, Black women have been
isolated from the mainstream of education. According to Bowman, et al., (2018), past and
present economic and social conditions are at the root of the achievement gap. Because of
this isolation, the basic education and information about general and common trends in
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the health care system, including breast cancer screening access, may not be within the
reach of Black women. Bowman et al., further stressed that societal efforts to overcome
the ill effects of prejudice and discrimination for Black women have not been effective
enough, and that there continued to be inequities in almost every aspect of life including
education, therefore, Black women are left in the lurch. BRFSS, (2016) asserted that
Black women with breast cancer are more likely to be diagnosed at a later stage and have
treatment delays than are White women.
Delays arise because African American women do not have much numerical
presence or visibility. Apparently, there is no systematic program for access that caused
them to be left out of the screening process. Most of the reasons are systemic.
Ramachandran et al. (2015) highlighted systemic problems with scheduling care (14%)
and timeliness of care as part of the reasons for delay. Black women tend to be beneath
the radar of the screening process. In a situation like that, there are perpetual delays in
everything from diagnosis to the beginning of treatment. They are given appointments
that may or may not be confirmed, spanning over a long period in the mammogram
clinic, within the healthcare organization. It is important that healthcare administrators
and other hospital leadership be sufficiently groomed in cultural sensitivity to be able to
communicate effectively to these patients under their care without condescension,
without overtly disparaging indigenous cultural beliefs, but at the same time ensuring that
the dangers of such beliefs are brought to the attention of every patient.
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It is also vital to ensure that these patients are made part of the decision-making
process. If carefully and adequately handled by the hospital administration, these
measures will create an environment for a wider sphere of wellness, safety, and recovery
without high cost. But above all, administration leadership should actively pursue the
implementation of policies that would make it possible for the women to access breast
cancer screening effectively. Solutions to this systemic problem should be geared towards
inclusiveness of the populations. Powerful cultural competence, understanding, education
about breast cancer screening, policy enactment, and patient advocacy would all be
necessary to ensure that these delays are abated, and that both the lives of the populations
as well as cost are saved.
Theoretical Framework of the Study
For the purposes of this research, I employed a methodology informed by the
Health Belief Framework. This is a theoretical framework originally developed by
Hochbaum and Kegels (1950). It is a psychological model that attempts to explain and
predict patterns of health behavior (Hochbaum & Kegels, 1950). Glanz, Rimer, and
Lewis (1997), NCI (2003) identified the Health Belief Model as by far the most
commonly used theory in health education and health promotion. The assumption of this
framework is that every person is a rational being and that when confronted with a choice
of undergoing a procedure, such as screening for cancer, the individual will take an action
determined by what he or she thoughtfully considers to be in his or her best interest.
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The framework highlights six main constructs that will affect the individual’s
decision to undergo or not to undergo the procedure in view. These six constructs are :-
(a) perceived susceptibility, (b) perceived severity, (c) perceived barrier, (d) perceived
benefit, (e) cues to action, and (f) self- efficacy, as highlighted by Hochbaum and Kegels,
(1950). (Perceived susceptibility) refers to the individual’s understanding of the extent to
which she feels susceptible to the disease for which she is to be screened. This often goes
with the retort: I don’t think I have cancer. Why should I be screening for cancer?
Secondly, according to Hochbaum and Kegels, (perceived severity) refers to the
individual’s sense or feeling of the seriousness of the symptoms that would warrant
undergoing any form of test, especially one that could be invasive or in which the person
does not feel any pain or any discomfort, that could suggest that she is even remotely
sick. The third construct (perceived barrier) refers to impediments, as suggested by
Hochbaum and Kegels, that affect the individual’s willingness to submit to screening.
This could be psychological, physical, or arising from fear of being a victim of
experiments such as the infamous Tuskegee syphilis experiment of 1932 by the Public
Health Service and the Tuskegee Institute and the prison women’s unwanted sterilization
and Eugenics programs in U.S Prisons as late as 2010 in California.
Hochbaum and Kegels indicated that the fourth construct (perceived benefits)
refers to the individual’s conviction or otherwise of the chances of receiving any practical
benefit from the screenings in view. Such considerations according to Hochbaum and
Kegels may be determined by actual experience of people known to her including
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relatives, friends, and family or hear say- information from the rumor mills, and such
rumor mills tend to have a very strong effect on people’s decisions about medical
intervention.
The fifth construct (cues to action) as cited by Hochbaum and Kegels refers to
reminders through email, phone-calls, diary entries, that are required to make a person
take the necessary action when due. The sixth construct (self-efficacy) as indicated by
Hochbaum and Kegels, refers to an individual’s ability to participate in a specific
behavior that is important in successfully changing a life-long behavior. It appeared from
the foregoing according to Hochbaum and kegels, that the health belief framework
encompassed and helped to eliminate practically all aspects of the problems than an
individual confronted with the necessity for cancer screening will need to overcome, for
taking a decision to submit to such screening.
Research Questions and Hypotheses
Creswell (2014) suggested that research questions inquire about the relationships
among the variables that the investigator seeks to know and that hypotheses are the
predictions that the researcher makes about the expected relationships among variables.
This study sought answers to the following research questions:
RQ 1: Is there any correlation between breast cancer screening and access to
personal healthcare provider among Black and White women aged 50-74 in Boston,
Massachusetts?
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Ha 1: There is a correlation between breast cancer screening and access to healthcare
provider among Black and White women aged 50-74 in Boston, Massachusetts?
Ho-2: There is no correlation between breast cancer screening and access to personal
healthcare provider among Black and White women aged 50-74 in Boston,
Massachusetts.
RQ 2: Is there any correlation between breast cancer screening and socioeconomic
status among Black and White women aged 50-74 in Boston, Massachusetts?
Ha-2: -There is a correlation between breast cancer screening and socioeconomic status
among Black and White women aged 50-74 in Boston, Massachusetts (BRFSS, 2016).
H0-2: There is no correlation between breast cancer screening and socioeconomic status
among African American Black and White women aged 50-74 in Boston, Massachusetts.
RQ 3: Is there any correlation between breast cancer screening and education
among Black and White women aged 50-74 in Boston, Massachusetts?
Ha-3: There is a correlation between breast cancer screening and educational level among
Black and White women aged 50-74 in Boston, Massachusetts.
H0-3: There is no correlation between breast cancer screening and educational level
among Black and White women aged 50-74 in Boston, Massachusetts.
Nature of the Study
This is a quantitative cross-sectional descriptive study that examined breast cancer
screening among Black and White women in Boston Massachusetts. This researcher
chose the quantitative design because a study of this kind is better explained by using
numbers to explain the results. As Wagner (2016) emphasized, information about
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correlation will tell the extent to which variables are related. Burkholder, Cox, and
Crawford (2016), suggested that the quantitative focus of this study is the best approach
for research on breast cancer screening among the target populations. Secondary data
materials were used for the study. The principles of multiple regression were used to
analyze the data. This was useful in predicting relationships between the two groups of
female populations on which the study focused—Black and White women in the City of
Boston, in the Commonwealth of Massachusetts.
Albright and Winston (2015) argued that using a quantitative focus for the study
would allow for comparison between the dependent and independent variables of breast
cancer screening, socioeconomic, access, and education, to see how they would impact
the dependent variables. One should note that this study will either be able to confirm the
support for the relationship between cancer screening practices, of Black and White
women or not. This researcher utilized SPSS (Version 23) in analyzing and running the
multiple regression for the study. Frankfort-Nachmias and Leon-Guerrero (2015) asserted
that multiple regression can be used when researchers are investigating how two or more
independent variables affect the dependent variables. Using the independent variables of
access, health education, socioeconomic status, race and ethnicity in this study, this
researcher could understand how they could impact the problem of the study—breast
cancer screening access and the impediments
Scope and Delimitations
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This study focused on the Black and White population of the United States
residing in the city of Boston, Commonwealth of Massachusetts, occupying the following
geographical localities, with an overall population of 890, 675 persons
Table 1
Boston Population
Locality
Population
Dorchester Plain
122,598
Roxbury
49.028
Jamaica Plains
38,425
Mattapan
24,042
Mission Hill
16,987
Total
890,675
Note. Adapted from “5 -Year American Community Survey,” by U.S. Census Bureau,
2010-2014.
The 34,381 population of the typically Bostonian district of Hyde Park was added
to bring the overall predominantly Black White population of Boston to 925,056.
Excluded are other typical racial-ethnic groups resident in the metropolitan districts of
Boston—among them, Asians (including Arabians, Iranians, Afghans, Pakistanis,
Indians, Chinese, Indonesians, Malaysians, and Filipinos) and Pacific Islanders from
Hawaii, Guam, Papua New Guinea and so on. Also excluded are the mixed population of
people of uncertain origins occupying rented apartments in the central districts of Boston,
which are largely populated by government offices and business supermarkets.
The focal populations included American-born individuals whose ancestors
migrated from Europe with the 16th century Pilgrims or were transported from Africa as
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human cargo in slave ships from the 16th to 19th centuries. They also included later-day
voluntary migrants of today from both Europe and Africa. Excluded in this study were
young adults under the age of 50 years, and women who had mastectomies and were
diagnosed with cancer prior to the survey. The study is limited by the sample population
of Black and White women, all residing in Boston, Massachusetts.
This researcher used the purposeful sampling method for this research. The use of
this method placed a limitation to the generalizability of the study and in addition the
participants selected from the (BRFSS) (2016), and the (CDC) means that the study can
only be generalizable within the Commonwealth of Massachusetts. Being a self-report
survey means that the study has disadvantages of accurate recall of information. The
CDC (2012) indicated that advantages such as convenience and participants answering
the exact same questions made self-report a reliable source of data collection.
Assumptions, Validity, and Potential Generalizability
A major assumption in the selection of the focal populations was that they are
representative of the behavior of residents of most of the diverse races and ethnicities in
the Boston Metropolis. The validity or believability of this assumption arise from the fact
that there are numerous patterns of commonalties of traditional belief systems across the
world, which made it possible to assume that such patterns are carried along by the
immigrant groups. Similarly, this researcher assumed that patterns of cultural
impediments to modern health care services among various new immigrant groups
would, for the most part, be identical to one another. Once verified for several diverse
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groups, the potential for generalizability asserted itself as valid for the most part in
Boston Massachusetts.
Other assumptions related to the study procedures and the sample population on
which the study focused. It was assumed that the study procedures were appropriate for
the survey, and that participants would inevitably be able to recall necessary information
accurately and honestly since they were put together by the CDC and BRFSS (2016),
reputable federal research agencies that conduct most surveys needed nationally and by
the states. It was also assumed that the sample taken would be representative of the target
population to yield reliable outcomes. Furthermore, it was assumed that the number of
participants chosen (8415) would be sufficiently representative to yield appropriate
results and that the women selected would meet the criteria set up for inclusion in the
study.
Definition of Key Terms
Access: - the actual use of personal health services and everything that facilitates
or impedes that use. (Anderson, 2012)
BRCA1 and BRCA 2: -BRCA is an abbreviation for breast cancer BRCA1, - and
BRCA 2 thus refer to the two known types of genes located in the mammary glands that
normally protect us from getting breast cancer (CDC, 2014),- Invitae.com cites that the
presence or absence of these genes can be observed by means of comprehensive, high
quality genetic testing with robust clinical evidence.
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Breast cancer screening: -The checking of a woman’s breasts for the presence of
cancer before the signs and symptoms of the disease. (CDC, 2014).
Breast self-examination (BSE) :- This refers to a situation in which a woman
checks her own personal breasts for lumps by carefully looking for such lumps (i e,
inspection) and gently pressing around and feeling for the lumps (i e palpation):- (ACS,
2015).
Ductal carcinoma in situ (DCIS):- This is a kind of breast cancer that has not
spread into nearby breast tissue. It is sometimes called a pre-cancer (cancer.org).
Lobular carcinoma in situ (LCIS :-This refers to cells are growing in the lobules
of the milk-producing glands of the breasts and not growing through the walls. It is also
called lobular neoplasia.
Low acculturation: -This refers to deficiency or tardiness in process of adopting
the cultural traits of social, psychological and cultural change that stems from blending
between cultures (Wikipedia.org).
Mammogram: --An X-ray picture of the breast used to look for early signs of
breast cancer (CDC, 2014).
MRI: -This is an abbreviation for Magnetic Resonance Imaging of the type
described by the CDC (2014) as Breast Magnet Resonance Imaging.
Socioeconomic Status (SES):- Impediment to breast cancer screening among
black and White women in Boston Massachusetts. (BRFSS, 2016)
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Literature Review
Literature Search Strategy
To complete a search strategy for the research, this researcher made sure that she
understood what her topic was all about, especially the research questions, which helped
her address those questions effectively. Besides noting all important components of her
research topic, defining her research questions was the key to effective search strategy.
This researcher conducted a search and a systematic evaluation of the search results,
which made the search more productive. Libguides (2019) identified a search strategy as
a well thought out approach and plan about how to search for relevant information.
For the purpose of this literature review, this researcher searched various
databases, comprising peer -reviewed journals, e-books, PubMed, EBSCO, and ProQuest
and these were important because they focused on multiple disciplines in their contents.
Additionally, Dissertations, Theses, Eric, Ask Eric, were all searched, as well as Google
Scholar and Google search. Essentially, the search strategy consisted of using key terms -
and concepts to search the various databases. This researcher also searched for
combinations of search term, in addition to reviewing and refining results from the
search. The- use of key word synonyms such as breast cancer screening, or
mammography, the use of phrases in the search process such as breast cancer screening
access, and refining the search by dates needed, for example 2015-2018 was important.
The insertion of the word – “NOT”- was used to eliminate aspects of the sentence
that were not relevant. An important search strategy enclosed phrases in quotation marks
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such as “breast cancer screening”, or by removing part of a sentence while leaving the
end of it like a sentence that contained mammography access at its end. In this breast, or
cancer access may be retrieved. Using Advanced Search Strategy area, key words like
breast cancer screening, and access were placed into separate search boxes in order to
retrieve desired results, and these were subjected to changes for productive results. The
crucial factor was to emphasize those areas that affect Black and White women’s breast
cancer screening and access to facilitate answering the research questions. Furthermore,
The Health Services databases of the Walden University Library were also searched.
Furthermore, the CINHAL and Medline search engines were used simultaneously,
targeting various concepts and terms relating to breast cancer screening, such as Black
women breast cancer screening, White women breast cancer screening, disparities,
implications, guidelines, stereotypes, impediments, and more. Internet search engines to
take a complementary look at cancer screening, and treatment listings in various Black
and White popular media were conducted and these yielded useful results. Among these
were ethnic, racial, and other cultural media that focused more on popular beliefs and
stereotypes about cancer than on medical science, thus offering a window into the
cultural impediments that constitute a significant part of the discourse on breast cancer
screening access in the present dissertation.
More than 100 relevant articles addressing various aspects of breast cancer
screening were found, from which this researcher carefully selected information relevant
to the present study. Against this background, the literature review that followed would
25
fall into three segments: (a) General Overview of the Literature on Cancer Screening; (b)
Focused Review of the Literature on Breast Cancer Screening, and (c) Barriers to Breast
Cancer Screening Access.
General Overview of the Literature on Cancer Screening
As the literature revealed, for many years, various types of cancer have flourished
as deadly diseases of unknown etiology as identified by the American Cancer Society
(2018). According to Kwok, Ogusiji, and Lee, (2016), in the traditional societies of
Africa, Asia, and Latin America, breast cancer is seen as a death sentence that cannot be
escaped from, where early detection through screening will make no difference. Ndukwe
and colleagues (2013) suggested that in Africa, cancer carries a stigma and therefore is a
taboo subject that must be discussed in strict confidence. Morris, (2018) identified
advances in technology and precision medicine as moving away from what he sees as one
-size -fits -all breast cancer screening. In Europe and North America, mammography
remains, according to Shah et al. (2014), the main tool used for breast cancer screening
and the detection of cancer. Furthermore, according to Shah et al. (2014) radiation
therapy and chemotherapy have been the usual treatment for breast cancer, along with a
multidisciplinary treatment approach that has been used in recent times in managing
cancer.
Today, mammography or breast cancer screening has evolved into a routine
radiological instrument for the preventive diagnosis of women at the risk of breast cancer,
regardless of their race or ethnicity (American Academy of Family Physicians, 2017).
26
Although reserchers have noted the wide availability of modern high-reliability
instruments for mammography and breast cancer treatment in large medical cities like
Boston, such availability also underlines the problem of the present study. Escobado
(2016) indicated that large pockets of the female population of the city are less likely than
others to get mammography screening.
According to the American Cancer Society (ACS 2014), the percentage of
women aged 40 years and older who had mammogram in the past 2 years stood at 69%
of) and 65% of (White), leaving 31% of Black women and 35% of White women
unaccounted for as far as preventive cancer screening and treatment goes. Translated into
a simple population count, this average of 33% of women in the two groups who have
failed to take advantage of the widely available mammography screening facilities in
Boston constitutes a considerable proportion of the estimated 673,184 residents of the
city in 2017, a fact that is reflected, as ACS (2014) suggested, in the high annual
incidence of breast cancer and the fatality from it in the city.
Focused Review of the Literature on Breast Cancer Screening
BRFSS (2016) noted that the cancer burden in the United States and in
Massachusetts remains high. This usually meticulous survey revealed that every day
nearly 35 of Massachusetts residents die of cancer, representing 36 % of all deaths from
the disease, (BRFSS, 2016). Against this background, the (ACS, 2011) estimated that
approximately 1,596,670 of new cancer cases would be diagnosed across the United
States in 2011, with 571,950 persons dying of the disease nationwide. The comparable
27
statistical picture for Massachusetts alone from the BRFSS (2014-2016) showed 37,470
residents diagnosed with cancer and 12, 910 dying of the disease. In addition to its
morbidity and mortality burden, the BRFSS (2013-15), with an acknowledgement of the
accuracy of these forecasts, noted how exponentially high the economic costs of the
disease have been over the years.
When the statistics for Boston over the same years were added, a picture of the
strong grip of cancer on the city vis-a-vis other parts of Massachusetts and the rest of the
U.S. becomes even more vivid. According to BRFSS (2016), apart from skin cancer,
breast cancer is the most frequently diagnosed cancer among both Black and White
women in Boston, and elsewhere in the Commonwealth of Massachusetts. BRFSS (2018)
asserts that it also ranked only second to lung cancer as the cause of cancer death among
women over the past 10 years. Thus, in (2014), the ACS reported an estimated 40,430
deaths in the United States due to breast cancer. Siegel et al., (2014) estimated that 232,
670 new cases of invasive breast cancer would be diagnosed among women in the United
States in the same year.
Pointing to results such as these, Underwood and Kelber (2015) stressed the need
for clinicians, health care administrators, and advocates committed to breast cancer
detection and control within targeted communities to be more scrupulous in their
deployment of available screening technologies to reach down to the most remote corners
of every health community, both urban and rural. Patel et al., (2014) suggested that
despite reported improvements in the rates of mammography screening among racial and
28
ethnic minorities many factors remain that affect the initiation of this practice among
these sub-groups. Patel et al., further indicated that educational interventions should
incorporate information obstacles and predictors to screening.
Despite the enforcement of these guidelines over the past decade, the incidence of
breast cancer and resultant mortality have either plateaued or continued to rise in Boston
and elsewhere across the United States. Accordingly, several professional healthcare
organizations have recommended yearly mammography and yearly clinical breast
examinations for asymptomatic women with an average risk for developing breast cancer
beginning at age 40. The U. S. College of Obstetricians and Gynecologists (USCOG)
(2018), recommended that women with the history of breast cancer, should talk with their
doctors about the benefits and limitations of the Magnetic Resonance Imaging (MRI)
screening.
The American College of Radiology (2018), suggested that women who have a
known BRCA 1 or BRCA 2 gene mutation, or women who have had radiation to the
chest between ages 10-30 should get a mammogram., and MRI annually. In addition, the
National Comprehensive Network (2018) advised that women with ductal carcinoma in
situ (DCIS), lobular carcinoma in situ (LCIS), or atypical lobular hyperplasia (ALH), and
women who have extremely dense breasts when viewed by mammograms, to talk with
their doctors regarding the benefits and limitations of adding an MRI to their annual
mammograms.
29
Over the past 10 years, the (ACS) (2017) - and the National Comprehensive
Cancer Network (2016)- have both recommended that women with a moderate risk or
high risk for developing breast cancer speak with their health care providers about their
health history. Smith et al., (2013) added that the women need to communicate with their
physicians to determine when they should begin and how often they should obtain breast
cancer screening. Underwood and Kelber (2015) and other health care activists have
added the wisdom that it is necessary to carefully assess all affected women, for the
impact of social structural factors on breast cancer screening, and the need to design
initiatives specifically targeted to those women who have received less than optimal or no
breast cancer screening. Smith et al, suggested that the problem is that of developing and
deploying better communication strategies designed to teach women the insidious nature
of breast cancer and other types of cancer, and how any neglect of the early stages can be
dangerous when the disease arrives undetected.
Underwood (2015) indicates that the impact of resistance to breast cancer
screening has been so debilitating that over the past decade, several social and clinical
efforts have been initiated to awaken urban women of all races and ethnicities to the life-
saving advantages of mammography, and follow-up procedures but that despite these
initiatives, available data revealed that many women do not receive the recommended
breast cancer screening. Accordingly, the response to statistics revealing the plateauing
and mortality rates of breast cancer, according to Underwood (2015), have explored
30
barriers faced by women relative to breast cancer, adding that cancer screening resistance
or barrier was in fact, a top-notch international concern.
Massachusetts is home to one of the 40 NCI Comprehensive Cancer Centers in
the United States. The state also houses the Dana-Faber and Harvard Cancer Center, as
well as 45 cancer programs accredited by the Commission on Cancer (COC). As BRFSS
(2013) noted, that these facilities must meet best practice standards related to the
diagnostic, treatment and other clinical rehabilitation support, prevention and early
detection services. Thus, BRFSS (2013) stated that 61% of Massachusetts hospitals were
accredited by the Commission on Cancer (CoC) as ranking 7th in US in top-quality
screening services. It is against this background that we must consider the paradoxical
plateauing in the incidence and mortality rates of breast cancer in Boston and elsewhere
in the Commonwealth. The following segments of this review will focus on the key
factors identified in the literature as affecting the willingness of the target population to
submit themselves to breast cancer screening.
Barriers to Breast Cancer Screening
To obtain high quality breast cancer screening care in the healthcare system in
Boston and elsewhere in the Commonwealth of Massachusetts, Black and White women
must first enter into the system. They must have access to care. Breast cancer can be
diagnosed at different stages of development, and when diagnosed early enough before
metastasis, it stands a good chance to treatment and cure. Shah et al., (2014) stated that
the World Health Organization believed that improving breast cancer outcome and
31
survival through early detection was the key to breast cancer screening. The NHDR,
(2013) indicated that cancers treated late with extensive spread often have poor
prognosis. --Additionally, NHDR (2016), highlighted that mammography remains the
most effective method for detecting breast cancer at its early stages, identify
malignancies before they can be felt, and before symptoms develop. Lunsford et al,
(2018) suggested that physicians, allied health professionals and the community could
assist women in getting accurate and timely information, about breast cancer screening
and access.
The Center for Disease Control (CDC) (2017), called on healthcare administrators
to investigate barriers that could impede the reception of breast cancer screening namely:
financial, structural, or personal barriers which include cultural or religious differences,
language barriers, not knowing what to do or when to seek care. In the US, breast cancer
among Black and White women is the most commonly diagnosed type of cancer. It was
important to point out that, breast cancer occurs in Black women at a later stage of the
disease compared with White women.
According to the Breast Cancer Incidence and Mortality Records, Massachusetts
(2013), White women had 136.3 numbers of breast cancer incidence and 23.4 mortality
rates. Accordingly, Black women had 113.2 numbers of breast cancer incidence and 29.7
mortality rates. In 2015, the percentage of women aged 40-74 that had mammograms
within the preceding two years stood at 72.3% for Blacks (non-Hispanic) and 68.2% for
32
Whites (non-Hispanic). The Center for Disease Control and Prevention (CDC) (2016)
suggested that an average of 196,370 women are diagnosed with breast cancer each year
and more than 40,000 women lose their lives to the disease annually. If numbers of this
kind are carefully examined, continued the CDC (2016), it can be seen whether breast
cancer is under control because of available access to screening and preventive treatment.
In a situation in which such a scenario presents a case of insufficient access, the
onus would be that of the healthcare administrators and other hospital professionals to
use every means available to them to reach as many members of the health populations as
possible as advised by the CDC (2016). As a follow up, Lunsfield et al., (2018), advised
physicians, allied health professionals, and the community to endeavor to help women
receive important and timely information about breast cancer screening which they
believed would increase their outlook to mammography. This is an impediment, gap
recognized by Shang et al., (2015) that requires urgent attention to increase breast cancer
screening access.
Five Barriers to Breast Cancer Screening
As identified in the literature, barriers in question are -five in number namely:
(a)Barriers to traditional cultural impediments to the acceptance of modern healthcare
services; (b) socio-economic status; (c) socio-psychological phobia, (d) health care
disparities; (e) and poor cancer screening guidelines health care management.
Barriers to traditional cultural impediments to acceptance of modern
healthcare services.
33
The immigrant health populations come with cultural impediments to the
acquisition of healthcare services. Ramathuba et al., (2015) stated that the acquisition of
healthcare services in the views of Akhigbe and Akhigbe, differs from culture to culture,
and that fatalism may be a prohibiting agent to participation in breast cancer screening,
and health promoting attitude. They further believed that cultural values affect health
belief practices, and that this may influence the way African women embrace Western
health services, especially conditions such as breast cancer screening. Archibong et al.,
(2017) highlighted the fact that witchcraft beliefs and practices in disease causation is
widely believed in Africa. Since adequate healthcare services are not usually available
where individuals believe in witchcraft, Archibong et al., (2017) suggested that
immigrant women find it difficult to participate appropriately in a doctor-patient
relationship, that which could result in breast cancer screening recommendation.
Archibong et al., (2017) noted that belief in witchcraft, deeply rooted in individuals’
consciousness will take a concerted effort to be dislodged.
Other traditional beliefs carried over by new African immigrants are those which
Ramjee and Daniels (2013) indicated that women and children in parts of South Africa
are being sexually violated by men who believe that sex with a virgin will cure HIV-
AIDS. Such superstitions have the effect according to Ranjee and Daniels (2013), of
driving away these new immigrants from connecting with their healthcare givers about
possible breast cancer screening. Gentry, et al., (2015) recognized the challenge faced by
leaders, and suggested that leaders in healthcare institutions should try to mobilize the
34
populations, sharpen their instrument of leadership, and focus on their goals towards
engaging these women for breast cancer screening.
Barriers arising from socioeconomic status.
Poverty is also an impediment to their subscription to usually expensive health
care insurance system before and even after the Affordable Care Act (ACA, Obamacare)
2010 which is now left fragmented by the Republican Party. The crises of ignorance in
the community is thus related to the endemic presence of certain diseases such as diseases
related to obesity, hypertension, diabetes and its host of complications. These diseases
particularly are common in the inner city, especially among new immigrant populations
and many of whom come with the belief that obesity is a virtue- evidence of good living.
Immigrants from Africa believe that women need to be buxom to be able to deliver
babies freely without harming the babies on the path- way.
Amnesty International (2016) indicated that gender inequality is a cause of
maternal deaths, often resulting in barriers to essential health services and information.
Poverty forces inner city dwelling natives surrounded by fast food restaurants like
McDonalds, Burger King, eating pounds of carbohydrate fast foods embedded in trans-fat
oils and washed down with coke, pepsi -soda and other equally sugar laden sodas. This is
their staple diet that makes the inner city a dangerous zone for human habitation. Then
obesity becomes their serious problem. World Health Organization (WHO), (2018)
defined obesity as a Body Mass index (BMI) greater than or equal to 30 for adults.
35
It is hoped that this study will be a major contribution to health care policy reform
by presenting an expose of the various reasons why access to breast cancer screening
should occupy an important niche in future health care training curricula, be it for
doctors, nurses or other professionals. Such curricula are at present shy of such
provisions and the consequence is that most professionals tend to marginalize the
problem. The literature suggested that there is a major gap in sensitivity of health care
professionals to the problems of new immigrants from everywhere in becoming part of
the culture of wellness in United States. Betancourt et al, (2013), suggested that a
culturally competent healthcare system should embrace and incorporate the culture of the
individuals.
They should assess the cultural relations, recognize the dynamics emerging from
the cultural differences, and adapt such differences to meet the patients’ healthcare needs.
Dauvrin, and Lorant (2015) highlighted the fact that, healthcare professionals, should
consider how their leadership affects cultural strategies developed and implemented in
healthcare services. Health care policy makers, providers, insurers, and educators noted
that cultural competence is a strategy to eliminate racial and ethnic disparities. A huge
part of the problem is the absence of systematic training of American health care
professionals in cultural sensitivity, which means that these beliefs that constitute
impediments to the reception or acceptance of modern health care services, such as breast
cancer screening, are held to be true by those new immigrants that come with them.
36
Such education should be a process of accelerated acculturation, which Neves et
al., (2013) cited as an expected result of the migratory process strongly related to health.
The training required includes the development of a better diplomatic and non-
condescending language to communicate to these immigrants, the facts of science in
modern health care in contra distinction to the irrationality of their folk belief. This study
is a survey of the attitudes to and impact of breast cancer screening of Black and White
women in the Commonwealth of Massachusetts. By Whites we mean American citizens
born in Massachusetts and those with European ancestry living in the Commonwealth of
Massachusetts.
Barriers arising from socio-psychological phobia.
Another major barrier to screening identified by the literature may be described as
medical technology phobia or the fear of free modern medical technology. At the
background of this phobia are several of the horrors of slavery in North America and of
the institutionalized racism that subsisted after the post-civil war emancipation
proclamation. The cruelties of Whites against Blacks under various subterfuges have
continued to haunt the memories of many black people in America till today. One of the
most frequently told tales pertains to the so-called Tuskegee experiment of 1932-1972.
The Tuskegee Study of Untreated Syphilis in the Negro Male, also known as the
Tuskegee Syphilis Study or Tuskegee Syphilis Experiment was an infamous clinical
study conducted by the U.S. Public Health Service.
37
According to the U.S. Public Health Service (PHS) (1932-1972), the purpose of
this study was to observe the natural progression of untreated syphilis in rural African
American men in Alabama under the guise of receiving free health care from the United
States government. Deceived with irreversible and unapologetic cruelty of the
experiment, several of the participants died of syphilis or lived with it in painful penury
to the end of lives. Reeves, (2017) stated that the last man involved in the syphilis study
died in 2004.
The story of a traumatic event such as the Tuskegee experiment is apt to occupy
dark and darkening spaces in the collective unconscious of those to whom it is told from
childhood, and so indeed did the story flourish, digging deep roots into the psyche of
most Blacks. Today, since its unraveling in 1972, it has become one of the centerpieces
of Black American folklore passed down from generation to generation. It has also
become a major deterrent for submitting to cancer-screening procedures—following all
the four constructs—(a) perceived susceptibility. (b) perceived severity. (c) perceived
barrier, and (d) perceived benefit—of the health belief theoretical model of Hochbaum
and Kegels (1950), out of the fear that it may well be another Tuskegee-like experiment
designed to deceive some blacks into ruining their lives by hankering for free or cheap
health care procedure from a deceptive public service.
The first construct of the theory—Amenability—is particularly tied up with this
barrier to breast and other cancer screening. It comes with the question: Why should any
rational person, confronted with a choice of undergoing a medical procedure such as
38
screening for cancer, not remember the dreadful Tuskegee experiments and several other
similar deceptive experiments with similar eugenic consequences and thoughtfully
consider such screening not to be in her best interest.
Barriers arising from health disparities.
Significantly, according to ACS (2014), the overall incidence of new cases of
breast cancer in the United States is slightly lower among Black women than among
White women. This statistical profile is reflected in the cancer profile of the City of
Boston.
However, breast cancer mortality is higher among Black women than White
women. (ACS, 2014). Howland et al., (2019) noted that even after accounting for
differences in income, past screening rates and access to care Black women are diagnosed
with more advanced breast cancers and have worse survival than White women. Added to
these is the fact that Black women tend in general to be diagnosed at a younger age than
White women (ACS, 2014).
The existence of disparities in cancer incidence and mortality as well as in
survival by race/ethnicity and socioeconomic status has been well-established by
research. Similarly, Gerend and Pai, (2019) stated that factors responsible for racial
disparities in mortality from breast cancer, are poorer outcomes in Black women, which
reflects the fact that breast cancer tends to be a more biologically aggressive disease in
Black women than in their White counterparts. These disparities, continued Gerend and
Pai, also reflect social, economic, and cultural barriers that disproportionately affect
39
Black women. A survey by the American Cancer Society (ACS, 2015) revealed that the
ending of educational and racial disparities can effectively result in the preempting of
one-third of premature cancer deaths among members of the lower levels of the
socioeconomic strata.
Barriers arising from poor cancer screening guidelines and management.
Guidelines for cancer screening have changed within the past few years because
population interventions did not show that earlier screening guidelines reduced mortality
rates. Consequently, the U.S Preventive Task Force (USPSTF) (2018), has been
mandated to change its screening guidelines for some cancers, especially breast cancer.
Kaiser Permanent (2017) indicated that the recommendations contained in the guidelines
may not be appropriate to be followed by women for mammography. While the US
Preventive Services Task Force (2016) suggested that a decision for women to start
mammograms should be a personal thing, at age 40 or 50, the American Cancer Society
(2016) passes the responsibility to women to start mammography at age 40, based on
their consideration of the benefits and risks.
The International Agency for Research (IAFR) (2015) highlighted the fact that
insufficient evidence exits about recommendation for or against screening at age 40 but
supports screening at age 50 and above. The American College of Obstetricians and
Gynecologists (ACOG) (2017) emphasized that women should engage in shared decision
making with their providers for everything concerning their mammography. This
confusing and inconsistent guidelines from authorities impeded breast cancer screening
40
among women.
Summary and Conclusion
In this section, the problem of access to breast cancer screening and impediments
among Black and White women in Boston, Massachusetts, has been examined as a
potential contribution to the discipline of preventive health care administration. Among
the barriers to breast cancer screening identified through the literature reviewed are —
traditional impediments to the acceptance of modern healthcare procedures,
socioeconomic status, socio psychological phobia, and access to healthcare services,
educational level and health disparities. This study was designed to bring to light a major
problem that needs to be better understood and tackled from a wide range of social and
psychological perspectives which are summed up in the statement of the significance of
the dissertation as opening the door to social and preventive medicine, public policy and
social change. Section two offers a research design considered to be most appropriate for
the analysis and interpretation of the related secondary data accumulated in this study.
Implications for Social Change
Walden University (2015) identified social change as the improvement of human
and social conditions. Social change is thus the organizing principle of research at
Walden University. It is the radical transformation of attitudes and perceptions, that bid
fare to contribute to the understanding of various components of individuals in this case-
Black and White women, taking care of themselves as well as other women. At the core
of these transformations are acculturation processes, which are important in the
41
receptivity of screenings which can be mistakenly avoided either as taboo out of
ignorance or fear including the fear of euthanasia and other dangerous experiments. So,
breast cancer screening will be quite an effective positive social change vehicle, because
it will from the perspective of Walden University (2015), educate, promote individuals,
communities, organizations, institutions, culture and society.
42
Section 2: Research Design and Data Collection
Introduction
The purpose of the present study was to employ secondary data from the - (CDC)
and the BRFSS (2016) Massachusetts, to examine the problem of the existence of
significant pockets of resistance and barriers to breast cancer screening among Black and
White women in Boston, Massachusetts, despite the existence of a large number of state-
of-the-art, high-reliability facilities for cancer screening and treatment in the metropolis.
The method of analysis was quantitative. In this section, this researcher surveyed and
discussed the main parameters of the quantitative research design employed. The first
segment focused on the nature and rationale of the design, whereas the second segment
focused on details of the methodology required, to ensure the empirical consistency of the
analysis, and the amenability of the outcomes, to replication by other scholars.
Research Design and Rationale
The quantitative, cross-sectional correlation research design was deemed most
appropriate for this study, for its usefulness, in examining independent variables, in
the present case, the socioeconomic status, access to healthcare services, and educational
level of the target population. In addition, this researcher examined the covariate
variables—age, gender, ethnicity and health disparities of the participant human
subjects—to see how they impact the target populations in the study. Because the primary
materials for the study were secondary data already collected, sorted, and validated by the
43
CDC and BRFSS (2016), the task of fieldwork was eliminated, allowing for a close focus
on the data themselves. A central analytical feature of the study was comparative.
By placing the data belonging to the two streams of the target population- Black
and White women, side by side, this researcher was attempting to observe closely any
differences between them, and to note the social and other significances of such
differences vis-à-vis the similarities in their socio- economic status, access to breast
cancer screening services, insurance coverage, and levels of education. No permission
was needed to obtain the dataset as data are public domain, and this researcher was able
to collect them. A permission letter was therefore not required by the IRB.
In general, the research design is consistent with well-established sciences of
human subject quantitative methodology. The data analysis tools used to analyze and
answer the research questions were the chi square and the Statistical Analysis System.
The main variables are breast cancer screening, access to care socioeconomic status, and
educational level, while all the other variables are covariates. The univariate descriptive
percentages constituted the main analytical tool. Thus, the dependent variable breast
cancer screening, and the independent variables socioeconomic status, access to breast
cancer screening services, and educational level, were compared among the target
populations. In this study, there was no time constraint. This is a cross-sectional study,
which compared two different population groups of women, at a single point in time, as
opposed to a longitudinal study, which spans across sequences of events.
44
The choice of this quantitative research design arose from the fact that such
designs possessed features that made them most amenable to advancing knowledge in the
discipline of health care administration and management. Such features included
demographic as well as statistical complexity and stability.
Methodology
As stated above, the dependent variable explored in this study was breast cancer
screening, and the independent variables were access to health care, socioeconomic status
and educational level. The covariate moderating variables were age, gender disparities,
and ethnicity. Similarly, the research design for the study was quantitative cross-sectional
study whose major aim was to investigate breast cancer screening among Black and
White women, in Boston Massachusetts.
This design was connected to the research questions through determining how
access to care, socioeconomic status, and educational level can either facilitate or impede
breast cancer screening, among the target population of African American and Caucasian
women in Boston. Through this quantitative design, this researcher sought to identify
differences, to see if there were any, between the two groups within the target population.
With regards to the design choice, the search for appropriate secondary dataset materials
suitable for research in this discipline, was very time consuming. No written permission
to obtain and utilize the dataset approval was necessary from CDC and BRFSS (2016)
Massachusetts since data are public domain.
45
Population and Sampling Methods
The target population comprised Black and White women, all residing in Boston,
Massachusetts. The total number of female participants surveyed for interviews by
BRFSS Massachusetts, and the CDC who self-reported was 8415 individuals aged, 18
years and above, among whom 3962 participants were interviewed by landline and 4453
by cell phones. Adults aged 50 to 74 years old African American and Caucasian women
from Boston, Massachusetts were also among the participants surveyed. The age groups
above 74 years were excluded by BRFSS researchers, because although they are required
to undergo annual mammograms, they are no longer at this point required to be subjected
to undergo the painful routine of mammography, on account of their ageing problems.
The selected age range for the population for this study is 50 to 74 years. None of
the participants has ever been diagnosed with cancer. None has ever had mastectomies
prior to the study. This study excluded young adults under 40 years of age. This 40 -year
old category population is suspicious of all government’s projects, which they saw as
potentially harmful to black people. This suspicion arose from memories of the Tuskegee
Experiments, in which African American women were infected with syphilis. One of the
most important outcomes of this research, was the principle that no human subject, could
be used for any experiment, without being told what the experiment was about, and what
the expected outcome would be.
Furthermore, memories and fears of the sterilization of African American women
without their consent in prisons, mainly in the Southern states, linger among the younger
46
adults till today. The younger adult women are still riled by memories of the harmful
eugenic experiments perpetrated against their grandparents, which prevented them from
having children. This researcher also excluded these young adult women from the study,
because any danger of cancer infection they face, could emanate from their having
multiple sexual partners, in which case, such cases that develop may not be natural. The
target population comprised Black and White women all resident in Boston in the
Commonwealth of Massachusetts.
These data were carefully selected by the CDC and BRFSS (2016) to be
representative and to yield accurate results. All data were also weighted so that all the
participants had the probability of being selected. Percentages were age-adjusted to
BRFSS female participants aged forty years and above. To gain access to the dataset, this
researcher typed in Mass. org into the google search engine and from there located the
dataset BRFSS (2016) appropriate for her study.
Sampling Strategy
The sampling strategy employed in this study, as indicated by the CDC and
BRFSS (2016), was simple purposeful sampling. The rationale was to ensure that only
women who have never reported the presence of cancer or those who have never had
mastectomies were included. As Frankfort-Nachmias and Leon- Guerrero (2015),
suggested purposive sampling, an extension of convenience sampling, was commonly
used when researchers felt confident that the data collected would represent the study
population.
47
Sampling Frame
The sampling frame consisted of adults who were surveyed, ages 18 years and
older (BRFSS, 2016). Among the participants surveyed were adult women Black and
White aged, between 50-74 years of age all of whom are resident in the localities of the
city of Boston, Massachusetts. Age groups above 74 were excluded because, although
they are required to do annual mammogram, but they are no longer required to be
subjected to undergo a painful routine mammography tests due to ageism. Women who
have a serious health problem may not benefit enough from having breast cancer
screening as well, due to ageism, according to Komen, (2017). Excluded also were
women with mastectomies who were diagnosed with cancer prior to the survey. Komen,
continued, stating that mammography is the most effective screening tool used to find
breast cancer.
Recruitment, Participation and Data Collection
This study consisted of the use of secondary datasets provided by the CDC and
BRFSS (2016) from Boston Massachusetts. The BRFSS (2016) data obtained for the
purpose of this study were weighted to ensure that participants are adult population. The
weighting guarantees that the sample is representative, making it possible to eliminate
bias from participants who failed to respond to the survey. Participants who were
surveyed were only those who had landlines telephone numbers in their households and
cell phones. Additionally, BRFSS (2016) administered more added Massachusetts
questions to make the survey more specific and representative among Massachusetts
48
population. The data collected were cross-sectional. The categories of participants in race
and ethnicity- included in the data collection were Whites (non-Hispanic) and Blacks
(non- Hispanic)
Power Analysis, Sample Size and G* Power
According to Htway, (2015), power analysis provides statistical power in multiple
regressions. With power analysis, this researcher could have the information needed to
accurately address the research questions, as well as the number of subjects needed for
the study. This researcher utilized G*Power 3.0.10 by Htway (2015), apriority to
determine a sample size of 62, an effect size of .5, and an alpha level of 0.05, a large
effect size. The power level was 0.95. The alpha level is the significance level, with
standard accepted level as 0.05. This was used to measure the p-value of our test to
declare it is significant. The effect size of .5 is moderate and greater than .5 is strong
according to Heale and Twycross (2015). The correlation of 0.3 signifies a weak
correlation in the study. All these portray areas of weakness and strength in correlation.
The power level was 0.95, The higher the power level, the smaller the sample size. This
meant, according to Heale and Twycross (2015), that we have a 95% confidence level
that our analysis is correct.
Instrumentation and Operationalization of Constructs
The developers of the instruments used for the study are the Centers for Disease
Control and Prevention, (CDC) and Behavioral BRFSS (2016). These tools have been
tested by the CDC and BRFSS, both of which are reputable public research agencies.
49
They have therefore been deemed appropriate to be utilized for the study. The CDC and
BRFSS (2016) Massachusetts published the secondary datasets as appropriate for any
study, and that established the reliability of the instruments used. Various researchers
across the world have access to the instruments and can utilize the data sets for various
categories of populations in their studies.
Being secondary datasets, as opposed to primary datasets, the instruments had
undergone scrutiny to establish their validity and reliability. The CDC and BRFSS (2016)
analyzes data from the Behavioral Risk Surveillance System. They are the largest, and
continuously conduct telephone health survey, on national and state -based health issues.
The survey is randomly performed on civilian non-institutionalized adult population. The
BRFSS (2016) data have been invaluable and vastly utilized by researchers all over the
world in building up literature reviews for their studies.
Predictive and Construct Validity and Instrumentation
The quantitative analysis of secondary data from the CDC and BRFSS (2016)
survey was used to determine the extent of breast cancer screening utilization, among the
two categories of the target population of women, Black and White, in Boston,
Massachusetts. In order to determine the validity and reliability of the analysis, this
researcher employed the Chi square analytical statistical tools which portrayed the
goodness of fit and indicated the relationship among the variables. To provide evidence
for reliability—internal consistency and test and retest, the chi Square statistics test was
performed using SPSS version 23, student version. The chi square test exhibited the
50
relationship among the variables, breast cancer screening, access, socioeconomic status,
and education of the target populations.
Results Interpretation
This study utilized univariate and descriptive statistics tools to compare the
demographic elements of the population samples, comprising access, breast cancer
screening, socioeconomic status, and education. The chi square analysis, and correlation
tests were used to generate a statistical result which indicated whether there was
significance or not with the variables according to Laureate Education, (2016). The
correlation test provides us with the strength of the relationship between the variables. All
these were addressing the research questions.
Validity
This part of the study dealing with validity sought to minimize or eradicate
possible limitations that could negatively impact the study results. This could result from
the use of secondary data sets from BRFSS, (2016), a national and comprehensive data
sets, utilized by researchers. Using such data sets could produce limitations in the study
through the questionnaires that contain non-institutionalized individuals, 18 years and
above. BRFSS data collection is self-reporting. Subjects can have the problems of
recalling information, and self -reported data which potentially carry biases. These could
constitute limitations to the study validity.
51
Predictive, Construct Validity, and Reliability
Heale and Twycross (2015) stated that predictive validity means that the
instrument should have high correlations with future criterions, which measured how
variables can predict outcomes based on information from other variables. It is the extent
to which an assessment accurately measures what it is intended to measure. Construct
validity according to Heale and Twycross (2015), referred to whether one can draw
inferences about the results of a test. It is one of the measures that can be used to validate
a test. Mohamad et al, (2015) identified reliability as the scores of an instrument that are
stable and consistent.
Threats to Validity.
Frankfort-Nachmias and Leon- Guerrero (2015), suggested that both extrinsic and
intrinsic factors are known potential threats to validity in research. The focus of this part
of the study was to decrease possible limitations and address any limitation that might
arise from the use of secondary dataset from BRFSS (2016). For the survey, BRFSS
(2016) interviewed only non-institutionalized participants 18 years and older. BRFSS’s
data collection was subject to self-reporting, recall and non -response bias. This
predisposes the design to lose validity. In addition, the probability is that vital
information could be missed. These are all important components that could alter the
results of external validity.
External validity: External validity deals with how the design allows
assumptions to be generalized outside the limitations of the study. The results of this
52
study will only be generalizable within the state of Massachusetts. External validity
addressed the limitations of using secondary data sets for the study. Any factor that
affected the generalizability of the results of this study, was a threat to the study validity.
Internal validity: Whenever we use the BRFSS datasets for studies, problems of
internal validity do present. One such problem may be the choice of wrong dataset
according to Schlemmer and Capp (2014). Threat to internal validity makes it difficult for
us to state that relationship exists between our independent and dependent variables. For
this study, all participants in the survey dataset by BRFSS (2016) were selected by
random sampling. There was no issue of participant drop out to affect internal validity.
The correct dataset was used for the study. Schlomer and Copp, (2014) spotlighted the
seven types of variables which could affect internal validity, namely: history, maturation,
testing instrumentation, statistical regression, experimental mortality and selection
maturation interaction. This study was not affected by any of the problems of these
variables. This researcher performed the chi -square statistics test to find the reliability
and validity of the data in SPSS (Version 23). The chi -square test portrayed the
relationship of the variables, the strength of the relationship.
Data Analysis Procedure
All data analyses were conducted using the Statistics Software, SPSS version 23.
This researcher summarized the variables by utilizing a single score identified in table 2
below. A binary dependent univariate and descriptive statistics comprising population
number, percentages and confidence interval were used for correlation analysis. Any
53
missing variable value were recorded as valid and observed closely but the values were
excluded at the final analysis. All the values were recoded applying implications method
such as 1, 2, and 3 and so on as indicated below.
Table 2 Operational Definitions of Variables
Name
Type of
Measurement
Definitions
Variable
Socioeconomic
Index- Independent
Nominal
Household income
1=<$25,000
2=$2500-34,999
3=$35,000-49,999
4 =$50,000-74,999
5=$75,000 or >
Access to healthcare
Nominal
Ability to access
care
1= Have personal
healthcare provider
2= Could not see
doctor due to cost
3= Had routine
check in past year
Education
Nominal
Education Level
1=< High School
2= High School
3= College 1-3
years
54
4= College 4+ years
Brest cancer
Screening
(dependent)
Binary
Adults
1= White
2= Black
Operationalization of Variables
A look at the Table 2 would show the nominal, and binary variables that were
employed in the analysis. These variables consisted of essentially breast cancer
screening, access to breast cancer screening, socioeconomic status and education. Of
special interest here is the binary variables referring specifically to the Black (non-
Hispanic) and Whites (non-Hispanic) women with regards to the Behavioral Risk Factor
Surveillance System (BRFSS) (2016) of Boston Massachusetts. All variables were
recoded using the Statistical Package for the Social Sciences, (SPSS) student version 23
program instrument.
Data Analysis Plan
This researcher utilized chi square test, correlation and descriptive statistics in
performing all data analyses in SPSS version 23 student program. The data were
downloaded from the BRFSS (2016) website as a Statistical Analysis System transport
file which included only women in Massachusetts 50-74 years old. The chi square test
would tell the relationship among variables if any. As Nelson and Nelson, (2016)
indicated, the chi square independence test is a procedure for testing if two categorical
55
variables are related in some populations. The chi square regression test was used to
estimate the relationship between the variables – breast cancer screening among Black
and White women, access to care, socio- economic status and education. These addressed
the Research Questions, 1, 2, and 3 regarding correlations.
Data Cleaning
Data cleaning essentially comprised the detection, diagnosis and editing of the
data. This researcher utilized the CDC and BRFSS (2016) related to breast cancer
screening among African American and Caucasian women, to recode all variables using
the Statistical Package for Social Sciences (SPSS) version 23 student program. The
variables were then organized into a chart and analyzed by performing a multiple
regression with SPSS version 23 student program.
Research Questions and Hypotheses
Creswell (2009) suggested that research questions inquired about the relationships
among the variables that the investigator seeks to know, and that hypotheses are the
predictions that the researcher makes about the expected relationships among variables.
The present study sought answers to the following research questions (RQs):
RQ1: Is there any correlation between breast cancer screening and access to a
personal healthcare provider among Black and White women aged 50-74 in
Massachusetts?
Ha1: There is correlation between breast cancer screening and access to personal
healthcare provider among Black and White women aged 50-74 in Massachusetts.
56
H0 2: There is no correlation between breast cancer screening and access to personal
healthcare provider among Black and White women in Boston Massachusetts.
RQ 2: Is there any correlation between breast cancer screening and socioeconomic
status among Black and White women aged 50 -74 in Massachusetts?
Ha 2: There is correlation between breast cancer screening and socioeconomic status
among Black and White women aged 50-74 in Massachusetts.
H0 2: There is no correlation between breast cancer screening and socioeconomic status
among Black and White women aged 50-74 in Massachusetts.
RQ 3: Is there any correlation between breast cancer screening and education among
Black and White women, aged 50-74 in Massachusetts?
Ha 3: There is correlation between breast cancer screening and educational level among
Black and White women, aged 50-74 in Massachusetts.
H0 3: There is no correlation between breast cancer screening and educational level
among Black and White women, aged 50-74 in Massachusetts.
Ethical Procedures:
Following the protocol of Walden University, an official letter is required from
the (BRFSS, 2016) Massachusetts, following an official request to use secondary dataset
for research in breast cancer screening study. The official letter was deemed unnecessary
by the Institutional Review Board, (IRB) Walden Protocol Team. As the protocol
requires, Walden Institutional Review Board (IRB) would review the Dissertation and
give approval to conduct research on breast cancer screening using the secondary dataset
57
and they did. My Approval number was 09-13-19 0641-042. CDC collected and analyzed
the secondary data from the Behavioral Risk Factor Surveillance System (BRFSS)
(2016). These were telephone- based random survey of non- institutionalized adult
population 18 years and above, and which continuously gathered from 50 states of the
nation by BRFSS.
Every year, more related mammography questions are added to the survey.
Participants who responded positively also had to respond to how long it had been since
their last mammogram. Participants who missed the survey, or failed to respond at all, or
responded that they could not answer the questions, were removed from the analyses.
Altogether a total number of 8415 participants were included in the survey. There was no
ethical conflict for this researcher using the National secondary dataset comprising all the
states, of which Massachusetts, the location of my research is based. All ethical issues
had been appropriately addressed by the BRFSS, (2016) to ensure the protection and
confidentiality of participants. All information regarding the study is securely held in this
researcher’s personal protected computer, with a password, and backed up with Seagate.
This researcher will retain the records for at least 5 - 7 years after her study before
discarding them.
Dissemination of Findings
The results of this study are geared towards being richly meaningful and very
useful. The results will be published in prestigious peer reviewed journals within the
discipline and disseminated across various libraries and universities nationally and
58
internationally for references by researchers and scholars. It should also be circulated to
women’s organizations as an important tool for social mobilization and empowerment.
This will also alert women about the significance of early breast cancer screening.
In addition, the results of this study are designed to be primarily useful in
reorienting the work of medical administrators in reaching out more thoroughly to the
grassroots with their services. The pockets of resistance or barriers to breast cancer
screening exists on account of inadequacies of the outreach method adopted by healthcare
leadership, nurses, administrators, and others. It is on account of this that we saw high
rates of breast cancer mortality. Special efforts will be made to pass the outcome down to
practicing healthcare administrators in Metropolitan environments like Boston,
Massachusetts.
Finally, it is important to recognize the fact that social change of the kind
envisaged in the outcome of the present investigation is very much in line with practical
social change advocated by Walden University, namely the radical transformation of the
personal, and collective worldviews of individuals and groups, in such a way as to put
aside the strictures of age-old folk beliefs and customs, and to live by the dictates of
modernity and present day realities such as modern, high-technological healthcare
delivery.
Summary and Conclusion
In this section, the main parameters of the quantitative research design employed
in the data collection and analysis for the present dissertation have been surveyed and
59
discussed. From the first segment that focused on the nature and rationale of the design,
through other segments that focused on details of the methodology, the requirement was
to ensure the empirical consistency of the analysis. Maintaining the amenability of the
outcomes to replication by other scholars, the section provided a solid foundation on
which the delicate statistical edifice, of the dissertation could be confidently laid. It was
from this foundation that the findings and results presentation in Section III was expected
to flow.
60
Section 3: Presentation of the Results and Findings
Introduction
The purpose of this quantitative cross-sectional study was to examine breast
cancer screening access to mammography services, of Black and White women, aged 50-
74 in Boston, Massachusetts. The study also evaluated whether correlation exits between
breast cancer screening access, and healthcare providers for the target populations,
whether Black and White women could or could not see their doctors due to
socioeconomic status and education, and whether they have had mammography within
the past 2 years.
The (BRFSS, 2016), indicated that 86-% of women aged 50-74 in Boston,
Massachusetts, had had a mammogram in the past 2 years. More specifically, 85 % of
White women (non-Hispanic) and 83-% of Black women (non-Hispanic), aged 50-74, in
Boston Massachusetts, reported that they had mammogram in the past 2 years Also,
whereas 92-% of White women had a healthcare provider they could see as needed, 88-
% of Black women could not see the doctor due to cost.
In this study, the researcher examined the independent variables of socioeconomic
status, access to mammography, and education level and the dependent variable breast
cancer screening of the target populations. Section 3 of this study comprised the results of
the analysis of the statistics, generated from the univariate and descriptive statistics, from
the demographic elements of the population sample. These were collected from the
BRFSS, (2016) Boston, Massachusetts. Laureate Education (2016) suggested that the chi
61
square analysis and correlation tests indicated whether there was significance or not with
the variables. The correlation test provided the strength of the relationship between the
variables, addressing the Research Questions 1, 2, and 3 in the study.
Descriptive Demographics of the Sample Populations in Boston, Massachusetts.
The BRFSS (2016) Massachusetts surveyed Black and White - non- Hispanic
women in Boston, Massachusetts, from both landlines and cell phones, totaling 8415
adult women between ages 18 and 74 years old. Overall 3.8% adults ages 18-64 stated
that they had no health insurance. BRFSS (2016) suggested that there has been an
average 2.5% per year decrease in those who reported not having health insurance since
2012. All female respondents were asked about breast cancer screening. Those women
who reported that they have ever had a mammogram were asked how long it had been
since their last mammogram. The percentage of women aged 50 to 74, in Boston,
Massachusetts, who acknowledged having had a mammogram in the past 2 years are as
shown in the Table 3.
Table 3 Mammogram in the Past 2 years.
Overall
N
%
95% Confidence
interval
Age Group
2,005
86.3
84.1–88.5
50-59
728
85.7
82.1–89.3
62
60-69
941
86.6
83.5–89.7
70-74
336
87.2
81.7–92.6
Breast Cancer Screening Among Massachusetts Women: Ages 50 -74 BRFSS (2016)
Table 4 Race /Ethnicity
Table 4
Race/Ethnicity
1680
85.4
82.9–87.9
Table 4
Race/Ethnicity
110
83.4
72.7-94.2
Table 4
Race/Ethnicity
N
%
Confidence Interval
Table 5 Education
<High School
126
82.3
71.7-92.9
High School
421
82.5
77.4-87.6
63
College 1-3 Yrs.
476
88.1
84.2-92.0
College 4 Yrs.
979
88.4
85.9-90.8
Table 6 Household Income
Household Income
N
%
Confidence Interval
<$25,000
253
85.3
78.1-92.5
$25,000-34,999
148
82.2
73.5-91.0
$35,000-49,999
199
82.0
74.9-89.1
$50,000-74,999
246
83.5
75.2-91.8
$75,000+
655
89.5
86.6-92.4
A Brief Analysis of Data on Race and Ethnicity
A critical look at the statistical demographic data on race and ethnicity
highlighted the categories of White and Black women in Boston, Massachusetts, who had
access to breast cancer screening in the past 2 years as indicated by BRFSS (2016). The
64
number of White women (non-Hispanic) who screened for breast cancer in the past 2
years was 1680 (85.4%), as opposed to Black (non- Hispanic) women whose number was
only 110 (83.4%).
The number of White women (non-Hispanic) who had a personal health care
provider was n = 6658 whereas for Black women, (non-Hispanic) n = 461 reported
having a personal healthcare provider. Ninety two percent of White women had
healthcare provider whom they could see as needed, whereas (88-%) of Black women
could not see the doctor due to cost. Therefore, we saw unequal distribution of breast
cancer screening due to cost as indicated by the BRFSS, 2016.
For White women (non-Hispanic), the percentage who had had routine check- up
in the past year was 80 % whereas for Black women it was 82-%. This could be because
Black women were scheduled more for follow- up because they had more possibility of
developing cancer because of the cost to screen. For health insurance, according to
BRFSS (2016), 3-% of White women had no health insurance, whereas for Black women,
there was no documentation in percentage due to insufficient data. Insufficient data for
African American women confirmed the fact that lack of access and various other
impediments deter them from having regular mammography.
65
All the respondents were asked if they had any form of insurance coverage during the
survey. Respondents who said that they had no coverage whatsoever, had a follow -up
question to make sure that they were aware of other health care coverages. Among those
other coverages according to BRFSS (2016) are from their employers, Medicare, Mass
health, Commonwealth care and coverage through the military. This researcher provided
a brief description according to the BRFSS (2016) Boston, Massachusetts, from the
dataset sample demographic statistics of breast cancer screening among Black and White
women in Boston, Massachusetts.
Table 7.
Operational Definition of Variables.
Name
Type of
measurement
Definition
Variable Value
Age Group
50-59
60-69
70-74
Nominal
Years of Life
1.
2.
3.
Race/ethnicity
White
Black
Nominal
Reported race and
ethnicity
1.
2.
66
Health Care
Have personal
healthcare provider
Could not see doctor
due to cost
Had routine check in
past year
Nominal
Access to care
1.
2.
3.
67
Socioeconomic
Index
<$25,000
$25,000-34,999
$35,000-49,999
$50,000-74,999
$75,000 or >
Nominal
Household income
1.
2.
3.
4.
5.
Education
< High School
High School
College 1-3 years
College 4+ years
Nominal
Education Level
2.
3.
4.
Breast Cancer
White
Black
Binary
1.
2.
68
Data Collection Time Frame
The Behavioral Risk Factor Surveillance System (BRFSS, 2016) runs as a
continuous survey of adults 18 years and older and is conducted in all 50 states of the
nation, in a collaborative manner, between the Federal Centers for Disease Control
(CDC) and Prevention, and the State of Massachusetts. The BRFSS collects data on
various health issues annually, including breast cancer screening survey. BRFSS (2016)
stated that this helps to identify areas of need for health interventions and preventive
programs.
Research Question 1: Is there any correlation between breast cancer screening and
access to personal healthcare provider among African American Black and White
women, aged 50-74, in Boston, Massachusetts?
Table 8 Black women Ages 50-74:
Have personal healthcare
provider:
Do not have personal
healthcare provider
Mammogram in the past 2
years
43326
105
No Mammogram in the past
2 years
7954
33
69
*All Ns are weighted
frequency
51280
138
Black Women Ages 50-74:
Mammogram in the past 2 years:
Have personal healthcare provider
84.5%
Do not have personal healthcare provider
76.1%
No Mammogram in the past 2 years
15.5%
100%
Rao- Scott Chi Square Test of Significance:
No mammogram in past 2 years
23.9%
100%
Rao Scott Chi Square 0.14
p-value 0.71
*All percentages are weighted proportions
Weighted percentages converted to
percentage of total.
70
Interpretation: Among (unweighted sample size = 100), Black women in Boston,
Massachusetts who provided information about whether they had a personal healthcare
provider or not, and whether they had had a mammogram in the last 2 years or not, 85%
of Black women who had a personal healthcare provider had a mammogram in the past 2
years, while 76% of Black women who did not have a personal healthcare provider had
had a mammogram in the past 2 years. This difference was found to be statistically
insignificant (p-0.71) using the Rao-Scott chi- square test at an alpha level of 0.05.
The (unweighted sample size of -100) was determined through the following
pathway: There were 486,303 women surveyed nationally by the Behavioral Risk Factor
Surveillance System, (BRFSS, 2016) dataset. Of those, 8415 of them were in
Massachusetts. Of those women, 3,759 women were Black or White women. Out of
those Black or White women, 1767 were 50-74 years of age, and provided data on
whether, or not they received a mammogram in the last 2 years. From that number-100
women were black. After applying BRFSS survey weights, we have 51,418. Out of those
1667 were white. After applying BRFSS weights, we have 762,308.
Table 9 White Women Ages 50-74:
Have personal healthcare provider
Do not have personal healthcare provider
71
Mammogram in the past 2 years: 64266
11654 653720
No mammogram in the past years: 103407
5181 108588
*All Ns are weighted frequencies: 745473
16835 762308
White Women Ages 50-74:
Have personal healthcare provider
Do not have personal healthcare provider
Mammogram in past 2 years: 86.1%
69.2%
No mammogram in past 2 years: 13.9%
100%
30.8%
100%
Rao-Scotts Chi Square Test of
Significance:
Rao- Scotts Chi Square 4.95
p-value 0.03
*All percentages are weighted proportions.
Interpretation: Among (unweighted sample size = 1667), white women residing
in Boston, Massachusetts in a Metropolitan area who provided information about whether
they had a personal healthcare provider or not, and whether they had a mammogram in
72
the last 2 years or not: 86% of White women who had a personal healthcare provider had
had a mammogram in the past 2 years, while 69% of White women who did not have a
personal healthcare provider had had a mammogram in the past 2 years. (All percentages
are calculated from weighted frequencies). This difference was found to be statistically
significant (p = 0.03) using the Rao-Scott Chi Square test at an alpha level of 0.05
The Behavioral Risk Factor Surveillance System (BRFSS) 2016 dataset provided
486, 303 women surveyed, of whom 8415 were in Massachusetts. Out of the 8415
women 3759 were Black or White. Out of Black or White women, 1767 were aged 50-
74 and provided data, as to whether they received a mammogram in the last 2 years or
not. Out of the 1767 women, 100 were Black. After applying BRFSS survey weights, we
have 51,418, out of which 1667 were White. After applying BRFSS survey weights, we
have 762,308. This was how the (unweighted sample size 1667) was determined.
In this study, people were excluded if they were not from Massachusetts, if their
gender was male, their race not Black or White, and if they were not within the 50-74 age
bracket. Participants were excluded if they did not provide data about whether they had a
mammogram or not in the last 2 years. They were included in the study if they were
Massachusetts’ residents. They were females, Black or White, lay between 50 to 74 age
range, and provided data as to whether they had a mammogram or not in the last 2 years.
These exclusion criteria were put in place to align with my research interests.
73
Research Question 2: Is there any correlation between breast cancer screening and
socioeconomic status among Black and White women, aged 50-74 in Boston,
Massachusetts?
Table 10 Black Women Ages 50-74
Mammog. past
2 years
<$15,000
3008
$15,000-
<$25,000
3659
$25,000-
$35,000
3841
$35,000-
$50,000
8284
$50,000 or >
1399
No mammog.
past 2 years.
154
3162
2469
6128
498
4339
135
8419
1233
2632
*All Ns are
Weighted
frequencies
Black Women Ages 50-74
<$15,000
$15,000-
<$25,000
$25,000-
$35000
$35000-
$50,000
$50,000 or >
Mammog.
95.1%
59.7%
88.5%
98.4%
99.9%
74
past 2 years
No
mammog.
past 2 years
4.9%
100%
40.3%
100%
11.5%
100%
1.6%
100%
0.1%
100%
Rao-Scott Chi Square Test of Significance: Rao-Scott Chi square 12.29
p-value 0.02
(Weighted frequencies converted to percentage of total). *All percentages are weighted
proportions
Interpretation: Among (unweighted sample size =71) Black women 50-74 years
of age in Boston, Massachusetts, that provided information about their income level, and
whether they had had a mammogram in the last 2 years or not: the income level with the
lowest percent of women screened for breast cancer was the $15,000 to less than $25,000
group, with only 60% of these women having had a mammogram in the past 2 years. The
income level with the highest percent of women screened for breast cancer was the
$35,000 to less than $50,000 group, with 98% of these women having had a mammogram
in the past 2 years. (All percentages are weighted). Comparing the difference between the
proportions of women screened for breast cancer across the five income levels, the
differences were found to be statistically significant (p = 0.02) using the Rao-Scott Chi
Square test, at an alpha level of 0.05.
Table 11 White Women Ages 50-74
<$15,000,
$15,000 -
$25,000 -
$35000
$50,000 or >
75
<$25,000
$35000
$50,000
Mammog.
past 2 years
22630
18430
39814
59698
363166
No
mammog.
past 2 years
6452
29082
1385
19815
10753
50567
14213
73911
52356
415522
*All Ns are weighted frequencies.
White Women ages 50-74
<$15,000
$15,000-
<$25,000
$25,000-
$35000
$35000-
$50,000
$50,000 or >
Mammog.
past 2 years
77.8%
93.0%
78.7%
80.8%
87.4%
No
mammog.
past 2 years
22.2%
100%
7.0%
100%
21.3%
100%
19.2%
100%
12.6%
100%
Rao-Scott Chi Square Test of Significance: Rao-Scott Chi Square 8.6
p-value 0.07
*Weighted frequencies converted to percent of total. *All percentages are weighted
proportions.
76
Interpretation: Among (unweighted sample size =1283) White women 50-74 years
of age, resident in Boston, Massachusetts Metropolitan area, that provided information
about their income level, and whether they had had a mammogram in the last 2 years or
not, the income level with the lowest percentage of women screened for breast cancer
was the less than $15,000 group, with only 78% of these women, having had a
mammogram in the past 2 years. The income level with the highest percentage of women
who were screened for breast cancer were the $35,000 to less than $50,000 group, with
98% of these women having had a mammogram in the past 2 years. (All percentages are
weighted). Comparing the differences between the proportions of White women screened
for breast cancer across the five income levels, the differences were found to be
statistically insignificant (p = 0.07) using the Rao- Scott Chi -Square test at an alpha level
of 0.05.
Research Question 3: Is there any correlation between breast cancer screening and
education level among Black and White women, aged 50-74 in Boston, Massachusetts?
Table 12 Black Women Ages 50-74
Did not finish high
school
High school
graduate
College graduate
Mammog. past 2
years
No mammog.
9135
24710
9587
past 2yrs
2991
3213
1783
77
Weighted Frequency
12126
27923
11370
*All Ns are weighted frequencies. Mammog. stands for mammogram abbreviated for
space.
Black Women ages 50-74
Did not finish high
school
High school
graduate
College graduate
Mammog. past 2
years
75.3%
88.5%
84.3%
No mammog. past 2
years
24.7%
11.5%
15.7%
Weighted Frequency
100%
100%
100%
Rao-Scott Chi Square Test of Significance:
Rao-Scott Chi -Square 0.96
P - value 0.62
*All percentages are weighted proportions.
