Health Education Research, Vol. 14, No. 5, 667-674,
October 1999
© 1999 Oxford University Press
Receptivity of a worksite breast cancer screening education program
Department of Public Health Sciences and
1 Comprehensive Cancer Center of Wake Forest University, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
A breast cancer screening education program was offered to 97 major worksites in Forsyth County, North Carolina. Worksites could design a program by choosing components that consisted of (1) brochures, (2) breast cancer education classes taught by program staff or (3) sending company nurses to be trained by program staff to then teach employees at the worksite. A total of 63 out of the original 97 companies (65%) accepted and offered a program to their employees. Worksites that chose to sponsor a program were more likely to have already sponsored breast cancer education programs at their worksites (P = 0.027) or to have a medical department (P = 0.006). The type of component selected was significantly associated with a history of sponsoring other health education programs (P < 0.001). Fourteen worksites chose the more intensive component, the training of a company nurse. More than half of the worksites that had never sponsored and had no plans to sponsor worksite breast education programs were receptive to our program (43 of 73, 59%). The majority of these sites (67%) chose the brochure. These results indicate that worksites are receptive to offering breast cancer educational programs if varying types of components can be selected.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
In 1999 an estimated 175 700 women will be diagnosed with and 43 300 women will die from breast cancer in the US (Landis et al., 1999
). Since prevention of this cancer has not been achieved, early detection affords the best strategy to reduce mortality. Although mammography and clinical breast examination have been shown to be effective in reducing mortality from breast cancer in women over age 50 (Baker, 1982; Shapiro et al., 1982; Tabar et al., 1992; Breen and Kessler, 1992), these screening modalities are still under-utilized by the majority of women. Efforts to increase compliance with screening recommendations have targeted certain groups such as minority women, women of low socio-economic levels, women with a family history of breast cancer and women in the workplace.
The advantages of targeting worksites for breast education programs are many. Large numbers of women are in the work force. In the county where this study was conducted, approximately 43% of women are employed outside of the home (Employment Security Commission of Forsyth County, 1988). Workplaces usually have established systems for the dissemination of information (i.e. inter-office mail systems, newsletters, bulletin boards), allowing large numbers of women to be reached at the same time (Hollander and Lengermann, 1988; Glasgow et al., 1990). There is usually a medical program in place at worksites, either in the form of a medical department or medical insurance coverage. Employer costs are less for treating a breast cancer detected at an early stage as compared to treating a late-stage cancer (Hollander and Lengermann, 1988). In addition, some women who have not previously received mammography screening obtain screening at worksite programs (King et al., 1992). Lastly, the importance of breast cancer screening can be established within the worksite community resulting in changing norms and causing a favorable impact in terms of the benefit of early detection (Glasgow et al., 1990). Thus, worksite programs offer women an opportunity to comply with screening guidelines.
Although less often mentioned, potential barriers to worksite health promotion programs can hamper the adoption of these programs from the perspective of the employer and the employee (Glasgow et al., 1990). Employees who may be more motivated to get time off from their jobs than adopt the message of the program on their own may participate in programs sponsored at work. In addition, employees may see such programs as a way for the employer to provide health benefits in a low-cost way and therefore be disgruntled with this alternative to more costly benefits. Employers, on the other hand, may view even the simplest program as a financial liability in terms of employee time away from the job and lost productivity.
Several worksite breast cancer education programs have been conducted with positive results in terms of improving screening behavior of female employees (Johnson, 1988; Kettlehake and Malott, 1988; Paskett et al., 1990; King et al., 1992; Vernon et al., 1992; Berkaw, 1993; Kurtz et al., 1993; Mayer et al., 1993). Little information is available on how receptive worksites are to sponsoring such programs. The goal of this study was to assess how worksites in a selected community would respond to sponsoring a breast cancer education program if the program components could be varied to match the interest level and degree of involvement the worksite wanted in such a program.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Target population
A listing of the major worksites, in terms of the number of employees, in Forsyth County, North Carolina was obtained from the Winston-Salem Chamber of Commerce. All the chief executive officers of the 102 worksites on this list were sent an introductory letter followed by a phone call. We first asked the worksites to provide the name of the head of their human resources department or a similar representative who could answer questions regarding characteristics of the worksite. This representative was then contacted by letter to introduce and explain the purpose of the study. The letter was followed within 1 week by a phone call from the project manager at which time the representative was asked to complete a brief questionnaire (15 min) covering worksite demographics, medical department characteristics, insurance coverage, and a description of previous and/or current worksite wellness programs. At the conclusion of the call, the representative was asked if the worksite would be interested in sponsoring a breast cancer screening education program. The program components were described. Each worksite's interest in sponsoring a program was recorded as were reasons given for not wanting to sponsor a program.
Education program
Worksites could choose from three increasingly intensive components: (1) a display with brochures related to breast cancer education from the National Cancer Institute and the American Cancer Society, and a special brochure designed for this program which discussed the importance of mammography screening and identified the mammogram centers in Forsyth County; (2) classes on breast cancer screening taught by the program nurse and held during work hours at the worksite; or (3) the training of company nurses in classes conducted by program staff at the Wake Forest University School of Medicine. The latter option provided trained company nurses who could reach female employees with messages about breast cancer during one-on-one encounters or formal classes. All of the classes taught by the program and company nurses included brochure distribution.
Classes taught to employees by the program staff included a brief discussion of breast cancer prevalence, risk factors, detection methods and recommendations for screening. Breast models were used to instruct and provide a discussion on breast self-examination. Sample mammograms were also displayed and discussed. Classes for the nurses from worksites covered the same information, but also discussed barriers to screening, the role of nurses in education, and how to plan and implement a breast cancer education program at the worksite. For all of these educational activities, a tabulation was kept regarding the number of classes held, attendance and number of brochures distributed. The number of company nurses trained was also recorded.
Analysis
Information collected from the baseline questionnaire was used to describe worksite characteristics that were predictive of willingness to sponsor a program. In addition, since worksites could select various components of a program, level of program intensity could be assessed. Level of participation was separated into four increasingly intensive levels: (1) no participation, (2) display and brochures only, (3) brochures and classes at worksite, and (4) brochure distribution and company nurses trained to conduct classes at worksites.
Two additional variables were created for the analysis. The first, a construct called health service activities, was the sum of variables dealing with the health services offered at the workplace including, a staff doctor, a staff nurse, health fairs, emergency care, wellness visits and disease prevention activities. The second variable created represented a worksite's past experience with sponsoring breast cancer education programs and had three levels: (1) had never sponsored and had no plans to sponsor breast cancer education activities, (2) had not sponsored but was planning to sponsor breast cancer education activities in the future, and (3) had sponsored breast cancer education activities in the past.
Descriptive statistics were calculated by whether or not the worksite agreed to sponsor a program. Wilcoxon rank-sum tests and 
2 tests were used to assess differences between those worksites that chose to sponsor a program and those that did not in continuous and categorical variables, respectively. Fisher exact tests for rxc contingency tables were used when expected cell frequencies were small. Logistic regression was used to determine which variables were jointly predictive of participating in a program. Forward and backward stepwise algorithms were used to determine a subset of variables jointly predictive of sponsoring a program. A Fisher's exact test was used to assess the association between a worksite's level of participation in this program and its past experience.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Demographic characteristics
A total of 97 (95%) of the 102 worksites agreed to complete the baseline survey and were offered the opportunity to sponsor a breast cancer screening education program. Thirty-five percent of the 97 worksites were service companies, followed by manufacturing companies (25%), retail companies (24%) and educational/health care companies (16%). Manufacturing and retail worksites were somewhat more likely to sponsor a breast cancer screening education program, but the difference among company types was not statistically significant. Demographic characteristics of these worksites are presented in Table I
. The median size of the workforce was 300 employees with a range from 19 to 9800 employees. The percentage of females at the worksites ranged from 2 to 88% with a median of 53%; on average, 34% of the female employees were over age 40. Worksites with a greater percentage of female employees over age 40 were more likely to sponsor a program (P = 0.05).
|
Health care characteristics
Health care characteristics of worksites by willingness to participate in the program are shown in Table II
. Approximately one-quarter of the worksites reported having a medical department. Those worksites with medical departments were much more likely to participate in a breast cancer screening education program (P = 0.006) than those worksites without a medical department. Those sites with nurses, emergency care, wellness visits and disease prevention programs were more likely to participate than those worksites without these services; however, these services are closely linked to medical departments. The distribution of health service activities is also shown in Table II by willingness to sponsor a program. The greater the number of activities, the more likely it was that the site participated in the program (P = 0.014). Self-insurance status was not associated with willingness to participate in the program. Eighteen percent of the worksites had sponsored breast cancer screening programs in the past and were more receptive to currently sponsoring a program (P = 0.027). Only 9% of the worksites that had not sponsored a program in the past planned to sponsor a breast cancer screening education program in the future.
|
Logistic regression was used to determine which variables were jointly predictive of willingness to sponsor a breast cancer screening education program. Company type (retail, manufacturing, service, health/education), number of employees, number of female employees, percent female employees, percent female employees age 40 and older, current or recent screening activities, plans for developing a screening program, self-insured status, plans for revising insurance coverage of screening activities, existing medical department, and level of participation (as defined previously) were included in the regression analysis. A forward stepping algorithm was used initially. Using this strategy, the variable most significantly associated with willingness entered first, followed by the variable that was most significant, after adjustment for the first to enter, and so forth. Having an existing medical department was the first variable to enter the model (P = 0.004). The odds of sponsoring a program are 5.4 times greater for those worksites with medical departments compared to those without departments (95% CI: 1.5–19.9). None of the other variables were significantly associated with willingness to sponsor a program once adjustment was made for the existence of a medical department. Plans to revise insurance coverage of screening activities was of borderline significance (P = 0.079), with the odds of sponsoring a program 3.1 times greater for those worksites planning to revise insurance coverage.
A backward stepping algorithm was then used. The strategy for this analysis was to include all variables mentioned above in the model initially. We then removed the least significant variable and repeated the analysis, repeating this sequence of steps until all variables remaining were significant at the 0.05 level. Again, only existence of a medical department was statistically significant. As several of the variables were highly correlated (specifically number of employees, number of female employees and percent of female employees), we repeated this latter analysis several times including only one of these at a time in the initial model and again including two of the three in the initial model. Results for all analyses were identical; only the existence of a medical department remained in the final reduced model.
Level of participation
Sixty-three (65%) of the 97 worksites agreed to sponsor a program. The majority of these (56%) chose to sponsor a display with brochures, while the remaining worksites were equally distributed between sponsoring classes at the worksites with brochures (22%) and sending company nurses to be trained to conduct classes at the worksite with brochures (22%). Level of participation in the present program was significantly associated with the history of sponsoring a program, as shown in Table III (P < 0.001). Worksites that had never sponsored a similar program were less likely to sponsor any type of program while worksites that had sponsored a similar program in the past or planned to sponsor such a program were more likely to send company nurses to be trained.
|
A total of 24 827 brochures were distributed to the 63 worksites. Thirty worksite classes were held with 563 women attending at 14 worksites. Fourteen companies sent at least one nurse to be trained by program staff at one of six training sessions. This represents 86% of eligible nurses at these worksites. At the end of the study, these nurses had taught 30 classes, reaching 258 employees, at their respective worksites.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Breast cancer screening is underutilized by women aged 40 and older. Worksites may provide opportunities to educate and motivate female employees to obtain regular screening examinations. Thus, programs targeted at worksites have the potential to reach large numbers of employees. We offered worksites a choice of three components, allowing worksites to choose the intensiveness of the program they offered. The results demonstrate that the majority of worksites were interested in sponsoring a program. Prior history of sponsoring a previous health-related program was significantly associated with the level of intensity of the program sponsored.
The fact that this project allowed worksites to sponsor differing types of programs may have allowed more worksites to participate, especially worksites that had not sponsored a program. For example, among the worksites surveyed, only 17 (18%) had sponsored a breast cancer education program in the past. In the present study, 65% offered a program. Worksites with no history of sponsoring a prior health-related program more often chose to distribute brochures. Overall, 71% of the female workforce over age 40 in these worksites received some type of breast cancer screening education program in this effort.
This study has several strengths. First, a high response rate (95%) was obtained, ensuring a valid sample representative of the major worksites in Forsyth County. Second, the quality of the information obtained from the worksites should be, for the most part, reliable and accurate since the company representative who completed the survey was usually the director of human resources and was prepared in advance to provide the necessary information. Thirdly, worksites smaller than these included in previous research of this kind were included in this study. Interestingly, worksites with as few as five women were willing to sponsor a breast education program.
A limitation of the present study is that it relied on self-reports of activities. Due to biases that occur with the use of self-reports, worksites could have over-estimated their activities and given inaccurate information regarding when their last activities were held. We did not validate self-reports, but feel confident that although some over-estimation may have occurred, there is no reason to believe that any systematic bias occurred in the self-report of sponsored previous activities.
The focus of this study was on assessing characteristics of worksites that were related to sponsoring a breast cancer education program. The intervention offered needed to be easily incorporated into a workplace setting and made appealing to employers. Thus, the minimal intervention of a display with brochures was included, even though previous studies have found that merely distributing brochures does not change screening behavior among women. However, providing information may prompt women to think about breast cancer screening. Also, it seems from the data presented that once a company is doing something, however minimal, they are more apt to do more at the next opportunity.
The effect of this program on employees screening behavior was not within the realm of this study. Some employers were reluctant to provide the investigators with the names of employees, which severely limited the ability to obtain an assessment of the impact of the program. However, many previous studies have shown beneficial effects of worksite programs on employees' screening behavior (Johnson, 1988; Kettlehake and Malott, 1988; Paskett et al., 1990; King et al., 1992; Vernon et al., 1992; Berkaw, 1993; Kurtz et al., 1993; Mayer et al., 1993).
Although 65% of the worksites in this study sponsored a program, 35% did not. Some reasons for reluctance to sponsor a program were provided in response to open-ended questions on our survey and included: (1) economic factors (some companies cited changes in organizational structure of the company or financial problems within the company as reasons for non-participation); (2) geographic make-up (some companies have branches in different areas and were unable to coordinate providing the program for each site); (3) other companies, which provide employees for temporary services, were unable to coordinate the participation by the employees in a central location; (4) employee characteristics (having a majority of employees under age 35 or having a majority of male employees); and (5) corporate policy (for several of the larger companies with branches in several counties or states, corporate policy prohibits offering a program for some of the employees while excluding others).
To overcome some of these obstacles efforts should be made to offer a program at several times during the year in order to provide for corporate adjustments as well as seasonal variations in staffing and workload requirements. For companies with employees in different locations a more compact packet of information could be developed for inclusion with payroll or for mailing to individuals. In large companies with headquarters based outside the county, a program developed cooperatively with corporate headquarters could be made available to employees at all sites.
The results of this study indicate that worksites were willing to sponsor a breast cancer screening education program. In addition, this study has shown that large numbers of women over the age of 40 can be reached regarding the importance of breast cancer screening through the worksite. Worksite programs designed with this degree of sensitivity and flexibility can be implemented for other types of health promotion issues also.
|
Notes |
|---|
Presented at the 120th Annual Meeting of the American Public Health Association, November 8–12, 1992, Washington, DC
|
Acknowledgments |
|---|
Supported by a grant from the Winston-Salem Foundation, Winston-Salem, North Carolina and Public Health Service grant CA-12197 from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Baker, L. (1982) Breast cancer detection demonstration project: five year summary report. CA Cancer Journal for Clinicians, 32, 194–230.
Berkaw, D. M. (1993) Industry sponsored breast cancer screening: the Zeneca program. Primary Care and Cancer, 13, 39–40.
Breen, N. and Kessler, L. (1992) Increases in screening mammography among US women 40 and older. Journal of the National Cancer Institute, 84, 1549.
Employment Security Commission of Forsyth County (1988) Manpower Information for Affirmative Action.
Glasgow, R. E., Hollis, J. F., Ary, D. V. and Lando, H. A. (1990) Employee and organizational factors associated with participation in an incentive-based worksite smoking cessation program. Journal of Behavioral Medicine, 13, 403–418.[Web of Science][Medline]
Hollander, R, and Lengermann, J. (1988) Corporate characteristics and worksite health promotion programs: survey findings from Fortune 500 companies. Social Science and Medicine, 26, 491–501.
King, G. E., Davis, R. L., Baron, R. C. and Horan, J. M. (1992) Female employee participation in a worksite mammography screening program. American Journal of Preventive Medicine, 8, 309–313.[Web of Science][Medline]
Kettlehake, J. and Malott, J. C. (1988) Mobile screening mammography for the corporate customer. Radiology Management, 10, 34–38.[Medline]
Kurtz, M. E., Given, B., Given, C. W. and Kurtz, J. C. (1993) Relationships of barriers and facilitators to breast self-examination, mammography, and clinical breast examination in a worksite population. Cancer Nursing, 16, 251–259.[Web of Science][Medline]
Johnson, S. (1988) Breast screening's bottom line: lives saved. Administrative Radiology, 7, 20–24.
Landis, S. H., Murray, T., Bolden, S. and Wingo, P. A. (1999) Cancer statistics. CA Cancer Journal for Clinicians, 49, 8–31.
Mayer, J. A., Jones, J. A., Eckhardt, L. E., Haliday, J., Bartholomew, S., Slymen, D. J. and Hovell, M. F. (1993) Evaluation of a worksite mammography program. American Journal Preventive Medicine, 9, 244–249.
Paskett, E. D., White, E., Urban, N., Gey, G. O., Hornecker, J. and Meadows, S. (1990) Implementation and evaluation of a worksite breast self-examination training program. In Engstrom, P. F. (ed.), Advances in Cancer Control: Screening and Prevention Research. Wiley-Liss, New York, pp. 281–302.
Shapiro, S., Venet, W., Strax, P., Venet, L. and Roeser, R. (1982) Ten-to-fourteen year effect of screening on breast cancer mortality. Journal of the National Cancer Institute, 69, 349–355.
Tabar, L., Fagerberg, G., Duffy, S. W., et al. (1992) Update of the Swedish two-county program of mammographic screening for breast cancer. Radiologic Clinics of North America, 30, 187–210.[Web of Science][Medline]
Vernon, S. W., Gilstrap, E. L., Jackson, G. L. and Hughes, J. I. (1992) Intervention to increase participation in a work site cancer screening program. Health Values, 16, 3–9.
Received on September 1, 1995; accepted on August 1, 1998
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  K. P. Williams, P. B. Mullan, and D. Todem Moving from theory to practice: implementing the Kin KeeperSM Cancer Prevention Model Health Educ. Res., April 1, 2009; 24(2): 343 - 356. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||