The early detection of cancer in the primary-care setting: factors associated with the acceptance and completion of recommended procedures

Assessing individual performance and maintaining breath sample integrity in biomedical detection dogs

In empirical tests of biomedical detection dogs, exhaled breath samples are often used because breath contains volatile organic compounds that can signal metabolic states, infection, or disease. However, in studies that present dogs with breath samples, results show a notable degree of variability both between and within studies. Differing protocols for the collection and storage of exhaled breath samples may contribute to this observed variability. The goal of the current study was therefore to test whether there was a difference in the detectability of breath samples collected using silicone-coated versus uncoated cotton balls. This was tested in two experiments. In the first experiment, breath samples were prepared using both silicone-coated and uncoated cotton balls, which were then left exposed to the surrounding air. Four dogs' detection of the samples was tested using a cued, three alternative forced choice (3AFC) procedure at regular intervals up to two hours after the samples were prepared. The results of Experiment 1 showed that the dogs' performance was above chance and there was no significant difference in the dogs' detection of the breath samples across conditions. In the second experiment, a series of breath samples were prepared and stored for one, two, three, and four week periods. The same four dogs' ability to detect the breath samples was tested each week using the same cued 3AFC procedure. The results of Experiment 2 showed that when silicone-coated cotton balls were used, all four dogs could detect the breath samples at above chance levels after the samples were stored for three weeks, and two dogs could detect the samples that were stored for four weeks. When the dogs were tested on their ability to detect the breath samples prepared using uncoated cotton, two dogs' performance fell to below chance levels at one week of storage time, while the other two dogs could detect the breath samples at above chance levels after the samples were stored for four weeks. Taken together, the results of the two experiments illustrate that silicone-coated cotton balls do not improve detectability of breath samples within two hours, but can greatly improve the detectability of breath samples stored over longer periods of time. Since the use of silicone-coated cotton balls only improved the detectability of the breath samples for two of the four dogs, these results highlight the importance of examining individual differences in dogs' performance. Furthermore, we argue that, given the inherent differences in olfactory ability across dogs, widespread use of silicone-coated cotton balls for the collection of breath samples would increase the pool of testable dogs for biomedical detection studies and would decrease the degree of variability both within and between studies.

Correlates of Mammography Screening Among Hispanic Women Living in Lower Rio Grande Valley Farmworker Communities

Factors contributing to the underuse of mammography screening by female Hispanic farmworkers aged 50 years and older in the Lower Rio Grande Valley were determined through home-based, Spanish-language personal interviews ( N = 200). Questions covered adherence to screening mammography guidelines (mammogram within 2 years), healthcare access, sociodemographic characteristics, and theoretical constructs related to breast cancer screening in the literature. Multivariate findings indicated that adherent women were 3.6 times more likely to have health insurance. Self-efficacy for obtaining a mammogram and decisional balance were also significantly related to adherence; age, income, and education variables were not associated, perhaps because of restricted variation. Results indicate continuing efforts are needed to ensure that medically underserved migrant farmworker women have access to health care services. In addition, efforts to increase their self-efficacy in obtaining a mammogram and to counter negative attitudes and opinions by stressing the positive prognosis associated with early detection are warranted.

Socio-psychological factors in the Expanded Health Belief Model and subsequent colorectal cancer screening

OBJECTIVE

CRC screening interventions tailored to the Expanded Health Belief Model (EHBM) socio-psychological factors have been developed, but the contributions of individual factors to screening outcomes are unclear.

METHODS

In observational analyses of data from a randomized intervention trial, we examined the independent associations of five EHBM factors - CRC screening knowledge, self-efficacy, stage of readiness, barriers, and discussion with a provider - with objectively measured CRC screening after one year.

RESULTS

When all five factors were added simultaneously to a base model including other patient and visit characteristics, three of the factors were associated with CRC screening: self-efficacy (OR=1.32, p=0.001), readiness (OR=2.72, p<0.001), and discussion of screening with a provider (OR=1.59, p=0.009). Knowledge and barriers were not independently associated with screening. Adding the five socio-psychological factors to the base model improved prediction of CRC screening (area under the curve) by 7.7%.

CONCLUSION

Patient CRC screening self-efficacy, readiness, and discussion with a provider each independently predicted subsequent screening.

PRACTICE IMPLICATIONS

Self-efficacy and readiness measures might be helpful in parsimoniously predicting which patients are most likely to engage in CRC screening. The importance of screening discussion with a provider suggests the potential value of augmenting patient-focused EHBM-tailored interventions with provider-focused elements.

Gender differences in attitudes impeding colorectal cancer screening

Background

Colorectal cancer screening (CRCS) is the only type of cancer screening where both genders reduce risks by similar proportions with identical procedures. It is an important context for examining gender differences in disease-prevention, as CRCS significantly reduces mortality via early detection and prevention. In efforts to increase screening adherence, there is increasing acknowledgment that obstructive attitudes prevent CRCS uptake. Precise identification of the gender differences in obstructive attitudes is necessary to improve uptake promotion. This study randomly sampled unscreened, screening - eligible individuals in Ontario, employing semi-structured interviews to elicit key differences in attitudinal obstructions towards colorectal cancer screening with the aim of deriving informative differences useful in planning promotions of screening uptake.

Methods

N = 81 participants (49 females, 32 males), 50 years and above, with no prior CRCS, were contacted via random-digit telephone dialing, and consented via phone-mail contact. Altogether, N = 4,459 calls were made to yield N = 85 participants (1.9% response rate) of which N = 4 participants did not complete interviews. All subjects were eligible for free-of-charge CRCS in Ontario, and each was classified, via standard interview by CRCS screening decision-stage. Telephone-based, semi-structured interviews (SSIs) were employed to investigate gender differences in CRCS attitudes, using questions focused on 5 attitudinal domains: 1) Screening experience at the time of interview; 2) Barriers to adherence; 3) Predictors of Adherence; 4) Pain-anxiety experiences related to CRCS; 5) Gender-specific experiences re: CRCS, addressing all three modalities accessible through Ontario’s program: a) fecal occult blood testing; b) flexible sigmoidoscopy; c) colonoscopy.

Results

Interview transcript analyses indicated divergent themes related to CRCS for each gender: 1) bodily intrusion, 2) perforation anxiety, and 3) embarrassment for females and; 1) avoidant procrastination with underlying fatalism, 2) unnecessary health care and 3) uncomfortable vulnerability for males. Respondents adopted similar attitudes towards fecal occult blood testing, flexible sigmoidoscopy and colonoscopy, and were comparable in decision stage across tests. Gender differences were neither closely tied to screening stage nor modality. Women had more consistent physician relationships, were more screening-knowledgeable and better able to articulate views on screening. Men reported less consistent physician relationships, were less knowledgeable and kept decision-making processes vague and emotionally distanced (i.e. at ‘arm’s length’).

Conclusions

Marked differences were observed in obstructive CRCS attitudes per gender. Females articulated reservations about CRCS-associated distress and males suppressed negative views while ambiguously procrastinating about the task of completing screening. Future interventions could seek to reduce CRCS-related stress (females) and address the need to overcome procrastination (males).

Individual-level factors in colorectal cancer screening: a review of the literature on the relation of individual-level health behavior constructs and screening behavior

OBJECTIVE

Compliance with colorectal cancer screening recommendations requires considerable conscious effort on the part of the individual patient, making an individual's decisions about engagement in screening an important contributor to compliance or noncompliance. The objective of this paper was to examine the effectiveness of individual-level behavior theories and their associated constructs in accounting for engagement in colorectal cancer screening behavior.

METHODS

We reviewed the literature examining constructs from formal models of individual-level health behavior as factors associated with compliance with screening for colorectal cancer. All published studies examining one or more constructs from the health belief model, theory of planned behavior, transtheoretical model, or social cognitive theory and their relation to screening behavior or behavioral intentions were included in the analysis.

RESULTS

By and large, results of studies supported the theory-based predictions for the influence of constructs on cancer screening behavior. However, the evidence base for many of these relations, especially for models other than the health belief model, is quite limited.

CONCLUSIONS

Suggestions are made for future research on individual-level determinants of colorectal cancer screening.

Patterns of diagnosis for colorectal cancer: screening detected vs. symptomatic presentation

PURPOSE

Colorectal cancer is a leading cause of cancer death in North America; studies have shown that screening improves survival. Conducted in British Columbia, Canada, this study was performed to identify the proportion of screening-eligible patients with sporadic colorectal cancer who are detected by screening tests vs. symptomatic presentation and to compare baseline patient and tumor characteristics of these two groups.

METHODS

This retrospective cohort study identified 571 consecutive patients referred to the British Columbia Cancer Agency at aged 50 years and older presenting with a first diagnosis of invasive colorectal cancer between November 2002 and April 2003. Questionnaires for self-completion were mailed to all patients to capture: previous screening history, screening vs. symptomatic presentation, and demographic information.

RESULTS

Of 212 eligible respondents (37 percent response), 14 patients (6.6 percent) with a new CRC were detected by screening vs. 198 patients (93.4 percent) presenting with symptoms. Respondents were 59 percent male, average age at diagnosis was 69 years, 91 percent white, 37 percent rectal, and 18 percent M1 at diagnosis. No significant differences in the age, gender, ethnicity, socioeconomic status, tumor stage, and site were detected between the screened vs. symptomatic cohorts. Only 33 of 212 patients (15.6 percent) reported ever having a screening test. Nineteen of 198 cancers (9.6 percent) were diagnosed by symptomatic presentation despite a compliant screening history.

CONCLUSIONS

Less than 7 percent of patients with a new diagnosis of CRC were detected via a screening test. Furthermore, only 15 percent of screening-eligible respondents had ever been screened. Significant effort is required to increase knowledge and compliance for CRC screening.

Self-efficacy scale for Pap smear screening participation in sheltered women

BACKGROUND

Sheltered, homeless women disproportionately experience cervical dysplasia and cervical cancer. Low rates of Pap smear screening contribute to late diagnosis with accompanying increased morbidity and mortality. Self-efficacy (SE) has been demonstrated to be predictive of several health behaviors, but limited evidence about SE for Pap smear screening exists.

OBJECTIVES

To develop, test, and refine the conceptually based Self-Efficacy Scale for Pap Smear Screening Participation (SES-PSSP).

METHODS

This correlational, descriptive study included a purposive sampling of sheltered women (N = 161).

RESULTS

The 20-item SES-PSSP demonstrated acceptable initial validity and reliability. Reliability estimates of stability (>or=84%) and internal consistency (alpha = .95) exceeded criteria. Content validity and construct validity were supported (e.g., common factor analysis and predictive model testing that included SE, decisional balance, knowledge regarding Pap smear screening, demographics, health-related behaviors, health status, and personal beliefs about risks for cervical cancer and dysplasia). Self-efficacy, decisional balance, illicit drug usage, and age predicted 28% of the variance in stages of change (precontemplation, contemplation, preparation, action, and maintenance) for Pap smear screening participation.

DISCUSSION

The SES-PSSP provides a new scale for measuring SE pertinent to Pap smear screening participation in a vulnerable, ethnically diverse sample of sheltered, inner-city women. Validity testing demonstrated that the SE concept was predictive of Pap smear screening behavior, suggesting that SE-based interventions tailored to the SES-PSSP subscale or total scores could increase screening. A 10-minute completion time supports feasibility for use in the clinic setting.

Time spent in the united states and breast cancer screening behaviors among ethnically diverse immigrant women: Evidence for acculturation?

The current study was designed to investigate the relations between time spent in the United States and breast cancer screening in a large sample (N=915) of ethnically diverse immigrant women living in New York City. Previous research among Hispanic women has suggested that acculturation positively influences health beliefs and preventive health behaviors. However, research has not yet extended to other growing immigrant groups, including women from Haiti and the English-speaking Caribbean, and has not tested whether time spent in the United States differentially impacts breast screening across groups that are known to vary in their health beliefs. As expected, time spent in the United States was associated with a greater number of mammograms and clinical breast exams. Importantly, these relations held even when controlling for (a) age, income, education, marital status; (b) morbidity, health insurance, physician's recommendation, physical exams; and (c) ethnicity. Moreover, time spent in the United States interacted with being Haitian to predict the number of clinical breast exams. Even though Haitians were less likely to utilize breast cancer screening overall, time spent in the United States had a stronger effect on the number of clinical breast exams for Haitian women. Results are discussed in terms of the ethnic-specificity of health beliefs, how they may change over time and their implications for preventive health behaviors.

Health locus of control and perceived risk for breast cancer in healthy women

Although early detection is closely linked to survival of breast cancer, many women do not adhere to recommended screening guidelines. One of the most studied factors that contribute to women's screening behavior is their perceived risk of developing breast cancer. In this study, the authors examined contributions of general health locus of control and breast cancer-specific control to understanding perceived risk. Sixty-six healthy women with and without family histories of breast cancer participated in the study. The following were the central findings: (1) internal locus of control and breast cancer-specific control predicted perceived risk, as measured by the certainty of remaining free of breast cancer, and (2) breast cancer-specific control mediated the relationship between internal locus of control and perceived risk. Findings suggest that significant relations between health locus of control and perceived risk variables may be overlooked in the absence of situation-specific measures.

Women's misconceptions about cancer screening: implications for informed decision-making

Informed decision-making about cancer screening requires that patients have a correct understanding of a test's purpose, benefits, and risks. Misconceptions, however, may be common. Semi-structured interviews were carried out and thematically coded using a purposive sample of 24 socioeconomically diverse white, African American, Latino and Chinese American women recruited from general medicine practices and community settings. Interviews focused on participants ideas related to cancer prevention and screening. Women expressed cancer-related beliefs characterized by inaccuracies, distortions, and over-simplifications. Many of these beliefs may go unrecognized in clinical settings yet have a profound influence on risk communication and, therefore, informed decision-making. Effective communication depends, first, on clinicians and patients sharing an accurate understanding of background concepts such as "prevention," "screening," and "cancer."

Physician Recommendation for Papanicolaou Testing Among U.S. Women, 2000

OBJECTIVE

Many women in the U.S. undergo routine cervical cancer screening, but some women have rarely or never had a Papanicolaou (Pap) test. Studies of other cancer screening tests (for example, mammograms) have shown that physician recommendation to get a screening test is one of the strongest predictors of cancer screening.

METHODS

In this study, we examined whether women in the U.S. had received a physician recommendation to get a Pap test using data from the 2000 National Health Interview Survey. Reported reasons for not receiving a Pap test were also explored.

RESULTS

Among women aged > or =18 years who had no history of hysterectomy, 83.3% [95% confidence interval (CI), 82.4-84.1%] of the 13,636 women in this sample had had a Pap test in the last 3 years. Among 2,310 women who had not had a recent Pap test, reported reasons for not receiving a Pap test included: "No reason/never thought about it" (48.0%; 95% CI, 45.5-50.7), "Doctor didn't order it" (10.3%; 95% CI, 8.7-12.0), "Didn't need it/didn't know I needed this type of test" (8.1%; 95% CI, 6.7-9.6), "Haven't had any problems" (9.0%; 95% CI, 7.6-10.5), "Put it off" (7.4%; 95% CI, 6.2-8.7), "Too expensive/no insurance" (8.7%; 95% CI, 7.3-10.2), "Too painful, unpleasant, embarrassing" (3.5%; 95% CI, 2.5-4.6), and "Don't have doctor" (1.7%; 95% CI, 1.2-2.4). Among women who had had a doctor visit in the last year but who had not had a recent Pap test, about 86.7% (95% CI, 84.5-88.6) reported that their doctor had not recommended a Pap test in the last year. African-American women were as likely as White women to have received a doctor recommendation to get a Pap test. Hispanic women were as likely as non-Hispanic women to have received a doctor recommendation to get a Pap test. In multivariate analysis, factors positively associated with doctor recommendation to get a Pap test included being aged 30 to 64 years, having been born in the U.S., and having seen a specialist or general doctor in the past year.

CONCLUSION

These findings suggest that lack of a physician recommendation contributes to underuse of Pap screening by many eligible women. Given research that shows the effectiveness of physician recommendations in improving use, increased physician recommendations could contribute significantly to increased Pap screening use in the U.S.

Obesity and awareness of obesity as risk factors for breast cancer in six ethnic groups

OBJECTIVE

To document BMI and knowledge regarding obesity as a risk factor for breast cancer among subpopulations of African-, Caribbean-, and European-American women and to consider the variables predicting obesity in these diverse groups.

RESEARCH METHODS AND PROCEDURES

A stratified cluster-sampling plan was used to recruit 1364 older women from Brooklyn, NY, during 2000-2002. Two groups were born in the United States (African Americans and European Americans), whereas others were from the English-speaking Caribbean, Haiti, the Dominican Republic, and Eastern Europe. Participants provided demographics, height and weight measures, and estimates of the risk obesity posed for breast cancer.

RESULTS

Women from all groups were significantly overweight (BMI > 25 kg/m(2)), although European Americans were lowest, followed by Dominicans and Haitians; African-American and English-speaking Caribbean women fell into the obese range, even when background variables were controlled. Knowledge of obesity as a breast cancer risk factor was also poor across groups, but Dominicans and Haitians had the lowest scores on knowledge. Importantly, knowledge was not associated with BMI in the overall sample, even when controlling for demographics and ethnicity, although logistic regressions comparing normal weight women with overweight and obese groupings suggested some knowledge of breast cancer risk in the overweight, but not the obese, group.

DISCUSSION

The findings remind health professionals of the need to consider more specific ethnic groupings than has hitherto been the case, as well as consider how ethnic and cultural variables may influence perceptions of obesity and its relation to cancer risk.

Participation in annual skin cancer screening among women seeking routine mammography

BACKGROUND

Early detection of skin cancer is associated with improved prognosis. The American Cancer Society's current skin cancer screening (SCS) recommendation states that adults over the age of 40 should receive an annual skin examination conducted by a health professional. However, little is known about the psychosocial factors related to participation in annual SCS, which remains relatively low among the general public.

METHODS

Data were collected from women, aged 50 and older, seeking routine mammography at a large, urban, breast diagnostic facility.

RESULTS

A total of 253 eligible women completed the survey. Overall, 20.2% of women reported receiving annual clinical SCS. Physician recommendation, self-efficacy, perceived susceptibility, and age were significantly associated with participation in annual skin screening.

CONCLUSIONS

Similar to previously reported findings in the literature, our rates of participation in annual clinical skin screening were lower than reported rates for other types of cancer screening. Among older women, multiple covariates for participation in annual skin cancer screening were determined and may serve to guide future health education interventions to promote screening. Our findings suggest that participation could improve through increasing physician recommendation, screening self-efficacy, and individuals' sense of perceived susceptibility to skin cancer.

Cancer Prevention Services and Physician Consensus in Primary Care Group Practices

Background: We conducted a randomized clinical trial of interventions to achieve physician consensus, practice changes, and patient activation designed to help primary care group practices enhance the delivery of cancer prevention and screening services. Methods: In each of 42 primary care practices in 1991 to 1994, we studied approximately 60 patients per physician who were between the ages 53 and 64. Data sources included patient and physician questionnaires, medical record audits of consenting patients for evidence of 11 cancer prevention services during the previous 3 years, and telephone interviews with key practice personnel. Results: None of the interventions was associated with significant changes in frequency of services or procedures received or provided. Increased frequencies of services overall and of specific activities were associated with HMO membership or insurance coverage for six screening procedures. Patient reports of clinic staff recommendations to have each of six screening procedures were specifically associated with higher frequencies of services (P = 0.001). Conclusions: Demonstration of intervention impact may have been limited because the rates of prevention services were significantly higher in this study than have been reported elsewhere. These results might be explained by selection biases inherent in studying patients with a regular provider, overall practice trends for changes in provision of the studied services, and the study methods.

Adherence to colorectal cancer screening in mammography-adherent older women

Colorectal cancer (CRC) is the third leading cause of cancer mortality among women. Screening can prevent the development of CRC or diagnose early disease when it can effectively be cured, however existing screening methods are underutilized. In this study, we examined the utility of an updated Health Belief Model to explain CRC screening adherence. The present study included 280 older women seeking routine mammography at a large, urban breast diagnostic facility. Overall, 50% of women were adherent to CRC screening guidelines. Multiple regression indicated that self-efficacy, physician recommendation, perceived benefits of and perceived barriers to screening accounted for 40% of variance in CRC screening adherence. However, there was no evidence for two mediational models with perceived benefits and perceived barriers as the primary mechanisms driving adherence to CRC screening. These findings may inform both future theoretical investigations as well as clinical interventions designed to increase CRC screening behavior.

Fear, Anxiety, Worry, and Breast Cancer Screening Behavior: A Critical Review

Anxiety, fear, and worry are variously described as facilitators and barriers of breast cancer screening. However, several contradictions are evident in this research. A review article described the literature regarding the relations among fear, anxiety, and worry, along with emotion regulatory styles, and breast cancer screening behaviors before critiquing it in an attempt to uncover preliminary explanations for these discrepancies. Three main conclusions are drawn. First, it is suggested that researchers need to clearly define the components of cancer and the screening process that women are afraid of as each may bear a different relation to screening behavior. Second, greater care needs to be taken to employ psychometrically valid and reliable measures of fear and anxiety. Third, studies need to more systematically test findings across the minority and ethnic groups at greatest risk. A framework is presented and suggestions regarding the continued development of this promising area of research are made.

Diversity matters: Unique populations of women and breast cancer screening

BACKGROUND

Ethnic differences in breast cancer screening behaviors are well established. However, there is a lack of understanding regarding exactly what causes these differences and which characteristics in low-screening populations should be targeted in an effort to modify screening behavior.

METHODS

Stratified cluster sampling was used to recruit 1364 women (ages 50-70 years) from 6 ethnic groups: African-American women; U.S.-born white women; English-speaking Caribbean, Haitian, and Dominican women; and immigrant Eastern-European women. In interviews, respondents provided information concerning demographic and structural variables related to mammogram utilization (age, education, income, marital status, physician recommendation, access, and insurance) and a set of cognitive variables (fatalism, perception of personal risk, health beliefs concerning cancer) and socioemotional variables (stress, cancer worry, embarrassment, and pain).

RESULTS

For data analysis, the authors used a 2-step logistic regression with frequency of mammograms over a 10-year period (< or = 4 mammograms over 10 years or > or = 5 mammograms over 10 years) as a dependent variable. U.S.-born African-American women and Dominican women were screened as frequently as European-American women, but the remaining minority groups were screened with less frequency. With one exception, ethnicity ceased to predict screening frequency once cognitive and emotional variables were controlled.

CONCLUSIONS

Although women from clearly operationalized ethnic groups continue to screen at rates substantially below those of the majority groups, these differences appear to be explained substantially by differences in psychologic variables. This is encouraging because, rather than targeting culture for intervention, variables can be targeted that are amenable to change, such as emotions and beliefs.

Predictors of colorectal cancer screening participation in the United States

OBJECTIVE

Our aim was to identify predictors of colorectal cancer screening in the United States and subgroups with particularly low rates of screening.

METHODS

The responses to a telephone-administered questionnaire of a nationally representative sample of 61,068 persons aged >/=50 yr were analyzed. Current screening was defined as either sigmoidoscopy/colonoscopy in the preceding 5 years or fecal occult blood testing (FOBT) in the preceding year, or both.

RESULTS

Overall, current colorectal cancer screening was reported by 43.4% (sigmoidoscopy/colonoscopy by 22.8%, FOBT by 9.9%, and both by 10.7%). The lowest rates of screening were reported by the following subgroups: those aged 50-54 yr (31.2%), Hispanics (31.2%), Asian/Pacific Islanders (34.8%), those with education less than the ninth grade (34.4%), no health care coverage (20.4%), or coverage by Medicaid (29.2%), those who had no routine doctor's visit in the last year (20.3%), and every-day smokers (32.1%). The most important modifiable predictors of current colorectal cancer screening were health care coverage (OR = 1.7, 95% CI = 1.5-1.9) and a routine doctor's visit in the last year (OR = 3.5, 95% CI = 3.2-3.8). FOBT was more common in women than in men (OR = 1.8, 95% CI = 1.6-2.0); sigmoidoscopy/colonoscopy was more common in Hispanics (OR = 1.4, 95% CI = 1.1-1.7) and Asian/Pacific Islanders (OR = 2.4, 95% = CI 1.5-3.9) relative to whites, in persons without routine doctor's visits in the preceding year (OR = 3.3, 95% CI = 2.8-4), and in persons with poor self-reported health (OR = 1.3, 95% CI = 1.2-1.5).

CONCLUSIONS

Interventions should be developed to improve screening for the subgroups who reported the lowest screening rates. Such interventions may incorporate individual screening strategy preferences.

Predictors of older Korean Americans' participation in colorectal cancer screening

BACKGROUND

Cancer is the second leading cause of death among Korean Americans aged 65 and older. Colorectal cancer is the second most commonly diagnosed cancer among Korean American women and the third among men. The purpose of this study was to examine the rates of colorectal cancer (CRC) screening and the correlates of screening tests.

METHODS

The study employed cross-sectional face-to-face interviews with a sample of 205 Korean American elderly aged 60 and older.

RESULTS

About 18% of respondents had ever had a fecal occult blood test (FOBT) and 11%, sigmoidoscopy. A history of bloody stool was related to having FOBT. In multiple logistic regression analyses, government assistance, routine checkups, having insurance, and speaking fluent English were associated with having FOBT. Marital status, proportion of time spent in the U.S., and general health status were related to having sigmoidoscopy.

CONCLUSIONS

The findings suggest a need for further research addressing barriers to cancer screening in Korean Americans.

Increasing cervical cancer screening among underserved women in a large urban county health system: can it be done? What does it take?

BACKGROUND

Further reduction in avoidable cervical cancer morbidity and mortality may require system-wide, integrated approaches implemented in the public health facilities serving the nation's indigent and minority women.

OBJECTIVES

Report on the evaluation of a 5-year demonstration project testing a multicomponent (provider, system, and patient) intervention to increase cervical cancer screening among women who receive their health care through the Los Angeles County Department of Health Services, the second largest County Health Department in the nation.

MATERIALS AND METHODS

A longitudinal nonequivalent control group design was utilized. Data were collected during a baseline (no intervention) year and 2.5 years of intervention. A large hospital, one feeder Comprehensive Health Centers (CHC), and three of the health center's feeder Public Health Centers (PHC) received the intervention. Another hospital, CHC and its three feeder PHCs (matched on size, patient characteristics, and range of services provided) served as comparison sites. Independent random samples of patients 18 years and older were drawn annually at each site (n = 18,642). The outcome measure was a receipt of a Papanicolaou smear during a 9-month period.

RESULTS

At the Hospital and CHC levels a statistically significant intervention effect was observed after controlling for baseline screening rates and case mix. No intervention effect was observed at the PHCs.

CONCLUSION

An intensive multicomponent intervention can increase cervical cancer screening in a large, urban, County health system serving a low-income minority population of under screened women. Retention of program elements in the postresearch phase, and the difficulties and importance of conducting this type of research, is described.

Breast and cervical carcinoma screening practices among women in rural and nonrural areas of the United States, 1998-1999

BACKGROUND

Prior studies have suggested that women living in rural areas may be less likely than women living in urban areas to have had a recent mammogram and Papanicolau (Pap) test and that rural women may face substantial barriers to receiving preventive health care services.

METHODS

The authors examined both breast and cervical carcinoma screening practices of women living in rural and nonrural areas of the United States from 1998 through 1999 using data from the Behavioral Risk Factor Surveillance System. The authors limited their analyses of screening mammography and clinical breast examination to women aged 40 years or older (n = 108,326). In addition, they limited their analyses of Pap testing to women aged 18 years or older who did not have a history of hysterectomy (n = 131,813). They divided the geographic areas of residence into rural areas and small towns, suburban areas and smaller metropolitan areas, and larger metropolitan areas.

RESULTS

Approximately 66.7% (95% confidence interval [CI] = 65.8% to 67.6%) of women aged 40 years or older who resided in rural areas had received a mammogram in the past 2 years, compared with 75.4% of women living in larger metropolitan areas (95% CI = 74.9% to 75.9%). About 73.0% (95% CI = 72.2% to 73.9%) of women aged 40 years or older who resided in rural areas had received a clinical breast examination in the past 2 years, compared with 78.2% of women living in larger metropolitan areas (95% CI = 77.8% to 78.7%). About 81.3% (95% CI = 80.6% to 82.0%) of 131,813 rural women aged 18 years or older who had not undergone a hysterectomy had received a Pap test in the past 3 years, compared with 84.5% of women living in larger metropolitan areas (95% CI = 84.1% to 84.9%). The differences in screening across rural and nonrural areas persisted in multivariate analysis (P < 0.001).

CONCLUSIONS

These results underscore the need for continued efforts to provide breast and cervical carcinoma screening to women living in rural areas of the United States.

Colorectal cancer screening: an overview of current trends

Colorectal cancer can be cured and, in some cases, even prevented if detected early through screening. Studies have demonstrated that regular screening for colorectal cancer with fecal occult blood testing, sigmoidoscopy, or colonoscopy can reduce mortality from this disease. Unfortunately, rates of participation in these screening tests are unacceptably low among the U.S. population. Nurses have a significant role to play in assisting individuals to incorporate regular colorectal cancer screening into their health maintenance routines.

Adherence to repeat screening flexible sigmoidoscopy in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial

BACKGROUND

Acceptance of screening flexible sigmoidoscopy has been poor, in part because of providers' concerns regarding the acceptability of the procedure. In the current prospective study, the authors used adherence to repeat testing to assess the acceptability of screening flexible sigmoidoscopy.

METHODS

The current study was a prospective study of a randomized clinical trial drawing volunteers from the community. Subjects included 10,164 Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial participants who were available for follow-up 3 years after undergoing a baseline screening flexible sigmoidoscopy examination. The authors measured adherence and identified those factors that appeared to affect adherence to repeat sigmoidoscopy.

RESULTS

Overall, 18.3% of women and 10.0% of men did not undergo a repeat sigmoidoscopy. Among individuals who attended the Year-3 clinic, 10.4% of women and 5.1% of men specifically refused repeat sigmoidoscopy when it was offered (risk of refusal in women compared with men, 2.04; 95% confidence interval, 1.76-2.36). Another factor found to be associated with refusal included a technically inadequate baseline sigmoidoscopy.

CONCLUSIONS

Gender and past experiences with sigmoidoscopy may impact adherence to repeat screening. Nonetheless, among research volunteers in a randomized clinical trial of screening, excellent adherence to repeat screening flexible sigmoidoscopy could be achieved.

Barriers to screening for colorectal cancer

Rapidly growing interest in colon cancer screening is a crucial first step to identifying and reducing many of the barriers that impede population screening for this common disease. Promoting screening demands health care policy change to increase the percentage of Americans with insurance coverage that includes a colon cancer screening benefit. A systematic approach to screening with invitations that come from a clinician are likely to be the most effective way to prompt more individuals to be screened. Awareness campaigns and patient educational aids, including decision tools, implemented in multiple sites, such as worksites, community centers, health care systems, and physician offices, increase the percent of eligible Americans who understand their personal risk, the need for screening, and the options available to them.

Influence of financial productivity incentives on the use of preventive care

PURPOSE

We examined whether physician factors, particularly financial productivity incentives, affect the provision of preventive care.

SUBJECTS AND METHODS

We surveyed and reviewed the charts of 4,473 patients who saw 1 of 169 internists from 11 academically affiliated primary care practices in Boston. We abstracted cancer risk factors, comorbid conditions, and the dates of the last Papanicolaou (Pap) smear, mammogram, cholesterol screening, and influenza vaccination. We obtained physician information including the method of financial compensation through a mailed physician survey. We used multivariable logistic regression to examine the association between physician factors and four outcomes based on Health Plan Employer Data and Information Set (HEDIS) measures: (1) Pap smear within the prior 3 years among women 20 to 75 years old; (2) mammogram in the prior 2 years among women 52 to 69 years old; (3) cholesterol screening within the prior 5 years among patients 40 to 64 years old; and (4) influenza vaccination among patients 65 years old and older. All analyses accounted for clus-tering by provider and site and were converted into adjusted rates.

RESULTS

After adjustment for practice site, clinical, and physician factors, patients cared for by physicians with financial productivity incentives were significantly less likely than those cared for by physicians without this incentive to receive Pap smears (rate difference, 12%; 95% confidence interval [CI]: 5% to 18%) and cholesterol screening (rate difference, 4%; 95% CI: 0% to 8%). Financial incentives were not significantly associated with rates of mammography (rate difference, -3%; 95% CI: -15% to 10%) or influenza vaccination (rate difference, -13%; 95% CI: -28% to 2%).

CONCLUSIONS

Our findings suggest that some financial productivity incentives may discourage the performance of certain forms of preventive care, specifically Pap smears and cholesterol screening. More studies are needed to examine the effects of financial incentives on the quality of care, and to examine whether quality improvement interventions or incentives based on quality improve the performance of preventive care.

Risk perception and risk communication for cancer screening behaviors: a review

This review summarizes and synthesizes research findings on risk perception and risk communication related to cancer screening behaviors. The focus is on cancers for which there is evidence that screening reduces mortality, i.e., cervical, breast, and colorectal cancers. The following questions are addressed: 1) Is perceived risk associated with relevant cancer screening behaviors? 2) What factors are associated with perceived risk? 3) Is the relationship between perceived risk and cancer screening behaviors modified by other factors? 4) Have interventions to change perceived risk been effective in modifying risk perceptions? 5) Are these changes related to subsequent cancer screening behaviors? Methodologic issues are discussed, and future research needs are identified. There was consistent evidence that perceived risk was associated with mammography screening, but there were insufficient data on these associations for cervical or colorectal cancer screening behaviors. There was some evidence that perceived risk mediated the association between other variables and screening behaviors; however, because of the small number of studies, the findings are best viewed as hypothesis generating. Studies of interventions to modify risk perceptions provided some support for the view that they are modifiable, but there was conflicting evidence that these changes were related to subsequent cancer screening. Methodologic studies of how best to measure perceived risk are needed. Because most data on the correlates of perceived risk were cross-sectional, it is difficult to determine whether perceived risk is a cause or an effect in relation to cancer screening. Longitudinal studies that measure perceived risk in defined populations with different cancer screening histories and that include follow-up for screening and repeated measurements of risk perception are needed to clarify this relationship.

Design and pilot evaluation of a system to develop computer-based site-specific practice guidelines from decision models

BACKGROUND

Local tailoring of clinical practice guidelines (CPGs) requires experts in medicine and evidence synthesis unavailable in many practice settings. The authors' computer-based system enables developers and users to create, disseminate, and tailor CPGs, using normative decision models (DMs).

METHODS

ALCHEMIST, a web-based system, analyzes a DM, creates a CPG in the form of an annotated algorithm, and displays for the guideline user the optimal strategy. ALCHEMIST'S interface enables remote users to tailor the guideline by changing underlying input variables and observing the new annotated algorithm that is developed automatically. In a pilot evaluation of the system, a DM was used to evaluate strategies for staging non-small-cell lung cancer. Subjects (n = 15) compared the automatically created CPG with published guidelines for this staging and critiqued both using a previously developed instrument to rate the CPGs' usability, accountability, and accuracy on a scale of 0 (worst) to 2 (best), with higher scores reflecting higher quality.

RESULTS

The mean overall score for the ALCHEMIST CPG was 1.502, compared with the published-CPG score of 0.987 (p = 0.002). The ALCHEMIST CPG scores for usability, accountability, and accuracy were 1.683, 1.393, and 1.430, respectively; the published CPG scores were 1.192, 0.941, and 0.830 (each comparison p < 0.05). On a scale of 1 (worst) to 5 (best), users' mean ratings of ALCHEMIST'S ease of use, usefulness of content, and presentation format were 4.76, 3.98, and 4.64, respectively.

CONCLUSIONS

The results demonstrate the feasibility of a web-based system that automatically analyzes a DM and creates a CPG as an annotated algorithm, enabling remote users to develop site-specific CPGs. In the pilot evaluation, the ALCHEMIST guidelines met established criteria for quality and compared favorably with national CPGs. The high usability and usefulness ratings suggest that such systems can be a good tool for guideline development.

Randomized controlled trial of a computer strategy to increase general practitioner preventive care

BACKGROUND

Previous interventions targeting primary care practitioners with the aim of increasing preventive care delivery have demonstrated limited effectiveness. The primary aim of this study was to assess the effectiveness of a computerized continuing medical education program to increase rates of three screening behaviors (cholesterol, blood pressure, and cervical screening) and to identify three risk behaviors (smoking, alcohol consumption, benzodiazepine use) in general practice.

METHODS

Nineteen general practitioners were randomly allocated to intervention or control conditions. Those given the intervention received a computerized feedback system. The intervention was delivered using a touch-screen computer located in the surgery waiting area. The preventive behaviors of interest were patient smoking, alcohol use, benzodiazepine use, and blood pressure, cholesterol and cervical screening using the Papanicolou test. Differences in performance by group in each of the outcomes was measured at baseline and 3-month follow-up. Logistic regression analyses with generalized estimating equations were conducted as the main analyses.

RESULT

At 3-month follow-up, statistically significant differences were evident in the following outcome measures: accurate classification of benzodiazepine users (z = 2.8540, P < 0.05); accurate classification of non-benzodiazepine users (z = 2.7339, P < 0.05); accurate classification of hazardous or harmful alcohol drinkers (z = 2.3079, P < 0.02); blood pressure screening (z = 3.4136, P < 0.001); and cholesterol screening (z = 6.6313, P < 0.001).

CONCLUSION

A computerized system of performance-specific feedback was effective at increasing some preventive care services in general practice.

Psychological and behavioral factors associated with colorectal cancer screening among Ashkenazim

BACKGROUND

Psychological and behavioral factors related to annual colorectal cancer (CRC) screening were examined in a sample of Ashkenazi Jewish individuals. Identification of factors related to regular CRC screening in this population is important because of the possibility of a heightened incidence of CRC.

METHODS

Eligible participants were 171 Ashkenazi Jewish adults 40 years or older attending an educational program about breast cancer genetics. Compliance with recommended guidelines for digital rectal examination and fecal occult blood test in the past year were dependent measures. Demographic variables, family history of CRC, perceived risk, physician recommendation, and worry about cancer were independent measures.

RESULTS

Digital rectal examinations and fecal occult blood tests had been obtained in the past year by 46 and 31% of the participants, respectively. A logistic regression showed that physician recommendation was related significantly to obtaining digital rectal examinations. Physician recommendation and education were related significantly to obtaining fecal occult blood tests. Although participants with family histories of CRC perceived themselves as being at increased risk of developing CRC, and were more worried about developing colon cancer, they were no more likely to adhere to CRC screening guidelines than those without such histories.

CONCLUSIONS

Overall, compliance with recommended CRC screening was low even among high-risk individuals. Physicians play a key role in motivating people to comply with CRC screening. Physicians need to en courage all asymptomatic patients 50 years and older to be screened for CRC.

Mammogram utilization among farm women

Utilization of preventive health care services is lower in rural populations than in urban populations, possibly as a result of barriers to preventive health care that are characteristic of rural settings. This study was conducted to identify factors associated with mammogram utilization among farm women. Mammogram utilization among farm women from six southern Minnesota counties was examined as part of a larger community-based cancer intervention study. Farm women aged 40 and older were randomly selected from a list of farm households and interviewed by telephone to determine mammogram utilization and factors related to utilization. Of the 606 respondents, 78 percent reported ever having a mammogram and 49 percent reported a mammogram within the past year. Physician recommendation for a screening mammogram and family history of breast cancer were found to be associated with ever having a mammogram. Correct knowledge of mammogram screening guidelines was associated with a mammogram within the past 12 months. Overall, physician recommendation was the most influential determinant of utilization. As more emphasis is placed on prevention, patient education by physicians can have the greatest impact on mammogram utilization.

Compliance in a screening program for neuroblastoma

BACKGROUND

The Quebec Screening Program for neuroblastoma was undertaken to determine if routine screening of infants for neuroblastoma would decrease the mortality rate from this cancer. All 476,603 children born in Quebec during a 5-year period (1989 to 1994) were offered this screening at ages 3 weeks and 6 months. Through various strategies, an attempt was made to attain the highest level of voluntary compliance possible.

METHODS

Each screening consisted of the analysis of the catecholamine metabolites vanillylmandelic acid and homovanillic acid on a dry, urine-saturated filter paper mailed to a central laboratory by the parents. The strategies employed to optimize compliance consisted of increasing the awareness of the parents, health professionals, and the public about neuroblastoma and the screening program.

RESULTS

The population responded well to this public health measure, with a 91% compliance rate at 3 weeks and a 74% compliance rate at 6 months.

CONCLUSIONS

A well-informed population accustomed to voluntary screening for metabolic disease in infants responds well to screening for cancer.

Clinic-based interventions to promote breast and cervical cancer screening

BACKGROUND

Breast and cervical cancer continue to claim the lives of women. Early detection modalities for these cancers are available; however, utilization rates are far from optimal. Studies have documented the motivating effect that physician recommendations have on compliance with preventive health behaviors. The goal of this study was to develop and implement strategies to improve the use of cervical and breast cancer screening among African-American women age 40 and older who resided in low-income housing communities.

METHODS

Baseline surveys among clinic providers and a random sample of women in the target population indicated areas to be included in intervention material. Community health center-based strategies included educational interventions for providers and patients, follow-up interventions for abnormal screening tests, and the implementation of a computer tracking system. Pap smear and mammogram utilization rates at the health center were tracked throughout the project period to assess the effect of the clinic-based interventions.

RESULTS

Both Pap smear and mammography rates increased over time. Fifteen cases of breast cancer and 1 case of invasive cervical cancer have been detected. Compliance rates for follow-up for cervical dysplasia have increased from 50 to 90%.

CONCLUSIONS

These results suggest that clinic-based interventions can improve the use of breast and cervical cancer screening and follow-up among low-income women.

Increasing women's knowledge and satisfaction with cervical cancer screening

In a randomized clinical trial, the efficacy of three interventions, designed to increase patient knowledge of cancer screening and satisfaction with preventive health care, were evaluated: verbal information; graphically supported information; information provided using video colposcopy; no standardized information (control condition). A sample of 147 healthy women were randomly assigned to the intervention group (IG) or the control group (CG). Pre- and post-test measures were obtained using a semi-structured interview, the State-Trait Anxiety Inventory and the Patient Satisfaction Tool. At pre-test, women had a low level of knowledge which increased significantly at post-test. The knowledge scores were slightly higher in women who received information supported by graphic or video colposcopy than in women who received standardized information without teaching aids. Compared to the CG, women in the IGs scored significantly higher on questions related to cervical cancer prevention. The level of satisfaction was significantly higher in women receiving video-supported information and graphic-supported information compared to women receiving information without teaching aids. The results indicated that visual teaching aids were effective: video colposcopy in increasing patient satisfaction with preventive health care; and graphic representation in improving knowledge regarding cancer screening. The combination of both should routinely accompany cervical cancer screening.

Participation in colorectal cancer screening: a review

The purpose of this review is to evaluate the published literature on adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT) and sigmoidoscopy. Specifically, the review addresses the following: 1) prevalence of FOBT and sigmoidoscopy; 2) interventions to increase adherence to FOBT and sigmoidoscopy; 3) correlates or predictors of adherence to FOBT and sigmoidoscopy; and 4) reasons for nonadherence. Other objectives are to put the literature on CRC screening adherence in the context of recently reported findings from experimental interventions to change prevention and early detection behaviors and to suggest directions for future research on CRC screening adherence. CRC screening offers the potential both for primary and for secondary prevention. Data from the 1992 National Health Interview Survey show that 26% of the population more than 49 years of age report FOBT within the past 3 years and 33% report ever having had sigmoidoscopy. The Year 2000 goals set forth in Healthy People 2000 are for 50% of the population more than 49 years of age to report FOBT within the past 2 years and for 40% to report that they ever had sigmoidoscopy. Thus, systematic efforts to increase CRC screening are warranted. To date, attempts to promote CRC screening have used both a public health model that targets entire communities, e.g., mass media campaigns, and a medical model that targets individuals, e.g., general practice patients. Most of these efforts, however, did not include systematic evaluation of strategies to increase adherence. The data on FOBT show that the median adherence rate to programmatic offers of FOBT is between 40% and 50%, depending on the type of population offered the test, e.g., patients or employees. Approximately, 50% of those initially offered testing in unselected populations will respond to minimal prompts or interventions. A salient issue for FOBT, however, is whether or not the behavior can be sustained over time. Fewer studies examined adherence to sigmoidoscopy. Adherence was highest in relatives of CRC cases and in employer-sponsored programs offered to workers at increased risk of CRC. At present, we know very little about the determinants of CRC screening behaviors, particularly as they relate to rescreening.

An examination of differential follow-up rates in cervical cancer screening

The purpose of this study was to test the hypothesis that follow-up rates for women with abnormal cervical cancer screening results vary by age, ethnicity, and initial screening results in California's Breast and Cervical Cancer Control Program. The sample consisted of women in the screening program who received an abnormal cervical screening result (N = 1.738). Bivariate and logistic regression analyses were utilized to examine variables that account for differences in follow-up rates among these women. Bivariate analysis showed significant differences by age, race/ethnicity, initial screening results, and urban/rural residence. In logistic regression analysis, these variables also retained significance. Severity of diagnosis was a highly significant predictor of follow-up. Women of color, older women, and women with less severe diagnoses should be targeted as groups needing assistance in adhering to follow-up recommendations.

Implementation of a breast and cervical cancer screening program in a public hospital emergency department. Cancer Control Center of Harlem

STUDY OBJECTIVE

To assess the feasibility and yields of screening for breast and cervical cancer in an urban public hospital emergency department.

METHODS

Women who presented to the ED of a large, urban public hospital during the study period with nonurgent conditions were eligible for a Papanicolaou test (Pap smear) and a clinical breast examination (CBE) if they were 18 years of age or older and for a mammogram if they were 40 years of age or older, provided they had not had the screening examination within the past year. The Pap smear and CBE were performed by a nurse, and mammography was scheduled for a later date. Women with gynecologic complaints were excluded.

RESULTS

On the basis of screening history, medical status, and age, 1,850 (32%) of the 5,830 women seen in the ER during the 23-month study period were eligible for both mammography and CBE, and 2,361 (41%) were eligible for Pap smears. Of these women, 116 (6%) completed mammography and CBE, and 644 (27%) received Pap smears. Among screened women, 10 (9%) and 20 (3%), respectively, had results that were suspicious or positive for breast or cervical cancer. Follow-up rates were low: 20% for breast screening and 50% for Pap smears. Among those receiving follow-up, 1 woman was found to have breast cancer and 8 were found to have cervical neoplasia.

CONCLUSION

ED cancer screening was feasible and yielded a high rate of cancer detection. Program efficiency was hampered by low volume and high numbers of patients lost to follow-up after abnormal screening results. Greater integration into the acute care setting and more intensive recruitment and follow-up strategies are needed to maximize the potential yield and cost effectiveness of such programs.

Screening sigmoidoscopy. Factors associated with utilization

Although screening sigmoidoscopy (SS) reduces colorectal cancer mortality, surveys indicate that fewer than half of primary care physicians routinely recommend SS and less than 10% of eligible patients receive this test. The purpose of this study was to explore barriers to compliance with SS through a cross-sectional survey of general medicine patients. Clinician advice, perceived benefit of the test, and having a family member who has had the test are associated with SS, while perceived pain is a barrier to compliance and can negate the positive effects of clinician advice. These factors can be targeted as part of efforts to improve compliance with SS.

Factors associated with Pap smear taking in general practice: focusing public health initiatives

This study ascertained the relationships of patient, practitioner and consultation factors with: 1. taking a Pap smear or referral to a specialist in the consultation; and 2. an unsuccessful offer to take a Pap smear or making an appointment for a smear. In a cross-sectional study of 3478 women presenting to 230 randomly selected general practitioners in Brisbane and Toowoomba, information about most recent Pap smear, screening in the consultation, and independent variables were collected from patients and doctors. Relationships between three levels of outcome variable (no action, Pap smear taken or referral, appointment or refusal), and independent variables (practitioner variables, consultation variables, patient variables) were modelled using polytomous logistic regression. Presenting for a routine checkup and breast cancer screening were associated with all types of action. Younger age, longer consultations and consultations with a female practitioner were associated with Pap smear taking and referrals, and not appointments or refusals. Being due for a Pap smear, having blood pressure measured, consulting a younger general practitioner and one who ascribed to current guidelines on screening were associated with an appointment or a refusal, when compared with no action. Results identify different profiles of those who get a Pap smear and those who do not, the former indicating a more proactive patient group, while the latter suggest more active general practitioners who attempted opportunistic screening of passive patients, or women who do not specifically seek Pap smears. We have identified factors that have significance for developing public health programs focused on consumers and providers.

Evaluation of factors potentially associated with inadequate follow-up of mammographic abnormalities

BACKGROUND

To increase the proportion of women who receive the recommended follow-up for mammographic abnormalities, factors which inhibit follow-up must be identified. Patient and health care delivery related factors were evaluated, stratified by type of follow-up recommendation, to determine reasons for inadequate follow-up.

METHODS

All Caucasian and African American women at the Henry Ford Medical Group, in southeastern Michigan, with an abnormal screening mammogram result between January 1, 1992 and July 31, 1992 were identified. All women with inadequate follow-up, and a random sample of women with adequate follow-up, were invited to participate in a telephone interview that assessed three major dimensions of the Health Belief Model (susceptibility, benefits, and barriers), general health and health behaviors, and related characteristics. The relationship between these factors and inadequate follow-up was evaluated separately for women with immediate and 6-month follow-up recommendations, using univariate and multivariate analyses.

RESULTS

A total of 555 women were invited to participate in the study (219 with inadequate follow-up and 336 with adequate follow-up). Interviews were completed for 418 women (75.3%). Women who were not notified of their mammographic abnormality were excluded from this study, leaving 399 women available for analysis. Among the women who had the recommended immediate follow-up, those who reported difficulty in obtaining medical appointments were 4 times more likely to have inadequate follow-up (95% confidence interval [CI] 1.5, 11.3), after adjusting for other variables. Among the women with six-month follow-up recommended, those who received fewer mammograms in the past 5 years were more likely to have inadequate follow-up (odds ratio [OR] = 4.0; 95% CI 1.6, 10.4). In this group, sociodemographic characteristics were not associated with inadequate follow-up, although women with transportation problems were at a higher risk (crude OR = 5.2; 95% CI 1.6, 16.7; adjusted OR = 3. 1; 95% CI 0.5, 18.3). Among women with 6-month follow-up recommended, those who perceived their health as poor or fair (crude OR = 2.4; 95% CI 1.2, 5.1; adjusted OR = 2.3; 95% CI 0.8, 6.8) and those who did not examine their own breasts frequently (crude OR = 2.3; 95% CI 1.0, 5.4; adjusted OR = 2.7; 95% CI 0.5, 18.3) were also more likely to have inadequate follow-up.

CONCLUSIONS

Results from this study demonstrate that the relative importance of factors associated with inadequate follow-up of abnormal mammograms differs according to the type of follow-up recommended. For both types of recommendations, the factors identified are noteworthy because they are amenable to intervention. Efforts should be made to facilitate appointment scheduling for follow-up of abnormal mammograms, and information about previous mammography screening should be obtained to identify women who are at a high risk for inadequate follow-up.

Cancer prevention and early detection among Egyptians

Although cancer is frequently not perceived as a significant health problem in developing countries, cancer death in developing countries is higher than in developed countries. Therefore, cancer prevention and early detection in developing countries is becoming a universal challenge to health care providers. The purpose of this exploratory study was to identify knowledge, attitudes, and behaviors related to cancer prevention and early detection among Egyptians. Data were collected from 99 people, and the design was descriptive and correlational, using a self-administered survey. Results showed that the Egyptians surveyed had some knowledge about warning signs of cancer as well as prevention and early detection strategies. In addition, results indicated a significant difference between males and females in warning signs of cancer as well as prevention and early detection methods. Participants were less likely to believe their lifestyle behaviors affect their chances of developing cancer. Current practices undertaken included dietary behaviors, abstinence from smoking, check-up for minor suspicious symptoms, and annual complete physical examinations. Barriers to undertaking practices included factors related to lack of preventive resources, lack of information about preventive strategies, family financial concerns, and specific attitudes toward cancer. The study findings indicate the need for providing people with information to help them make decisions regarding undertaking cancer prevention and early detection practices.

Breast cancer control among the underserved--an overview

This paper explores barriers to the use of standard screening and breast cancer treatment that result in systematic differences in health outcomes. We review available data on individual, socioeconomic, and health system determinants of access to standard breast cancer care, including screening, diagnostic, and treatment services. Based on this review, we discuss the combination of factors which result in underservice. We argue that a broad framework which considers health system and social class as well as individual factors is useful for analyzing how structures of health care delivery tend to provide less than standard care to women who are older, have less income, or are less educated, black, or Hispanic. Data collection efforts which do not include structural and socioeconomic variables may result in an incomplete or misleading understanding of the determinants of underservice. These factors also need to be considered in the design and evaluation of public health policies and interventions meant to ameliorate the effects of underservice.

Factors related to enrollment in the breast cancer prevention trial at a comprehensive cancer center during the first year of recruitment

BACKGROUND

Using an a priori theoretic model of behavior change, factors predicting enrollment in a randomized chemoprevention trial during the first year of recruitment were assessed prospectively.

METHODS

Eligible participants were asked to complete a 90-item semistructured questionnaire after attendance at an informational meeting. Components of the Health Belief Model (including perceived susceptibility, perceived severity, perceived benefits and barriers, cues to action, and health motivation), health status, preventive health behaviors, and social influence were assessed in relation to enrollment.

RESULTS

Overall, 331 women attended one of the meetings, and 73% completed a questionnaire; 45% enrolled on the trial and 55% did not. In bivariate analyses, all but one of the perceived barriers were associated negatively with enrollment; however, items assessing perceived susceptibility, perceived severity, and perceived benefits were not. Nonparticipants also were more likely to be over 49 years of age, to be currently or to have been on estrogen replacement therapy, and to have had hot flashes. In logistic regression analysis, not being able to take estrogen replacement therapy was the strongest predictor of nonparticipation (odds ratio [OR], 12.13, 95% confidence interval [CI], 3.63, 40.60). Other factors associated with nonparticipation were concern about side effects of tamoxifen (OR, 5.06; CI, 2.37, 10.80); the possibility of getting a placebo (OR, 7.75; CI, 1.51, 39.67); the costs associated with the trial (OR, 3.21; CI, 1.12, 9.24); and absence of concern that significant others would be reassured if the respondent was taking tamoxifen (OR, 2.58; CI, 1.04, 6.41).

CONCLUSIONS

These findings support the view that recruitment efforts for chemoprevention trials should address barriers specific to their circumstances. In addition, increasing the support available from personal social networks may enhance recruitment to chemoprevention trials for breast cancer.