Background The Avon Breast Health Outreach Program (BHOP) supports community-based organizations to conduct education and outreach to link low-income and uninsured women to routine breast cancer screening. These organizations capture health and demographic information for clients screened as a result of outreach using a standardized Client Intake Form (CIF). Prior research demonstrated higher rates of overall form completion for data collected via audio-computer assisted self-interview (ACASI) versus face-to-face or self-administered paper interview. Advances in tablet computer technology provide additional options and potential advantages for collecting client-level data electronically. Objective To determine if electronic CIF data collection via tablet is a practical alternative to paper-based data collection, and assess the relative administrative burden, advantages and disadvantages for Avon BHOP-funded organizations for each method. Methods English and Spanish copies of the CIF were created in iSurvey, an application developed for iPad. Currently funded grantees (n = 101) were invited to apply for the pilot; 34 of 38 applicants in 24 states were selected, with priority given to organizations with a majority of English- or Spanish-speaking clients, and greater annual client volume. Pilot sites received a tablet pre-loaded with iSurvey. Grantees received web-based training and individual technical assistance on tablet use, data collection and submission procedures. Avon BHOP staff conducted telephone follow-up to assess organizations’ feedback concerning acceptability to program staff and clients of CIF data collection using the tablet, and effects on data quality and administrative processes relative to paper CIFs. Quality assurance was conducted on all CIFs submitted via iSurvey to identify duplicate or invalid records. Results 948 CIFs (838 English, 110 Spanish) were submitted using the tablets during a two month period from March 21 to May 21, 2013. Five organizations submitted fewer than 5 CIFs, eight did not submit any CIFs, and three organizations discontinued participation; their tablets were reassigned to different organizations. Grantees using the tablets for CIF data collection found the program easy to use and data entry efficient. Challenges reported included difficulties integrating the tablets into clinic flow, lack of familiarity with tablet technology among clients and staff, and an inability to review data for errors or completeness prior to electronic submission. Conclusion CIF data collection via tablet is an option for electronic data capture for some organizations. However, many organizations reported challenges in effectively integrating this new technology into existing clinic flow and administrative processes. Discussion While tablets are a relatively inexpensive and practical option for electronic client data collection in some settings, some organizations reported a preference for paper forms. Many of the identified administrative barriers may be resolved through the provision of technical assistance and capacity building support to grantee organizations. Future analysis may focus on the completeness of data collected via tablet versus paper. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-08-15.

Background: Lesbian, gay, bisexual, and transgender (LGBT) individuals experience health disparities in breast cancer screening related to multiple socioeconomic factors, including stigma and discrimination. Since 2001, the Avon Breast Health Outreach Program (Avon BHOP) has granted almost $60 million to 240+ organizations to promote breast cancer screening. Avon BHOP beneficiaries collect a standardized set of de-identified, self-reported client level health and demographic data to ensure that programs reach their target population. Prior to 2011, no data on client gender or sexual orientation were collected. Methods: From 2009–2010, the Avon BHOP conducted a review of the standard confidential client intake form (CIF), last revised in 2006. Based on stakeholder input, including the Avon Foundation for Women and Avon BHOP beneficiaries, the CIF was updated in 2011 to incorporate variables for gender and sexual orientation. Proposed revisions were presented to current beneficiaries in June 2010 for feedback. Although the CIF has historically included many sensitive elements such as race/ethnicity and income, several programs expressed concern that clients or program staff would be uncomfortable addressing questions on gender and sexual orientation in particular. In response, the Avon BHOP Coordinating Center provided standard language that programs could use to help ease the concerns of staff and clients that incorporated three key messages: 1) the same form is used for all clients and programs funded by the Avon BHOP to help ensure funds are reaching clients in need; 2) all responses are kept confidential; and 3) clients may skip any question they are not comfortable answering. Results: Preliminary CIF data for January-March 2011 were analyzed for 20,672 clients from 109 programs. Overall, 96.6% (n=19,966) indicated female gender; 0.5% (n=101) self-reported gender as follows: 75 male, 8 transgender, 12 “other”, and 6 “unknown”; and 2.9% (n=605) did not respond to this question. For sexual orientation, 77.7% (n=16,067) of clients selected “heterosexual”. Of the remaining 22.3% (n=4,606), 175 (0.8%) selected “lesbian, gay or bisexual”, 431 (2.1%) selected “other”, 1045 (5.1%) selected “unknown”, and 2,954 (14.3%) did not respond to this question. By program, the non-response rate ranged from 0% to 40.2% for gender, and from 0% to 81.9% for sexual orientation. Discussion: Avon BHOP programs were able to collect sensitive information on client gender and sexual orientation during the first three months during which this information was requested. Despite concerns expressed among staff, overall response rates were high and rates of “unknown” (which may indicate that a staff person did not ask a client to complete the question) were low. Beneficiaries receive a quarterly summary of their own CIF data, which allows program staff to review client responses and ensure that client needs are met in a culturally sensitive manner. The Avon BHOP is committed to supporting diversity among funded programs; requesting data on client gender and sexual orientation may help improve services for LGBT clients by giving them a voice and reducing stigma. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-11-14.

Introduction: In 2009, the US Preventive Services Task Force (USPSTF) changed its recommendations on the age and frequency for routine mammography. To this point, responses to this change among ethnically diverse women have been not been well examined. The objective of this qualitative study is to describe women's awareness of the change in mammography screening guidelines by the U.S. Preventive Services Task Force and to describe their attitudes toward this change. Methods: White, Black and Hispanic women ages 40–49 years were recruited from a variety of community settings in the Greater Boston, MA area to participate in focus groups (k = 10; N=73). Groups were segmented by race/ethnicity (Black = 29%; White=29%; Hispanic=15%). Women were asked if they were aware of the change in USPSTF guidelines, and if so, their understanding about reasons for this change and intention to comply. Focus groups were audio-taped and transcribed verbatim. Thematic content analysis was used to cull recurring discussion themes. Results: Most women in this study were not aware of changes in the USPSTF mammography screening guidelines. Those who were aware of the guideline change were highly suspicious that it was motivated by a desire for cost savings on the part of insurance companies and/or providers. Concerns regarding the accuracy of mammography, pain associated with screening, and fear of receiving positive test results were prevalent. Nevertheless, most said that they did not intend to comply with changes in guidelines; many believed that regular (yearly) mammography should start at a young age (40 or before) and continue indefinitely. Conclusion: Most women in this sample were unaware about changes in mammography screening guidelines and lacked understanding regarding underlying reasons for the change. Communication about the rationale for changes in mammography screening guidelines has left many women unconvinced about the potential downsides of screening and has generated a high degree of mistrust of insurance companies and medical providers. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-14-02.

Background: The Avon Breast Health Outreach Program (BHOP) supports community-based organizations and safety-net providers in conducting outreach and education to recruit underserved, low-income and uninsured women for breast cancer screening mammography. Funded organizations report mammography outcomes as part of routine program monitoring. NCI Breast Cancer Consortium data for 2009 reported a cancer detection rate of 3.92 per 1,000 for screening mammograms and 33.21 per 1,000 for diagnostic mammograms. In CY2009, CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) reported 14 percent of mammograms had abnormal results requiring further investigation, with an overall cancer detection rate of 10.2 per 1,000 mammograms. Objective: To describe reported breast cancer detection rates and rates of abnormal mammography findings among Avon BHOP-funded programs. Methods: We reviewed routinely reported program outcomes data for 98 organizations funded continuously through the Avon BHOP for a three-year period from 2009 to 2011. Data for 17,839 mammograms were available in aggregate by year by grantee agency including the number of mammograms reported, number with a preliminary abnormal finding, and number of confirmed cancer diagnoses. Results: Agencies reported an average of 981 mammogram outcomes per year over 3 years (range 108 to 5,946 by agency). The average agency-specific rate of abnormal findings across 3 years was 13.2% (median 11.2%; range 0.49% to 51.0%). The average agency-specific cancer detection rate was 8.1 per 1,000 (median 6.4 per 1,000; range zero to 31.7 per 1,000). 28 organizations had 3-year average cancer detection rates in excess of 10 per 1,000, and 6 had rates exceeding 20 per 1,000. Large fluctuations in the proportion of mammogram outcomes reported as abnormal by a given agency year-over-year were common. Conclusion: Avon BHOP agencies reported overall abnormal and cancer detection rates similar to those of the NBCCEDP, but higher than the general population. Fluctuations in year-over-year rates were common, and may indicate changes in the way program data were reported over time, changes in screening practices (e.g. new clinical providers or new equipment), and/or differences in breast cancer risk among clients recruited for screening over time. High rates of abnormal screening results could indicate delays in obtaining results from follow-up diagnostic testing, problems with the calibration of equipment, or other quality issues. Discussion: Grantees with unusually high or low rates of abnormal or cancer outcomes or significant year-over-year rate fluctuations would benefit from technical assistance to identify and explain the underlying causes of these trends. Ensuring that all clients recruited for breast cancer screening receive high quality mammography services – including accurate imaging and reliable interpretation by experienced radiologists – is critical to minimize client anxiety and to ensure that screening results in improved health outcomes. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-02-07.

Background: Income-related disparities in breast cancer screening rates are due to barriers to mammography that are more prevalent among lower-income groups. To address barriers to completion of screening mammography, the US Preventive Services Task Force recommends client-oriented interventions to increase demand and improve access. While evidence-based strategies have shown increased use of mammography for lower-income populations, little is known about the use of these strategies in real-world settings. Since 2001 the Avon Foundation for Women Breast Health Outreach Program (Avon BHOP) has granted over $53 million to more than 200 organizations to promote screening for breast cancer. Data collection and reporting requirements examine the reach of the program and utilization of evidenced-based interventions in diverse settings to promote repeat use of mammography among low-income women. Methods: This cross-sectional study describes the use of evidence-based strategies among Avon BHOP grantees to promote rescreening among returning clients, age 40-64, with no history of breast cancer; and examines associations between the strategies and use of mammography within the previous two years. Data were collected from two sources: 1) online survey administered to 149 organizations in 2009 to ascertain program strategies and 2) client intake form completed by clients or staff at Avon-funded agencies when women returned for annual mammograms. Organizational-level analysis included agencies that responded to the online survey and were funded by Avon from 2006-2009. Results: Characteristics of the 86 organizations in the sample included: US geographic location (17% Mid-West, 27% Northeast, 30% South, and 26% West); 45% clinical sites; and delivery of the program to underserved populations including a high percentage of clients that: belonged to racial or ethnic minority group (62%), reported annual income of $25k or less (72%), and/or were uninsured (62%). Use of evidence-based strategies was common across organizations, including use of client reminders to schedule appointments (83% printed reminders, 74% telephone calls) and provision of patient navigation (51%). Use of strategies did not differ between clinical sites and community groups, and the rate of recent mammogram use was similar for both (clinical sites 84%, community groups 88%) and exceeded the target rate for Healthy People 2010 (70%). Figure 1. The Proportion of Returning Clients Age 40-64 Yeats Who Had a Mammogram Within the Past 2 Years, by Type of Organization, Avon BHOP. 2007-2009. Discussion: Avon BHOP programs are effective in recruiting underserved women for mammography screening. Both clinical and non-clinical organizations reported high rates of use of evidence-based strategies and high rates of recent mammogram for returning clients. These results suggest that strategies used to promote use of mammography among underserved populations previously enrolled in programs may be equally effective if implemented in clinical or non-clinical settings. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-10-10.