Compliance rates and predictors of cancer screening recommendations among Appalachian women

Body Mass Index and Breast and Cervical Cancer Screening

Background:

Breast and cervical cancer screening are responsible for dramatically reducing cancer deaths. Overweight and obesity are associated with deleterious health outcomes, including increased risk of developing cancer. This study adds to the existing literature examining the association of having overweight and obesity and receipt of breast or cervical cancer screening.

Methods:

Using the 2013 Brazos Valley Community Health Needs Assessment, we examined the association between body mass index (BMI) and receipt of breast or cervical cancer screening among women meeting age recommendations for breast cancer and cervical cancer screening (n = 1979 and n = 2040), respectively. We used SPSS 22 statistical software for descriptive and logistic regression analysis.

Results:

Overall, 26.6% of women missed the breast cancer screening guidelines, and 13.3% missed the cervical cancer screening guidelines. BMI had a weak association with missing cervical cancer screenings (odds ratio [OR] = 1.02; confidence interval [CI] = 1.01–1.04), but no association with missing breast cancer screenings (OR = 1.01; CI = 0.99–1.03). Higher age, race (non-White), rural area, no health insurance, smoking, and delayed health care were associated with missing breast cancer screenings. Higher age, marital status (single), lower education, no health insurance, smoking, and delayed health care were associated with missing cervical cancer screening. Further research is needed to better understand the association using larger, more diverse samples.

Contextual factors associated with cancer screening uptake: A systematic review of observational studies

We conducted a systematic review of a wide range of contextual factors related to cancer screening uptake that have been studied so far. Studies were identified through PubMed and Web of Science databases. An operational definition of context was proposed, considering as contextual factors: social relations directly aimed at cancer screening, health care provider and facility characteristics, geographical/accessibility measures and aggregated measures at supra-individual level. We included 70 publications on breast, cervical and/or colorectal cancer screening from 42 countries, covering a data period of 24 years. A wide diversity of factors has been investigated in the literature so far. While several of them, as well as many interactions, were robustly associated with screening uptake (family, friends or provider recommendation, provider sex and experience, area-based socio-economic status…), others showed less consistency (ethnicity, urbanicity, travel time, healthcare density …). Screening inequities were not fully explained through adjustment for individual and contextual factors. Context, in its diversity, influences individual screening uptake and lots of contextual inequities in screening are commonly shared worldwide. However, there is a lack of frameworks, standards and definitions that are needed to better understand what context is, how it could modify individual behaviour and the ways of measuring and modifying it.

Place, Power, and Premature Mortality: A Rapid Scoping Review on the Health of Women in Appalachia

OBJECTIVE

Appalachian women continue to die younger than in other US regions. We performed a rapid scoping review to summarize women's health research in Appalachia from 2000 to 2019, including health topics, study populations, theoretical frameworks, methods, and findings.

DATA SOURCE

We searched bibliographic databases (eg, PubMed, PsycINFO, Google Scholar) for literature focusing on women's health in Appalachia.

STUDY INCLUSION AND EXCLUSION CRITERIA

Included articles were: (1) on women's health in Appalachia; (2) published January 2000 to June 2019; (3) peer-reviewed; and (4) written in English. We excluded studies without reported data findings.

DATA EXTRACTION

Two coders reviewed articles for descriptive information to create summary tables comparing variables of interest.

DATA SYNTHESIS

Two coders co-reviewed a sub-sample to ensure consensus and refine data charting categories. We categorized major findings across the social-ecological framework.

RESULTS

A search of nearly 2 decades of literature revealed 81 articles, which primarily focused on cancer disparities (49.4%) and prenatal/pregnancy outcomes (23.5%). Many of these research studies took place in Central Appalachia (eg, 42.0% in Kentucky) with reproductive or middle-aged women (82.7%). Half of the studies employed quantitative methods, and half used qualitative methods, with few mixed method or community-engaged approaches (3.7%). Nearly half (40.7%) did not specify a theoretical framework. Findings included complex multi-level factors with few articles exploring the co-occurrence of factors across multiple levels.

CONCLUSIONS

Future studies should: 1) systematically include Appalachian women at various life stages from under-represented sub-regions; 2) expand the use of rigorous methods and specified theoretical frameworks to account for complex interactions of social-ecological factors; and 3) build upon existing community assets to improve health in this vulnerable population.

Factors Associated with Self-Reported Cervical Cancer Screening Among Women Aged 18 Years and Older in the United States

In 2016, an estimated 4120 women will die as a result of cervical cancer. The objective of this study was to examine the factors associated with cervical cancer screening among women 18 years of age and older in the United States (U.S.). Using the 2012 Behavioral Risk Factor Surveillance System survey, women over the age of 18 in the U.S. were examined to assess factors associated with cervical cancer screening. Analyses were conducted using SAS 9.2. Of the 272,692 study participants, 258,496 (95 %) had obtained cervical cancer screening. After adjusting for demographic and socioeconomic factors, being non-Hispanic White, Hispanic or Latino, Asian, Native Hawaiian or Other Pacific Islander, in the age group 18-44 years and 75 years and above, having less than a high school education and an annual household income of less than a $25,000, having never married, and residing in the West region of the U.S. reduced the likelihood of participation in cervical cancer screening. Also, after adjusting for demographic and socioeconomic factors, being between the ages of 45-74 years of age, having more than a high school education, having a higher income, and residing in the South region of the U.S. increased the likelihood of participation in cervical cancer screening. The results of this study suggest that socio-demographic factors and region of residence are predictors of cervical cancer screening. These findings highlight the need to identify potential prevention strategies to promote cervical cancer screening among at-risk populations and groups.

Psychosocial Correlates of Ever Having a Pap Test and Abnormal Pap Results in a Sample of Rural Appalachian Women

BACKGROUND

Despite known prevention and screening efforts, there are higher invasive cervical cancer rates in Appalachia than in other areas of the United States and higher mortality rates in the Appalachian region of Kentucky compared to Appalachian regions of other states.

PURPOSE

The primary purpose of this study was to investigate the association of psychosocial factors relevant to cervical cancer and the outcome of ever having a Pap test in a rural sample of women. The secondary purpose was to determine whether any of the same psychosocial factors were also associated with ever having an abnormal Pap test result among women with a self-reported history of having one or more Pap tests in their lifetime.

METHODS

Data were collected in fall of 2013 from 393 women in 8 economically distressed counties of rural Appalachian Kentucky. Women completed an interviewer-administered survey assessing sociodemographic and health information as well as beliefs about cervical cancer.

FINDINGS

Multivariate logistic regression results indicated that low income and greater perceived local fatalism were significant predictors of never having a Pap test. Lack of personal control over prevention, and peer and family influences were significant predictors of ever having an abnormal Pap test result.

CONCLUSIONS

Educational efforts targeted in rural Appalachia would be supported by encouraging the benefits of early and consistent screening, altering the established norms of community fatalism and lack of personal control over prevention, and creating targeted messages through public campaigns that convince rural Appalachian women that cervical cancer is highly preventable and screenable.

Stigma in Practice: Barriers to Health for Fat Women

In this paper, we explore barriers to health for fat people. By shifting the focus from what fat people do or do not do, neoliberal principles are replaced by a focus instead on structural and institutional policies, attitudes, and practices. This includes the impact of stigma on the health treatment and health-seeking behavior of fat people. For example, we consider the role that provider anti-fat attitudes and confirmation bias play in the failure to provide evidenced-based healthcare to fat patients. This is an autoethnographic paper, which provides the opportunity to read research from the perspective of fat scholars, framed by questions such as: can fat people have health? Is health itself a state of being, a set of behaviors, a commodity, a performance; perhaps the new social contract? As a co-written autoethnographic paper, one aspect of the evidence provided is the recorded experiences of the two fat authors. This includes writing from notes, journals, compiled and repeated experiences with medical professionals, family, and the community. Framed by feminist standpoint and supported by literature drawn from Fat Studies, Public Health, Obesity Research, and other interdisciplinary fields, this is a valuable opportunity to present an extended account of fat discrimination and the impact of the stigma fat people face through the medical profession and other sectors of the community, written by fat individuals. The paper concludes by considering the health pathways available to fat people. Special attention is paid to whether Bacon and Aphramor's Health at Every Size paradigm provides a path to health for fat individuals.

Adherence to Multiple Cancer Screening Tests among Women Living in Appalachia Ohio

BACKGROUND

There is a lack of information about the correlates of completing all three cancer screening tests among women living in Appalachia.

METHODS

Cross-sectional telephone interviews were conducted (April-September 2013) among women (n = 637) ages 51 to 75 years from 12 Appalachia Ohio counties. Outcomes of within screening guidelines were verified by medical records. Multivariable logistic regression models identified correlates of being within guidelines for all three cancer screening tests.

RESULTS

Screening rates included mammography (32.1%), Pap test (36.1%), and a colorectal cancer test (30.1%). Only 8.6% of women were within guidelines for all tests. Having had a check-up in the past 2 years and having received a screening recommendation were significantly related to being within guidelines for all three tests (P < 0.01). Participants with higher annual household incomes [$60,000+; OR, 3.53; 95% confidence interval (CI), 1.49-8.33] and conditions requiring regular medical visits (OR, 3.16; 95% CI, 1.29-7.74) were more likely to be within guidelines for all three screening tests.

CONCLUSION

Less than 10% of women had completed screening within guidelines for all three screening tests. Regular contact with the health care system and higher incomes were significant predictors of being within guidelines.

IMPACT

Within guidelines rates for the three recommended cancer screening tests are low among women in Appalachia Ohio. This finding illustrates the need for innovative interventions to improve rates of multiple cancer screening tests.

Uptake of breast screening and associated factors among Hong Kong women aged ≥50 years: a population-based survey

OBJECTIVE

To examine the uptake of breast screening and its associated factors among Hong Kong Chinese women aged ≥50 years.

STUDY DESIGN

Cross-sectional population-based survey.

METHODS

A sample of Hong Kong Chinese women was recruited through telephone random-digit dialling. The survey consisted of six sections: perceived health status, use of complementary medicine, uptake of breast screening, perceived susceptibility to cancer, family history of cancer and demographic data. The factors associated with uptake of breast screening were analysed using logistic regression analysis.

RESULTS

In total, 1002 women completed the (anonymous) telephone survey. The mean age was 63.5 (standard deviation 10.6) years. The uptake rate of breast screening among Hong Kong Chinese women aged ≥50 years was 34%. The primary reasons for undertaking breast screening were as part of a regular medical check-up (74%), prompted by local signs and symptoms (11%) and a physician's recommendation (7%). Higher educational level, married or cohabiting, family history of cancer, frequent use of complementary therapies, regular visits to a doctor or Chinese herbalist, and the recommendation of a health professional were all independently and significantly associated with increased odds of having had a mammogram.

CONCLUSIONS

This study provides community-based evidence of the need for public health policy to promote broader use of mammography services among this target population, with emphasis on the active involvement of health care professionals, through the development and implementation of appropriate evidence-based and resource-sensitive strategies.

Barriers to cervical cancer screening among middle-aged and older rural Appalachian women

Although cervical cancer rates in the United States have declined sharply in recent decades, certain groups of women remain at elevated risk, including middle-aged and older women in central Appalachia. Cross-sectional baseline data from a community-based randomized controlled trial were examined to identify barriers to cervical cancer screening. Questionnaires assessing barriers were administered to 345 Appalachian women aged 40-64, years when Papanicolaou (Pap) testing declines and cervical cancer rates increase. Consistent with the PRECEDE/PROCEED framework, participants identified barriers included predisposing, enabling, and reinforcing factors. Descriptive and bivariate analyses are reported, identifying (a) the most frequently endorsed barriers to screening, and (b) significant associations of barriers with sociodemographic characteristics in the sample. Recommendations are provided to decrease these barriers and, ultimately, improve rates of Pap tests among this traditionally underserved and disproportionately affected group.

Self-collecting a cervico-vaginal specimen for cervical cancer screening: an exploratory study of acceptability among medically underserved women in rural Appalachia

OBJECTIVE

Innovative screening methods such as self-testing for human papillomavirus (HPV) may alleviate barriers to cervical cancer screening. The purpose of this exploratory study was to determine whether Appalachian Kentucky women would be amenable to self-collecting a cervico-vaginal specimen for HPV testing.

METHODS

Women aged 30-64 who were overdue for guideline-recommended cervical cancer screening were recruited from a primary care clinic in southeastern Kentucky. The women were asked to self-collect a specimen, using a cervico-vaginal brush, based on verbal and printed directions provided by a research nurse. All study participants, regardless of laboratory-confirmed HPV status, received the same counseling on the importance of cervical cancer screening and offered navigation to follow-up Pap testing at the local health department.

RESULTS

Thirty-one women were approached and recruited to participate in the study, indicating a 100% acceptance rate of HPV self-testing. Of the 31 women, 26 tested negative for high-risk HPV and five tested positive. All of the women with negative results declined nurse navigation to Pap testing, whereas four of the five women with positive results accepted nurse navigation and received subsequent Pap smear screenings (all results were normal).

CONCLUSIONS

Among this sample of Appalachian Kentucky women, self-collecting a cervico-vaginal specimen for HPV testing was highly acceptable. This exploratory study provides impetus for larger studies among high-risk, medically underserved women in rural communities. Tailoring alternative cancer screening strategies to meet the complex needs of rural women is likely to lead to reductions in cervical cancer incidence and mortality among this vulnerable population.

Epidemiological association between body fat percentage and cervical cancer: a cross-sectional population-based survey from Mexico

BACKGROUND AND AIMS

Various studies have reported a direct association of cervical cancer risk with obesity and weight but not with the body fat percentage (BFP). The aim of this study was to analyze various anthropometric measures as potential risk factors for cervical cancer.

METHODS

A total of 20,236 women were included in a cross-sectional population-based survey. Obesity was defined according to the World Health Organization criteria, and central obesity was ≥80 cm; the BFP was defined using the Deurenberg equation (BFP = 1.2 [BMI] + 0.23 [age] - 10.8 [sex] - 5.4). The odds ratio (OR) was estimated from the chi square test and logistic regression models.

RESULTS

The prevalence of cervical cancer increased from 514 (95% confidence interval [CI] 321, 707) and 680 (95% CI 494, 866) to 732 (95% CI 535, 928) per 100,000 inhabitants in subjects with a normal weight, subjects who were overweight and subjects who were obese, respectively. Moreover, an association between cervical cancer and BFP (OR 1.027; CI 95% 1.006, 1.048; p = 0.012) was observed, and the risk increased with a BFP ≥45% (OR 2.369; CI 95% 1.284, 4.369; p = 0.006).

CONCLUSIONS

These data suggest a trend between the body mass index and the increasing prevalence of cervical cancer. In addition, the data showed a significant association between the BFP and cervical cancer, and this epidemiological association was higher as the BFP increased.

Community strategies to address cancer disparities in Appalachian Kentucky

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

Obesity and Cancer Screening according to Race and Gender

The relationship between obesity and cancer screening varies by screening test, race, and gender. Most studies on cervical cancer screening found a negative association between increasing weight and screening, and this negative association was most consistent in white women. Recent literature on mammography reports no association with weight. However, some studies show a negative association in white, but not black, women. In contrast, obese/overweight men reported higher rates of prostate-specific antigen (PSA) testing. Comparison of prostate cancer screening, mammography, and Pap smears implies a gender difference in the relationship between screening behavior and weight. In colorectal cancer (CRC) screening, the relationship between weight and screening in men is inconsistent, while there is a trend towards lower CRC screening in higher weight women.

The impact of obesity on gynecologic cancer screening: an integrative literature review

INTRODUCTION

Evidence indicates lower rates of breast and cervical cancer screening among obese compared to nonobese women. This integrative review examines the association between gynecologic cancer screening and body weight, as well as potential barriers to screening.

METHODS

A literature search of standard computerized databases was conducted for peer-reviewed articles published between 1950 and January 2009.

RESULTS

Twenty-three studies met the criteria for review. Of the 17 studies that evaluated rates of cervical cancer screening, 13 found obese women significantly less likely than their nonobese counterparts to have had a recent Papanicolaou test, a trend that was stronger in white women when compared to African American women. Eight of the 15 studies examining routine mammography found an inverse association between increasing body weight and recent screening, although findings generally pertained only to women who were white and/or severely obese. Possible barriers to care included embarrassment and perceived weight stigma in the clinical setting, lack of appropriately sized examination equipment, and poor patient-provider communication.

DISCUSSION

Further research is needed to clarify the challenges that obese women face in accessing care and to evaluate strategies such as ensuring the availability of appropriate equipment and supplies, the use of alternative screening methodologies, and more culturally sensitive counseling approaches that may improve screening rates in obese women.

Family physicians' barriers to cancer screening in extremely obese patients

Extremely obese women are less likely than nonobese women to receive breast and cervical cancer screening examinations. Reasons for this disparity are unclear and may stem from patient and/or physician barriers. This sequential mixed-methods study used individual in-depth interviews of 15 family physicians followed by a mail survey of 255 family physicians (53% response rate) to understand the barriers they faced in performing cancer screening examinations in extremely obese women. Barriers fell into three main areas: (i) difficulty doing pelvic and breast exams; (ii) inadequate equipment; and (iii) challenges overcoming patient barriers and refusal. This led some physicians to avoid performing breast and pelvic examinations on extremely obese women. Having more knowledge about specific examination techniques was associated with less difficulty in palpating lumps on breast and pelvic examinations (P < 0.005). Physicians perceived that embarrassment, aversion to undressing, and avoidance of discussions related to their weight were the most frequent barriers extremely obese women had with getting physical examinations. Educating and/or motivating patients and addressing fears were strategies used most frequently when patients refused mammograms or Pap smears. Interventions focusing on physician barriers, such as educating them on specific examination techniques, obtaining adequate equipment and supplies, and providing resources to assist physicians in dealing with patient barriers and refusal, may be fruitful in increasing cancer screening rates in extremely obese patients. Future research studies testing the effectiveness of these strategies are needed to improve cancer outcomes in this high-risk population.

Cancer risk perceptions, beliefs, and physician avoidance in Appalachia: results from the 2008 HINTS Survey

Appalachians experience increased rates of cancer incidence and mortality and high-risk health behaviors. Additionally, Appalachians are often characterized by lower socioeconomic status, geographic isolation, and cultural beliefs such as fatalism. The purpose of this descriptive analysis is to identify cancer-related risk perceptions, beliefs, and physician avoidance behaviors among Appalachians as compared with non-Appalachians using data from the National Cancer Institute's 2008 Health Information National Trends Survey (HINTS), which contained a newly created "Appalachia" variable. Results suggest that compared with non-Appalachians, Appalachians have a significantly higher perceived risk of developing cancer in the future and are significantly more likely to associate cancer with death; believe individuals can tell they have cancer before a diagnosis; believe everything causes cancer; and admit to avoiding their physician even when they suspect they should plan a visit. Both Appalachians and non-Appalachians share similar mistaken beliefs about cancer prevention, screening, and curability, and frustration over the abundance of cancer prevention recommendations. In a geographic region recognized for cancer health disparities, development of tailored communication strategies and educational interventions designed to increase cancer knowledge may help to accurately explain cancer risk and incidence, dispel negative cancer beliefs, and promote a positive image of the doctor-patient relationship.

Decisions to seek healthcare based on family health history among urban Appalachian women

Family health history (FHH) is a valuable health promotion tool that can be used to assess disease risk and make lifestyle and screening recommendations. However, few FHH resources exist for medically underserved populations such as the urban Appalachian community in Cincinnati Ohio. Women of Appalachian heritage with less than a college education who did and did not participate in a prior FHH education session were interviewed by phone in a semi-structured format. Interviewees were asked to discuss their understanding of FHH and the role FHH played in seeking (or not seeking) medical care. Analysis of their discussion identified four overarching themes as well as a model identifying conditions that facilitated or impeded the choice to seek medical care based on FHH. Findings from this study may be used to develop targeted FHH educational interventions in the urban Appalachian and other communities.

Obesity and mammography: a systematic review and meta-analysis

BACKGROUND

Obese women experience higher postmenopausal breast cancer risk, morbidity, and mortality and may be less likely to undergo mammography.

OBJECTIVES

To quantify the relationship between body weight and mammography in white and black women.

DATA SOURCES AND REVIEW METHODS

We identified original articles evaluating the relationship between weight and mammography in the United States through electronic and manual searching using terms for breast cancer screening, breast cancer, and body weight. We excluded studies in special populations (e.g., HIV-positive patients) or not written in English. Citations and abstracts were reviewed independently. We abstracted data sequentially and quality information independently.

RESULTS

Of 5,047 citations, we included 17 studies in our systematic review. Sixteen studies used self-reported body mass index (BMI) and excluded women <40 years of age. Using random-effects models for the six nationally representative studies using standard BMI categories, the combined odds ratios (95% CI) for mammography in the past 2 years were 1.01 (0.95 to 1.08), 0.93 (0.83 to 1.05), 0.90 (0.78 to 1.04), and 0.79 (0.68 to 0.92) for overweight (25-29.9 kg/m(2)), class I (30-34.9 kg/m(2)), class II (35-39.9 kg/m(2)), and class III (> or =40 kg/m(2)) obese women, respectively, compared to normal-weight women. Results were consistent when all available studies were included. The inverse association was found in white, but not black, women in the three studies with results stratified by race.

CONCLUSIONS

Morbidly obese women are significantly less likely to report recent mammography. This relationship appears stronger in white women. Lower screening rates may partly explain the higher breast cancer mortality in morbidly obese women.

The association of obesity and cervical cancer screening: a systematic review and meta-analysis

Obese women are at an increased risk of death from cervical cancer, but the explanation for this is unknown. Through our systematic review, we sought to determine whether obesity is associated with cervical cancer screening and whether this association differs by race. We identified original articles evaluating the relationship between body weight and Papanicolaou (Pap) testing in the United States through electronic (PubMed, CINAHL, and the Cochrane Library) and manual searching. We excluded studies in special populations or those not written in English. Two reviewers sequentially extracted study data and independently extracted quality using standardized forms. A total of 4,132 citations yielded 11 relevant studies. Ten studies suggested an inverse association between obesity and cervical cancer screening. Compared to women with a normal BMI, the combined odds ratios (95% CI) for Pap testing were 0.91 (0.80-1.03), 0.81 (0.70-0.93), 0.75 (0.64-0.88), and 0.62 (0.55-0.69) for the overweight and class I, class II, and class III obesity categories, respectively. Three out of four studies that presented the results by race found this held true for white women, but no study found this for black women. In conclusion, obese women are less likely to report being screened for cervical cancer than their lean counterparts, and this does not hold true for black women. Less screening may partly explain the higher cervical cancer mortality seen in obese white women.

Stability and change in health-related behaviors of midlife Swedish women

We investigated the dimensions and stability in health-related behaviors (HRBs) among midlife Swedish women, and the factors that predicted change in those behaviors. At age 43, 569 women from a representative longitudinal sample completed questionnaires about lifestyle (diet, exercise, smoking, alcohol) and participated in medical screening. Four years later we mailed a follow-up questionnaire. HRBs clustered in two dimensions: healthy eating and addictions. There was a high degree of stability in HRBs; all women slightly increased their HRBs over time. After controlling for previous HRBs, we found that education, marital status, and having children at home were significant predictors of HRBs 4 years later.

Obesity and screening for breast, cervical, and colorectal cancer in women: a review

The literature examining obesity as a barrier to screening for breast, cervical, and colorectal cancer has not been evaluated systematically. With the increasing prevalence of obesity and its impact on cancer incidence and mortality, it is important to determine whether obesity is a barrier to screening so that cancers among women at increased risk because of their body size can be detected early or prevented entirely. On the basis of 32 relevant published studies (10 breast cancer studies, 14 cervical cancer studies, and 8 colorectal cancer studies), the authors reviewed the literature regarding associations between obesity and recommended screening tests for these cancer sites among women in the U.S. The most consistent associations between obesity and screening behavior were observed for cervical cancer. Most studies reported an inverse relation between decreased cervical cancer screening and increasing body size, and several studies reported that the association was more consistent among white women than among black women. For breast cancer, obesity was associated with decreased screening behavior among white women but not among black women. The literature regarding obesity and colorectal cancer screening adherence was mixed, with some studies reporting an inverse effect of body size on screening behavior and others reporting no effect. Overall, the results indicated that obesity most likely is a barrier to screening for breast and cervical cancers, particularly among white women; the evidence for colorectal cancer screening was inconclusive. Thus, efforts to identify barriers and increase screening for breast and cervical cancers may be targeted toward obese women, whereas outreach to all women should remain the objective for colorectal cancer screening programs.

Promotion of cancer family history awareness: Jameslink Cancer Risk Assessment Tool at community health fairs

This article examines the impact of providing personalized familial cancer risk assessments with the Jameslink Cancer Risk Assessment Tool. Users of the Jameslink (N = 166) at eight community health fairs completed a survey including demographic, psychosocial and behavioral variables to better understand responses to the Jameslink. No differences were found between whites and those of other races for variables of interest, indicating suitability of the Jameslink for diverse populations. Those with higher Jameslink-assessed risk had higher perceived risk of cancer. Approximately half (53.8%) reported that they would speak to their physician about their Jameslink-assessed risk. A regression found Jameslink-assessed risk, cancer worry, and perceived risk of cancer predicted intentions to speak to a physician about their risk. In addition, open-ended data provided suggestions to improve the Jameslink. Changes in content and format were suggested; however most were happy with the program and encouraged its promotion. The lack of findings for differences as a function of race bolsters the use of computerized Cancer Risk Assessment Tools in diverse communities. The positive feedback of users and the close association between cancer risk assessment, perceived risk, and intention to speak to a physician are supportive of continued use and development of Cancer Risk Assessment Tools in the community to promote awareness of cancer risk.

Breast health education for working women in Appalachia: insights from focus group research

BACKGROUND

This study seeks to understand rural working women, their knowledge of health systems, and how breast health issues fit into their lives. A key aim of this study was to identify regionally and culturally specific factors that influence how these women approach breast health and to identify ways that more positive breast health behaviors can be achieved.

METHODS

Five focus groups (N = 42) were conducted among women at sites where the Breast Health Outreach Program (BHOP) had been conducted. Focus groups were composed of 7 to 10 women who were in about the same age cohort.

RESULTS

Women provided multiple insights about their attitudes and behaviors related to breast heath concerns. Analysis of the data revealed that many of the comments clustered around two types of "systems" in these women's lives: the professional health care system and personal community systems. The BHOP provides a bridge between these two systems and seems to facilitate positive actions. Workplace health professionals also provide a bridge between professional and personal systems.

CONCLUSIONS

Women exhibited the general distrust of the medical system that the literature indicates is often associated with Appalachian culture. However, this study found that distrust can be overcome with education programs that meet women where they live and work. Such programs are most likely to be successful when the materials and methods are sensitive to Appalachian culture and when medical services are brought into the community.

Do cervical cancer screening rates increase in association with an intervention designed to increase mammography usage?

OBJECTIVES

To assess cervical cancer screening behaviors among underserved women participating in an intervention designed to increase mammography use.

METHODS

This was a randomized trial of 897 women from three racial groups (white, African American, Native American) living in a rural county in North Carolina. Baseline and followup surveys were completed by 815 women; 775 women provided data to be included in these analyses. The intervention group received an educational program focused on mammography delivered by a lay health advisor, and the control group received a physician letter/brochure focusing on Pap tests.

RESULTS

Women in both the intervention (OR 1.70; 1.31, 2.21, p < 0.001) and control groups (OR 1.38; 1.04, 1.82, p = 0.025) significantly increased cervical cancer screening rates within risk appropriate guidelines. No differences by racial group were documented. Women categorized in the high-risk group for developing cervical cancer (>2 sexual partners, age <18 years at first sexual intercourse, smoker; treated for sexually transmitted disease [STD] or partner with treated STD) significantly (OR 1.88; 1.54, 2.28, p < 0.001) increased Pap test completion. However, a nonsignificant increase (OR 1.25; 0.87, 1.79, p = 0.221) in Pap test completion was demonstrated in women categorized as low risk for cervical cancer.

CONCLUSIONS

This study suggests that women in an intensive behavioral intervention designed to increase mammography use may also increase Pap test completion, similar to a minimal intervention focused only on increasing Pap test completion. These results have implications for the design and evaluation of behavioral intervention studies.

Cancer screening in women: body mass index and adherence to physician recommendations

BACKGROUND

The reasons that obese women are less likely to obtain mammograms and Papanicolaou tests (Pap smears) are poorly understood. This study evaluated associations between body mass index (BMI) and receipt of and adherence to physician recommendations for mammography and Pap smear.

METHODS

Data from the 2000 National Health Interview Survey (8289 women aged 40 to 74 years) were analyzed in 2006 using logistic regression. Women with previous hysterectomy were excluded from Pap smear analyses (n=5521). Outcome measures were being up-to-date with screening, receipt of physician recommendations, and women's adherence to physician recommendations for mammography and Pap smear.

RESULTS

After adjusting for sociodemographic variables, healthcare access, health behaviors, and comorbidity, severely obese women (BMI > 40 kg/m(2)) were less likely to have had mammography within 2 years (odds ratio [OR]=0.50, 95% confidence interval [CI]=0.37-0.68) and a Pap smear within 3 years (OR=0.43, 95% CI=0.27-0.70). Obese women were as likely as normal-weight women to receive physician recommendations for mammography and Pap smear. Severely obese women were less likely to adhere to physician recommendations for mammography (OR=0.49, 95% CI=0.32-0.76). Women in all obese categories (BMI > 30 kg/m(2)) were less likely to adhere to physician recommendations for Pap smear (ORs ranged from 0.17 to 0.28, p<0.001).

CONCLUSIONS

Obese women are less likely to adhere to physician recommendations for breast and cervical cancer screening. Interventions focusing solely on increasing physician recommendations for mammography and Pap smears will probably be insufficient for obese women. Additional strategies are needed to make cancer screening more acceptable for this high-risk group.

Key informants' perspectives prior to beginning a cervical cancer study in Ohio Appalachia

Higher-than-average cervical cancer incidence and mortality rates occur in Ohio Appalachia. Little is known, however, about societal norms and social determinants that affect these rates. To examine county-level sociocultural environments to plan a cervical cancer prevention program, the authors interviewed key informants from 17 of 29 Ohio Appalachia counties. Findings include the perceived offensiveness of the term Appalachia, the importance of long-standing family ties, urban and rural areas within counties, use and acceptability of tobacco, the view that cancer is a death sentence, and the stigmatization of people with cancer. Barriers to screening included cost, lack of insurance, transportation problems, fear, embarrassment, and privacy issues. These findings highlight the important role of geography, social environment, and culture on health behaviors and health outcomes. The interviews provided information about the unique characteristics of this population that are important when developing effective strategies to address cancer-related health behaviors in this medically underserved population.

Breast and cervical cancer screening in obese minority women

PURPOSE

Studies using survey data from mostly white women showed that obese women are less likely than nonobese women to undergo breast and cervical cancer screening. It is unclear if these findings are true in nonwhite women. Using chart audit data, we examined the relationship between obesity and mammography and Pap smear screening among minority women.

METHODS

Data from retrospective chart review of women in three urban New Jersey academic family medicine practices were analyzed (n = 1809) using hierarchical logistic regression models. Outcome measures were being up-to-date in mammography and Pap smears among obese and nonobese women.

RESULTS

There was no difference in mammography rates among obese and nonobese women. Independent risk factors for not being up-to-date in mammography included age 40-49, smoking, and comorbidity. Obese women were less likely than nonobese women to be upto- date in Pap smears (69% vs. 77%, p = 0.001). In multivariate analysis, obesity was associated with 25% decreased odds of being up-to-date on Pap smears (OR, 0.75, 95% CI, 0.58-0.99, p = 0.041). Age >or=65 years was also associated with decreased odds of being up-to-date in Pap smears. Hispanic women had increased odds of being up-to-date in mammography (OR 2.43, 95% CI 1.63-3.63) and Pap smears (OR 1.94, 95% CI 1.24-3.03) compared with white women.

CONCLUSIONS

Obesity was associated with decreased Pap smear screening but not with decreased mammography. Further studies are needed to determine barriers and effective interventions to improve screening in obese minority women.

Comparative analysis of invasive cervical cancer incidence rates in three Appalachian states

BACKGROUND

Invasive cervical cancer (ICC) rates remain elevated in the Appalachian region of the United States. We investigated patterns of invasive cervical cancer incidence rates in three Appalachian states (Kentucky, West Virginia, Pennsylvania) to uncover specific high-risk subgroups within this large and heterogeneous region.

METHODS

The analysis was conducted for the three states combined and individually. Invasive cervical cancer rates were characterized by individual and county-level sociodemographic variables, including age, race, poverty, education, Appalachian status, and rural/urban status. Bivariate analyses and multivariable Poisson regression models were conducted to address the relative contributions of each variable to the risk of invasive cervical cancer.

RESULTS

The three states differed in the contribution of each factor to the risk of invasive cervical cancer. The overall invasive cervical cancer incidence rates for Kentucky, West Virginia, and Pennsylvania were 13.4, 13.9, and 10.2 per 100,000/yr, respectively. After controlling for other demographic variables, the effect of Appalachian status on invasive cervical cancer was weaker, while rural status, education, and race were stronger, significant predictors.

CONCLUSIONS

This study illustrates the heterogeneity of population demographics and invasive cervical cancer risk, and the need to identify subregions and subgroups within Appalachia at highest risk for this disease.

Effect of patient socioeconomic status on perceptions of first- and second-year medical students

BACKGROUND

Physician decision-making and perceptions of patients are affected by a patient's socioeconomic status (SES). We sought to determine if the perceptions of first- and second-year medical students are similarly affected. We also wanted to determine whether a student's own SES affects his or her perceptions of patients from a low or high SES background.

METHODS

Two similar videos of a physician-patient interview were created. One video featured a patient of apparently high SES and the other featured a patient of apparently low SES. Differences in SES were portrayed by means of clothing, accessories and dialogue. First- and second-year medical students at the University of Western Ontario were recruited to view 1 of the videos and to answer a questionnaire using a 5-point Likert scale.

RESULTS

Responses were obtained from 205 (89%) of the 231 medical students invited to participate. Respondents' perceptions of the low SES and high SES patients were significantly different in the following respects. The low SES patient was perceived to be less compliant in taking medications and less likely to return for follow-up visits; was perceived to have a lower level of social support, poorer overall health and a worse prognosis; and was perceived to be more adversely affected in his occupational duties by illness (p < 0.05). Furthermore, second-year students who watched the video with the low SES patient were less inclined to want that patient in their practice than second-year students who watched the video with the high SES patient (p = 0.032). One hundred and six students (52%) were categorized as having high SES and 37 (18%) as having low SES (the remaining students were categorized as having mid-level SES). Among students who watched the video with the low SES patient, the level of agreement with the statement "This person is the kind of patient I would like to have in my practice" was greater among low SES students than among high SES students (p = 0.012).

INTERPRETATION

First- and second-year medical students have negative perceptions of low SES patients on several dimensions.