Clinic-based interventions to promote breast and cervical cancer screening

A Systematic Review of the Effectiveness of Cervical Cancer Screening and Prevention Interventions for African American Women: Implications for Promoting Health Equity

African American women suffer under the burden of cervical cancer as they are first in mortality, diagnosed at later stages, and have a survivorship rate that is lower than the national average. The aim of our review is to evaluate the effectiveness of cervical cancer screening and prevention interventions for African American women living in the United States and to assess their commitment to health equity. A literature search was conducted using PubMed, Embase, CINAHL, and Scopus using MeSH terms related to cervical cancer, human papillomavirus (HPV), screening and prevention, and African Americans. This resulted in 1970 articles. Studies were included if they promoted cervical screening or prevention, sampled African American women aged 18 and over, and evaluated interventions. Among the 23 articles that met inclusion criteria, there were a wide variety of intervention strategies, that is, community health workers, patient navigation, patient reminders, self-sampling collection, and HPV vaccination. Health education interventions, when coupled with patient navigation or community health workers, were effective in promoting screening participation (odds ratio: 2.43, 95% confidence interval: 1.47-4.02). There were mixed results regarding the incorporation of health equity principles. This review supports the importance of incorporating health equity principles and community based methods in screening and prevention interventions. Future research and practice should incorporate African American women's perspectives in intervention development and implementation.

Community Health Centers' Performance in Cancer Screening and Prevention

INTRODUCTION

Little is known about what clinic-level factors differentiate community health centers that achieve high performance on cancer-preventive care metrics. This study aims to describe the longitudinal trends in the delivery of 3 cancer-preventive care metrics (cervical and colorectal cancer screenings and tobacco-cessation intervention) and define and compare community health centers with high cancer-preventive care performance with those with low cancer-preventive care performance.

METHODS

This observational study used 2012-2019 community health center data (N=933) from the Uniform Data System. High/low performance was based on Healthy People 2020 targets and sample distribution. For each cancer-preventive care metric, the percentage of community health centers that met high (≥70.5% at cervical or colorectal cancer screening or >80% tobacco-cessation intervention) and low thresholds at 1, 2, and all the 3 screenings was estimated. Multivariable generalized estimating equations logistic regression modeling was used to assess the community health center‒level factors associated with screening performance.

RESULTS

The community health centers' performance for tobacco-cessation intervention remained at ≥80%, with a small increase over time. Performance for cervical cancer screening remained unchanged with about 50% of patients screened. Colorectal cancer screening performance increased from around 30% in 2012 to 44% in 2019. Very few community health centers reached high performance (3%) in all the 3 indicators, and 13% of community health centers were high in any 2 of the outcomes in 2019. Higher patient volume, a greater proportion of Hispanic patients, fewer uninsured patients, and community health centers located in the Northeast region were associated with high performance in 2019.

CONCLUSIONS

Very few community health centers meet all Healthy People 2020 goals in cancer screenings and may struggle to achieve the 2030 goals. Very few indicators differentiated high performers from low performers.

Using Google Trends Data to Study Public Interest in Breast Cancer Screening in Brazil: Why Not a Pink February?

Background

One of the major challenges of the Brazilian Ministry of Health is to foster interest in breast cancer screening (BCS), especially among women at high risk. Strategies have been developed to promote the early identification of breast cancer mainly by Pink October campaigns. The massive number of queries conducted through Google creates traffic data that can be analyzed to show unrevealed interest cycles and their seasonalities.

Objectives

Using Google Trends, we studied cycles of public interest in queries toward mammography and breast cancer along the last 5 years. We hypothesize that these data may be correlated with collective interest cycles leveraged by national BCS campaigns such as Pink October.

Methods

Google Trends was employed to normalize traffic data on a scale from 0 (<1% of the peak volume) to 100 (peak of traffic) presented as weekly relative search volume (RSV) concerning mammography and breast cancer as search terms. A time series covered the last 261 weeks (November 2011 to October 2016), and RSV of both terms were compared with their respective annual means. Polynomial trendlines (second order) were employed to estimate overall trends.

Results

We found an upward trend for both terms over the 5 years, with almost parallel trendlines. Remarkable peaks were found along Pink October months— mammography and breast cancer searches were leveraged up reaching, respectively, 119.1% (2016) and 196.8% (2015) above annual means. Short downward RSVs along December-January months were also noteworthy along all the studied period. These trends traced an N-shaped pattern with higher peaks in Pink October months and sharp falls along subsequent December and January.

Conclusions

Considering these findings, it would be reasonable to bring Pink October to the beginning of each year, thereby extending the beneficial effect of the campaigns. It would be more appropriate to start screening campaigns at the beginning of the year, when new resolutions are taken and new projects are added to everyday routines. Our work raises attention to the study of traffic data to encourage health campaign analysts to undertake better analysis based on marketing practices.

Breast Cancer Screening Practices among Low-Income Vietnamese Women

Cancer is the leading cause of death among Asian-American women in the United States and breast cancer is the most commonly diagnosed cancer among Asian-American women. Early detection through breast cancer screening has been found to improve the rate of survival for breast cancer. This study examined factors associated with breast cancer screening among 345 Vietnamese women ≥40 years old residing in a low-income Houston area. Data were collected through a self-administered questionnaire assessing socio-demographic characteristics, access to care factors, acculturation, and perceived susceptibility and severity of risks. Results showed 38 percent, 49 percent, and 33 percent of the respondents reporting having had a breast self-exam, a clinical breast exam, and a mammogram, respectively. Predictors of breast cancer screening include education, employment, ability to speak English, having lived in the United States for more than five years, and having a regular place of care. Implications of this study include the need for a culturally-relevant educational program for this understudied population.

Utilization of screening mammography among middle-aged and older women

AIMS

This study examines patterns of screening mammogram use, investigating the relationship of screening with demographic, health status, and healthcare factors.

METHODS

Data from 1242 women aged ?41 were obtained from a random sample of mailed surveys to community households in an eight-county region in Central Texas in 2010. The dependent variable was the timing of the participants' most recent screening mammography (in the past 12 months, between 1 and 2 years, or >2 years). Predictor variables included demographic, health status, and healthcare access factors. Multinomial logistic regression identified variables associated with screening mammography practices.

RESULTS

The majority of women reported having at least one mammogram during their lifetime (93.0%) and having a mammography within the past 2 years (76.2%). Participants who reported not having a routine checkup in the past 12 months (odds ratio [OR] 0.12, p<0.001), having a lapse of insurance in the past 3 years (OR 2.95, p<0.05), and living in a health provider shortage area (OR 1.42, p<0.05) were less likely to be screened within the past 2 years.

CONCLUSIONS

Routine healthcare plays a major role in preventive screening, which indicates screening mammography practices can be enhanced by improving participation in routine checkups with medical providers, continuity of insurance coverage, and women's access to healthcare. Interventions to encourage screening mammography may be particularly needed for women who have experienced a lapse in insurance or have not had a checkup in the past year.

Improving Rescreening In Community Clinics: Does A System Approach Work?

Community clinics provide inadequate breast cancer screening services to low-income, racially- and ethnically-diverse communities. This study develops and evaluates the effectiveness of multifaceted organizational system interventions--operational assessments, tracking systems, reminder calls, tailored education, physician prompts and a tailored counseling call--on mammography rescreening rates within three community clinics. We used the Chronic Care Model and Put Prevention Into Practice framework to redesign breast screening delivery services within the California Cancer Detection Programs: Every Woman Counts (CDP:EWC), community clinic settings. We used a quasi-experimental design with a random selection of 400 patients at pre-intervention. To establish a post-intervention clinic's rescreening rate a new comparable cross-sectional random sample of 347 women was drawn. Measures A chart abstraction instrument was used to establish clinics' rescreening rates. Subjects participants at pre and post-intervention were low-income women 50 years of age and older who had received normal mammography results and had not been diagnosed with breast cancer in the last five years. General linear mixed model analysis revealed significant improvements for the organizational system redesign condition [pre-intervention rescreening rate: 32.1 percent v. post-intervention rescreening rate 50.2 percent, (p < .001)]. For the organizational system redesign plus tailored counseling call condition, there was maintenance in the rescreening rate following the intervention [pre-intervention: 44.4 percent v. post-intervention: 45.1 percent, (p > 0.05)]. Multilevel interventions directed at redesigning community clinics primary care breast cancer screening services, can improve mammography rescreening rates.

Randomized trial of an intervention to improve mammography utilization among a triracial rural population of women

INTRODUCTION

Mammography is underused by certain groups of women, in particular poor and minority women. We developed a lay health advisor (LHA) intervention based on behavioral theories and tested whether it improved mammography attendance in Robeson County, NC, a rural, low-income, triracial (white, Native American, African American) population.

METHODS

A total of 851 women who had not had a mammogram within the past year were randomly assigned to the LHA intervention (n = 433) or to a comparison arm (n = 418) during 1998-2002. Rates of mammography use after 12-14 months (as verified by medical record review) were compared using a chi-square test. Baseline and follow-up (at 12-14 months) surveys were used to obtain information on demographics, risk factors, and barriers, beliefs, and knowledge about mammography. Linear regression, Mantel-Haenszel statistics, and logistic regression were used to compare barriers, beliefs, and knowledge from baseline to follow-up and to identify baseline factors associated with mammography.

RESULTS

At follow-up, 42.5% of the women in the LHA group and 27.3% of those in the comparison group had had a mammogram in the previous 12 months (relative risk = 1.56, 95% confidence interval [CI] = 1.29 to 1.87). Compared with those in the comparison group, women in the LHA group displayed statistically significantly better belief scores (difference = 0.46 points on a 0-10 scale, 95% CI = 0.15 to 0.77) and reduced barriers at follow-up (difference = -0.77 points, 95% CI = -1.02 to -0.53), after adjusting for baseline scores.

CONCLUSIONS

LHA interventions can improve mammography utilization. Future studies are needed to assess strategies to disseminate effective LHA interventions to underserved populations.

Implementation of recommendations on hypertension: the Canadian Hypertension Education Program

The diffusion of research evidence or practice guidelines does not, by itself, lead to changes in practice behaviour or patient outcomes. The Canadian Hypertension Education Program (CHEP) was specifically structured to have an explicit process to improve the ability of primary care professionals to use CHEP recommendations. The key features of this process are reviewed in the present report. The responsibility for implementation of recommendations is divided between the executive committee of CHEP and the Implementation Task Force (ITF). The executive develops an extensive array of summaries and implementation tools for the recommendations, and encourages and facilitates other organizations to develop educational materials and programs. The ITF creates further implementation tools, tailors the tools to specific health care disciplines and creates discipline-specific dissemination strategies. Currently, CHEP recommendations are disseminated through updated full scientific manuscripts, short scientific and clinical summaries, one-page handouts, wall posters, pocket cards, advertisements, extensive slide kits, textbooks, didactic lectures and workshops. A Web site with the recommendations in different formats is maintained to allow easy access. More recently, media releases have been used to alert the public and health care professionals to important recommendations. The transparent and interactive annual process of developing the recommendations by most of Canada's clinical hypertension experts is also viewed as critical to providing uniform educational messages to health care professionals from national and local opinion leaders. The CHEP ITF includes primary care disciplines and specialties important to blood pressure control. The CHEP process for the implementation of recommendations is very extensive and continues to evolve. There is early evidence for improvement in the management of hypertension in Canada that coincides with the initiation of CHEP, suggesting that CHEP could serve as a model for disease management recommendations.

How important are psychosocial predictors of mammography receipt among older women when immediate access is provided via on-site service?

PURPOSE

The purpose of the study was to examine the relative importance of psychosocial variables (i.e., health beliefs, knowledge, barriers) in predicting mammogram receipt compared with providing access through a mobile mammography unit among older women who participated in a mobile mammography intervention.

DESIGN

The data were collected during a randomized trial involving 499 women (60 to 84 years old) recruited from 60 community sites.

SETTING

The study was conducted at 60 sites in Los Angeles where seniors gather, including meal sites, senior centers, and recreational clubs.

SUBJECTS

Participants were older women (60 to 84 years old) who spoke English or Spanish, had a telephone, had no significant cognitive deficits, and had not received a mammogram during the past 12 months.

MEASURES

The baseline survey assessed demographics and psychosocial factors (i.e., health beliefs, knowledge, barriers). A follow-up telephone survey at 3 months assessed mammography receipt.

RESULTS

Results support the importance of behavioral intentions in predicting mammogram receipt, even among women able to access a mammogram through the mobile unit. However, other recognized psychosocial factors failed to predict screening receipt among women randomized to the mobile mammography intervention. Results suggest that the importance of psychosocial predictors might be diminished when a major access barrier has been removed, and they highlight the importance of convenience.

CONCLUSION

Future interventions should focus on not only removing obvious concrete and psychosocial barriers but also on enhancing convenience.

Who has regular mammograms? Effects of knowledge, beliefs, socioeconomic status, and health-related factors

BACKGROUND

Breast cancer accounts for the largest proportion of female cancer deaths and new cases in New South Wales (NSW). Biennial screening is recommended for women aged 50-69 years. Objectives were to (1) identify associations between beliefs and knowledge about breast cancer and mammography, socioeconomic (SES) indicators, and health-related factors, and having a mammogram (a) ever and (b) within the last 2 years; and (2) describe utilization of mammography.

METHODS

2974 women aged 50-69 years selected from the BreastScreen NSW (BSNSW) database and the NSW Electoral Roll were administered a structured telephone survey. Associations were assessed using weighted Chi squares and age-adjusted odds ratios from logistic regression with 95% confidence intervals.

RESULTS

Strong positive associations were found between age, married/de facto relationship, knowledge about and belief in the benefits of screening, indicators of health status and service utilization, and whether women had had a mammogram or had one within the recommended period. SES was weakly associated with regularity of mammography. Most respondents (97.4%) reported having had at least one mammogram.

CONCLUSIONS

Specific aspects of knowledge and beliefs about mammograms and individual health-related factors would be important components of initiatives to encourage initial and repeat screening in the targeted age group.

Cervical cancer screening among U.S. women: analyses of the 2000 National Health Interview Survey

BACKGROUND

Cervical cancer screening is not fully utilized among all groups of women in the United States, especially women without access to health care and older women.

METHODS

Papanicolaou (Pap) test use among U.S. women age 18 and older is examined using data from the 2000 National Health Interview Survey (NHIS).

RESULTS

Among women who had not had a hysterectomy (n = 13,745), 83% reported having had a Pap test within the past 3 years. Logistic regression analyses showed that women with no contact with a primary care provider in the past year were very unlikely to have reported a recent Pap test. Other characteristics associated with lower rates of Pap test use included lacking a usual source of care, low family income, low educational attainment, and being unmarried. Having no health insurance coverage was associated with lower Pap test use among women under 65. Despite higher insurance coverage, being age 65 and older was associated with low use. Rates of recent Pap test were higher among African-American women.

CONCLUSIONS

Policies to generalize insurance coverage and a usual source of health care would likely increase use of Pap testing. Also needed are health system changes such as automated reminders to assist health care providers implement appropriate screening. Renewed efforts by physicians and targeted public health messages are needed to improve screening among older women without a prior Pap test.

A randomized controlled trial to increase cancer screening among attendees of community health centers

BACKGROUND

We assessed the efficacy of the Cancer Screening Office Systems (Cancer SOS), an intervention designed to increase cancer screening in primary care settings serving disadvantaged populations.

METHODS

Eight primary care clinics participating in a county-funded health insurance plan in Hillsborough County, Fla, agreed to take part in a cluster-randomized experimental trial. The Cancer SOS had 2 components: a cancer-screening checklist with chart stickers that indicated whether specific cancer-screening tests were due, ordered, or completed; and a division of office responsibilities to achieve high screening rates. Established patients were eligible if they were between the ages of 50 and 75 years and had no contraindication for screening. Data abstracted from charts of independent samples collected at baseline (n = 1,196) and at a 12-month follow-up (n = 1,237) was used to assess whether the patient was up-to-date on one or more of the following cancer-screening tests: mammogram, Papanicolaou (Pap) smear, or fecal occult blood testing (FOBT).

RESULTS

In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms (odds ratio [OR] = 1.62, 95% confidence interval [CI], 1.07-9.78, P = .023) and fecal occult blood tests (OR = 2.5, 95% CI, 1.65-4.0, P <.0001) with a trend toward greater use of Pap smears (OR = 1.57, 95% CI, 0.92-2.64, P = .096).

CONCLUSIONS

The Cancer SOS intervention significantly increased rates of cancer screening among primary care clinics serving disadvantaged populations. The Cancer SOS intervention is one option for providers or policy makers who wish to address cancer related health disparities.

Short- and long-term effects of tailored information versus general information on determinants and intentions related to early detection of cancer

BACKGROUND

Since it is widely accepted that the earlier cancer is detected, the better the chances of treatment and survival, people should be encouraged to create positive intentions toward early detection of several types of cancer, for instance, skin cancer, breast cancer, and colon cancer. This can be done by being alert to the warning signs of cancer and seeking help once a cancer symptom is detected.

METHODS

A randomized controlled study (n = 1,500) assessed the effects of computer-tailored information and general information on determinants and intentions to engage in early detection behaviors (i.e., passive detection and help seeking) compared with those in a control group. Possible negative side effects, like increased chronic fear of cancer and more fatalistic attitudes toward cancer, were studied as well.

RESULTS

Shortly after the intervention, differences between the study groups were found in intention, several social psychological determinants, and knowledge. Six months after the intervention, there were still differences between the tailored information group and the control group in intentions toward help seeking. Neither of the interventions resulted in increased chronic fear nor more fatalistic attitudes toward cancer.

CONCLUSIONS

It is concluded that there were positive effects of the tailored intervention on determinants, passive detection, and help-seeking intentions in the short-term, but additional research is needed to assess ways of maintaining these effects in the long-term.

A Large Population-Based Randomized Controlled Trial to Increase Attendance at Screening for Cervical Cancer

Objective: Although cervical cancer is one of the potentially most preventable malignancies, it is still fairly common. In settings with established screening programs, increased compliance is important for future reduction in cervical cancer incidence, but it is presently unclear how this can be effectively achieved. Methods: We conducted a randomized controlled trial including all 12,240 women invited to organized screening in Sweden. To increase compliance, three successive interventions were tested: (a) modified invitation versus the standard invitation letter, (b) reminder letter to nonattenders after the first intervention versus no reminder letter, and (c) phone reminder to nonattenders after the reminder letter versus no phone reminder. We analyzed the proportion of women attending screening after each intervention and the cumulative proportion after the interventions as well as the cumulative proportions of cytologic abnormalities. Results: The modified invitation did not increase attendance compared with the standard invitation letter [difference 1.3% 95% confidence interval (CI) −0.3 to 2.9]. In contrast, a reminder letter increased the proportion of women attending with 9.2% (95% CI 7.9–10.5) compared with women who did not receive a reminder letter, and a phone reminder increased the proportion of women attending with 31.4% (95% CI 26.9–35.9). Combinations of modified invitation, written reminder, and phone reminder almost doubled attendance within 12 months, and the number of detected cytologic abnormalities was more than tripled. Conclusion: Simple reminders by mail and phone can drastically increase women's participation in Papanicolaou smear screening and increase the number of detected precursor lesions and thereby save lives.

The influence of previous breast cancer upon mammography utilization

Women with a previous history of breast cancer are at increased risk for developing cancer in the opposite breast. However, the literature is inconsistent regarding whether a previous history of breast cancer is associated positively with mammography utilization. Some studies indicate that women with a previous history of breast cancer are less likely to utilize mammography, although behavioral models of health care theorize that women with a history of breast cancer may be more vigilant regarding the disease. We analyzed responses from 830 women > or =50 years who participated in the 1998 National Health Interview Survey. A significantly greater proportion of women with breast cancer reported had a mammogram in the previous year (73.13%) as compared with women who did not have breast cancer (56.69%). Although a previous history of breast cancer was found to be associated positively with mammography use, women with public sources of health insurance are less likely to report mammography use. Results indicate that women with a previous history of breast cancer appear aware of the necessity for continued screening. However, enabling factors such as type of health insurance continue to exert an influence upon the utilization of mammography.

Abnormal cervical screen follow-up among low-income Latinas: Project SAFe

BACKGROUND

Cervical cancer incidence and mortality rates are dramatically higher among low-income women than in the general population, in part due to poor adherence to recommended diagnostic follow-up after an index Pap test. This report describes a pilot study of the Screening Adherence Follow-Up Program (SAFe), an individualized, structured case management program designed to assess for and intervene in response to a variety of potential personal and systems barriers to follow-up adherence. Interventions included health education, counseling, and systems navigation.

METHODS

A clinical decision-making algorithm was used to determine service intensity and level of intervention. Services were provided to 196 low-income women, predominantly Latinas, who had either a low-grade or high-grade squamous intraepithelial lesion (LGSIL or HGSIL) abnormal Pap result. Adherence rates to at least one follow-up appointment after enrollment and baseline intervention were 83% following LGSIL and 93% for HGSIL.

RESULTS

Over 1 year post-enrollment, 41% of women with LGSIL were fully adherent, with 42% partially adherent; 61% of women with HGSIL were fully adherent, with 32% partially adherent. In a comparison group of 369 nonenrollees (women who refused participation or could not be located for consent), adherence rates were 58% for LGSIL and 67% for HGSIL. A survey among a random sample of women served indicated that 93% were "mostly" or "very" satisfied, overall, with SAFe services.

CONCLUSIONS

The intervention team--a peer counselor and a master's degreed social worker--addressed multiple psychosocial and systems navigation problems to reduce potential barriers to adherence, including knowledge, attitudinal, psychosocial, psychological distress, systems communication, and resource access problems. SAFe appears highly acceptable to women and may significantly enhance medical care management following an abnormal cervical screen for a carefully targeted group of women at risk for suboptimal follow-up adherence.

Exploring loss to follow-up: abnormal Pap screening in Hispanic patients

PURPOSE

The loss of patients to follow-up for abnormal findings from Pap screenings is an important public health concern, particularly among poor and minority women. This study explores factors affecting incomplete follow-up among a group of Hispanic women with low incomes.

DESCRIPTION OF STUDY

A qualitative descriptive study was conducted of 11 Hispanic patients with incomplete Pap smear follow-up at a public clinic in a major city in south Texas. Patients were interviewed using a semistructured, open-ended schedule of questions, and their medical records were abstracted. The clinic's five staff members also were interviewed. Comparative chronologies were constructed for each case, contrasting patient and staff accounts of the same set of events. All data were coded by at least two investigators.

RESULTS

All study patients had mildly abnormal Pap smear results and had not met the follow-up criteria, but all understood and were committed to Pap screening. Although viewed by staff as noncompliant, none of the patients viewed her behavior this way. This staff-patient discrepancy was attributable to poor communication, mixed messages, clinic errors, and, perhaps most importantly, to a conflict between program policies and the specific circumstances of individual cases. Two case examples are presented to illustrate key points.

CLINICAL IMPLICATIONS

Strategies that may help to reduce loss to follow-up among similar patients include the following: allowing clinic staff more flexibility in follow-up procedures for women who have consistently normal follow-up tests, including Spanish translations of written messages; enlisting patients' agreement in setting appointments; and updating patient records to reflect follow-up care that had been received in other clinics.

Factors associated with testing for hepatitis C in an internet-recruited sample of men who have sex with men

BACKGROUND

Nearly 4 million individuals in the United States (1.8%) have been infected with hepatitis C virus, yet few are aware of their infection.

GOAL

To identify correlates associated with hepatitis C virus testing among a sample of men who have sex with men.

STUDY DESIGN

Internet communications were used for solicitation and collection of data, using a 31-question survey.

RESULTS

When the study was restricted to men who have sex with men in the United States (n = 381), 95% of the respondents (n = 361) reported at least one risk factor for hepatitis C virus transmission, 39% of these respondents (n = 140) reported having been tested for hepatitis C virus. Testing was associated with a history of nonsexual risk behavior, increased knowledge of the hepatitis C virus, and healthcare provider communication.

CONCLUSION

A significant proportion of at-risk respondents had not been tested. Interventions are needed to increase hepatitis C virus knowledge in the community of men who have sex with men, and to encourage providers to communicate about hepatitis to the men in this group who screen as high risk on the basis of their risk behaviors.

The impact of Put Prevention into Practice on selected clinical preventive services in five Texas sites

OBJECTIVE

To determine whether the implementation of the Put Prevention Into Practice (PPIP) office-based system would increase the delivery rates of specific clinical preventive services among demonstration clinics.

METHODS

Chart review was conducted before (n=372) and 33 to 39 months after (n=376) the implementation of the PPIP office-based system in two community health centers and three family practice residency programs in Texas. The population included all adult patients aged > or = 19 years who had presented to the clinic during the study periods.

RESULTS

Documentation of timely cholesterol screening increased from 70% to 84%; smoking assessment, from 56% to 80%; for women, up-to-date Papanicolaou smear, from 70% to 81%; annual mammograms (women aged > or =51), from 30% to 48%; and up-to-date tetanus-diphtheria immunizations, from 19% to 59%. For adults aged > or =66 years, documentation of pneumococcal immunization increased from 22% to 48%, while influenza immunizations improved, although not significantly (45% to 49%). Blood pressure screening was almost universal (99%) at baseline and at 33- to 39-month follow-up.

CONCLUSION

PPIP system changes were associated with an observed increase in delivery of selected clinical preventive services.

Correlates of hepatitis B vaccination in a high-risk population: an Internet sample

PURPOSE

We sought to identify factors associated with hepatitis B virus vaccination, including knowledge and attitudes about hepatitis vaccination, and sexual and nonsexual risk behaviors among at-risk homosexual and bisexual men.

SUBJECTS AND METHODS

Internet electronic communications were used to collect data from homosexual and bisexual men from the United States, using a 31-item online questionnaire accessible for 1 month.

RESULTS

The mean (+/- SD) age of the 336 respondents was 38 +/- 11 years. Nearly 42% (142) reported at least one dose of vaccine; the remainder were completely unvaccinated. About 21% (n = 71) reported having no information about hepatitis. Approximately 72% (242) of respondents reported never using condoms during oral intercourse, and 26% (n = 87) reported using condoms during less than half of their episodes of anal intercourse. In multivariate analysis, variables associated with vaccination were younger age (odds ratio [OR] 0.7 per 10-year increase in age; 95% confidence interval [CI] 0.59 to 0.84, P = 0.002), high level of knowledge about the vaccine (OR 1.4; 95% CI: 1.03 to 1.83, P = 0.007), communication with a health-care provider about hepatitis (OR 1.98; 95% CI 1.31 to 2.98, P = 0.006), and professional training that included hepatitis education (OR 2.77; 95% CI 1.7 to 4.5, P = 0.001).

CONCLUSIONS

Our findings underscore the need for health care providers to emphasize vaccine efficacy and safety, and to encourage high-risk patients to receive vaccination, particularly among men at high risk based on sexual and drug use behaviors.

Colorectal cancer screening participation by older women

OBJECTIVE

Although recent screening guidelines recommend annual fecal occult blood testing (FOBT) for adults aged > or = 50, a number of studies report that these tests are underused. Systematic efforts to increase awareness of colorectal cancer (CRC) and to promote screening participation are needed to meet national objectives for CRC control.

METHODS

This study examined CRC-screening practices and evaluated factors related to recent participation in screening by FOBT in a sample of women aged 50 to 80 who were surveyed about their use of clinical preventive services at Group Health Cooperative, a managed care organization in western Washington State.

RESULTS

Of the 931 women eligible for analysis, 75% reported ever having been screened by FOBT and 48% reported having been screened within 2 years before the survey. Participation in screening did not vary by demographic characteristics or by perceived or actual risk of CRC. Women with a positive attitudes toward CRC screening had sevenfold greater odds of recent screening by FOBT (odds ratio=7.1; 95% confidence interval, 4.4 to 11.6). Only 58% of study women reported that their physicians encouraged CRC screening, but this factor was strongly related to participation (odds ratio=12.7; 95% confidence interval, 6.6 to 24.4).

CONCLUSIONS

We identified several areas in which understanding of CRC risk may be low. As a whole, these findings suggest that effective strategies to control CRC may include efforts to improve knowledge of risk and prevention, but must also appeal directly to primary care physicians to identify and address their barriers to screening recommendations.

Feasibility of a tailored intervention to improve preventive care use in women

BACKGROUND

Women age 50 years and older are in need of multiple preventive health care services. Despite recent improvements in rates of delivery of preventive care services, especially within managed care organizations, substantial numbers of women are still being underscreened. Efforts to improve delivery of preventive care services have often focused on one outstanding service despite the fact that patients often are in need of many services.

METHODS

A total of 893 women age 50 to 55 years were mailed a self-administered survey to identify outstanding preventive health care service needs. Patients in need of three or more outstanding preventive health care services were identified from survey respondents to participate in a feasibility study evaluating a tailored, customized intervention called Tic Tac Health.

RESULTS

Five-hundred ninety-one women returned the survey (67%). Four-hundred forty-eight (76%) women were in need of one or more preventive health services; 92 (16%) were in need of three or more. Twenty-two patients (24%) completed the Tic Tac Health card. The women who completed the card were similar to those who did not.

CONCLUSIONS

Despite documented physician visits, presence of managed care health insurance, and a designated primary care provider, a significant number of women are still in need of multiple preventive health services. An intervention targeting multiple preventive health services was demonstrated to be both feasible and effective. Further evaluation via a randomized controlled trial should be conducted to determine if an intervention like Tic Tac Health would be an effective modality for improving rates of receipt of multiple preventive health care services.

A population-based study of age and gender differences in patterns of health-related behaviors

PURPOSE

Most research on preventive health behaviors has focused on individual rather than groups of behaviors. This study examined interrelationships among multiple preventive health behaviors in different age and gender groups.

METHODS

From 1990 to 1992, Maryland residents were surveyed by telephone through the Behavioral Risk Factor Surveillance System. The study sample of 4455 was divided into 8 groups based on age (18-24, 25-39, 40-54, and 55+) and gender. Correlation and oblique rotated factor analyses were used to examine patterns of 8 to 11 preventive health behaviors in each age-gender group.

RESULTS

Medical checkup and cholesterol test formed one behavioral cluster in the four male age groups. Breast and cervical cancer screening (mammogram, clinical breast examination [CBE], and Pap Smear) did not form one cluster until age 55 or older; Pap smear, CBE formed one cluster for women of all ages. Risk-taking behaviors were only prominent in the youngest age group: Seatbelt non-use, smoking, and drinking formed one cluster in younger males, and drinking and driving after drinking clustered in younger females.

CONCLUSION

Screening and risk-taking behaviors form distinct groups, and behavioral patterns differ by age and gender. Public health programs should consider multi-behavioral approaches, and be sensitive to the gender and age of the target population.