An intervention study on screening for breast cancer among single African-American women aged 65 and older

The Effect of Educational Intervention Based on the Theory of Planned Behavior on Mammography Screening in Iranian Women

Mammography is the most special screening method for early diagnosis of breast cancer. The purpose of present research is investigating the effect of educational intervention based on theory of planned behavior on mammography screening of women in Fasa city, Fars province, Iran. In this quasi-experimental study, 400 subjects (200 subjects for experimental group and 200 subjects for control group) were selected in 2017-2018. Educational intervention for the experimental group included 8 educational sessions. A questionnaire used for evaluating demographic information and constructs of theory of planned behavior (knowledge, perceived behavioral control, subjective norms, and attitude) investigated mammography performance of women before and 6 months after intervention. Data were analyzed by using SPSS 22 through chi-square test, McNemar's test, and Wilcoxon-Mann-Whitney test at significance level of P < 0.05. The average age of subjects was 45.52 ± 6.76 years in the experimental group and 45.12 ± 6.64 years in the control group. Six months after intervention, the experimental group showed significant increase in knowledge, perceived behavioral control, subjective norms, and attitude compared to the control group and 174 people (78%) of the experimental group had intention for doing mammography and 148 people (74%) of the experimental group performed mammography. Also, 6 months after educational intervention, 38 people (19%) of the control group had intention for performing mammography and 14 people (7%) of the control group performed mammography.

Translating new science into the community to promote opportunities for breast and cervical cancer prevention among African American women

BACKGROUND

New evidence has found breast and cervical cancer risk factors unique to African American women. Thus, there is a significant need to increase their knowledge and understanding of relevant risk factors and the potential protective benefits associated with breast-feeding and HPV vaccination. The National Witness Project is a robust, evidence- and community-based lay health advisor programme that uses group education, navigation and survivor narratives to increase cancer screening among diverse underserved women.

METHODS

A multi-phase, community-based participatory research study was conducted across three sites in Buffalo, NY, New York City and Arkansas between October 2016 and January 2017. Pre-/post-test surveys were administered during volunteer trainings and community programmes. An evaluation survey was also administered at the Annual Meeting for Education and Networking. Paired sample t tests were used to compare pre-/post-test survey scores.

RESULTS

Trainee survey results showed the overall mean per cent correct pre-/post-test scores were 47.7% (SD: 21.87) and 79.2% (SD: 16.14). Altogether, 31 educational programmes reached 332 community participants. Participants' breast and cervical cancer knowledge scores were significantly higher after the education programme (84.4%) than before (55.3%) with a mean change score of 29% (P ≤ .001).

CONCLUSION

This paper reveals the underlying complexities to update the educational curriculum content of a multi-site, community-based outreach organization. The new curriculum significantly improved African American women's knowledge about breast and cervical cancer by 10%-36%, clearly demonstrating that this information was new to them. The need for education programming in African American communities to disseminate cancer prevention and risk information remains high.

Evaluation of Health Belief Model-Based Intervention on Breast Cancer Screening Behaviors among Health Volunteers

Breast cancer is the most common cancer and the second leading cause of death among women. Regarding the lack of knowledge about the cause of breast cancer and considering the fact that all women are prone to this disease, training on methods of early diagnosis to reduce its complications is of great importance. Thus, this study aimed to determine the effect of education based on the health belief model on breast cancer screening behaviors in health volunteers of health centers in Isfahan. In this experimental study, 480 healthy volunteers were randomly divided into two groups: the case (n = 240) and control (n = 240). The training program was designed according to health belief model structures. Before the training interventional program, the Champion standard questionnaire and functional checklist were completed for both groups. A standard questionnaire was completed during three stages (before, immediately after, and 2 months after the training). The experimental group received the educational intervention during eight sessions, and the collected data was eventually analyzed using the SPSS statistical software version 16 with relevant statistical tests. Participation of all individuals in the present research was voluntary and with informed consent. The results showed that mean scores of knowledge, perceived susceptibility, severity, benefits, barriers, self-efficacy, and behavioral intention related to breast self-examination (BSE) and mammography in the intervention group significantly increased compared with those of the control group immediately after and 2 months after educational intervention. There was a significant difference between groups in BSE skill 2 months after the intervention, but there was no significant difference between the two groups in BSE behavior and mammography 2 months after the intervention. The results confirmed the efficiency and effectiveness of an educational intervention based on the health belief model on improving factors affecting breast cancer screening behaviors.

Effectiveness of the Theory-Based Educational Interventions on Screening of Breast Cancer in Women: A Systematic Review and Meta-Analysis

Screening plays an essential role in the reduction of mortality and morbidity of breast cancer, which is one of the most common cancers in women worldwide. The aim of this study was to find out whether the use of health education model and theory-based behavioral interventions is effective in women’s breast cancer screening behavior. Applying different search strategies, we searched electronic databases including PubMed, ScienceDirect, Web of Science, and Scopus without time limit from January 12 to March 11, 2017. Keywords included “Breast neoplasm,” Screening,” “Women,” and “Health Education.” First, screening was conducted based on title, abstract, and full text. Then, the studies were screened according to the selection criteria of our study. The relevant and eligible studies were critically appraised by Delphi checklist. In addition, a meta-analysis of eligible studies was conducted with the random-effect approach. Twenty-six of 8,620 initial studies (with sample size of 10,681 in the intervention group and 8,854 in the control group) were included in the final analysis. The results of the meta-analysis showed that the probability of screening behavior in the intervention group is 1.4 times of that in the control group. Furthermore, subgroup analysis by the type of screening behavior indicates that the probabilities of conducting breast self-examination and mammography in the intervention group are 1.9 and 1.4 times of those in the control group. The health education program has a significant impact on breast cancer screening behaviors, particularly breast self-examination. Thus, given the positive effects of the educational screening programs in women, it is suggested that these programs must be continuously pursued with long-term follow-up and increasing rates of screening behaviors should be monitored.

Effectiveness of Interventions for Breast Cancer Screening in African American Women: A Meta-Analysis

OBJECTIVE

The purpose of this study was to report the results of a meta-analysis conducted on the effects of clinical trials in breast cancer screening for African American women between 1997 and 2017.

DATA SOURCES

Articles published in English and in the United States, between January 1997 and March 2017, were eligible for inclusion if they (1) conducted psychosocial, behavioral, or educational interventions designed to increase screening mammography rates in predominantly African American women of all ages; (2) utilized a randomized, controlled trial (RCT) design; and (3) reported quantitative screening rates following the intervention.

STUDY DESIGN

Randomized clinical trials on breast cancer screening in African American women, published between January 1997 and March 2017, were selected from database searches.

DATA COLLECTION METHODS

Data collected included effect size of screening versus comparison interventions, intervention characteristics, and a number of study characteristics to explore potential moderators. Search results yielded 327 articles, of which 14 met inclusion criteria and were included in analyses.

PRINCIPAL FINDINGS

Findings indicated that screening interventions for African American women were significantly more likely to result in mammography than control (OR = 1.56 [95 percent CI = 1.27-1.93], p < .0001). Although no patient or study characteristics significantly moderated screening efficacy, the most effective interventions were those specifically tailored to meet the perceived risk of African American women.

CONCLUSIONS

Screening interventions are at least minimally effective for promoting mammography among African American women, but research in this area is limited to a small number of studies. More research is needed to enhance the efficacy of existing interventions and reduce the high morbidity and mortality rate of this underserved population.

Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review

BACKGROUND

Community-based health workers (CBHWs) are frontline public health workers who are trusted members of the community they serve. Recently, considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable populations who often face health inequities.

OBJECTIVES

We performed a systematic review to synthesize evidence concerning the types of CBHW interventions, the qualification and characteristics of CBHWs, and patient outcomes and cost-effectiveness of such interventions in vulnerable populations with chronic, noncommunicable conditions.

SEARCH METHODS

We undertook 4 electronic database searches-PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane-and hand searched reference collections to identify randomized controlled trials published in English before August 2014.

SELECTION

We screened a total of 934 unique citations initially for titles and abstracts. Two reviewers then independently evaluated 166 full-text articles that were passed onto review processes. Sixty-one studies and 6 companion articles (e.g., cost-effectiveness analysis) met eligibility criteria for inclusion.

DATA COLLECTION AND ANALYSIS

Four trained research assistants extracted data by using a standardized data extraction form developed by the authors. Subsequently, an independent research assistant reviewed extracted data to check accuracy. Discrepancies were resolved through discussions among the study team members. Each study was evaluated for its quality by 2 research assistants who extracted relevant study information. Interrater agreement rates ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions.

MAIN RESULTS

All but 4 studies were conducted in the United States. The 2 most common areas for CBHW interventions were cancer prevention (n = 30) and cardiovascular disease risk reduction (n = 26). The roles assumed by CBHWs included health education (n = 48), counseling (n = 36), navigation assistance (n = 21), case management (n = 4), social services (n = 7), and social support (n = 18). Fifty-three studies provided information regarding CBHW training, yet CBHW competency evaluation (n = 9) and supervision procedures (n = 24) were largely underreported. The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in 24 studies that reported length of training. Eight studies reported the frequency of supervision, which ranged from weekly to monthly. There was a trend toward improvements in cancer prevention (n = 21) and cardiovascular risk reduction (n = 16). Eight articles documented cost analyses and found that integrating CBHWs into the health care delivery system was associated with cost-effective and sustainable care.

CONCLUSIONS

Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions, particularly when partnering with low-income, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.

E-mail to Promote Colorectal Cancer Screening Within Social Networks: Acceptability and Content

Effective techniques to encourage colorectal cancer screening in underscreened populations have included social support interventions and e-mail reminders from physicians. Personalized e-mail messages to promote colorectal cancer screening within social networks could be even more effective but have not been studied. The authors interviewed 387 e-mail users, aged 42-73 years in Georgia, Hawaii, and Massachusetts. Participants were asked to edit a sample message in which the sender shares a recent colonoscopy experience and urges the recipient to discuss colorectal cancer screening with a doctor. For those reporting willingness to send this message, changes to the message and suggested subject lines were recorded. Edited text was analyzed for content and concordance with original message. The majority of participants (74.4%) were willing to e-mail a modifiable message. Of those willing, 63.5% edited the message. Common edits included deletion (17.7%) or modification (17.4%) of a negatively framed sentence on colon cancer risks and addition or modification of personalizing words (15.6%). Few edits changed the meaning of the message (5.6%), and even fewer introduced factual inaccuracies (1.7%). Modifiable e-mail messages offer a way for screened individuals to promote colorectal cancer screening to social network members. The accuracy and effects of such messages should be further studied.

A systematic review of randomised controlled trials examining the effectiveness of breast and cervical cancer screening interventions for ethnic minority women

PURPOSE

To examine the effect that breast and/or cervical cancer screening programmes for ethnic minority women have on their knowledge of and beliefs about breast or cervical cancer and screening, and on their screening intentions and uptake rates. Recommendations are also made for the format and content of such programmes, based on existing evidence.

METHODS

A comprehensive literature search was carried out both manually and by means of five electronic databases. The findings are summarised and synthesised in narrative fashion.

RESULTS

The ten RCTs included here were conducted among ethnic minority women in the United States or Canada, where breast or cervical cancer screening programmes have led to improvements in screening intentions, knowledge of cervical cancer and pap test uptake. The Breast Cancer Screening Belief Scale and self-reporting were the methods commonly used to measure outcomes. The shared characteristics of both countries' programmes were that they were theory- and language-based, the instruction took place in a community setting, the materials were culturally relevant, the content highlighted key messages about breast or cervical cancer and screening measures, and there were multiple intervention strategies.

CONCLUSION

Breast or cervical cancer screening programmes in Western countries have demonstrated improvements in knowledge of the disease, screening intentions and pap test uptake, although evidence on the effectiveness of the interventions has been limited. The common characteristics of programmes are identified, but a comprehensive model is still needed to link these characteristics with other factors and mediators influencing outcomes.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

Comparison the effects of two educational methods on knowledge, attitude and practices of Arak physicians about breast cancer

Breast cancer is the most common and most preventable cancer in women and early detection has the important role in reducing its morbidity and mortality, so increase 95% survival time. The present study conducted to compare the effects of two educational methods on knowledge, attitude and practices of Arak physicians. An interventional study after randomized allocation of each 64 physician to any of two different educational methods (video and systematic review) used to compare knowledge; attitude and practices score variation about breast cancer screening skills. Data collection carried out with structured questionnaire and entered to SPSS software. Data analyzed by t-test, paired t-test and Man-Whitney test in significant level of 0.05. Mean of total score of knowledge, attitude and practices (KAP) showed a significant difference before and after training and the total score of KAP increase (p < 0.05). But KAP score variation and their subscales were same in two groups and didn't show any significant difference (p > 0.05). Although KAP in Arak physician is appropriate and any educational program increase their KAP level, but continuing and repetition of educational courses seems to be necessary.

Interventions to increase the uptake of mammography amongst low income women: a systematic review and meta-analysis

Background

Two previous reviews found that access-enhancing interventions were effective in increasing mammography uptake amongst low-income women. The purpose of this study was to estimate the magnitude of the effect of interventions used to increase uptake of mammography amongst low-income women.

Methods

Searches were conducted in MEDLINE and EMBASE (2002–April 2012) using relevant MeSH terms and keywords. Randomised controlled trials which aimed to increase mammography use in an asymptomatic low-income population and which had as an outcome receipt of a mammogram, were eligible for inclusion. The primary outcome was the post-intervention difference in the proportion of women who had a mammogram in the intervention and control groups. The quality of the studies was assessed using the Cochrane risk of bias tool. We calculated summary estimates using random effects meta-analyses. Possible reasons for heterogeneity were investigated using sub-group analyses and meta-regression. Publication bias was assessed using Egger's test.

Results

Twenty-one studies met the inclusion criteria, including 33 comparisons. Interventions increased the uptake of mammography in low income women by an additional 8.9% (95% CI 7.3 to 10.4%) compared to the control group. There was some evidence that interventions with multiple strategies were more effective than those with single strategies (p  = 0.03). There was some suggestion of publication bias. The quality of the included studies was often unclear. Omitting those with high risk of bias has little effect on the results.

Conclusions

Interventions can increase mammography uptake among low-income women, multiple interventions being the most effective strategy. Given the robustness of the results to sensitivity analyses, the results are likely to be reliable. The generalisability of the results beyond the US is unclear.

Evaluating the training of Filipino American community health advisors to disseminate colorectal cancer screening

Community health advisor-led interventions are associated with improved health promotion behaviors, such as cancer screening, but the process of training community health advisors is rarely described and evaluated. We trained 91 Filipino Americans from 19 organizations to conduct small-group sessions with members of their organizations to promote colorectal cancer screening. Community health advisors completed brief pre- and post-training surveys that included knowledge of colorectal cancer screening guidelines (four items), perceived self-efficacy of performing specific tasks (15-item scale, Cronbach's alpha > 0.90) and satisfaction with the training itself (five items). Community health advisors had high levels of knowledge and self-efficacy at pre-training, but levels increased significantly immediately after the 6-h training (percent of knowledge items answered correctly: 63-94 %; self-efficacy: 8.2-8.9 on a 10 point scale, both p < 0.001). Correlates of self-efficacy at pre- and post-test were high educational attainment, health care background, high level of participation in the organization, being perceived by others as a leader, and frequent participation in research activities in the past. Consistent evaluation measuring similar constructs across studies may help to standardize the quality of the training, and may improve the implementation of community health advisor-led programs.

Using the interactive systems framework to support a quality improvement approach to dissemination of evidence-based strategies to promote early detection of breast cancer: planning a comprehensive dynamic trial

Dissemination efforts must optimize interventions for new settings and populations. As such, dissemination research should incorporate principles of quality improvement. Comprehensive Dynamic Trial (CDT) designs examine how information gained during dissemination may be used to modify interventions and improve performance. Although CDT may offer distinct advantages over static designs, organizing the many necessary roles and activities is a significant challenge. In this article, we discuss use of the Interactive Systems Framework for Dissemination and Implementation to systematically implement a CDT. Specifically, we describe "Bronx ACCESS", a program designed to disseminate evidence-based strategies to promote adherence to mammography guidelines. In Bronx ACCESS, the Intervention Delivery System will elicit information needed to adapt strategies to specific settings and circumstances. The Intervention Synthesis and Translation System will use this information to test changes to strategies through "embedded experiments". The Intervention Support System will build local capacities found to be necessary for intervention institutionalization. Simulation modeling will be used to integrate findings across systems. Results will inform on-going policy debate about interventions needed to promote population-level screening. More generally, this project is intended to advance understanding of research paradigms necessary to study dissemination.

Receipt of genetic counseling recommendations among black women at high risk for BRCA mutations

Low use of BRCA counseling and testing services among black women has been reported in several studies, even though such services may play an important role in reducing racial disparities in breast cancer. Surprisingly, little is known about the extent to which black women at high risk for BRCA mutations actually receive recommendations for BRCA counseling. Thus, a primary goal of the current study was to identify sociodemographic and clinical factors associated with the receipt of physician recommendation for genetic counseling based on the self-report of black women at high risk for BRCA mutations. In this cross-sectional study, participants were 125 black women with a family history suggestive of a hereditary breast and/or ovarian cancer syndrome. Participants were asked about their receipt of genetic counseling recommendation or referral. Physician recommendation was reported by over two-thirds of the sample. Multivariate analyses revealed that older age and study recruitment source, specifically community-based recruitment, were significantly and independently associated with lower likelihood of physician recommendation. Findings highlight the need for additional research to identify subgroups of high-risk black women among whom physician recommendation of genetic counseling is low but would benefit from such counseling.

Lay health advisors: promoting cancer screening and reducing disparities

Cancer health disparities between racial and ethnic minorities have led to the use of lay health advisors to educate minority populations about cancer and promote cancer screening and other healthy behaviors. This article discusses the benefits of using lay health advisors to increase cancer awareness and screening in African American, Vietnamese, and Hispanic women in the United States.

Do community health worker interventions improve rates of screening mammography in the United States? A systematic review

BACKGROUND

Community health workers (CHW) are lay individuals who are trained to serve as liaisons between members of their communities and health care providers and services.

METHODS

A systematic review was conducted to synthesize evidence from all prospective controlled studies on effectiveness of CHW programs in improving screening mammography rates. Studies reported in English and conducted in the United States were included if they: (i) evaluated a CHW intervention designed to increase screening mammography rates in women 40 years of age or older without a history of breast cancer; (ii) were a randomized controlled trial (RCT), case-controlled study, or quasi-experimental study; and (iii) evaluated a CHW intervention outside of a hospital setting.

RESULTS

Participation in a CHW intervention was associated with a statistically significant increase in receipt of screening mammography [risk ratio (RR): 1.06 (favoring intervention); 95% CI: 1.02-1.11, P = 0.003]. The effect remained when pooled data from only RCTs were included in meta-analysis (RR: 1.07; 95% CI: 1.03-1.12, P = 0.0005) but was not present using pooled data from only quasi-experimental studies (RR: 1.03; 95% CI: 0.89-1.18, P = 0.71). In RCTs, participants recruited from medical settings (RR: 1.41; 95% CI: 1.09-1.82, P = 0.008), programs conducted in urban settings (RR: 1.23; 95% CI: 1.09, 1.39, P = 0.001), and programs where CHWs were matched to intervention participants on race or ethnicity (RR: 1.58, 95% CI: 1.29-1.93, P = 0.0001) showed stronger effects on increasing mammography screening rates.

CONCLUSIONS

CHW interventions are effective for increasing screening mammography in certain settings and populations.

IMPACT

CHW interventions are especially associated with improvements in rate of screening mammography in medical settings, urban settings, and in participants who are racially or ethnically concordant with the CHW.

Cluster randomized trials of cancer screening interventions: are appropriate statistical methods being used?

The design and analysis of cluster randomized trials can require more sophistication than individually randomized trials. However, the need for statistical methods that account for the clustered design has not always been appreciated, and past reviews have found widespread deficiencies in methodology and reporting. We reviewed cluster randomized trials of cancer screening interventions published in 1995-2010 to determine whether the use of appropriate statistical methods had increased over time. Literature searches yielded 50 articles reporting outcome analyses of cluster randomized trials of breast, cervix and colorectal cancer screening interventions. Of studies published in 1995-1999, 2000-2002, 2003-2006 and 2007-2010, 55% (6/11), 82% (9/11), 92% (12/13) and 60% (9/15) used appropriate analytic methods, respectively. Results were suggestive of a peak in 2003-2006 (p =.06) followed by a decline in 2007-2010 (p =.08). While the sample of studies was small, these results indicate that many cluster randomized trials of cancer screening interventions have had deficiencies in the application of correct statistical procedures for the outcome analysis, and that increased adoption of appropriate methods in the early and mid-2000's may not have been sustained.

The Relationships Between Feelings of Satisfaction and Burden With Respect to Activity and Social Support Among Health Promotion Volunteers in Japan

Health promotion volunteers (HPVs) working to promote community health in Japan feel both satisfaction and burden with their community engagement activities. This study examined the relationship between their satisfaction and burden toward their activities and social support. A mail-in self-check questionnaire survey was distributed to 604 HPVs in Japan in September 2005. Multiple regression analysis showed that high “activity attachment” was associated with more support from family, colleagues, and public health nurses; high “personal benefit” was associated with more support from colleagues and public health nurses. It was also found that low “burden on everyday life” was associated with more support from family and colleagues and that low “psychological burden” was associated with more support from colleagues and community members. It became clear that social support from various sources was positively related to HPVs’ satisfaction and negatively related to HPVs’ burden with their activities. To encourage HPV activities, it is important to consider what kinds of social support would be most useful to increase the satisfaction and reduce the burden felt by HPVs.

Uptake in cancer screening programmes

For cancer screening programmes to bring about reductions in mortality, a substantial proportion of the population must participate. Programmes with low uptake can be ineffective and can promote inequalities in health-service provision. Strategies to promote uptake are multifaceted, reflecting differences in the cancers targeted, invitees, health-service contexts, and the tests themselves. Accordingly, there is no universal approach. Strategies should accommodate the many factors that can influence uptake and should incorporate the need to promote informed choice. Screening has the potential to cause harm, and there is an ethical imperative to seek out strategies that provide balanced information on cancer screening. Further research is needed to assess newer approaches to promoting uptake, such as IT-based programmes, and to identify strategies that are balanced, self-sustaining, and affordable.

Design and analysis of group-randomized trials in cancer: a review of current practices

BACKGROUND

Previous reviews have identified problems in the design and analysis of group-randomized trials in a number of areas. Similar problems may exist in cancer research, but there have been no comprehensive reviews.

METHODS

We searched Medline and PubMed for group-randomized trials focused on cancer prevention and control that were published between 2002 and 2006. We located and reviewed 75 articles to determine whether articles included evidence of taking group randomization into account in establishing the size of the trial, such as reporting the expected intraclass correlation, the group component of variance, or the variance inflation factor. We also examined the analytical approaches to determine their appropriateness.

RESULTS

Only 18 (24%) of the 75 articles documented appropriate methods for sample size calculations. Only 34 (45%) limited their reports to analyses judged to be appropriate. Fully 26 (34%) failed to report any analyses that were judged to be appropriate. The most commonly used inappropriate analysis was an analysis at the individual level that ignored the groups altogether. Nine articles (12%) did not provide sufficient information.

CONCLUSIONS

Many investigators who use group-randomized trials in cancer research do not adequately attend to the special design and analytic challenges associated with these trials. Failure to do so can lead to reporting type I errors as real effects, mislead investigators and policy-makers, and slow progress toward control and prevention of cancer. A collaborative effort by investigators, statisticians, and others will be required to ensure that group-randomized trials are planned and analyzed using appropriate methods so that the scientific community can have confidence in the published results.

Use of a population-based survey to describe the health of Boston public housing residents

OBJECTIVES

We compared the health of public housing residents with other Boston residents through a random-digit-dial survey.

METHODS

We used data from the Boston Behavioral Risk Factor Surveillance System collected in 2001 and 2003 to make crude and demographically adjusted comparisons between public housing residents and other city residents on measures of health status, access and utilization, and health behaviors.

RESULTS

Public housing residents were more likely to report fair or poor overall health status, ever-diagnosed hypertension, current asthma, ever-diagnosed diabetes, obesity, disability, loss of 6 or more teeth, and feelings of depression for 15 days or more in the past month. Public housing residents were slightly more likely than others to be without health insurance or report financial barriers to medical care. Public housing residents reported more smoking and physical inactivity, less past-month binge drinking and past-year marijuana use, and similar levels of lifetime drug use.

CONCLUSIONS

Public housing residents reported substantially poorer health than did other city residents across a variety of conditions but similar levels of access to and utilization of health care. Public health departments may be able to use established surveys to measure health among public housing residents.

Effective lay health worker outreach and media-based education for promoting cervical cancer screening among Vietnamese American women

OBJECTIVES

We sought to promote cervical cancer screening among Vietnamese American women in Santa Clara County, Calif.

METHODS

In 2001-2004, we recruited and randomized 1005 Vietnamese American women into 2 groups: lay health worker outreach plus media-based education (combined intervention) or media-based education only. Lay health workers met with the combined intervention group twice over 3 to 4 months to promote Papanicolaou (Pap) testing. We used questionnaires to measure changes in awareness, knowledge, and Pap testing.

RESULTS

Testing increased among women in both the combined intervention (65.8% to 81.8%; P<.001) and media-only (70.1% to 75.5%; P<.001) groups, but significantly more in the combined intervention group (P=.001). Among women never previously screened, significantly more women in the combined intervention group (46.0%) than in the media-only group (27.1%) obtained tests (P<.001). Significantly more women in the combined intervention group obtained their first Pap test or obtained one after an interval of more than 1 year (became up-to-date; 45.7% to 67.3%, respectively; P<.001) than did those in the media-only group (50.9% to 55.7%, respectively; P=.035).

CONCLUSIONS

Combined intervention motivated more Vietnamese American women to obtain their first Pap tests and to become up-to-date than did media education alone.

A comparison of permutation and mixed-model regression methods for the analysis of simulated data in the context of a group-randomized trial

Our first purpose was to determine whether, in the context of a group-randomized trial (GRT) with Gaussian errors, permutation or mixed-model regression methods fare better in the presence of measurable confounding in terms of their Monte Carlo type I error rates and power. Our results indicate that given a proper randomization, the type I error rate is similar for both methods, whether unadjusted or adjusted, even in small studies. However, our results also show that should the investigator face the unfortunate circumstance in which modest confounding exists in the only realization available, the unadjusted analysis risks a type I error; in this regard, there was little to distinguish the two methods. Finally, our results show that power is similar for the two methods and, not surprisingly, better for the adjusted tests. Our second purpose was to examine the relative performance of permutation and mixed-model regression methods in the context of a GRT when the normality assumptions underlying the mixed model are violated. Published studies have examined the impact of violation of this assumption at the member level only. Our findings indicate that both methods perform well when the assumption is violated so long as the ICC is very small and the design is balanced at the group level. However, at ICC>or=0.01, the permutation test carries the nominal type I error rate while the model-based test is conservative and so less powerful. Binomial group- and member-level errors did not otherwise change the relative performance of the two methods with regard to confounding.

A systematic review of mammography educational interventions for low-income women

OBJECTIVE

We conducted a systematic review to examine the effectiveness of educational interventions in increasing mammography screening among low-income women.

DATA SOURCES

Bibliographic databases, including MEDLINE, The Cochrane Central Register of Controlled Trials, The Cochrane Database of Systematic Reviews, and the ISI Web of Science, were searched for relevant articles.

STUDY INCLUSION AND EXCLUSION CRITERIA

Randomized, community-based trials targeting low-income women and published between January 1980 and March 2003 were included.

DATA EXTRACTION

The search yielded 242 studies; 24 met all inclusion criteria.

DATA SYNTHESIS

Three studies used mammography vans, three used low-cost vouchers or provided free mammograms, three used home visits, one used community education alone, one provided referrals, five incorporated multiple intervention strategies, two used phone calls, one used videos and print material, and five used primarily print material.

RESULTS

Of nine studies that reduced barriers to care via mammography vans, cost vouchers, or home visits, eight showed statistically significant increases in mammography screening. Seven of the eight studies that used peer educators had significant increases in screening, as did four of the five studies that used multiple (intervention) components.

CONCLUSIONS

Interventions that used peer educators, incorporated multiple intervention strategies, or provided easy access via vans, cost vouchers, or home visits were effective in increasing screenings. Mailed letter or telephone reminders were not effective in trials involving low-income women, which is contrary to findings from middle/upper-income studies.

Long-term results from a randomized controlled trial to increase cancer screening among attendees of community health centers

PURPOSE

We assessed whether increased cancer screening rates that were observed with Cancer Screening Office Systems (Cancer SOS) could be maintained at 24 months' follow-up, a period in which clinics were expected to be largely self-sufficient in maintaining the intervention.

METHODS

Eight primary care clinics serving disadvantaged populations in Hills-borough County, Fla, agreed to take part in a cluster-randomized experimental trial. Charts of independent samples of established patients aged 50 to 75 years were abstracted, with data collected at baseline (n = 1,196) and at 24 months' follow-up (n = 1,296). Papanicolaou (Pap) smears, mammography, and fecal occult blood testing were assessed.

RESULTS

At 24 months of follow-up, intervention patients had received a greater number of cancer screening tests (mean 1.17 tests vs 0.94 tests, t test = 4.42, P <.0001). In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms slightly (odds ratio [OR]) = 1.26; 95% confidence interval [CI], 1.02-1.55; P = .03) but had no effect on fecal occult blood tests (OR = 1.17; 95% CI, 0.92-1.48; P =0.19) or Pap smears (OR = 0.88; 95% CI, 0.0.68-1.15; P = .34).

CONCLUSIONS

The Cancer SOS intervention had persistent, although modest, effects on screening at 24 months' follow-up, an effect that had clearly diminished from results reported at 12 months' follow-up. Further study is needed to develop successful intervention strategies that are either self-sustaining or that are able to produce long-term changes in screening behavior.

Use of community health workers in research with ethnic minority women

PURPOSE

To explore roles and effectiveness of community health workers in research with ethnic minority women in the United States (US).

METHODS

Medline (1966-2002) and CINAHL (Cumulative Index to Nursing and Allied Health Literature; 1982-2002) databases were used to locate published research studies on the use of community health workers with ethnic minority women in the US. Key words for searches were community health workers, community health aides, health promoters, and community workers.

RESULTS

An integrative analysis of 24 studies showed that, despite varying roles and functions, evidence indicates that community health workers are effective in increasing access to health services, increasing knowledge, and promoting behavior change among ethnic minority women. Other advantages of using community health workers are to provide social support and culturally competent, cost-effective care. Recommendations for future directions of research with community health workers and ethnic minority women include improved conceptualization of the community health worker role, theoretical frameworks for research designs, enhanced methods for evaluating effectiveness, and increased community involvement.

Social Ties and Colorectal Cancer Screening among Blacks and Whites in North Carolina

Few studies have examined the relationship between social networks and colorectal cancer screening in diverse populations. Prior research suggests that the type of social support as well as the amount or frequency of support available from one's social network may be associated with health outcomes. Therefore, the current study examined relationships between both structural (i.e., quantitative aspects of the social network, such as number of ties and frequency of contact with ties) and functional (i.e., functions provided by social network ties, such as offering emotional or instrumental support) aspects of social ties and utilization of colorectal cancer screening tests. Analyses included 697 randomly selected Blacks and Whites ages 51 to 80 years enrolled as controls in the North Carolina Colon Cancer Study. Social tie and screening information was obtained from face-to-face interviews. Forty-seven percent of participants (40% Blacks and 51% Whites) reported use of one of the options for colorectal cancer screening according to the guidelines at that time. Compared with those with the fewest social connections, those who were most socially connected were more likely to report recent use of colorectal cancer screening [odds ratio (OR), 3.2; 95% confidence interval (95% CI), 1.7-6.2]. This association was stronger among Blacks (OR, 3.8; 95% CI, 1.3-10.7) than Whites (OR, 2.9; 95% CI, 1.2-6.9; P for interaction = 0.006). There were also positive associations between being a church group (OR, 1.9; 95% CI, 1.4-2.7) and other group member (OR, 1.6; 95% CI, 1.1-2.2) and screening. Neither emotional (e.g., offering reassurance that one is cared for) nor instrumental (e.g., giving material assistance) support was associated with screening behavior. These data suggest that structural rather than functional aspects of social ties may be important in influencing colorectal cancer screening behavior.

Nursing intervention and older adults who have cancer: specific science and evidence based practice

This review of a small and heterogeneous body of literature suggests intriguing and useful approaches to nursing interventions with older adults who have cancer and areas that clearly deserve greater attention in future research. Research such as that done by McCorkle and Goodwin,while disparate in design, clearly demonstrate the ability of interventions to achieve better continuity of care and appropriate treatment for physically and socially vulnerable older adults with cancer. Comparison across settings and studies that investigate similar clinical phenomena would illuminate further how to achieve more effective intervention with elders who have cancer. In studies addressing case management, comparison of work by McCorkle et al with that completed by Goodwin et al suggests that programs that are longer than 4-week interventions are more likely to be beneficial than are shorter programs. Goodwin et al constructed a 12-month intervention that might be extended even further to improve continuity to older adults who may lack family/social support. Continuity may be especially important as older patients move from primary or geriatric care to surgical care to medical oncology care. Such a program also may offer added benefits in care of older adults who survive an initial cancer but require vigilant follow-up for recurrence or a second primary cancer and who may face ageist assumptions about screening and early detection of those cancers. The work of Coleman, Earp, and Powe and Weinrich underscores the necessity of understanding the precise needs of rural elders in relation to cancer. These studies strongly suggest that nurses can improve screening rates and symptom management. Rural health care may have particularly poor specialty resources for cancer and aging. Increasing oncology nurses' presence in rural communities and supporting those nurses with specific content in aging may be a successful mechanism to ameliorate these deficits. Coleman's study especially found that increasing opportunities to ensure that practice is grounded in current evidence is critical to improving evidence-based practice and avoiding misconceptions about the effects of age in cancer care. The weak effects associated with the use of lay educators to improve cancer screening behaviors strongly reinforce the influence of nurses over other personnel to carry out educational interventions. In rural and urban areas alike, the credibility and professionalism of nurses was clearly of benefit. McDougall's research highlights the effects of cancer treatment on older people's cognitive status. His intervention supports the further testing of group activities led by nurses as a way to improve aspects of memory. Clinical application of this low-risk, possibly high-benefit intervention strategy, which is congruent with current work in dementia care, implies that elder care facilities might benefit from having a nurse on staff to address institutional and individual concerns related to cognitive function among older residents with cancer. A single often unstated theme throughout these studies is the impact of the nurse-patient relationship on outcome variables for older adults at risk for or living with cancer. The nurse-patient relationship, a touchstone of practice, reminds each nurse to focus on the individual elder, to look past chronological age and cancer diagnosis to understand that individual as having a life that, though it may be decades long in time, is still to be lived each day in the manner and capacity that the person can command and desires. Knowledge of that elder will aid the nurse in asking critical questions, using existing research, adapting other relevant evidence, and intervening more effectively over the course of that relationship.

Design and analysis of group-randomized trials: a review of recent practices

We reviewed group-randomized trials (GRTs) published in the American Journal of Public Health and Preventive Medicine from 1998 through 2002 and estimated the proportion of GRTs that employ appropriate methods for design and analysis. Of 60 articles, 9 (15.0%) reported evidence of using appropriate methods for sample size estimation. Of 59 articles in the analytic review, 27 (45.8%) reported at least 1 inappropriate analysis and 12 (20.3%) reported only inappropriate analyses. Nineteen (32.2%) reported analyses at an individual or subgroup level, ignoring group, or included group as a fixed effect. Hence increased vigilance is needed to ensure that appropriate methods for GRTs are employed and that results based on inappropriate methods are not published.