Patterns and determinants of breast and cervical cancer non-screening among Appalachian women

Breast and cervical cancer account for nearly one-third of new cancer cases and one-sixth of cancer deaths. Cancer, the second leading cause of all deaths in the United States, will claim the lives of nearly 800,000 women this year, which is particularly unfortunate because effective modes of early detection could significantly reduce mortality from breast and cervical cancer. Researchers examined patterns of non-screening among Appalachian women. In-person interviews were conducted with 222 Appalachian women who fell outside of screening recommendations for timing of Pap tests and mammograms. These women, from six Appalachian counties, were participating in a group-randomized, multi-component trial aimed at increasing adherence to cancer screening recommendations. Results indicated that participants who were rarely or never screened for breast cancer were also likely to be rarely or never screened for cervical cancer. In addition, four key barriers were identified as independently and significantly associated with being rarely or never screened for both cervical and breast cancer. An improved understanding of cancer screening patterns plus the barriers underlying lack of screening may move researchers closer to developing effective interventions that facilitate women's use of screening.

Perspectives on Physical Activity and Exercise Among Appalachian Youth

Background:

Most children in the United States receive far less physical activity (PA) than is optimal. In rural, under resourced areas of Appalachian Kentucky, physical inactivity rates are significantly higher than national levels. We sought to understand children’s perceptions of PA, with the goal of developing culturally appropriate programming to increase PA.

Methods:

During 11 focus groups, we explored perspectives on PA among 63 Appalachian children, ages 8−17. Sessions were tape recorded, transcribed, content analyzed, and subjected to verification procedures.

Results:

Several perspectives on PA emerged among these rural Appalachian youth, including the clear distinction between PA (viewed as positive) and exercise (viewed as negative) and an emphasis on time and resource factors as barriers to adequate PA. Additional PA determinants expressed in the focus groups are similar to those of other populations. We include children’s recommendations for appealing PA programs.

Conclusions:

Appalachian and other rural residents contend with the loss of rural health advantages (due to declines in farming/other occupational and avocational transitions). At the same time, Appalachian residents have not benefitted from urban PA facilitators (sidewalks, recreational facilities, clubs and organized leisure activities). Addressing low PA levels requires extensive community input and creative programming.

Primary care physicians' prevention counseling with patients with multiple morbidity

The prevalence of multiple health conditions, or multiple morbidity (MM), is increasing. Providing medical care for adults with MM presents challenges, including balancing disease management with prevention. We conducted in-depth semistructured interviews with 12 primary care physicians to explore their perspectives on prevention counseling among patients with MM. Participants described the complex relationship between disease management and prevention, highlighted the importance of patient motivation, and discussed various strategies to promote receptivity to prevention recommendations. The perceived potential benefits of prevention recommendations encouraged physicians to persist with such counseling, despite challenges presented by visit time constraints, reimbursement procedures, and concerns over futility. Physicians recommended the development of alternate care delivery and reimbursement models to overcome challenges of the existing health care system and to meet the prevention needs of patients with MM. We explore the implications of these findings for maximizing the health and quality of life of adults with MM.

A community-based randomized trial of a faith-placed intervention to reduce cervical cancer burden in Appalachia

OBJECTIVE

Faith Moves Mountains assessed the effectiveness of a faith-placed lay health advisor (LHA) intervention to increase Papanicolaou (Pap) test use among middle-aged and older women in a region disproportionately affected by cervical cancer and low screening rates (regionally, only 68% screened in prior 3 years).

METHOD

This community-based RCT was conducted in four Appalachian Kentucky counties (December 2005-June 2008). Women aged 40-64 and overdue for screening were recruited from churches and individually randomized to treatment (n=176) or wait-list control (n=169). The intervention provided LHA home visits and newsletters addressing barriers to screening. Self-reported Pap test receipt was the primary outcome.

RESULTS

Intention-to-treat analyses revealed that treatment group participants (17.6% screened) had over twice the odds of wait-list controls (11.2% screened) of reporting Pap test receipt post-intervention, OR=2.56, 95% CI: 1.03-6.38, p=0.04. Independent of group, recently screened participants (last Pap >1 but <5 years ago) had significantly higher odds of obtaining screening during the study than rarely or never screened participants (last Pap ≥5 years ago), OR=2.50, 95% CI: 1.48-4.25, p=0.001.

CONCLUSIONS

The intervention was associated with increased cervical cancer screening. The faith-placed LHA addressing barriers comprises a novel approach to reducing cervical cancer disparities among Appalachian women.

Perceptions of smoking cessation programs in rural Appalachia

OBJECTIVES

To identify perspectives on smoking cessation programs in Appalachian Kentucky, a region with particularly high smoking rates and poor health outcomes.

METHODS

Insufficient existing research led us to conduct 12 focus groups (smokers and nonsmokers) and 23 key informant interviews.

RESULTS

Several findings previously not described in this high-risk population include (1) transition from pro-tobacco culture toward advocacy for tobacco cessation approaches, (2) region-specific challenges to program access, and (3) strong and diverse social influences on cessation.

CONCLUSIONS

To capitalize on changes from resistance to support for smoking cessation, leaders should incorporate culturally appropriate programs and characteristics identified here.

Disparities in underserved white populations: the case of cancer-related disparities in Appalachia

There are meaningful cancer-related disparities in the Appalachian region of the U.S. To address these disparities, the Appalachia Community Cancer Network (ACCN), a collaboration of investigators and community partners in five states (Kentucky, Ohio, Pennsylvania, Virginia, and West Virginia), is involved in increasing cancer education and awareness, conducting community-based participatory research (CBPR), and creating mentorship and training opportunities. The primary objective of this paper is to describe cancer-related disparities in the Appalachian region of the U.S. as an example of the disparities experienced by underserved, predominantly white, rural populations, and to describe ACCN activities designed to intervene regarding these disparities. An ACCN overview/history and the diverse activities of ACCN-participating states are presented in an effort to suggest potential useful strategies for working to reduce health-related disparities in underserved white populations. Strengths that have emerged from the ACCN approach (e.g., innovative collaborations, long-standing established networks) and remaining challenges (e.g., difficulties with continually changing communities, scarce resources) are described. Important recommendations that have emerged from the ACCN are also presented, including the value of allowing communities to lead CBPR efforts. Characteristics of the community-based work of the ACCN provide a framework for reducing health-related disparities in Appalachia and in other underserved white and rural populations.

Community strategies to address cancer disparities in Appalachian Kentucky

Central Appalachian residents suffer disproportionate health disparities, including an all-cancer mortality rate 17% higher than the general population. During 10 focus groups and 19 key informant interviews, 91 Appalachian residents identified cancer screening challenges and strategies. Challenges included (1) inadequate awareness of screening need, (2) insufficient access to screening, and (3) lack of privacy. Strategies included (1) witnessing/storytelling, (2) capitalizing on family history, (3) improving publicity about screening resources, (4) relying on lay health advisors, and (5) bundling preventive services. These insights shaped our community-based participatory research intervention and offered strategies to others working in Appalachia, rural locales, and other traditionally underserved communities.

Formative research conducted in rural Appalachia to inform a community physical activity intervention

PURPOSE

Despite the well-established benefits of physical activity (PA), most Americans, especially those in rural, traditionally underserved areas, engage in considerably less PA than recommended. This study examines perceived barriers to and facilitators of PA and promising organized PA programs among rural Appalachians.

DESIGN

Eight focus groups and seven group key informant interviews were conducted.

SETTING

This study was conducted in eastern Kentucky, in central Appalachia.

SUBJECTS

One hundred and fourteen rural Appalachian residents (74% female, 91% white) participated.

MEASURES

Open-ended, semistructured, and structured questions regarding perceptions of, barriers to/facilitators of, and examples of successful/failed PA programs were asked.

ANALYSIS

Qualitative data analysis was conducted, including codebook development and steps taken to ensure rigor and transferability. Interrater reliability was over 94%.

RESULTS

In addition to barriers that are consistent with those found in other populations, rural Appalachian residents indicated that travel time, family commitments, and inadequate community resources undermine PA. Suggested avenues to increase PA include partnership with churches and the U.S. Department of Agriculture's Cooperative Extension Service; programs that include families, are well advertised, and focus on health rather than appearance; and, underlying all suggestions, culturally relevant yet nonstereotyping activities.

CONCLUSIONS

When developing PA interventions in rural Appalachia, it is important to employ community-based participatory approaches that leverage unique assets of the population and show potential in overcoming challenges to PA.

The role of social support in multiple morbidity: self-management among rural residents

Social support generally is considered a valuable asset that may compensate for health service deficiencies among rural populations. Employing a mixed methods approach, we explored how vulnerable rural residents described social support in the context of self-management for multiple chronic conditions. Participants generally felt support was available, though emotional/informational support was perceived as less available than other types of support. Participants did not rely heavily on informal support to help them manage their multiple morbidities, preferring to call on their doctor and their own resources. We discuss implications of these findings for meeting this vulnerable population's self-management needs.

Deconstructing fatalism: ethnographic perspectives on women's decision making about cancer prevention and treatment

Researchers have long held that fatalism (the belief in a lack of personal power or control over destiny or fate) constitutes a major barrier to participation in positive health behaviors and, subsequently, adversely affects health outcomes. In this article, we present two in-depth, ethnographic studies of rural women's health decisions surrounding cancer treatments to illustrate the complexity and contestability of the long-established fatalism construct. Narrative analyses suggest that for these women, numerous and complex factors--including inadequate access to health services, a legacy of self-reliance, insufficient privacy, combined with a culturally acceptable idiom of fatalism--foster the use of, but not necessarily a rigid conviction in, the notion of fatalism.

Appalachian residents' experiences with and management of multiple morbidity

Approximately three fourths of middle-aged and older adults have at least two simultaneously occurring chronic conditions ("multiple morbidity," or MM), a trend expected to increase dramatically throughout the world. Rural residents, who tend to have fewer personal and health resources, are more likely to experience MM. To improve our understanding of the ways in which vulnerable, rural residents in the United States experience and manage MM, we interviewed 20 rural Appalachian residents with MM. We identified the following themes: (a) MM has multifaceted challenges and is viewed as more than the sum of its parts; (b) numerous challenges exist to optimal MM self-management, particularly in a rural, underresourced context; however, (c) participants described strategic methods of managing MM, including prioritizing certain conditions and management strategies and drawing heavily on assistance from informal and formal sources.

Predictors of cervical cancer screening for rarely or never screened rural Appalachian women

BACKGROUND AND PURPOSE

Women who have not had a Papanicolaou test in five years or more have increased risk of developing invasive cervical cancer. This study compares Appalachian women whose last screening was more than one year ago but less than five years ago with those not screened for the previous five years or more.

METHODS

Using PRECEDE/PROCEED as a guide, factors related to obtaining Pap tests were examined using cross-sectional data from 345 Appalachian Kentucky women. Bivariate and multivariate analyses were conducted to identify predictors of screening.

RESULTS

Thirty-four percent of participants were rarely- or never-screened. In multiple logistic regression analyses, several factors increased those odds, including belief that cervical cancer has symptoms, and not having a regular source of medical care.

CONCLUSION

The findings from this study may lead to the development of effective intervention and policies that increase cervical cancer screening in this population.

Factors associated with participation in cancer prevention and control studies among rural Appalachian women

Rural Appalachian women bear a disproportionate burden from many types of cancer yet often are underrepresented in cancer research. This article uses 2 case studies to illustrate barriers faced and strategies used when recruiting hard-to-reach rural participants. Recruitment barriers include the population's competing demands and lack of trust of outsiders. Strategies employed include involving insider advocates, highlighting the positive experiences of early participants, spending extensive time in the community, and emphasizing potential community benefits of the study. We suggest recruitment strategies to better involve rural women and others who, by virtue of being "hard-to-reach," often are overlooked.

The emergency department as a potential intervention recruitment venue among vulnerable rural residents

Meeting the health care needs of rural residents is complicated by their substantial medical burdens that frequently outstrip patient and community resources. Nowhere is this more evident than in central Appalachia. Preventive procedures are often sacrificed as patients and providers attend to more pressing medical issues. We report the results of a pilot study designed to explore the need for and appropriateness of a potential intervention placed in an emergency department (ED), with the eventual goal of using the ED to link traditionally underserved patients to preventive services. We used a convenience sample of 49 ED patients to explore their characteristics and health needs and compare them with a sample of 120 case management clients participating in the Kentucky Homeplace Program (KHP), and a general sample of 3,165 Appalachian Kentuckians. The recruited ED patients had low socio-economic status, numerous health conditions, and several unmet health needs, including need for colorectal, cervical, and breast cancer screening. Compared to their KHP counterparts, more ED patients were uninsured. Participants in the ED and KHP groups had particularly low income, were less educated, and had less insurance coverage than an average Appalachian resident. Although case management services, including the KHP have been successful in increasing access to health care by those in need, certain segments of the population remain underserved and continue to be missed by such programs. Our study suggests the need for and appropriateness of reaching out to such underserved populations in the ED and involving them into potential interventions designed to enhance preventive health services.

Intergenerational energy balance interventions: a systematic literature review

Many nations have witnessed a dramatic increase in the prevalence of obesity and overweight across their population. Recognizing the influence of the household environment on energy balance has led many researchers to suggest that intergenerational interventions hold promise for addressing this epidemic. Yet few comprehensive reviews of intergenerational energy balance interventions have been undertaken. Our review of the literature over the past decade revealed that intergenerational intervention approaches to enhance energy balance use a broad array of designs, target populations, and theoretical models, making results difficult to compare and "best practices" challenging to identify. Additional themes include variation in how interventions incorporate the intergenerational component; an increasing acknowledgment of the importance of ecological models; variations in the location of interventions delivery; diversity in the intervention flexibility/structure, intensity, and duration; and variation in outcomes and measures used across studies. We discuss implications and future directions of intergenerational energy balance approaches.

Colorectal cancer screening among rural Appalachian residents with multiple morbidities

INTRODUCTION

Colorectal cancer is the second leading cause of cancer deaths in the USA. Although early detection through screening has been shown to be effective in preventing colorectal cancer mortality, adherence to screening guidelines remains low. Among certain populations--namely those with lower socioeconomic status, a greater number of chronic conditions or multiple morbidity, and those living in rural locations-- colorectal cancer screening is particularly underused. This study explored the prevalence of such screening and explanations for how multiple chronic conditions might affect colorectal cancer screening among an especially vulnerable group of middle-aged and older adults.

METHODS

In total, 41 participants were recruited aged 50-76 years with two or more chronic conditions, from three rural health clinics in Appalachian Kentucky, USA. Using semi-structured and structured questions and instruments, participants engaged in two interviews.

RESULTS

Study results demonstrate colorectal cancer screening rates lower than state and national averages. In addition to commonly expressed barriers including unpleasant screening modality, lack of health insurance, and shortage of gastroenterologists to perform colonoscopy, participants described the ways in which multiple morbidities undermine screening. Barriers specific to multiple morbidity include competing demands from other conditions, such as financial pressures, physical limitations, and worries over regimen interference.

CONCLUSION

The window of opportunity left open by more frequent visits to health care professionals should be used to patients' advantage, especially as people with multiple morbidity are living longer with their chronic conditions. Efforts must accelerate to establish clinical guidelines and practices incorporating both management of existing conditions and the prevention of additional future morbidity.

Mammography promotion in the emergency department: a pilot study

OBJECTIVES

The objective of this pilot study is to assess the need, desire, and applicability of a mammography promotion project in the emergency department (ED).

DESIGN AND SAMPLE

A convenience sample from the ED of a public University hospital was surveyed to determine their mammography status, interest in a program to promote mammography, and barriers to mammography.

MEASURES

The survey included demographics information, health care access, including health insurance and primary care provider, mammography status and date of mammogram, as well as a checklist of potential barriers. Participants were also asked whether they would be interested in mammography promotion in this setting.

RESULTS

More than 15% of the 197 women surveyed had never received a mammogram, and more than half had not received 1 in the past year. The most common barriers to mammography were competing demands and money. Three quarters of the women said they would be interested in mammography promotion while waiting for care in the ED.

CONCLUSIONS

This study provides promise that mammography promotion activities may be appropriately placed in the ED and provides a solid platform from which researchers and nurses may launch efforts to develop preventive health interventions in innovative public health care settings.

Rural Residents' Perspectives on Multiple Morbidity Management and Disease Prevention

Middle-aged and older adults often experience several simultaneously occurring chronic conditions or "multiple morbidity" (MM). The task of both managing MM and preventing chronic conditions can be overwhelming, particularly in populations with high disease burdens, low socioeconomic status, and health care provider shortages. This article sought to understand Appalachian residents' perspectives on MM management and prevention. Forty-one rural Appalachian residents aged 50 and above with MM were interviewed about disease management and colorectal cancer (CRC) prevention. Transcripts were examined for overall analytic categories and coded using techniques to enhance transferability and rigor. Participants indicate facing various challenges to prevention due, in part, to conditions within their rural environment. Patients and providers spend significant time and energy on MM management, often precluding prevention activities. This article discusses implications of MM management for CRC prevention and strategies to increase disease prevention among this rural, vulnerable population burdened by MM.

Human subjects protection training for community workers: an example from "Faith Moves Mountains"

BACKGROUND

Despite widespread agreement on the necessity of protecting human subjects, questions regarding ethical treatment and protection of human subjects remain and are particularly vexing for community-based participatory research (CBPR). There has been a notable lack of attention paid to what type of training should be provided and how to balance "real-life" concerns with official requirements.

OBJECTIVES

The purpose of this article is to demonstrate how, in consultation with the Office of Research Integrity (ORI) at our institution and our community partners, we developed training that overcame concerns related to instruction of community workers on protection of human subjects.

METHODS

We developed a training module written in lay terms and containing only information pertinent to non-key personnel and their role in the CBPR project. We designed and piloted this material in collaboration with our community partners who work with us to recruit and train lay health advisors (LHAs) and oversee the day-to-day operations of the CBPR project.

RESULTS

The educational module was presented to the community workers as a part of a day-long training session. The written materials were a part of a notebook of information accompanied by an oral Power Point presentation. Each of the workers was given a written test to evaluate knowledge of the content presented. The test was administered by the project director, a community member herself, and then sent to our institution for grading by personnel not involved in this project. To date, all community workers have passed the written test.

CONCLUSIONS

The community members, research partners, and the ORI are satisfied with the scope and simplicity of the training program developed. Our team's collaborative approach to community-based human subjects training contributes to advancing a grounded, feasible, and rigorous process of protecting human subjects while implementing CBPR ideals.

"Is it half full or half empty?" Affective responses to chronic illness

Using a combined qualitative/quantitative approach, we interviewed 132 older African-Americans and whites with either osteoarthritis of the hip or knee (OAK/OAH) or ischemic heart disease (IHD) to address two questions: 1) What types of reactions to illness are expressed by this group of older adults who have OA or IHD? 2)? Are there differences in the characteristics of the respondents who respond more positively than those who respond more negatively? The responses were coded to illustrate those that reflected positive, negative, or combined (positive/negative) statements. The majority of the respondents, who were categorized as positive or combined, approached the illness experience with statements illustrating their ability to cope with their illness and adapt their lifestyles to the limitations imposed by the disease such as acceptance, feeling that others were worse off, or changing their lifestyles to adapt to their limitations. Those expressing negative reactions to their illness were fewer in number and responded with terms reflecting loss of identity, physical limitations, and other disease symptoms. The differences were more pronounced between the positive and negative groups where the latter were somewhat more likely to be African-American and female and significantly more likely to have less income, greater perceived disease severity, and more disability. We should look to the larger group in both the positive only and combined responses to explore how culture may play a role in perceptions of subjective well-being and the importance of "the local worlds of experience" experienced by both men and women, and African-Americans and whites. This study illustrates that using a simple, open-ended question that stimulates older people to narrate their reactions to having a chronic illness may allow clinicians to identify the persons most at-risk and intervene appropriately.

An internet-based abstinence reinforcement smoking cessation intervention in rural smokers

The implementation of cigarette smoking abstinence reinforcement programs may be hindered by the time intensive burden placed on patients and treatment providers. The use of remote monitoring and reinforcement of smoking abstinence may enhance the accessibility and acceptability of this intervention, particularly in rural areas where transportation can be unreliable and treatment providers distant. This study determined the effectiveness of an Internet-based abstinence reinforcement intervention in initiating and maintaining smoking abstinence in rural smokers. Sixty-eight smokers were enrolled to evaluate the efficacy of an Internet-based smoking cessation program. During the 6-week intervention period, all participants were asked to record 2 videos of breath carbon monoxide (CO) samples daily. Participants also typed the value of their CO readings into web-based software that provided feedback and reinforcement based on their smoking status. Participants (n=35) in the Abstinence Contingent (AC) group received monetary incentives contingent on recent smoking abstinence (i.e., CO of 4 parts per million or below). Participants (n=33) in the Yoked Control (YC) group received monetary incentives independent of smoking status. Participants in the AC group were significantly more likely than the YC group to post negative CO samples on the study website (OR=4.56; 95% CI=2.18-9.52). Participants assigned to AC were also significantly more likely to achieve some level of continuous abstinence over the 6-week intervention compared to those assigned to YC. These results demonstrate the feasibility and short-term efficacy of delivering reinforcement for smoking abstinence over the Internet to rural populations.

Faith Moves Mountains: an Appalachian cervical cancer prevention program

OBJECTIVE

To provide a conceptual description of Faith Moves Mountains (FMM), an intervention designed to reduce the disproportionate burden of cervical cancer among Appalachian women.

METHODS

FMM, a community-based participatory research program designed and implemented in collaboration with churches in rural, southeastern Kentucky, aims to increase cervical cancer screening (Pap tests) through a multiphase process of educational programming and lay health counseling.

RESULTS

We provide a conceptual overview to key elements of the intervention, including programmatic development, theoretical basis, intervention approach and implementation, and evaluation procedures.

CONCLUSIONS

After numerous modifications, FMM has recruited and retained over 400 women, 30 churches, and has become a change agent in the community.

"It's a toss up between my hearing, my heart, and my hip": prioritizing and accommodating multiple morbidities by vulnerable older adults

Nearly three quarters of older adults have multiple morbidities (MM). This study investigated which morbidities older adults prioritize, why, and how they accommodate these conditions, focusing on elders with two or more chronic conditions and low socioeconomic status. Methods. In-depth interviews were conducted with 41 older adults (most being African American women from the southeastern U.S., with two or more chronic illnesses). Results. Many participants reported worrying most about their heart disease, diabetes, and disability/mobility problems, and about their synergistic effects. Many worried that MMs might tip them into a downward spiral. Participants spent the most time and money on arthritis and diabetes. Few received help; when they did, relatives assisted with arthritis/mobility, diabetes, and effects of stroke. Discussion. Enhanced formal care coordination, increased use of technological innovations, and understanding elders' priorities are necessary to improve self-care/management and quality of life.

Diabetes self-care among a multiethnic sample of older adults

Type 2 diabetes constitutes a leading and increasing cause of morbidity and mortality among older adults, particularly African Americans, Native Americans, Mexican Americans, and rural dwellers. To understand diabetes self-care, an essential determinant of diabetic and overall health outcomes, 80 middle aged and older adults from these four disproportionately affected racial/ethnic/residential groups engaged in in-depth interviews, focusing on approaches to and explanations for diabetes self-care. Certain self-care activities (medication-taking, diet, foot care) were performed regularly while others (blood glucose monitoring, exercise) were practiced less frequently. Despite research suggestions to the contrary, only one in four elders used unconventional diabetes therapies, and only one-third listed someone other than a health care provider as a primary information source. Few self-care differences emerged according to race/ethnicity/residence, perhaps because of the influential and common circumstance of low income. Thematic analyses suggest that inadequate resources, perceived efficacy of medication, great respect for biomedical authority, and lack of familiarity with and concerns about unconventional therapies are influential in establishing these patterns of self-care. We discuss the similarity of self-care practices and perspectives irrespective of race/ethnicity/residence and the predominance of biomedical acceptability.