Tenant-Based Housing Voucher Programs: A Community Guide Systematic Review

CONTEXT

Unaffordable or insecure housing is associated with poor health in children and adults. Tenant-based housing voucher programs (voucher programs) limit rent to 30% or less of household income to help households with low income obtain safe and affordable housing.

OBJECTIVE

To determine the effectiveness of voucher programs in improving housing, health, and other health-related outcomes for households with low income.

DESIGN

Community Guide systematic review methods were used to assess intervention effectiveness and threats to validity. An updated systematic search based on a previous Community Guide review was conducted for literature published from 1999 to July 2019 using electronic databases. Reference lists of included studies were also searched.

ELIGIBILITY CRITERIA

Studies were included if they assessed voucher programs in the United States, had concurrent comparison populations, assessed outcomes of interest, were written in English, and published in peer-reviewed journals or government reports.

MAIN OUTCOME MEASURES

Housing quality and stability, neighborhood opportunity (safety and poverty), education, income, employment, physical and mental health, health care use, and risky health behavior.

RESULTS

Seven studies met inclusion criteria. Compared with low-income households not offered vouchers, voucher-using households reported increased housing quality (7.9 percentage points [pct pts]), decreased housing insecurity or homelessness (-22.4 pct pts), and decreased neighborhood poverty (-5.2 pct pts).Adults in voucher-using households had improved health care access and physical and mental health. Female youth experienced better physical and mental health but not male youth. Children who entered the voucher programs under 13 years of age had improved educational attainment, employment, and income in their adulthood; children's gains in these outcomes were inversely related to their age at program entry.

CONCLUSION

Voucher programs improved health and several health-related outcomes for voucher-using households, particularly young children. Research is still needed to better understand household's experiences and contextual factors that influence achievement of desired outcomes.

Grounding implementation science in health equity for cancer prevention and control

BACKGROUND

The past decade of research has seen theoretical and methodological advances in both implementation science and health equity research, opening a window of opportunity for facilitating and accelerating cross-disciplinary exchanges across these fields that have largely operated in siloes. In 2019 and 2020, the National Cancer Institute's Consortium for Cancer Implementation Science convened an action group focused on 'health equity and context' to identify opportunities to advance implementation science. In this paper, we present a narrative review and synthesis of the relevant literature at the intersection of health equity and implementation science, highlight identified opportunities (i.e., public goods) by the action group for advancing implementation science in cancer prevention and control, and integrate the two by providing key recommendations for future directions.

DISCUSSION

In the review and synthesis of the literature, we highlight recent advances in implementation science, relevant to promoting health equity (e.g., theories/models/frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes). We acknowledge the contributions from the broader field of health equity research and discuss opportunities for integration and synergy with implementation science, which include (1) articulating an explicit focus on health equity for conducting and reviewing implementation science; (2) promoting an explicit focus on health equity in the theories, models, and frameworks guiding implementation science; and (3) identifying methods for understanding and documenting influences on the context of implementation that incorporate a focus on equity. To advance the science of implementation with a focus on health equity, we reflect on the essential groundwork needed to promote bi-directional learning between the fields of implementation science and health equity research and recommend (1) building capacity among researchers and research institutions for health equity-focused and community-engaged implementation science; (2) incorporating health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); and (3) continuing a focus on transdisciplinary opportunities in health equity research and implementation science. We believe that these recommendations can help advance implementation science by incorporating an explicit focus on health equity in the context of cancer prevention and control and beyond.

Satisfaction with care and attention to salient concerns by race in a diverse national sample of young women with breast cancer

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Background: Young women with breast cancer (BC) have unique issues, including fertility, genetic, and emotional health concerns; these may sometimes be inadequately addressed by providers. Given documented disparities in BC care and outcomes, we sought to explore whether provider attention to these issues differs by race, as well as to examine racial differences in satisfaction with care among young patients with BC. Methods: The Young & Strong Study was a cluster randomized trial of an educational and supportive care intervention at 14 academic + 40 community oncology practices across the US enrolling women with newly diagnosed BC at age ≤45 and their providers. Patients completed surveys at baseline, 3, 6, and 12 months after enrollment. Race was self-reported at baseline. Provider attention to fertility, genetics, and emotional health was evaluated by medical record review. The proportions of patients with attention to these concerns by 3 months was compared by race (white, Black, Asian, multi-racial/other/unknown) using Fisher’s exact tests. Satisfaction with care was assessed with the Patient Satisfaction Questionnaire-18 (PSQ-18) at 3 months. Median scores for each of 7 PSQ-18 subscales (1-5 scale, higher scores=more satisfaction) were compared by race with the Kruskal-Wallis test. Results: 465/467 (99.6%) of enrolled patients had evaluable data. 77% were white, 12% Black, 4% Asian, and 7% multiracial/other/unk. Median age at diagnosis was 40 (range: 22-45) years. Provider attention to genetics (≥85%) and emotional health (≥90%) was high across groups, and there were no differences by race in attention to fertility, genetics, or emotional health (Table). Among 359/465 women (77%) who completed the PSQ-18, median subscale scores ranged from 3.5-4.5, indicating high levels of satisfaction with care. For the PSQ-18 technical quality domain, median scores were lower (p=.03), indicating less satisfaction, in Black and Asian women (4.0) and higher in white women (4.5). Median scores for other PSQ-18 domains (general satisfaction, interpersonal manner, communication, financial, time spent with doctor, accessibility) did not differ by race. Conclusions: Satisfaction with care was high and issues related to fertility, genetics and emotional health were addressed by providers in the majority of young women in our study, with minimal differences by race. These patients were all enrolled in a clinical trial and had access to high-quality care, limiting the generalizability of our findings. Larger, population-based studies in more diverse settings are warranted. Clinical trial information: NCT01647607.

Attention to psychosocial concerns by race.

[Table: see text]

Design of a student-led organizational partnership to host an annual statewide Science Olympiad K-12 outreach tournament

Since fall 2015, the University of Virginia's (UVA) Engineering Student Council (ESC) has partnered with the nonprofit Virginia Science Olympiad (VASO) organization to host a Science Olympiad (SciOly) state tournament in Charlottesville, Virginia, each spring. This annual tournament brings over 2,000 middle and high school students, teachers, and parents to the UVA campus, and teams of 15-17 people from roughly 90 schools across Virginia participate in 46 different events (23 middle school, Division B; 23 high school, Division C) relating to the science, technology, engineering, and mathematics (STEM) fields throughout the day-long competition. The national SciOly organization sets the events and rules to comply with national education standards, and the VASO board coordinates the teams and tournaments within the state. By collaborating with VASO, UVA ESC was able to plan a large-scale SciOly tournament at UVA in approximately 10 mo with the support of the UVA School of Engineering and Applied Science. Since this event was planned and executed solely by undergraduates in cooperation with the nonprofit organization, there were institutional hurdles that were overcome through the months of planning. The Virginia SciOly state tournament has continued to be held at UVA with the support and cooperation of the UVA ESC and VASO, and bringing this tournament to UVA has allowed for increased excitement for participating K-12 students and a mitigated burden to the VASO organizers in planning the state competition. This paper aims to provide a resource for other universities to support STEM activities in K-12 outreach organizations, like SciOly, in the future.

Precision Prevention and Early Detection of Cancer: Fundamental Principles

Prevention and early detection is critical for reducing the population cancer burden. Two approaches have been used: Population approaches change social norms (e.g., smoking bans) or impose incentives (e.g., cigarette taxes); high-risk strategies intervene upon individuals with elevated cancer risk (e.g., smoking cessation). Knowledge about carcinogenesis mechanisms, extreme exposures, and inherited susceptibility provides opportunities to develop precision prevention and early-detection (PPED) strategies. PPED aims to understand the basis of risk, identify groups that optimally benefit from interventions, characterize heterogeneity in intervention responses, optimize intervention timing, and minimize toxicities. We propose a framework around which PPED strategies can be developed. Currently available cancer prevention and early-detection approaches have the potential to reduce a large proportion of the cancer burden in the population. However, even if fully implemented, existing methods cannot fully eliminate the cancer burden. New PPED approaches that exploit the growing knowledge of molecular and biological cancer mechanisms should be developed and implemented. Cancer Discov; 8(7); 803-11. ©2018 AACR.

Family-Based Smoking Cessation Intervention for Smoking Fathers and Nonsmoking Mothers with a Child: A Randomized Controlled Trial

OBJECTIVE

To examine whether a family-based intervention targeting both smoking fathers and nonsmoking mothers in well-child health clinics is effective in increasing fathers' abstinence from cigarette smoking.

STUDY DESIGN

This parallel 2-arm randomized controlled trial recruited a total of 1158 families with a daily-smoking father, a nonsmoking mother, and a child aged 0-18 months from the 22 maternal and child health centers in Hong Kong. The intervention group received the family-based intervention, including 6 nurse-led individual face-to-face and telephone counseling sessions within 1 month after recruitment and a voluntary face-to-face family counseling session (FCS). The control group received a leaflet, a self-help booklet, and brief quitting advice only. Father-reported 7-day and 6-month abstinence, smoking reduction, quit attempts, mother-reported help and support, and child salivary cotinine level were assessed at 12 months. Generalized estimating equation models were used to compare these outcomes between the 2 study groups.

RESULTS

Compared with the control group, the intervention group reported a greater prevalence of 7-day (13.7% vs 8.0%; OR, 1.92; 95% CI, 1.16-3.17; P < .01) and 6-month self-reported abstinence (13.4% vs. 7.5%; OR, 2.10; 95% CI, 1.30-3.40; P < .01). Within the intervention group, compared with receipt of individual counseling only, participation in the FCS was associated with increases in fathers' self-reported abstinence (20.2% vs 12.3%; P = .02), mothers' help (66.1% vs 43.8%; P < .01), and support to the fathers (55.0% vs 45.4%; P < .01).

CONCLUSIONS

The family-based smoking cessation intervention for the families in the well-child healthcare setting was effective in increasing the fathers' self-reported abstinence. Additional participation in the FCS increased mothers' help and support to the fathers.

TRIAL REGISTRATION

Controlled-trials.com: ISRCTN99111655; Hkuctr.com: HKUCTR-465.

The Life History Interview Method: Applications to Intervention Development

There is an urgent need to develop and test health promotion strategies that both address health disparities and elucidate the full impact of social, cultural, economic, institutional, and political elements on people's lives. Qualitative research methods, such as life history interviewing, are well suited to exploring these factors. Qualitative methods are also helpful for preparing field staff to implement a social contextual approach to health pro-motion. This article reports results and application of findings of life history interviews conducted as part of intervention planning for the Harvard Cancer Prevention Program Project, “Cancer Prevention in Working-Class, Multi-Ethnic Populations.” The salient themes that emerged from interviews with a multi-ethnic, purposive sample are centered on six construct domains: immigration and social status, social support, stress, food, physical activity, and occupational health. Insights gained from thematic analysis of the interviews were integrated throughout intervention and materials development processes.

Impact of Young and Strong on physical activity in young breast cancer survivors

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Background: Inactivity is common in breast cancer survivors and has been linked to poor outcomes. Few trials have tested physical activity (PA) interventions in young women with breast cancer, who may face unique PA barriers due to demands of jobs and young families. Methods: Young and Strong was a cluster-randomized study evaluating the effect of education interventions for young breast cancer survivors.Sites were randomized 1:1 to a young women’s intervention (YWI), focused on fertility and other issues facing young women, or to a physical activity intervention (PAI). At PAI sites, providers were instructed to discuss PA with patients, and participants were given materials to encourage PA. PA was measured with the modified Godin Leisure Score Index at baseline, and 3, 6, and 12 months. Medical records were reviewed to assess provider attention to PA. Changes in weekly min of PA were compared between the PAI and YWI groups using general estimating equations to evaluate clustered binary and Gaussian data. Results: 467 patients enrolled between 7/12 -12/13 across 54 sites. Median age at dx was 40yrs (range 22-45). At baseline, participants were moderately active. PA increased in both groups over time (Table); there was no significant difference in PA between groups at any time (all p > 0.1). Provider attention to PA was documented in 74% of participants on PAI and 61% on YWI (p = 0.15), and correlated with PA at 12 months (median 100 min/wk of PA in participants with provider attention to PA vs. 60 min/wk in those without, p = 0.016). Participants who reported reading all or most the PAI materials reported higher levels of PA vs. those who read less (78% vs. 64%, p = 0.05) Conclusions: Young breast cancer survivors assigned to a PA intervention did not increase PA more than those assigned to an intervention focused on young women’s issues. However, the higher levels of PA among women who engaged with the PAI materials and those whose oncology providers addressed PA suggests the importance of enhancing patient and provider engagement with healthy lifestyle information and recommendations. Clinical trial information: NCT01647607. [Table: see text]

Perspectives of African Americans on lung cancer: a qualitative analysis

BACKGROUND

Disparities in incidence and mortality for lung cancer in African Americans are well documented; however, the extent to which disparities reflect differences in patient perceptions of tobacco and lung cancer treatment is unclear. The objective of this study was to explore African Americans' knowledge of lung cancer, perceived risk, interest in smoking cessation, attitudes toward lung cancer treatment, and lung cancer diagnosis and treatment experiences.

PATIENTS AND METHODS

The cohort comprised 32 African-American current and former smokers without a cancer diagnosis who participated in focus groups and 10 African Americans with lung cancer who participated in in-depth interviews. Transcripts were analyzed using a modified grounded theory approach.

RESULTS

Participants without a cancer diagnosis were aware of the link between smoking and lung cancer, the common symptoms of the disease, and its poor prognosis. They desired specific, personalized smoking-cessation information. If diagnosed, the majority reported, they would seek medical care. Most believed that insurance and socioeconomic factors were more likely to affect treatment access than racial discrimination. Participants with a cancer diagnosis were also aware of the relationship between smoking and lung cancer. They felt their treatment plans were appropriate and trusted their physicians. Most did not believe that race affected their care.

CONCLUSION

This qualitative study suggests that African-American smokers are aware of the relationship between smoking and lung cancer and are interested in smoking-cessation treatment. These data also indicate that lung cancer disparities are unlikely to be associated with differential willingness to receive care but that African Americans may perceive financial and insurance barriers to lung cancer treatment.

The Society of Behavioral Medicine position statement on the CMS decision memo on intensive behavior therapy for obesity

In 2011, the Centers for Medicare and Medicaid Services (CMS) issued a decision to cover intensive behavior therapy for obesity in the primary care setting. The Society of Behavioral Medicine (SBM) Public Policy Leadership Group reviewed the CMS decision and has issued a position statement. SBM is in support of the CMS decision to cover intensive behavior therapy for obesity but expresses significant concern that aspects of the decision will severely limit the impact of the decision. Concerns focus on the degree to which this care can be feasibly implemented in its current form given the limitations in providers who are covered and the short length of counseling visits relative to evidence-based protocols. SBM is in strong support of modifications that would include providers who have expertise in weight control (e.g., psychologists and dietitians) and to expand the treatment time to better match protocols with confirmed efficacy.

Smoking Restrictions Among Households of Childhood and Young Adult Cancer Survivors: Implications for Tobacco Control Efforts

PURPOSE

This study assessed the prevalence of smoking restrictions among households of survivors of childhood and young adult cancer who smoke. It also examined the relationship between home smoking restrictions and motivation to quit smoking, as well as other smoking, psychosocial, and environmental factors.

METHODS

Participants included 374 smokers who were childhood or young adult cancer survivors (between the ages of 18 and 55 years) recruited from five cancer centers to participate in a randomized smoking cessation trial. Survivors completed baseline measures about the smoking restrictions in their households, their smoking behavior, and related psychological and environmental factors, which are the focus of the current manuscript.

RESULTS

Almost 54% of survivors reported that smoking was prohibited in their households. Living with a nonsmoking partner, having a strict smoking policy at work, and not being nicotine dependent all increased the likelihood of having a total home smoking ban. Participants who were older, smoked more cigarettes per day over the prior week, and received prior chemotherapy were less likely to reside in households that adopted total bans.

CONCLUSION

Findings suggest that socio-environmental factors and current smoking behaviors are associated with complete smoking restrictions in the homes of survivors. These factors should be considered when communicating with survivors about the importance of establishing strict smoking policies in their private residences.

Weight gain prevention among black women in the rural community health center setting: the Shape Program

BACKGROUND

Nearly 60% of black women are obese. Despite their increased risk of obesity and associated chronic diseases, black women have been underrepresented in clinical trials of weight loss interventions, particularly those conducted in the primary care setting. Further, existing obesity treatments are less effective for this population. The promotion of weight maintenance can be achieved at lower treatment intensity than can weight loss and holds promise in reducing obesity-associated chronic disease risk. Weight gain prevention may also be more consistent with the obesity-related sociocultural perspectives of black women than are traditional weight loss approaches.

METHODS/DESIGN

We conducted an 18-month randomized controlled trial (the Shape Program) of a weight gain prevention intervention for overweight black female patients in the primary care setting. Participants include 194 premenopausal black women aged 25 to 44 years with a BMI of 25-34.9 kg/m2. Participants were randomized either to usual care or to a 12-month intervention that consisted of: tailored obesogenic behavior change goals, self-monitoring via interactive voice response phone calls, tailored skills training materials, 12 counseling calls with a registered dietitian and a 12-month YMCA membership.Participants are followed over 18 months, with study visits at baseline, 6-, 12- and 18-months. Anthropometric data, blood pressure, fasting lipids, fasting glucose, and self-administered surveys are collected at each visit. Accelerometer data is collected at baseline and 12-months.At baseline, participants were an average of 35.4 years old with a mean body mass index of 30.2 kg/m2. Participants were mostly employed and low-income. Almost half of the sample reported a diagnosis of hypertension or prehypertension and 12% reported a diagnosis of diabetes or prediabetes. Almost one-third of participants smoked and over 20% scored above the clinical threshold for depression.

DISCUSSION

The Shape Program utilizes an innovative intervention approach to lower the risk of obesity and obesity-associated chronic disease among black women in the primary care setting. The intervention was informed by behavior change theory and aims to prevent weight gain using inexpensive mobile technologies and existing health center resources. Baseline characteristics reflect a socioeconomically disadvantaged, high-risk population sample in need of evidence-based treatment strategies.

TRIAL REGISTRATION

The trial is registered with clinicaltrials.gov NCT00938535.

Behavioral medicine and the health of our nation: accelerating our impact

PURPOSE

A key goal of this paper is to illustrate the impact of behavioral medicine on the factors that influence population health. A second goal is to consider the delicate balance between relevance and excellence as we bring our science to bear on important social and public health problems. If we are to increase the translation of our evidence and accelerate our impact, we must increase our relevance while maintaining excellence in our scientific methods.

METHODS

What are the pressing questions facing those that we would like to use our work, and how we can increase our relevance to theirs? We must work on the marriage of relevance and excellence-use rigorous methodologies, but be flexible in our approach, using study designs and methods that will get rapid yet rigorous answers to the questions that are facing practice and policy settings.

CONCLUSION

We have the tools and the knowledge to impact the health of our nation.

GIS walking maps to promote physical activity in low-income public housing communities: a qualitative examination

INTRODUCTION

Walking is the most commonly reported leisure-time activity. Members of racial/ethnic minority groups and people of low socioeconomic status disproportionately live in urban environments that are perceived to be unsafe, thereby reducing opportunities for engaging in walking. We examined the use of walking maps for increasing physical activity (PA) among low-income residents of public housing sites in Boston, Massachusetts.

METHODS

PA facilities, local businesses, and destinations in a walkable half-mile radius of the housing community were identified and plotted on maps by using geographic information systems technology. Four focus groups (n = 24) were conducted to learn how the walking maps were used by the residents and to understand map features that promoted use.

RESULTS

Maps were used by participants to increase their PA, and use of the maps increased participants' awareness of community resources. Maps changed participants' perception of distances and were discussed as a means of fostering a sense of community. Use of the maps also increased participants' awareness of neighborhood incivilities. Barriers to map use were difficulty in interpreting the maps and lack of access to the maps.

CONCLUSION

Walking maps that display PA opportunities and resources may be useful in increasing walking among residents of public housing sites.

The impact of a novel computer-based decision aid on shared decision making for colorectal cancer screening: a randomized trial

BACKGROUND

Eliciting patients' preferences within a framework of shared decision making (SDM) has been advocated as a strategy for increasing colorectal cancer (CRC) screening adherence. Our objective was to assess the effectiveness of a novel decision aid on SDM in the primary care setting.

METHODS

An interactive, computer-based decision aid for CRC screening was developed and evaluated within the context of a randomized controlled trial. A total of 665 average-risk patients (mean age, 57 years; 60% female; 63% black, 6% Hispanic) were allocated to 1 of 2 intervention arms (decision aid alone, decision aid plus personalized risk assessment) or a control arm. The interventions were delivered just prior to a scheduled primary care visit. Outcome measures (patient preferences, knowledge, satisfaction with the decision-making process [SDMP], concordance between patient preference and test ordered, and intentions) were evaluated using prestudy/poststudy visit questionnaires and electronic scheduling.

RESULTS

Overall, 95% of patients in the intervention arms identified a preferred screening option based on values placed on individual test features. Mean cumulative knowledge, SDMP, and intention scores were significantly higher for both intervention groups compared with the control group. Concordance between patient preference and test ordered was 59%. Patients who preferred colonoscopy were more likely to have a test ordered than those who preferred an alternative option (83% v. 70%; P < 0.01). Intention scores were significantly higher when the test ordered reflected patient preferences.

CONCLUSIONS

Our interactive computer-based decision aid facilitates SDM, but overall effectiveness is determined by the extent to which providers comply with patient preferences.

Are neighborhood-level characteristics associated with indoor allergens in the household?

BACKGROUND

Individual home characteristics have been associated with indoor allergen exposure; however, the influence of neighborhood-level characteristics has not been well studied. We defined neighborhoods as community districts determined by the New York City Department of City Planning.

OBJECTIVE

We examined the relationship between neighborhood-level characteristics and the presence of dust mite (Der f 1), cat (Fel d 1), cockroach (Bla g 2), and mouse (MUP) allergens in the household.

METHODS

Using data from the Puerto Rican Asthma Project, a birth cohort of Puerto Rican children at risk of allergic sensitization (n = 261), we examined associations between neighborhood characteristics (percent tree canopy, asthma hospitalizations per 1,000 children, roadway length within 100 meters of buildings, serious housing code violations per 1000 rental units, poverty rates, and felony crime rates), and the presence of indoor allergens. Allergen cutpoints were used for categorical analyses and defined as follows: dust mite: >0.25 microg/g; cat: >1 microg/g; cockroach: >1 U/g; mouse: >1.6 microg/g.

RESULTS

Serious housing code violations were statistically significantly positively associated with dust mite, cat, and mouse allergens (continuous variables), adjusting for mother's income and education, and all neighborhood-level characteristics. In multivariable logistic regression analyses, medium levels of housing code violations were associated with higher dust mite and cat allergens (1.81, 95%CI: 1.08, 3.03 and 3.10, 95%CI: 1.22, 7.92, respectively). A high level of serious housing code violations was associated with higher mouse allergen (2.04, 95%CI: 1.15, 3.62). A medium level of housing code violations was associated with higher cockroach allergen (3.30, 95%CI: 1.11, 9.78).

CONCLUSIONS

Neighborhood-level characteristics, specifically housing code violations, appear to be related to indoor allergens, which may have implications for future research explorations and policy decisions.

Explanations for side effect aversion in preventive medical treatment decisions

OBJECTIVE

Many laypeople demonstrate excessive sensitivity to negative side effects of medical treatments, which may lead them to refuse beneficial therapies. This Internet-based experiment investigated three possible explanations for such "side effect aversion." One was derived from mental accounting, one examined the mere presence of a side effect, and one focused on computational difficulties.

DESIGN

Participants (N = 5,379) were presented with a hypothetical cancer preventive treatment situation that was or was not accompanied by one or two small side effects. The side effects were either beneficial or harmful. In all conditions, the net absolute risk reduction associated with the treatment was 15%.

MAIN OUTCOME MEASURES

Participants indicated their willingness to accept treatment and their perceptions of the treatment's effects on their overall cancer risk.

RESULTS

Data were consistent only with the "mere presence" explanation of side effect aversion, the idea that side effects act as a strong negative cue that directly affects treatment appraisal. The number of negative side effects did not influence treatment willingness.

CONCLUSION

Side effect aversion is a challenge to informed decision making. Specific mechanisms that produce side effect aversion should be identified.

Dissemination research in cancer control: where are we and where should we go?

Dissemination of evidence-based programs and policies is a critical final step in reducing the burden of cancer in the general public. Yet, we have not been fully successful to date in improving clinical or public health practice by disseminating programs found to be effective in research. Therefore, research is needed into the dissemination process and outcomes to enable better efforts in the future. This paper explores the definitions and models used for dissemination, the designs of dissemination studies, and possible research questions in dissemination research, all focused on cancer prevention and control. We hope that this paper will encourage dissemination research in our field.

Primary prevention, aging, and cancer: overview and future perspectives

Cancer-specific primary prevention efforts for the geriatric population are not understood well and currently are underused despite the rapidly growing elderly population. It has been established that lifestyle changes, such as smoking cessation, dietary changes, and increasing physical activity, decrease the incidence of cancer in younger populations. However, a multitude of conceptual, methodological, and dissemination challenges arise when the objective is to apply primary prevention of cancer to the elderly. For this article, the state of the science was reviewed to reveal barriers in the uptake of cancer-specific primary prevention practices, including the lack of data for the applicability of clinical research findings to older populations. Under-representation of older adults in behavioral trials and research programs is hindering progress in understanding the physical health and lifestyle choices of older individuals. Efforts directed toward prevention in terms of promoting health behaviors may be not only clinically advantageous but also cost-effective. In addition, models for translating research findings on primary prevention from younger individuals to the elderly population needs to be addressed. Practitioners need to gain a better understanding of the opportunities for cancer-specific primary prevention, because such an understanding could enhance the management of chronic disease.

Physical activity behaviors in women with newly diagnosed ductal carcinoma-in-situ

Epidemiological evidence suggests that physical activity may affect breast cancer risk and other health outcomes. Little information is available regarding changes in activity after diagnosis and treatment of in-situ cancer. We enrolled 487 women with newly diagnosed ductal carcinoma-in-situ (DCIS) in a longitudinal cohort study. Exercise behaviors were assessed at enrollment and at 18 months. Changes in exercise frequency over time were compared, and the impact of demographic and treatment-related variables was evaluated. Enrollment and 18-month exercise data were available for 391 women (80%). At enrollment, most women performed strenuous physical activity infrequently, and only half engaged in any type of exercise more than twice a week. Overall activity patterns did not change greatly over the course of the study. However, logistic regression modeling of changes in exercise revealed that women who underwent unilateral or bilateral mastectomy (hazard ratio [HR], 2.4; 95% confidence interval [95% CI], 1.3-4.4) and those who were anxious at enrollment (HR, 2.1; 95% CI, 1.1-4.1) were statistically significantly more likely to decrease exercise levels, and women who worked were significantly more likely to increase exercise over the course of the study (HR, 1.9; 95% CI, 1.1-3.3). Nonsignificant variables included age, reconstructive surgery, depressive symptoms, financial status, education, and tamoxifen use. A large proportion of women with newly diagnosed DCIS were inactive and remained so over time. Women who underwent mastectomy, as well as women who were more anxious, were more likely to decrease their level of physical activity. Women with DCIS might benefit from targeted interventions to increase physical activity.

Colorectal cancer screening awareness and intentions among low income, sociodemographically diverse adults under age 50

Colorectal cancer (CRC) screening rates in the US are suboptimal, particularly among lower income and racial/ethnically diverse groups. If specific populations have limited awareness of screening when they reach age 50, there may be delays in screening adoption. This study investigated sociodemographic and social contextual factors associated with awareness of CRC and intentions to be screened at age 50 among 692 low income, racial, and ethnic minority adults living in low income housing. The majority of respondents (62%) were between ages 30 and 49, and 94% had some form of health insurance (e.g., Medicaid). About 70% reported having heard about CRC screening; 66% reported intentions to be screened at age 50. In multivariable analyses, screening awareness was associated with age and education. Immigrants who had English as a second language had lower awareness. Females tended to have higher awareness if they had private insurance; there were no differences among males. Multivariable analyses found that screening intentions were higher among men, those with more role responsibilities, more role conflicts, and higher levels of social cohesion. It is important to identify opportunities for maximizing screening uptake among those who become age-eligible for screening if we are to make a significant impact on CRC disparities.

A test of numeric formats for communicating risk probabilities

BACKGROUND

Because people frequently encounter information about the probability of health risks, there is a need for research to help identify the best formats for presenting these probabilities.

METHODS

Three waves of participants were recruited from visitors to a cancer-related Internet site. Participants were presented with a hypothetical scenario that required them to perform 2 mathematical operations of the types that might be encountered in discussions of risk. Each wave encountered different operations. The operations used were compare, halve, triple, add, sequence, and tradeoff. Three numeric formats for communicating risk likelihoods were tested: percentages (e.g., 12%), frequencies (e.g., 12 in 100), and 1 in n (e.g., 1 in 8), and many levels of risk magnitude were crossed with the 3 formats.

RESULTS

The total sample of 16,133 individuals represented an overall participation rate of 36.1%. Although the relative performance of the formats varied by operation, aggregated across operations, the percentage and frequency formats had higher overall accuracy rates than the 1-in-n format (57% and 55% v. 45%, respectively). Participants with less education, African Americans, Hispanics, and women had more difficulty with the mathematical operations.

DISCUSSION

Percentage and frequency formats facilitate performance of simple operations on risk probabilities compared with the 1-in-n format, which should usually be avoided.

Manager beliefs regarding worksite health promotion: findings from the Working Healthy Project 2

PURPOSE

To explore differences in manager beliefs about worksite health promotion programs (HPPs).

DESIGN

Cross-sectional written survey.

SETTING

Twenty-four manufacturing worksites, with 11,811 employees and 1719 eligible managers.

SUBJECTS

Sixty-six percent (1133/1719) of managers completed the survey; 1047 managers were categorized by level (169 senior, 567 middle, and 311 line supervisors).

ANALYSIS

Results are reported on overall manager beliefs (and by manager level) about importance, efficacy, barriers, and benefits of HPPs. Multilevel analysis modeled the influence of manager level, age, and experience with HPPs on beliefs about HPPs, while accounting for worksite-level effects.

RESULTS

Seventy-five percent of managers believed that offering HPPs is highly important. Eighty percent believed that HPPs improved employee health, 68% believed that they reduced health care costs, and 67% believed that they improved employee morale. Few significant differences by manager level were observed on the perceived importance of health promotion, employer responsibilities for health promotion and protection, and efficacy of health promotion strategies or perceived benefits. Senior managers (vs. line supervisors) were significantly less likely to believe that space or cost was a barrier to offering HPPs and were less likely than middle managers or line supervisors to believe that production conflicts were barriers to offering HPPs.

CONCLUSION

Targeted interventions to address manager beliefs, including differences by age, experience, and manager level, are worth consideration when planning worksite HPPs.

Physical Inactivity in Adult Survivors of Childhood Acute Lymphoblastic Leukemia: A Report from the Childhood Cancer Survivor Study

PURPOSE

To determine if adult survivors of childhood acute lymphoblastic leukemia (ALL) are less active (and more inactive) than the general population and to identify modifying factors.

PATIENTS AND METHODS

Physical activity was assessed by self-report in 2,648 adult survivors of the Childhood Cancer Survivor Study. Participants in the Behavioral Risk Factor Surveillance System (BRFSS) survey administered through the Centers for Disease Control and Prevention (CDC) were used as a comparison group.

RESULTS

Survivors had a mean age of 28.7 years (range, 18.0-44.0 years) and were a mean of 23.1 years from their cancer diagnosis (range, 16.0-33.8 years). In multivariate models, ALL survivors were more likely to not meet CDC recommendations for physical activity [odds ratio (OR), 1.44; 95% confidence interval (95% CI), 1.32-1.57] and more likely to be inactive (OR, 1.74; 95% CI, 1.56-1.94) in comparison with the BRFSS general population. Survivors treated with >20-Gy cranial radiotherapy were at particular risk. Compared with BRFSS participants and adjusted for age, race, and ethnicity, survivors were more likely to not meet CDC recommendations (females: OR, 2.07, 95% CI, 1.67-2.56; males: OR, 1.43, 95% CI, 1.16-1.76) and more likely to be inactive (females: OR, 1.86; 95% CI, 1.50-2.31; males: OR, 1.84; 95% CI, 1.45-2.32).

CONCLUSIONS

Long-term survivors of childhood ALL are less likely to meet physical activity recommendations and more likely to report no leisure-time physical activity in the past month. This level of inactivity likely further increases their risk of cardiovascular disease, osteoporosis, and all-cause mortality.

Assessment of parents' smoking behaviors at a pediatric emergency department

The pediatric emergency department is an important source of treatment for children with complaints related to environmental tobacco smoke (ETS) and may provide a teachable moment to address parent smoking. Parents who smoke were recruited from a pediatric emergency department waiting room and completed an interview assessment used to develop intervention messages. Of the 715 parents in the final sample, 77% were women, 60% White, and 60% low income (<US$30,000/year); 25% wanted to quit smoking in the next month, 50% wanted to quit within 6 months, and 48.5% "almost always" smoked outside. Parents reporting more frequent ETS protection behaviors had stronger beliefs about harmful effects of ETS and about ETS protection, and more confidence to resist smoking when tempted. Parents more ready to quit smoking were more likely to be men, and were more likely to report more daily hassles, stronger cons of smoking, higher personal vulnerability to smoking effects, and stronger beliefs about ETS protection. Findings showed that most parents in this setting are concerned about limiting their children's ETS exposure. However, this concern alone appeared insufficient to motivate parents to quit smoking. Interventions should encourage parents to limit ETS exposure, while encouraging quitting for optimal protection from effects of cigarette smoke for their children and themselves.

Complementary medicine use before and 1 year following genetic testing for BRCA1/2 mutations

PURPOSE

We explored change in complementary and alternative medicine (CAM) use by unaffected women and cancer survivors from enrollment into a randomized BRCA1/2 testing program to CAM use 1 year following results disclosure.

METHODS

A cohort of 243 high-risk women completed questionnaires at enrollment into a BRCA1/2 randomized trial and 1 year post results disclosure. Uses of several CAMs for cancer prevention were explored, including ingestible, behavioral, and physical modalities. Assessment of the change in CAM use from baseline to 1 year follow-up was conducted using a repeated self-administered questionnaire. Correlates of the number of CAMs used at 1 year were explored using multivariable linear regression models.

RESULTS

Among the subset of women who changed their CAM behavior from enrollment to 1 year following BRCA1/2 results disclosure, there was a significantly higher proportion who changed from no CAM use to CAM use among the overall cohort (P=0.01), among women without cancer at enrollment (P=0.003), among women found to be BRCA1/2 carriers (P=0.03), and among women randomized to the genetic counseling intervention arm of the study (P=0.009). Number of CAMs used at 1 year was positively associated with number of CAMs used at baseline, sunscreen use, and BRCA1/2 mutation status.

CONCLUSION

High-risk women who have received BRCA1/2 counseling and testing frequently adopt new CAM use in the first year after learning their genetic status. Mutation carriers frequently initiate CAM use after learning their genetic status as part of their cancer preventive regimen. Further studies are warranted to determine the efficacy of CAM-related strategies for cancer prevention.

Formats for improving risk communication in medical tradeoff decisions

To make treatment decisions, patients should consider not only a treatment option's potential consequences but also the probability of those consequences. Many laypeople, however, have difficulty using probability information. This Internet-based study (2,601 participants) examined a hypothetical medical tradeoff situation in which a treatment would decrease one risk but increase another. Accuracy was assessed in terms of the ability to determine correctly whether the treatment would increase or decrease the total risk. For these tradeoff problems, accuracy was greater when the following occurred: (1) the amount of cognitive effort required to evaluate the tradeoff was reduced; (2) probability information was presented as a graphical display rather than as text only; and (3) information was presented as percentages rather than as frequencies (n in 100). These findings provide suggestions of ways to present risk probabilities that may help patients understand their treatment options.

Attitudes Regarding Overweight, Exercise, and Health among Blacks (United States)

OBJECTIVE

To investigate Blacks'views regarding the connections among overweight, exercise, and health.

METHODS

A national randomized telephone survey of 986 US Blacks, conducted between 6 July 2004 and 15 July 2004.

RESULTS

The majority (65%) of respondents reported their weight as average or underweight. Most participants also reported being regularly physically active in the last month (84.5%). The majority of participants reported believing that it is possible to be overweight and healthy. Most acknowledged the connection between exercise and health, and just over half of respondents identified the association between overweight and cancer risk. There was little sociodemographic variation in responses, although findings differed by self-reported overweight and physical activity.

CONCLUSIONS

Some Blacks may underestimate the extent of their overweight, perhaps resulting from the high prevalence of the condition in the population. Gaps exist in Blacks' recognition of the connection between weight and health, although the importance of exercise for health promotion was widely acknowledged. These data may highlight an important target for intervention attention.

Home health care nurses as a new channel for smoking cessation treatment: outcomes from project CARES (Community-nurse Assisted Research and Education on Smoking)

BACKGROUND

Clinical guidelines for smoking cessation may not be sufficient for helping some subgroups of smokers quit. Incorporating smoking cessation into home-based medical care can proactively reach high-risk smokers who may not have access to (or spontaneously seek) smoking cessation.

METHOD

Home health care nurses (N = 98) were randomly assigned to deliver either Motivational Enhancement (ME; Motivational Interviewing + Carbon Monoxide Feedback) or Standard Care (AHCPR Guidelines for smoking cessation) to their patients. Seventy percent of patients were eligible and willing to participate (N = 273; 54% female, mean age = 57 years, 83% Caucasian, 41% < high school education). The study was conducted in Providence, RI, USA from 1998 to 2003.

RESULTS

Biochemically verified continuous abstinence rates at the 12-month follow-up were 4.2% (SC) and 8.7% (ME) for intent to treat analyses, and 5.2% (SC) and 11.8% (ME) using all available cases (P > 0.05). ME reported more quit attempts and significantly greater reductions in the number of cigarettes smoked per day at all follow-ups through 12 months of post-treatment (all P values < 0.05).

CONCLUSIONS

Use of an existing public health channel such as home health care to reach smokers who vary in their motivation to quit could have the potential for large public health impact.

Methods and baseline characteristics of two group-randomized trials with multiracial and multiethnic working-class samples

INTRODUCTION

Few papers address the methodological challenges in recruiting participants for studies of cancer prevention interventions designed for multiracial and multiethnic working-class populations. This paper reports the results of the sample selection and survey methods for two group-randomized intervention studies.

METHODS

The two group-randomized intervention studies, Healthy Directions-Small Business (HD-SB) and Healthy Directions-Health Centers (HD-HC), included a worksite-based study in 26 small manufacturing businesses and a study in 10 outpatient health centers. We used selection and recruitment methods to obtain a multiracial and multiethnic working-class study sample. In 2000 and 2001, we assessed baseline measures of sociodemographic characteristics and behavioral outcomes by self-report. We then computed intraclass correlation coefficients (ICCs).

RESULTS

Of the 1740 participants in the HD-SB study, 68% were non-Hispanic whites, and 76% had working-class occupations. In the HD-HC study, 59% of 2219 participants were non-Hispanic whites. Among those who worked, 51% had working-class occupations. Large percentages of both samples reported not meeting recommended guidelines for the target behaviors. For example, 86% of members of both samples consumed fewer than the recommended five servings of fruits and vegetables per day. The ICCs for the four target behaviors in HD-SB were between 0.006 and 0.02. In the HD-HC study, the ICCs ranged from 0.0004 to 0.003.

CONCLUSION

The two studies were successful in recruiting multiracial and multiethnic working-class participants. Researchers will find the estimates of the primary outcomes and their ICCs useful for planning future studies.

Introduction to the Special Section on Dissemination: Dissemination Research and Research Dissemination: How Can We Close the Gap?

One of the greatest challenges facing health promotion and disease prevention is translating research findings into evidence-based public health and clinical practices that are actively disseminated and widely adopted. Despite the tremendous strides made in developing effective disease prevention and control programs, there has been little study of effective dissemination of evidence-based programs to and adoption by community, public health, and clinical practice settings. This special section provides a venue in which to highlight exemplary dissemination research efforts while also identifying limitations in research to date and framing important future research questions. This issue establishes a resource for investigators interested in dissemination research, with relevance to health psychology. In this sense, it can serve as a benchmark by which to examine subsequent progress. The 6 articles reflect the state of the science in dissemination research for the promotion and adoption of health behavior change interventions.

Characteristics Associated With Use or Intention to Use Indoor Tanning Among Adolescents

BACKGROUND

Indoor tanning is a popular behavior that may increase skin cancer risk.

OBJECTIVE

To examine characteristics associated with use or intention to use indoor tanning among adolescents.

METHODS

A telephone interview was conducted with 1273 adolescents, aged 14 to 17 years, in the Minneapolis-St Paul, Minn, and Boston, Mass, metropolitan areas. Questions included demographic and phenotypic characteristics, knowledge, attitudes, social factors, use of indoor tanning, and intention to tan indoors.

RESULTS

Twelve percent of boys and 42% of girls had tanned indoors. Among nontanners, 22.4% planned to start, and 77.2% of tanners planned to continue tanning indoors. Nontanners and tanners at risk for future indoor tanning use were each significantly more likely to be female, less likely to use sun protection, less knowledgeable about skin cancer risks, more likely to agree that tans were attractive, and more strongly influenced by social factors compared with their low-risk counterparts.

CONCLUSIONS

Our data suggest that intention to tan indoors may identify a group of adolescents at risk for adopting the behavior; prospective studies are needed for confirmation.

Multiple risk behaviors among smokers in the childhood cancer survivors study cohort

The literature on health behaviors of young adult cancer survivors is very limited, and thus little is known about preventable risk factors in this population. This paper describes the prevalence of five behavioral risk factors among 541 young adult survivors of childhood cancers from the CCSS cohort who were identified as smokers and enrolled in a randomized controlled trial of a smoking cessation intervention. The relationship between presence of multiple risk factors and a number of smoking-related factors was examined. About 31% of the sample engaged in zero or one health-risk behavior in addition to smoking; 63% engaged in 2 or 3, and 6% engaged in 4 or 5. There were positive linear relationships between number of risk factors and smoking rate and nicotine dependence. Number of risk factors was not associated with self-efficacy for quitting, but was related to readiness to quit. This study demonstrated that childhood cancer survivors who smoke have a number of other risk factors for the development of preventable disease and the presence of these risks was associated with factors that decrease the likelihood of quitting smoking. Attention to other health behaviors may be an important strategy for helping smokers quit. In particular, helping childhood cancer survivors who smoke to reduce other risk behaviors might also encourage them to quit smoking.

Oncology physician and nurse practices and attitudes regarding offering clinical trial results to study participants

Despite recent interest on the part of advocates and researchers of oncology clinical trials in sharing study results, participants in these trials are not routinely informed about the results. We identified oncology physicians and nurses through the Cancer and Leukemia Group B database and surveyed them about sharing clinical trial results with participants. Of 1977 eligible members, 796 (40.3%) responded to the mailed survey, 497 (62.4%) of whom reported that they offer trial results to participants less than one-fifth of the time. A total of 576 (72.4%) of responders believed that most patients want to know the results of studies, and 634 (79.7%) of responders expressed willingness to offer results to most study participants in the future, believing that most patients want to know trial results and that routinely offering results would not have a negative effect on patients. Concerns of some responders about routinely offering trial results included negative emotional effect on patients, patient difficulty understanding the information, and resources required to offer the results. Of concern, 16.2% (129/796) of responders believed an obligation to offer results to study participants would make them less likely to enroll patients on studies. Future studies should consider sharing trial results with patients and evaluating the process and its effect on both patients and clinicians.

Barriers to endoscopic colorectal cancer screening: are women different from men?

OBJECTIVES

The goals of this study were to compare women and men's understanding of screening flexible sigmoidoscopy (FS) and to identify predictors of endoscopic colorectal cancer (CRC) screening.

METHODS

We mailed a 36-item questionnaire to asymptomatic patients aged 50 years or older who were scheduled for routine health assessments at a large multispecialty health-care group. Data collection included demographics, health behaviors, psychosocial factors, and CRC screening compliance. We followed participants for 1 year and assessed completion of endoscopic CRC screening. Both cross-sectional results examining previous screening and prospective results examining screening 1 year later were evaluated.

RESULTS

554 (54%) of 998 patients responded to the survey. Responses of 13 patients were excluded in the analyses due to unverifiable screening outcome. The majority of the respondents were white, and their average age was 62 years. Women reported significantly more embarrassment and fear about having FS than men. Women were more willing to consider having a FS if a female endoscopist performed the procedure. Of the 334 participants who were eligible to have endoscopic CRC screening, 53 (16%) had the procedure within a year. The odds of having the endoscopic procedures increased with the length of time the patients were under the care of their primary care providers and how strongly patients believed that one should have an FS even without symptoms.

CONCLUSION

Our findings suggest some unique gender-specific attitudes and beliefs that act as potential barriers for CRC screening and further support the important role of primary care providers in facilitating timely completion of screening.

Reducing social disparities in tobacco use: a social-contextual model for reducing tobacco use among blue-collar workers

In the United States in 1997, the smoking prevalence among blue-collar workers was nearly double that among white-collar workers, underscoring the need for new approaches to reduce social disparities in tobacco use. These inequalities reflect larger structural forces that shape the social context of workers' lives. Drawing from a range of social and behavioral theories and lessons from social epidemiology, we articulate a social-contextual model for understanding ways in which socioeconomic position, particularly occupation, influences smoking patterns. We present applications of this model to worksite-based smoking cessation interventions among blue-collar workers and provide empirical support for this model. We also propose avenues for future research guided by this model.

Skin cancer prevention and detection practices among siblings of patients with melanoma

BACKGROUND

Family members of patients with melanoma have an increased risk of the disease, and families with multiple affected members account for about 10% of melanoma cases. These statistics suggest that first-degree relatives of patients with melanoma, who are at particularly high risk, warrant targeted public health action.

OBJECTIVE

We sought to document rates for dermatologist examinations for cutaneous lesions, the practice of skin self-examination, and sunscreen use in this at-risk group.

METHODS

Before participation in a randomized trial, 404 siblings of recently diagnosed patients with melanoma completed a survey on beliefs and practices regarding skin cancer prevention and detection.

RESULTS

Sixty-two percent of participants had carefully examined their skin, 54% routinely used sunscreen, and 27% had received a skin cancer examination by a dermatologist during the past year; 47% had never received a dermatologist examination. Multivariate analysis found modifiable positive predictors for skin self-examination and dermatologist examinations, including having a clinician with whom to talk about melanoma and believing in the importance of regular skin examinations by a physician. Significant modifiable negative predictors included enjoyment of being tanned, not being sure what to look for when examining moles, and feeling uncomfortable having others look at their skin.

CONCLUSIONS

Skin self-examination rates among these high-risk siblings are markedly higher than in population-based studies. However, many siblings were not screened for skin cancer by a dermatologist despite having strong risk profiles, being nearly fully insured, and being under care of primary care physicians. Improvements in communication between physicians and high-risk families and changes in office systems to assess family history of melanoma could increase screening rates for the estimated 1 million siblings of patients with melanoma.

Model for incorporating social context in health behavior interventions: applications for cancer prevention for working-class, multiethnic populations

BACKGROUND

This article proposes a conceptual framework for addressing social contextual factors in cancer prevention interventions, and describes work that operationalizes this model in interventions for working class, multiethnic populations.

METHODS

The Harvard Cancer Prevention Program Project Includes Three Studies: (1) an intervention study in 25 small businesses; (2) an intervention study in 10 health centers; and (3) a computer simulation modeling project that translates risk factor modifications into gains in life expectancy and number of cancers averted. The conceptual framework guiding this work articulates pathways by which social context may influence health behaviors, and is used to frame the interventions and guide evaluation design.

RESULTS

Social contextual factors cut across multiple levels of influence, and include individual factors (e.g., material circumstances, psychosocial factors), interpersonal factors (e.g., social ties, roles/responsibilities, social norms), organizational factors (e.g., work organization, access to health care), and neighborhood/community factors (e.g., safety, access to grocery stores). Social context is shaped by sociodemographic characteristics (e.g., social class, race/ethnicity, gender, age, language) that impact day-to-day realities.

CONCLUSIONS

By illuminating the pathways by which social contextual factors influence health behaviors, it will be possible to enhance the effectiveness of interventions aimed at reducing social inequalities in risk behaviors.

A comprehensive worksite cancer prevention intervention: behavior change results from a randomized controlled trial (United States)

OBJECTIVE

Workplace cancer prevention initiatives have been least successful with blue-collar workers. This study assesses whether an intervention integrating health promotion with occupational health and safety results in significant and meaningful increases in smoking cessation and consumption of fruits and vegetables, compared to a standard health promotion intervention, for workers overall and for blue-collar workers in particular.

METHODS

A randomized controlled design was used, with 15 manufacturing worksites assigned to a health promotion (HP) or a health promotion plus occupational health and safety intervention (HP/OHS), and compared from baseline (1997) to final (1999). The response rates to the survey were 80% at baseline (n = 9019) and 65% at final (n = 7327). Both groups targeted smoking and diet; the HP/OHS condition additionally incorporated reduction of occupational exposures.

RESULTS

Smoking quit rates among blue-collar workers in the HP/OHS condition more than doubled relative to those in the HP condition (OR = 2.13, p = 0.04), and were comparable to quit rates of white-collar workers. No statistically significant differences between groups were found for mean changes in fruits and vegetables.

CONCLUSIONS

Integration of occupational health and safety and health promotion may be an essential means of enhancing the effectiveness of worksite tobacco control initiatives with blue-collar workers.

Complementary medicine use among women enrolled in a genetic testing program

The purpose of this study is to explore complementary and alternative medicine (CAM) use and factors influencing CAM use by women enrolled in a genetic testing program for predisposition to breast/ovarian cancer. A cohort of 236 high-risk women completed baseline questionnaires at enrollment into BRCA1/2 testing program. CAM use and correlates of use were assessed using logistic regression models. CAM was used by 53% of the overall cohort. Cancer survivors reported significantly more use of complementary treatments than did unaffected women (61 versus 42%; P < 0.05). Participants had good overall health behaviors; daily fruit/vegetable consumption was significantly related to CAM use. Increased depression level, knowledge of cancer genetics, and frequency of breast self-examination were significantly associated with using CAM for cancer survivors. Among unaffected women only, cancer risk perception and sunscreen use were significantly correlated with CAM use. Recognition of heightened breast cancer risk is correlated with increased complementary therapy use by unaffected women undergoing genetic testing for cancer predisposition but not to the extent that cancer survivors use these strategies. Any potential effects of the genetic information itself on CAM use, and any possible relationship of CAM use to other risk reduction behaviors, require further research.