Facilitators and Barriers to Implementing a Digital Informed Decision Making Tool in Primary Care: A Qualitative Study

BACKGROUND

Informed decision aids provide information in the context of the patient's values and improve informed decision making (IDM). To overcome barriers that interfere with IDM, our team developed an innovative iPad-based application (aka "app") to help patients make informed decisions about colorectal cancer screening. The app assesses patients' eligibility for screening, educates them about their options, and empowers them to request a test via the interactive decision aid.

OBJECTIVE

The aim of the study is to explore how informed decision aids can be implemented successfully in primary care clinics, including the facilitators and barriers to implementation; strategies for minimizing barriers; adequacy of draft training materials; and any additional support or training desired by clinics.

DESIGN

This work deals with a multicenter qualitative study in rural and urban settings.

PARTICIPANTS

A total of 48 individuals participated including primary care practice managers, clinicians, nurses, and front desk staff.

APPROACH

Focus groups and semi-structured interviews, with data analysis were guided by thematic analysis.

KEY RESULTS

Salient emergent themes were time, workflow, patient age, literacy, and electronic health record (EHR) integration. Saving time was important to most participants. Patient flow was a concern for all clinic staff, and they expressed that any slowdown due to patients using the iPad module or perceived additional work to clinic staff would make staff less motivated to use the program. Participants voiced concern about older patients being unwilling or unable to utilize the iPad and patients with low literacy ability being able to read or comprehend the information.

CONCLUSION

Integrating new IDM apps into the current clinic workflow with minimal disruptions would increase the probability of long-term adoption and ultimate sustainability.

NIH TRIAL REGISTRY NUMBER

R01CA218416-A1.

Abstract A015: Integrating research and outreach to increase CRC screening knowledge in underserved communities: The Geographic Management of Cancer Health Disparities Program and National Outreach Network Screen to Save partnership

Introduction: The Geographic Management of Cancer Health Disparities Program (GMaP) is a national NCI program with the goal of increasing cancer health disparities (CHD) research. GMaP Region 1 North (R1N) is one of seven GMaP Regional “hubs” based at NCI-designated cancer centers (CCs) across the country, covering the states of DE, KY, ME, MD, NH, VA, VT, WV, and the District of Columbia. The National Outreach Network (NON) is a national NCI program with the goal of conducting cancer education and outreach in underserved communities to reduce CHD. NON Community Health Educators (CHEs) are based at 38 NCI-designated CCs across the country. Six NCI-designated CCs with NON CHEs fall within the GMaP R1N coverage area.

Methods: GMaP R1N staff and NON CHEs within the R1N coverage area met bimonthly to collaborate on the Screen to Save (S2S): NCI Colorectal Cancer (CRC) Outreach and Screening Initiative. The goal of S2S was to educate underserved communities on CRC and CRC screening. NON CHEs conducted the projects in diverse urban and rural communities within their CC catchment areas. Participants attended a CRC education event that provided an inflatable colon or a PowerPoint presentation and completed demographic and pre-/post-event surveys to gauge their knowledge of CRC screening. Surveys were submitted to NCI Center to Reduce Cancer Health Disparities program staff for review and data entry. Raw data files were returned to NON CHEs and shared with GMaP R1N staff for analysis. R1N staff provided research expertise to compare results between urban and rural S2S participants.

Results: There were a total of 328 participants in S2S (n=200 urban; n=128 rural) in the GMaP R1N/NON coverage area. The median age of urban participants was 59.5 vs. 49.0 for rural participants. 95% of urban participants and 96.1% of rural participants reported having health insurance (public or private). 92.9% of urban and 88.1% of rural participants attained at least a high school diploma or GED. 76.5% of urban and 41.4% of rural participants reported ever being screened for CRC by any method. The percent increase between pre- and post-test scores for the educational intervention was 15% for urban vs. 13.3% for rural participants, with an overall percent increase in knowledge of 14.2%.

Conclusions: The urban and rural participants were similar in educational and health insurance attainment levels. Urban residents reported much higher rates of previous CRC screening than rural residents, but this is likely due to the fact that more rural participants were younger than the recommended CRC initial screening age at the time (age 50). The S2S educational intervention was effective in increasing knowledge of CRC screening among both rural and urban participants, with similar increase between the two groups. Overall, this project demonstrated that two different yet complementary programs, GMaP and NON, can work together by utilizing program strengths to successfully implement an educational intervention conducted across a wide and diverse geographic area.

Citation Format: Mark Cromo, Rhonda Boozer-Yeary, Melinda L. Rogers, Katelyn Schifano, Jenna Schiffelbein, Katherine L. Jones, Marcela Blinka, Julia F. Houston, Betsy Grossman, Lindsay Hauser, James Zabora, Mark B. Dignan, Tracy Onega. Integrating research and outreach to increase CRC screening knowledge in underserved communities: The Geographic Management of Cancer Health Disparities Program and National Outreach Network Screen to Save partnership [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A015.

A randomized trial to reduce smoking among American Indians in South Dakota: The walking forward study

BACKGROUND

Lung cancer is an important public health issue, particularly among American Indians (AIs). The reported decline in tobacco use for most racial/ethnic groups is not observed among AIs. This project was designed to address the research question, "Why don't more Northern Plains American Indians alter tobacco use behaviors known to increase the risk of cancer?"

METHODS

Guided by the Theory of Planned Behavior, a multi-component intervention study was implemented. Adult AIs, age 18 years or older and currently smoking, were enrolled. Eligible subjects were randomized to one of 15 groups and exposed to either a MINIMAL or an INTENSE level of 4 intervention components. The intervention was delivered face-to-face or via telephone by Patient Navigators (PN). The primary outcome was self-reported abstinence from smoking verified by carbon monoxide measurement.

RESULTS

At 18 months post-quit date, 88% of those who were still in the study were abstinent. This included 6% of all participants who enrolled in the study (14/254) and 13% of those who made it to the quit date (14/108). No intervention groups were found to have significant proportions of participants who were abstinent from smoking at the quit date (visit 5) or primary outcome visit (18 months post-quit date, visit 11), but use of pharmacologic support for abstinence was found to be an effective strategy for individuals who continued participation throughout the study. Those who remained in the study received more visits and were more likely to be abstinent.

CONCLUSIONS

Use of NRT increased the odds of not smoking, as assessed at the 18-month follow-up visit, but no other interventions were found to significantly contribute to abstinence from smoking. Although the intervention protocol included numerous points of contact between CRRs and participants (11 visits) loss to follow-up was extensive with only 16/254 remaining enrolled. Additional research is needed to improve understanding of factors that influence enrollment and retention in smoking cessation interventions for AI and other populations.

Predictors of Willingness to Participate in Biospecimen Donation and Biobanking among Appalachian Adults

BACKGROUND

Rural residents in the U.S., particularly residents of Appalachia, are underrepresented in biomedical research, limiting the generalizability of research findings.

OBJECTIVE

To examine factors associated with Appalachian adults' willingness to participate in biospecimen donation and banking.

METHODS

A survey assessing willingness to donate blood, saliva, and buccal specimens and to have these biospecimens stored for future use in genetic studies was conducted among 493 Appalachian adults.

RESULTS

Most participants 73% (358/493) were willing to donate one or more biospecimen type; among them, 75% (268/358) were willing to donate blood, saliva, and buccal specimens. Approximately 61% (300/493) were willing to have their biospecimens banked and 97% (290/300) of these were willing to have their samples used for genetic studies. Appalachian self-identity predicted willingness to donate biospecimens, to have them stored, and used in genetic studies (OR1.52, 95% CI 1.03-2.24).

CONCLUSIONS

Appalachian adults were generally willing to participate in biobanking research.

A Group Randomized Trial to Reduce Obesity among Appalachian Church Members: The Walk by Faith Study

Background: Appalachia is a rural, socioeconomically disadvantaged region with high rates of cancer and obesity. Using community-based participatory research principles, the Appalachia Community Cancer Network tested an initiative to reduce weight among overweight and obese participants by partnering with churches, an important community-based institution in Appalachia.Methods: A group randomized trial was conducted with counties or groups of counties in five Appalachian states. These groups were randomly assigned to receive either monthly diet and exercise education sessions ("Walk by Faith"; WbF) or an educational program focused on cancer screening and education ("Ribbons of Faith"; RoF) to examine effects on weight change. Participants completed questionnaires and biometric measurements at baseline and 12 months. The primary outcome of the study was weight change from baseline to 12 months.Results: The relative difference in weight loss from baseline to 12 months for WbF compared with RoF was 1.4% but was not statistically significant (P = 0.13). However, results varied by sex and marital status. WbF men experienced a significant 2.8% decrease in body weight, married WbF women a 1.5% decrease, and unmarried WbF women a 1.5% increase compared with their respective RoF subgroups (interaction P = 0.016). Among WbF participants, greater participation in monthly educational sessions was associated with greater weight loss (P = 0.002).Conclusions: WbF facilitated weight loss mainly in male participants. Level of participation in WbF activities correlated with weight loss.Impact: Findings suggest that additional research is needed to better understand factors associated with participation in health promotion programs for underserved rural communities. Cancer Epidemiol Biomarkers Prev; 27(11); 1289-97. ©2018 AACR.

Lessons Learned While Developing “Clinical Trials Education for Native Americans” Curriculum

This paper highlights lessons learned while developing the Clinical Trials Education for Native Americans (CTENA) curriculum. The CTENA is a culturally specific clinical trials education curriculum that evolved from another ongoing NCI-supported project, Clinical Trials Education for Colorado Providers. The multicultural team learned many lessons while developing, pretesting, and revising this curriculum. These include allocating sufficient time and resources to tailor presentations for diverse tribal settings and workshop participants, addressing barriers to participation in clinical trials through culturally appropriate strategies, providing information to foster informed decision making related to participation, and writing as a team to increase cultural breadth of examples and interactive experiences. There are multiple challenges to developing and implementing a culturally acceptable curriculum on clinical trials within medically underserved communities. Both the multicultural team and the curriculum benefited from the collaborative process, resulting in a culturally relevant clinical trials curriculum that will assist Native Americans to make informed choices about clinical trials participation. The lessons shared here, which may need to be modified to be culturally relevant to other underrepresented communities, may be beneficial to others developing similar curricula for other medically underserved populations.

Reality Versus Grant Application Research "Plans"

This article describes the implementation of the American Indian mHealth Smoking Dependence Study focusing on the differences between what was written in the grant application compared to what happened in reality. The study was designed to evaluate a multicomponent intervention involving 256 participants randomly assigned to one of 15 groups. Participants received either a minimal or an intense level of four intervention components: (1) nicotine replacement therapy, (2) precessation counseling, (3) cessation counseling, and (4) mHealth text messaging. The project team met via biweekly webinars as well as one to two in-person meetings per year throughout the study. The project team openly shared progress and challenges and collaborated to find proactive solutions to address challenges as compared to what was planned in the original grant application. The project team used multiple strategies to overcome unanticipated intervention issues: (1) cell phone challenges, (2) making difficult staffing decisions, (3) survey lessons, (4) nicotine replacement therapy, (5) mHealth text messages, (6) motivational interviewing counseling sessions, and (7) use of e-cigarettes. Smoking cessation studies should be designed based on the grant plans. However, on the ground reality issues needed to be addressed to assure the scientific rigor and innovativeness of this study.

Abstract LB-174: Patient navigation in Appalachia: results from a survey of current practices

Purpose: The Appalachian region of the US includes 420 counties in 13 states that begin with New York, follow the Appalachian Mountains and extend to Mississippi. The region has a heterogeneous population that shares distinct cultural characteristics, high rates of unemployment, low income, and high rates of chronic disease, including cancer. Patient navigators (PN) provide one-on-one guidance and assistance through the health care continuum from prevention to end-of-life and address barriers and enhance access to healthcare through the use of individual navigators who are sensitive to the needs, interests and values of the community. Although there are numerous PN training programs available, there are no known programs that are designed for the Appalachian population. As a first step in developing such a program, we designed and conducted a survey of PN training needs in Appalachia.

Methods: With guidance from formative research involving a variety of stakeholders, we identified key individuals, professional groups, health care systems, and public health agencies serving the Appalachian region. We developed a 26-item survey to collect information on current patient navigation programs, sources of current training, and training needs. After pretesting, the survey was distributed online. Data were collected from June, 2015 through May, 2016.

Results: A total of 152 responses were received. The responses were from community based organizations (29.3%), academic medical centers (15.5%), hospitals (35.8%), and community cancer centers (19.5%). PN was currently provided by individuals from a variety of professional backgrounds, chiefly nursing (32.8%) and social work (8.4%), and 15.3% were community navigators. Only 63.8% of respondents reported having received formal PN training. About half (47.3%) indicated that they were interested in attending PN training and suggested specific content and format.

Conclusions: Survey respondents identified a need for PN training that focuses on Appalachia. These results supported the development of an Appalachia Patient Navigation Training Program, currently underway.

Note: This abstract was not presented at the meeting.

Citation Format: Mark B. Dignan, Sharon Dwyer, Carol White, Elizabeth A. Rohan, Dana White, Georgina Castro, Reda Wilson, Mary Boyd, Eric Stockton. Patient navigation in Appalachia: results from a survey of current practices [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr LB-174. doi:10.1158/1538-7445.AM2017-LB-174

Abstract A81: Utilizing the Geographic Management of Cancer Health Disparities Program (GMaP) Region 1 North partnership survey as a tool to promote mentoring and collaborative grant applications

Introduction:

Region 1 North of the National Cancer Institute's Geographic Management of Cancer Health Disparities Program (GMaP) is based at the University of Kentucky Markey Cancer Center (UK MCC). GMaP was funded for a three-year period as a supplement to the UK MCC Cancer Center Support Grant with an overall goal to reduce cancer health disparities. Efforts to achieve this goal include enhancing the capacity of regional cancer centers, associated academic partners, community partners, and early-stage investigators to increase research on disparities by fostering collaborative research applications and facilitating the career development of the next generation of underrepresented cancer and cancer health disparities investigators.

Methods:

UK MCC GMaP investigators are partnering with researchers at Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, the University of Virginia Cancer Center, the University of South Carolina Cancer Prevention and Control Program, and other regional cancer center and academic partners to implement multi-faceted programming to increase and strengthen collaborative research and training efforts across the Region 1 North coverage area, which includes DC, DE, KY, ME, MD, NH, VA, VT, and WV. GMaP Region 1 North has implemented an online survey of investigators and partners throughout the region to assess their career level, research focus and interests, and readiness to submit grant applications within the next 12 months.

Results:

A total of 161 responses to the survey have been received. The respondents include undergraduate and graduate students, faculty members, research and administrative staff and community members. Over 70% of respondents described themselves as researchers (32% cancer center researchers) and almost 50% as mentors. The most common response categories for types of research conducted include basic science (52%), translational (44%), cancer health disparities (39%) and behavioral/population focused research (36%). Of those currently funded by extramural sources, 26% reported R01 funding and nearly all of the remaining respondents reported funding by a wide variety of other NIH mechanisms. Most (88%) respondents indicated that they are planning R01 and/or R21 applications within the next 12 months.

Conclusion:

The survey has provided Region 1 North investigators with a working foundation for matching mentors with underrepresented early-stage investigators for K- and R-series grant applications. Additionally, the survey results provide a tool to promote collaborative applications across regional institutions through targeted communication and media efforts.

Citation Format: Mark B. Dignan, Nathan L. Vanderford, B Mark Evers, Mark Cromo, Janice Bowie, Adrian Dobs, Ashleigh Gallagher, Olive Mbah, Julia F. Houston, Neha Jaggi, Roger Anderson, James R. Hebert. Utilizing the Geographic Management of Cancer Health Disparities Program (GMaP) Region 1 North partnership survey as a tool to promote mentoring and collaborative grant applications. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A81.

Intention to Breastfeed as a Predictor of Initiation of Exclusive Breastfeeding in Hispanic Women

Exclusive breastfeeding (EBF) is the most efficacious form of infant feeding and nutrition. Hispanic mothers in the US are more likely than mothers of other racial/ethnic groups to supplement with formula in the first 2 days of life. The purpose of this study was to explore infant feeding intentions during the prenatal period as a predictor of EBF at postpartum discharge in a sample of Hispanic women (n = 99). At discharge, 51 % of the women were EBF, 44 % were breastfeeding and supplementing with formula, and 5 % were feeding only formula. Intention to breastfeed was found to be a strong and potentially modifiable predictor of breastfeeding behavior, showing a significant association with EBF upon discharge from the hospital after birth when linked with acceptance of pregnancy and method of delivery. Prenatal care offers a unique opportunity to enhance intentions to breastfeed that may lead to improved EBF in this health vulnerable population.

Randomized Trial Testing a Worksite Sun Protection Program in an Outdoor Recreation Industry

Health communication campaigns intended to reduce chronic and severe exposure to ultraviolet radiation in sunlight and prevent skin cancer are a national priority. Outdoor workers represent an unaddressed, high-risk population. Go Sun Smart (GSS), a worksite sun safety program largely based on the diffusion-of-innovations theory, was evaluated in a pair-matched, group-randomized, pretest-posttest controlled design enrolling employees at 26 ski areas in Western North America. Employees at the intervention ski areas were more aware of GSS (odds ratio [OR] = 8.27, p < .05) and reported less sunburning (adjusted OR = 1.63, p < .05) at posttest than employees at the control areas. A dose response was evident (OR = 1.46, p < .05) with greater observed program implementation associated with fewer sunburns among employees. Program awareness per se was not predictive ( p > .05) of reduced sunburning in a mediational analysis. Analyses of nonrespondents, including intent-to-treat analyses, further supported the success of GSS.

The Effect of Changes in Health Beliefs Among African-American and Rural White Church Congregants Enrolled in an Obesity Intervention: A Qualitative Evaluation

Church interventions can reduce obesity disparities by empowering participants with knowledge and skills within an established community. The purpose of this study was to evaluate the Biomedical/Obesity Reduction Trial (BMORe) and investigate changes in health beliefs among obese adult participants. Ten pre-/post-intervention focus groups applying the Health Belief Model conducted in two African-American churches in Tennessee (n = 20) and South Carolina (n = 20), and one rural Appalachian church in Kentucky (n = 21). Two independent coders using NVivo analyzed transcribed audio data and notes. Participants' health status of being overweight/obese and having comorbidities of diabetes and high blood pressure motivated enrollment in BMORe. Initially participants voiced low self-efficacy in cooking healthy and reading food labels. BMORe made participants feel "empowered" after 12 weeks compared to initially feeling "out of control" with their weight. Participants reported improvements in emotional health, quality of life, and fewer medications. During post-intervention focus groups, participants reported increased self-efficacy through family support, sharing healthy eating strategies, and having accountability partners. Solidarity and common understanding among BMORe participants led focus group attendees to comment how their peers motivated them to stay in the program for 12 weeks. Long-term barriers include keeping the weight off by maintaining habits of exercise and healthy eating. Implementation of pre-/post-intervention focus groups is an innovative approach to evaluate an obesity intervention and track how changes in health beliefs facilitated behavior change. This novel approach shows promise for behavioral interventions that rely on participant engagement for sustained effectiveness.

Modeling the Influence of Early Skin-to-Skin Contact on Exclusive Breastfeeding in a Sample of Hispanic Immigrant Women

Using data from a longitudinal study of breastfeeding in Hispanics, this study evaluated the influence of early skin-to-skin contact (SSC) on initiation and sustained exclusive breastfeeding (EBF) at 1 month postpartum. Two-thirds of the women in the sample participated in early SSC. At discharge, over half of the women were EBF; this proportion decreased to one-third at 1 month postpartum. Controlling for demographic and clinical variables in the model, participation in early SSC was associated with a greater than sevenfold increase in the odds of EBF at discharge (p = .005) but was not predictive of EBF at 1 month post-discharge (p = .7). Younger maternal age and increased prenatal infant feeding intention were associated with an increased likelihood of EBF across both timepoints. Promoting early SSC may help with initiation of EBF, while further breastfeeding support may be needed to maintain EBF following discharge for this vulnerable population.

Abstract A41: Willingness of adults in Appalachia to participate in research involving biospecimens, biobanking and genetics

Introduction: Rural residents in the U.S., specifically residents of Appalachia, continue to be underrepresented in cancer-related research, which limits the generalizability of findings. In this study, we examined factors associated with willingness of Appalachian adults to participate in donation and banking of biospecimens for research.

Methods: As a component of the Appalachian Community Cancer Network (ACCN) II Research Study, between January 2012 and September 2013, we conducted a survey among a faith-based sample of 493 Appalachian adults age 18-92 years (mean = 55.8 years). Five questions aimed at assessing participants' willingness (five-point scale: not willing at all, hesitant but willing, neutral, willing, very willing) to donate blood, saliva, and buccal specimens and to have their specimens banked and used in future genetics studies were included in the survey. Using univariate logistic regression models, where the outcomes were dichotomized (“willing” [very willing or willing] vs. “not willing” [neutral, hesitant but willing, or not willing at all]), we calculated odds ratios (ORs) and 95% confidence intervals (CIs) to describe factors significantly associated with participants' willingness to provide these samples. Future analyses will include multivariable-adjusted models.

Results: Approximately 73% (358/493) indicated willingness to donate ≥1 biospecimen type; among them, 75% (268/358) were willing to donate all 3 types. Years of education (16 yrs vs. ≤12 yrs: OR 1.85, 95% CI 1.15-2.99), being employed (OR 1.63, 95% CI 1.07-2.49), having private insurance (OR 1.75, 95% CI 1.18-2.63), identifying as Appalachian (OR 1.61, 95% CI 1.00-2.58), being religious (OR 1.66, 95% CI 1.03-2.66) and being normotensive (OR 1.64, 95% CI 1.12-2.38) were associated with willingness to donate blood. Years of education (16 yrs vs. ≤12 yrs: OR 2.47, 95% CI 1.48-4.11), being employed (OR 1.64, 95% CI 1.06-2.52) and having private insurance (OR 1.52, 95% CI 1.01-2.27) were associated with willingness to donate a buccal sample. Years of education (16 yrs vs. ≤12 yrs: OR 1.94, 95% CI 1.22-3.10) and being employed (OR 1.52, 95% CI 1.01-2.31) were associated with willingness to donate saliva. Approximately 61% (300/493) of participants indicated willingness to have their biospecimens banked for use in future studies; among them, 97% (290/300) were willing to have their samples used for future genetics studies. Years of education (16 yrs vs. ≤12 yrs: OR 2.04, 95% CI 1.27-3.28), regularly engaging in physical activity (OR 1.60, 95% CI 1.10-2.33) and experiencing fewer depressive symptoms (OR 1.85, 95% CI 1.10-3.13) were associated with willingness to have donated biospecimens stored for future research. Years of education (16 yrs vs. ≤12 yrs: OR 2.29, 95% CI 1.40-3.74) and being employed (OR 1.66, 95% CI 1.08-2.54) were associated with willingness to allow donated biospecimens to be used in genetics studies.

Conclusions: Appalachian adults in this study responded favorably to questions regarding willingness to participate in biospecimen donation and banking for future research, including genetics studies. Respondents with higher socioeconomic status and positive self-reported health status were most likely to endorse biospecimen donation. This study offers insights into the predictors of willingness to participate in donation and banking of biospecimens for research and may contribute to future efforts to increase equitable representation of Appalachian residents in biomedical research.

Citation Format: Adana A.M. Llanos, Gregory S. Young, Eugene J. Lengerich, Ryan Baltic, Betsy B. Aumiller, Mark B. Dignan, Electra D. Paskett. Willingness of adults in Appalachia to participate in research involving biospecimens, biobanking and genetics. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A41.

Study design, intervention, and baseline characteristics of a group randomized trial involving a faith-based healthy eating and physical activity intervention (Walk by Faith) to reduce weight and cancer risk among overweight and obese Appalachian adults

BACKGROUND

Increased prevalence of overweight and obesity among Appalachian residents may contribute to increased cancer rates in this region. This manuscript describes the design, components, and participant baseline characteristics of a faith-based study to decrease overweight and obesity among Appalachian residents.

METHODS

A group randomized study design was used to assign 13 churches to an intervention to reduce overweight and obesity (Walk by Faith) and 15 churches to a cancer screening intervention (Ribbons of Faith). Church members with a body mass index (BMI) ?25 were recruited from these churches in Appalachian counties in five states to participate in the study. A standard protocol was used to measure participant characteristics at baseline. The same protocol will be followed to obtain measurements after completion of the active intervention phase (12months) and the sustainability phase (24months). Primary outcome is change in BMI from baseline to 12months. Secondary outcomes include changes in blood pressure, waist-to-hip ratio, and fruit and vegetable consumption, as well as intervention sustainability.

RESULTS

Church members (n=664) from 28 churches enrolled in the study. At baseline 64.3% of the participants were obese (BMI?30), less than half (41.6%) reported regular exercise, and 85.5% reported consuming less than 5 servings of fruits and vegetables per day.

CONCLUSIONS

Church members recruited to participate in a faith-based study across the Appalachian region reported high rates of unhealthy behaviors. We have demonstrated the feasibility of developing and recruiting participants to a faith-based intervention aimed at improving diet and increasing exercise among underserved populations.

Translation of a Ski School Sun Safety Program to North American Ski and Snowboard Schools

Health promotion programs that develop and implement strategies to promote sun safety practices to children have the potential to reduce skin cancer occurrence later in life. Go Sun Smart (GSS), a sun safety program for employees and guests of ski areas, was distributed to determine if an enhanced dissemination strategy was more effective than a basic dissemination strategy at reaching parents at ski and snowboard schools. On-site observations of GSS use and surveys of 909 parents/caregivers with children enrolled in ski and snowboard schools at 63 ski areas were conducted and analyzed using techniques for clustered designs. No differences were identified by dissemination strategy. Greater implementation of GSS (>5 messages posted) was associated with greater parental recall, 36.6% versus 16.7%, of materials, but not greater sun protection practices. Greater recall of messages, regardless of level of implementation, resulted in greater sun protection practices including applying sunscreen (p < .05), providing sunglasses and goggles (p < .01), and more use of all sun protection practices (p < .01). Ski areas with more program materials appeared to reach parents with sun safety advice and thus convinced them to take more precautions for their children. Sun safety need not be at odds with children's outdoor recreation activities.

Factors influencing exclusive breastfeeding at 4 months postpartum in a sample of urban Hispanic mothers in Kentucky

BACKGROUND

Although Hispanic mothers in the United States have slightly higher rates of breastfeeding initiation than the national average, they are more likely to supplement with formula.

OBJECTIVES

To describe infant feeding decisions in a sample of 72 urban Hispanic mothers and assess whether demographic and personal factors influence exclusive breastfeeding (EBF) status at 4 months postpartum.

METHODS

The study was longitudinal and included assessments during pregnancy, in the hospital following childbirth, and monthly up to 4 months following birth.

RESULTS

Nearly all of the 72 mothers were breastfeeding at discharge after the birth of their infant (94%); half of these were EBF. By 2 months postpartum, the rate of EBF had declined to 26%, dropping to 22% by 4 months. Significant predictors of EBF status at 4 months included the baseline indicator for mother's partner as the most important person in life (adjusted odds ratio [AOR], 5.42; 95% confidence interval [CI], 1.03-28.66) and breastfeeding self-efficacy score at 1 month (AOR, 1.20; 95% CI, 1.07-1.34).

CONCLUSION

These findings have particular relevance in this population, given the high rate of breastfeeding initiation coupled with breastfeeding self-efficacy being a modifiable factor. Support during pregnancy and postpartum, including consultation with a lactation consultant, may increase the self-efficacy of EBF in this low-income population, leading to higher rates of extended EBF among Hispanics.

Research Partnerships with Healthcare Providers in Rural Community Health Centers: Needs and Challenges in Diabetes Research

Kentucky has among the highest rates of diabetes and obesity in the United States. The Kentucky Diabetes and Obesity Collaborative (KDOC) was designed to develop a novel research infrastructure that can be used by researchers focusing on obesity and diabetes among patients cared for by Federally Qualified Health Centers (FQHC) serving rural Kentucky. Focus groups were carried out to develop an understanding of the needs and interests of FQHC practitioners and staff regarding participation in KDOC. Focus groups were conducted with 6 FQHCs and included a total of 41 individuals including health care providers, administrative staff and clinical staff. The discussions ranged in time from 30 to 70 minutes and averaged 45 minutes. Analysis of the transcripts of the focus groups revealed 4 themes: 1) contextual factors, 2) infrastructure, 3) interpersonal relationships, and 4) clinical features. The participants also noted four requirements that should be met for a research project to be successful in rural primary care settings: 1) there must be a shared understanding of health priorities of rural communities between the researcher and the practices/providers; 2) the proposed research must be relevant to clinics and their communities; 3) research and recommendations for evidence-based interventions need to reflect the day-to-day challenges of rural primary care providers; and 4) there needs to be an understanding of community norms and resources. Although research-clinic partnerships were viewed favourably overall, challenges in data integration to support both research and clinical outcomes were identified.

Findings from the native navigators and the Cancer Continuum (NNACC) study

Native Navigators and the Cancer Continuum (NNACC) was a community based participatory research study among Native American Cancer Research Corporation, CO; Inter-Tribal Council of Michigan, MI; Rapid City Regional Hospital's Walking Forward, SD; Great Plains Tribal Chairman's' Health Board, SD; and Muscogee (Creek) Nation, OK. The project goal was to collaborate, refine, expand, and adapt navigator/community education programs to address American Indian communities' and patients' needs across the continuum of cancer care (prevention through end-of-life). The intervention consisted of four to six site-specific education workshop series at all five sites. Each series encompassed 24 h of community education. The Social Ecology Theory guided intervention development; community members from each site helped refine education materials. Following extensive education, Native Patient Navigators (NPNs) implemented the workshops, referred participants to cancer screenings, helped participants access local programs and resources, and assisted those with cancer to access quality cancer care in a timely manner. The intervention was highly successful; 1,964 community participants took part. Participants were primarily American Indians (83 %), female (70 %) and between 18 and 95 years of age. The education programs increased community knowledge by 28 %, facilitated referral to local services, and, through site-specific navigation services, improved access to care for 77 participants diagnosed with cancer during the intervention. Approximately, 90 % of participants evaluated workshop content as useful and 92.3 % said they would recommend the workshop to others. The intervention successfully increased community members' knowledge and raised the visibility of the NPNs in all five sites.

Dissemination of go sun smart in outdoor recreation: effect of program exposure on sun protection of guests at high-altitude ski areas

Go Sun Smart is a theory-based health communication program designed to influence sun-protection behaviors of employees and guests at high-altitude ski areas to reduce skin cancer risk. The effects of Go Sun Smart, in a Phase IV dissemination randomized posttest-only trial, on sun-protection behaviors of ski area guests are reported. Program use was assessed by on-site observation and guest message exposure, and sun protection was measured in intercept surveys at ski areas. Dissemination strategy-enhanced versus basic-was not significantly related to sun safety practices. Additional analyses examined the relation between message exposure and guests' sun safety practices. Ski areas displaying at least 6 Go Sun Smart materials in guest-only areas and 9 Go Sun Smart materials throughout the area increased guests' message exposure. Higher message exposure within the high-use ski areas was associated with improved sun protection by guests but not within the low-use ski areas. The authors underscore the importance of program implementation and message exposure on the success of evidence-based health communication efforts applied industrywide.

Mobile mammography in underserved populations: analysis of outcomes of 3,923 women

Mobile health units are increasingly utilized to address barriers to mammography screening. Despite the existence of mobile mammography outreach throughout the US, there is a paucity of data describing the populations served by mobile units and the ability of these programs to reach underserved populations, address disparities, and report on outcomes of screening performance. To evaluate the association of variables associated with outcomes for women undergoing breast cancer screening and clinical evaluation on a mobile unit. Retrospective analysis of women undergoing mammography screening during the period 2008-2010. Logistic regression was fitted using generalized estimating equations to account for potential repeat annual visits to the mobile unit. In total, 4,543 mammograms and/or clinical breast exams were conducted on 3,923 women with a mean age of 54.6, 29 % of whom had either never been screened or had not had a screening in 5 years. Age < 50 years, lack of insurance, Hispanic ethnicity, current smoking, or having a family relative (<50 years of age) with a diagnosis of cancer were associated with increased odds of a suspicious mammogram finding (BIRADS 4,5,6). Thirty-one breast cancers were detected. The mobile outreach initiative successfully engaged many women who had not had a recent mammogram. Lack of insurance and current smoking were modifiable variables associated with abnormal screens requiring follow up.

Evaluation of Patient Needs and Patient Navigator Communication about Cervical Cancer Prevention in Appalachian Kentucky

Few studies describe the way patient navigation processes may address disparities in treatment and follow-up care for medically underserved populations. Using a social ecological framework, we analyzed survey assessments of 519 patients completing a randomized navigation trial in Appalachia Kentucky to examine patient-reported barriers to follow-up cervical cancer care. We also analyzed in-depth interview transcripts with four lay patient navigators in the trial to identify barriers to follow-up care and to learn what communication strategies navigators use to successfully (or unsuccessfully) help patients navigate around those barriers. Our analysis provides insight into how patient navigation may improve adherence to follow-up care through assisted uncertainty management. We also discuss opportunities for improving navigator training to address disparities in clinical outcomes.

Enhancing industry-based dissemination of an occupational sun protection program with theory-based strategies employing personal contact

PURPOSE

Industry-based strategies for dissemination of an evidence-based occupational sun protection program, Go Sun Smart (GSS), were tested.

DESIGN

Two dissemination strategies were compared in a randomized trial in 2004-2007.

SETTING

The North American ski industry.

SUBJECTS

Ski areas in the United States and Canada (n  =  69) and their senior managers (n  =  469).

INTERVENTION

Employers received GSS through a basic dissemination strategy (BDS) from the industry's professional association that included conference presentations and free starter kits. Half of the areas also received the enhanced dissemination strategy (EDS), in which project staff met face-to-face with managers and made ongoing contacts to support program use.

MEASURES

Observation of program materials in use and managers' reports on communication about sun protection.

ANALYSIS

The effects of two alternative dissemination strategies were compared on program use using PROC MIXED in SAS, adjusted for covariates using one-tailed p values.

RESULTS

Ski areas receiving the EDS used more GSS materials (x¯  =  7.36) than those receiving the BDS (x¯  =  5.17; F  =  7.82, p < .01). Managers from more areas receiving the EDS reported communicating about sun protection in employee newsletters/flyers (x¯  =  .97, p  =  .04), in guest e-mail messages (x¯  =  .75, p  =  .02), and on ski area Web sites (x¯  =  .38, p  =  .02) than those receiving the BDS (x¯  =  .84, .50, .15, respectively).

CONCLUSION

Industry professional associations play an important role in disseminating prevention programs; however, active personal communication may be essential to ensure increased implementation fidelity.

An increase in HPV-related knowledge and vaccination intent among parental and non-parental caregivers of adolescent girls, age 9-17 years, in Appalachian Pennsylvania

A theory and community-based educational intervention was designed to increase HPV-related knowledge and intent to vaccinate adolescent girls, against human papillomavirus (HPV) in Appalachia, a region with high cervical cancer incidence and mortality. An HPV educational session was conducted with immediate pre-/post-test questionnaires and 1-month follow-up telephone interview. McNemar tests and paired t tests evaluated change in individual knowledge variables and change in overall knowledge and intent to vaccinate against HPV, respectively. Of 117 attendees, 38 (32.5%) were parents of vaccine-eligible daughters and 79 (67.5%) non-parental caregivers. HPV-related knowledge increased for all participants (p < 0.0001) and among parents (p < 0.0001). Intent to vaccinate daughters within 1 month increased among parents (p = 0.002). Of nine (23.7%) parents who completed the follow-up interview, 100% reported the intervention as helpful and 44.4% reported that they started vaccination. Our education intervention was associated with increased HPV-related knowledge and intent to vaccinate girls in Appalachia against HPV.

Assessment of cancer education seminars for Appalachian populations

Cancer education seminars for Appalachian populations were conducted to: (1) increase knowledge of existing cancer disparities, (2) disseminate findings from Appalachian community-based participatory research (CBPR) projects, and (3) foster CBPR capacity building among community members by promoting social networking. Evaluation of the seminars was completed by: (1) using pre-post-surveys to assess changes in knowledge and attitudes at three regional and one national seminar and (2) measuring a change in the social network patterns of participants at a national seminar by analyzing the names of individuals known at the beginning and at the end of the seminar by each participant. Among participants, there was a significant increase in knowledge of Appalachian cancer disparities at two seminars [national, t(145) = 3.41, p = 0.001; Pennsylvania, t(189) = 3.00, p = 0.003] and a change in attitudes about Appalachia at one seminar [Ohio t(193) = -2.80, p = 0.006]. Social network analysis, operationally defined for this study as familiarity with individuals attending the conference, showed participation in the national seminar fostered capacity building for future CBPR by the development of new network ties. Findings indicate that short-term outcomes of the seminars were accomplished. Future educational seminars should consider using social network analysis as a new evaluation methodology.

A community-based randomized trial of a faith-placed intervention to reduce cervical cancer burden in Appalachia

OBJECTIVE

Faith Moves Mountains assessed the effectiveness of a faith-placed lay health advisor (LHA) intervention to increase Papanicolaou (Pap) test use among middle-aged and older women in a region disproportionately affected by cervical cancer and low screening rates (regionally, only 68% screened in prior 3 years).

METHOD

This community-based RCT was conducted in four Appalachian Kentucky counties (December 2005-June 2008). Women aged 40-64 and overdue for screening were recruited from churches and individually randomized to treatment (n=176) or wait-list control (n=169). The intervention provided LHA home visits and newsletters addressing barriers to screening. Self-reported Pap test receipt was the primary outcome.

RESULTS

Intention-to-treat analyses revealed that treatment group participants (17.6% screened) had over twice the odds of wait-list controls (11.2% screened) of reporting Pap test receipt post-intervention, OR=2.56, 95% CI: 1.03-6.38, p=0.04. Independent of group, recently screened participants (last Pap >1 but <5 years ago) had significantly higher odds of obtaining screening during the study than rarely or never screened participants (last Pap ≥5 years ago), OR=2.50, 95% CI: 1.48-4.25, p=0.001.

CONCLUSIONS

The intervention was associated with increased cervical cancer screening. The faith-placed LHA addressing barriers comprises a novel approach to reducing cervical cancer disparities among Appalachian women.

A pilot study for using fecal immunochemical testing to increase colorectal cancer screening in Appalachia, 2008-2009

INTRODUCTION

The Appalachian region of the United States has disproportionately high colorectal cancer (CRC) death rates and low screening rates. The purpose of this pilot study was to assess acceptability of a take-home fecal immunochemical test (FIT) and the effect of follow-up telephone counseling for increasing CRC screening in rural Appalachia.

METHODS

We used a prospective, single-group, multiple-site design, with centralized laboratory reports of screening adherence and baseline and 3-month questionnaires. Successive patients, aged 50 or older, at average CRC risk and due for screening were enrolled during a routine visit to 3 primary care practices in rural Appalachian Pennsylvania and received a free take-home FIT and educational brochure. Those who had not returned the test 2 weeks later were referred for telephone counseling.

RESULTS

Of 232 patients approached, 200 (86.2%) agreed to participate. Of these, 145 (72.5%) completed the FIT as recommended (adherent) and 55 (27.5%) were referred for telephone counseling (nonadherent), of whom 23 (41.8%) became adherent after 1 to 2 counseling sessions, an 11.5 percentage-point increase in screening after telephone counseling and 84% FIT adherence overall. Lack of CRC-related knowledge and perceived CRC risk were the screening barriers most highly associated with nonadherence. Although not statistically significant, the rate of conversion to screening adherence was higher among participants who received telephone counseling compared to an answering machine reminder.

CONCLUSION

If confirmed in future randomized trials, provider-recommended take-home FIT and follow-up telephone counseling may be methods to increase CRC screening in Appalachia.

Compliance with sunscreen advice in a survey of adults engaged in outdoor winter recreation at high-elevation ski areas

BACKGROUND

Adults are advised to wear sunscreen with a sun protection factor (SPF) of 15 or higher, apply it up to 30 minutes before sun exposure, and reapply it after 2 hours to reduce exposure to ultraviolet radiation in sunlight for the prevention of skin cancer.

OBJECTIVE

This study investigated the extent to which adults comply with sunscreen advice.

METHODS

A survey was conducted with 4837 adult skiers and snowboarders at 28 high-altitude ski areas in western North America in January through April 2001 through 2002. Respondents self-reported use of sunscreen, its SPF, time of first application, and reapplication.

RESULTS

Only 4.4% (95% confidence interval [CI] = ±0.6) of adults were in full compliance with all sunscreen advice. Half (49.8% [95% CI = ±1.4]) complied with SPF 15 or higher advice. Of those wearing sunscreen, 73.2% (95% CI = ±1.8) applied the sunscreen 30 minutes before beginning skiing/snowboarding, but only 20.4% (95% CI = ±2.0) complied with advice to reapply it after 2 hours. Total compliance was lowest during inclement weather, on low-ultraviolet days, by men, and among respondents who believed skin cancer was unimportant and with low sun-sensitive skin. It was positively associated with wearing lip balm and hats with a brim.

LIMITATIONS

The sample was predominantly male and of high socioeconomic status; the results apply most to winter recreation when ultraviolet radiation levels are low, and sunscreen use was assessed by self-report.

CONCLUSION

Although the recommendation to use SPF 15 or higher sunscreen has reached many adults, the reapplication advice is heeded by few adults and needs to be highlighted in future sun safety promotions.

Sustainability of the dissemination of an occupational sun protection program in a randomized trial

Sustainability of an occupational sun safety program, Go Sun Smart (GSS), was explored in a randomized trial, testing dissemination strategies at 68 U.S. and Canadian ski areas in 2004-2007. All ski areas received GSS from the National Ski Areas Association through a Basic Dissemination Strategy (BDS) using conference presentations and free materials. Half of the ski areas were randomly assigned to a theory-based Enhanced Dissemination Strategy (EDS) with personal contact supporting GSS use. GSS use was assessed at immediate and long-term follow-up posttests by on-site observation. Use of GSS declined from immediate (M = 6.24) to long-term follow-up (M = 4.72), F(1, 62) = 6.95, p = .01, but EDS ski areas (M = 6.53) continued to use GSS more than BDS ski areas (M = 4.49), F(1, 62) = 5.75, p = .02, regardless of timing of posttest, strategy × observation F(1, 60) = 0.05, p = .83. Despite declines over time, a group of ski areas had sustained high program use and active dissemination methods had sustained positive effects on implementation.

Abstract A18: Cancer patient navigation in the unique social and health care environment of Appalachia: Results from the Appalachia Community Cancer Network (ACCN)

Research Objective: Many cancer patients face substantial barriers to the delivery of effective, coordinated care. Coupled with areas of low socio-economic status, the mountainous region and shortage of cancer care providers present unique challenges to these patients. As a result, cancer patient navigation has emerged as a possible solution to these problems; with its community and organization-focused strategy to alleviate barriers to obtaining timely screening, diagnosis, and treatment. Our study aims were to examine cancer patient navigation in Appalachia and consisted of three main objectives; (1) to assess the extent of cancer patient navigation utilization in Appalachia, (2) to describe the characteristics and functions of patient navigators, and (3) to identify facilitators and barriers to successful navigation adoption and execution in Appalachia.

Study Design: Using a snowball sampling technique that began with program managers of the ACCN, we conducted 29 semi-structured interviews with key informants in Appalachia. Interviewees included patient navigators, representatives from health care and voluntary organizations, and government agencies, including those who do not, but would like to, offer patient navigation. We used a predetermined coding scheme with review by multiple reviewers of audio transcripts to identify patient navigator characteristics, barriers and facilitators to cancer services, and the use of patient navigation across communities. We stratified our analysis into organizations that do and do not currently utilize cancer patient navigation.

Sample: We studied community and organization-based cancer patient navigation programs in Appalachia. Principle Findings: Cancer patient navigation is limited but growing in Appalachia. Our findings suggest that strong cultural networks embedded within the rural regions heighten the need for navigators that have personal relationships with and knowledge of Appalachian communities. Community connection optimizes the navigator's functionality in attaining compliance to cancer treatments by disparate populations. Thus, the most common characteristics of successful patient navigators suggested by the interviewees included “close community connection” and “the ability to work with others”. Moreover, the vast majority of informants were paid, female staff members residing in rural areas. Sixty-five percent of our informants were trained health care professionals, while 35% were lay persons. Interviewees also acknowledged limited coordination of cancer services across health care and non-health care institutions in addition to a lack of cancer treatment resources. This elevates barriers for patients including transportation to appointments, accessing medications, and insurance.

Conclusions: In addition to socio-economic challenges, many Appalachian residents experience increased distances to cancer services, fewer cancer centers, and unique cultural characteristics. The contributions of navigators with strong community affiliations are more positively accepted by local residents. Navigators exhibiting these characteristics also promote more efficient use of organizational and community resources. Thus, consideration of this during the creation of a patient navigator program is paramount.

Implications for Policy, Delivery, or Practice: Limited financial resources for patient navigation have halted progress in improving cancer health outcomes. Increased attention in this area will enable organizations to commence patient navigation programs in underserved areas of Appalachia and assist in alleviating barriers to cancer care. Managers of health care and non-health care institutions may also use patient navigation to collaborate more effectively in aligning cancer services for residents.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A18.

How do rural health care providers and patients view barriers to colorectal cancer screening? Insights from appalachian kentucky

This article reports findings from a qualitative study that explored the attitudes and beliefs concerning colorectal cancer (CRC) screening among patients and health care providers in Appalachian Kentucky. Results from 5 focus groups are discussed here: 3 with primary care providers and 2 with patients. Although there are some areas of agreement, there are marked differences between the perceptions of Appalachian health care providers and participants regarding CRC screening. This article compares and contrasts those perceptions and provides suggestions for culturally competent practice and culturally relevant research to improve CRC screening in this vulnerable population.

Academic detailing to increase colorectal cancer screening by primary care practices in Appalachian Pennsylvania

BACKGROUND

In the United States, colorectal cancer (CRC) is the third most frequently diagnosed cancer and second leading cause of cancer death. Screening is a primary method to prevent CRC, yet screening remains low in the U.S. and particularly in Appalachian Pennsylvania, a largely rural area with high rates of poverty, limited health care access, and increased CRC incidence and mortality rates. Receiving a physician recommendation for CRC screening is a primary predictor for patient adherence with screening guidelines. One strategy to disseminate practice-oriented interventions is academic detailing (AD), a method that transfers knowledge or methods to physicians, nurses or office staff through the visit(s) of a trained educator. The objective of this study was to determine acceptability and feasibility of AD among primary care practices in rural Appalachian Pennsylvania to increase CRC screening.

METHODS

A multi-site, practice-based, intervention study with pre- and 6-month post-intervention review of randomly selected medical records, pre- and post-intervention surveys, as well as a post-intervention key informant interview was conducted. The primary outcome was the proportion of patients current with CRC screening recommendations and having received a CRC screening within the past year. Four practices received three separate AD visits to review four different learning modules.

RESULTS

We reviewed 323 records pre-intervention and 301 post-intervention. The prevalence of being current with screening recommendation was 56% in the pre-intervention, and 60% in the post-intervention (p=0.29), while the prevalence of having been screened in the past year increased from 17% to 35% (p<0.001). Colonoscopies were the most frequently performed screening test. Provider knowledge was improved and AD was reported to be an acceptable intervention for CRC performance improvement by the practices.

CONCLUSIONS

AD appears to be acceptable and feasible for primary care providers in rural Appalachia. A ceiling effect for CRC screening may have been a factor in no change in overall screening rates. While the study was not designed to test the efficacy of AD on CRC screening rates, our evidence suggests that AD is acceptable and may be efficacious in increasing recent CRC screening rates in Appalachian practices which could be tested through a randomized controlled study.

Predictors of cervical cancer screening for rarely or never screened rural Appalachian women

BACKGROUND AND PURPOSE

Women who have not had a Papanicolaou test in five years or more have increased risk of developing invasive cervical cancer. This study compares Appalachian women whose last screening was more than one year ago but less than five years ago with those not screened for the previous five years or more.

METHODS

Using PRECEDE/PROCEED as a guide, factors related to obtaining Pap tests were examined using cross-sectional data from 345 Appalachian Kentucky women. Bivariate and multivariate analyses were conducted to identify predictors of screening.

RESULTS

Thirty-four percent of participants were rarely- or never-screened. In multiple logistic regression analyses, several factors increased those odds, including belief that cervical cancer has symptoms, and not having a regular source of medical care.

CONCLUSION

The findings from this study may lead to the development of effective intervention and policies that increase cervical cancer screening in this population.

Accuracy of screening mammography varies by week of menstrual cycle

PURPOSE

To investigate sensitivity, specificity, and cancer detection rate of screening mammography according to week of menstrual cycle among premenopausal women.

MATERIALS AND METHODS

In this institutional review board-approved HIPAA-compliant study, sensitivity, specificity, and cancer detection rate of 387,218 screening mammograms linked to 1283 breast cancers in premenopausal women according to week of menstrual cycle were studied by using prospectively collected information from the Breast Cancer Surveillance Consortium. Logistic regression analysis was used to test for differences in mammography performance according to week of menstrual cycle, adjusting for age and registry.

RESULTS

Overall, screening mammography performance did not differ according to week of menstrual cycle. However, when analyses were subdivided according to prior mammography, different patterns emerged. For the 66.6% of women who had undergone regular screening (mammography had been performed within the past 2 years), sensitivity was higher in week 1 (79.5%) than in subsequent weeks (week 2, 70.3%; week 3, 67.4%; week 4, 73.0%; P = .041). In the 17.8% of women who underwent mammography for the first time in this study, sensitivity tended to be lower during the follicular phase (week 1, 72.1%; week 2, 80.4%; week 3, 84.6%; week 4, 93.8%; P = .051). Sensitivity did not vary significantly by week in menstrual cycle in women who had undergone mammography more than 3 years earlier. There were no clinically meaningful differences in specificity or cancer detection rate.

CONCLUSION

Premenopausal women who undergo regular screening may benefit from higher sensitivity of mammography if they schedule screening mammography during the 1st week of their menstrual cycle.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100974/-/DC1.

Intraclass correlation estimates for cancer screening outcomes: estimates and applications in the design of group-randomized cancer screening studies

BACKGROUND

Screening has become one of our best tools for early detection and prevention of cancer. The group-randomized trial is the most rigorous experimental design for evaluating multilevel interventions. However, identifying the proper sample size for a group-randomized trial requires reliable estimates of intraclass correlation (ICC) for screening outcomes, which are not available to researchers. We present crude and adjusted ICC estimates for cancer screening outcomes for various levels of aggregation (physician, clinic, and county) and provide an example of how these ICC estimates may be used in the design of a future trial.

METHODS

Investigators working in the area of cancer screening were contacted and asked to provide crude and adjusted ICC estimates using the analysis of variance method estimator.

RESULTS

Of the 29 investigators identified, estimates were obtained from 10 investigators who had relevant data. ICC estimates were calculated from 13 different studies, with more than half of the studies collecting information on colorectal screening. In the majority of cases, ICC estimates could be adjusted for age, education, and other demographic characteristics, leading to a reduction in the ICC. ICC estimates varied considerably by cancer site and level of aggregation of the groups.

CONCLUSIONS

Previously, only two articles had published ICCs for cancer screening outcomes. We have complied more than 130 crude and adjusted ICC estimates covering breast, cervical, colon, and prostate screening and have detailed them by level of aggregation, screening measure, and study characteristics. We have also demonstrated their use in planning a future trial and the need for the evaluation of the proposed interval estimator for binary outcomes under conditions typically seen in GRTs.

Breast screening navigator programs within three settings that assist underserved women

Medically underserved women in the Greater Denver Metropolitan Area had low rates of routine repeat mammograms in the latter 1990s. "Increasing Mammography Adherence among Medically Underserved Women" was designed to increase annual rescreening among medically underserved populations living in this area. Four community-based organizations collaborated to implement this 5-year study. A culturally modified navigator model including both face-to-face and telephone formats was used to facilitate mammography for African Americans, Latinas, Native Americans, and poor White women who had not been rescreened in more than 18 months. The navigator-implemented intervention was statistically significant at the 0.05 level for increasing rescreening.

Native American breast cancer survivors' physical conditions and quality of life

BACKGROUND

Based on Survivors' Guidance, an interactive, Web-based, culturally relevant Native American cancer survivorship program, Native American Cancer Education for Survivors (NACES), was developed. The focus of the program is to improve quality of life (QOL) for Native American breast cancer survivors.

METHODS

NACES is a community-driven research and education project, based on the Social Cognitive Theoretical Model. Participants complete a QOL survey that includes physical, psychosocial, spiritual, and social components. This publication focuses on the physical component of the survey collected by trained Native American patient advocates, and compares physical conditions among Native American breast cancer survivors who were diagnosed within 1 year, those diagnosed between 1 and 4 years, and those who are long-term survivors (diagnosed > or = 5 years ago).

RESULTS

For the first time, survivorship issues are reported specifically for Native American breast cancer patients (n = 266). Selected access issues document situations that contribute to disparities. Comorbidities such as high blood pressure and arthritis are common in the survivors, with more than a third having diabetes, in addition to breast cancer. Numerous side effects from cancer treatments are experienced by these survivors.

CONCLUSIONS

These data describe what Native American breast cancer patients are experiencing based on self-reported information. Clearly there is need for much more work and long-term tracking of Native American patients to begin to document if or how the severity of physical symptoms lessens over time and if their experiences are significantly different from non-Native Americans.

The effect of a motivational intervention on weight loss is moderated by level of baseline controlled motivation

BACKGROUND

Clinic-based behavioral weight loss programs are effective in producing significant weight loss. A one-size-fits-all approach is often taken with these programs. It may be beneficial to tailor programs based on participants' baseline characteristics. Type and level of motivation may be an important factor to consider. Previous research has found that, in general, higher levels of controlled motivation are detrimental to behavior change while higher levels of autonomous motivation improve the likelihood of behavior modification.

METHODS

This study assessed the outcomes of two internet behavioral weight loss interventions and assessed the effect of baseline motivation levels on program success. Eighty females (M (SD) age 48.7 (10.6) years; BMI 32.0 (3.7) kg/m(2); 91% Caucasian) were randomized to one of two groups, a standard group or a motivation-enhanced group. Both received a 16-week internet behavioral weight loss program and attended an initial and a four-week group session. Weight and motivation were measured at baseline, four and 16 weeks. Hierarchical regression analysis was conducted to test for moderation.

RESULTS

There was significant weight loss at 16-weeks in both groups (p < 0.001); however there were no between group differences (p = 0.57) (standard group 3.4 (3.6) kg; motivation-enhanced group 3.9 (3.4) kg). Further analysis was conducted to examine predictors of weight loss. Baseline controlled motivation level was negatively correlated with weight loss in the entire sample (r = -0.30; p = 0.01). Statistical analysis revealed an interaction between study group assignment and baseline level of controlled motivation. Weight loss was not predicted by baseline level of controlled motivation in the motivation-enhanced group, but was significantly predicted by controlled motivation in the standard group. Baseline autonomous motivation did not predict weight change in either group.

CONCLUSIONS

This research found that, in participants with high levels of baseline controlled motivation for weight loss, an intervention designed to enhance motivation for weight loss produced significantly greater weight loss than a standard behavioral weight loss intervention.

Faith Moves Mountains: an Appalachian cervical cancer prevention program

OBJECTIVE

To provide a conceptual description of Faith Moves Mountains (FMM), an intervention designed to reduce the disproportionate burden of cervical cancer among Appalachian women.

METHODS

FMM, a community-based participatory research program designed and implemented in collaboration with churches in rural, southeastern Kentucky, aims to increase cervical cancer screening (Pap tests) through a multiphase process of educational programming and lay health counseling.

RESULTS

We provide a conceptual overview to key elements of the intervention, including programmatic development, theoretical basis, intervention approach and implementation, and evaluation procedures.

CONCLUSIONS

After numerous modifications, FMM has recruited and retained over 400 women, 30 churches, and has become a change agent in the community.

Testing a theory-based health communication program: a replication of Go Sun Smart in outdoor winter recreation

The epidemic of preventable skin cancer in the United States creates an urgent need for health communication campaigns to improve sun protection. Go Sun Smart (GSS), a theory-driven multichannel health communication campaign showed positive effects on sun safety behaviors of employees and guests in a randomized trial at high-altitude ski areas. In this article we report findings from the North American GSS campaign for guests at ski areas that comprosed the original control-group resorts, replicating the results of the original guest intervention. Results showed that after GSS was deployed, guests at the original control group ski areas increased sun protection and reported greater recall of sun safety messages. Conversely, GSS had no effect on sunburning attitudes or self-efficacy beliefs. Like the original GSS guest intervention, the present study found that greater exposure to GSS messages was associated with greater use of sunscreen, sunscreen lip balm, and face covering, but not gloves or overall sun protection. There was no evidence that GSS decreased sunburning or attitudes and self-efficacy beliefs regarding sun safety.

Men's knowledge and beliefs about prostate cancer: education, race, and screening status

OBJECTIVE

African American men die from prostate cancer at higher rates than do White men, a health disparity that may result from differences in knowledge and beliefs about prostate cancer and screening. Studies conflict on whether race or socioeconomic status affects knowledge of prostate cancer and screening. This study compared education, race, and screening status to determine how each factor shapes men's knowledge of prostate cancer and screening.

METHODS

In-depth interviews were conducted with 65 African American and White men, aged 40-64 years, with diverse educational backgrounds.

RESULTS

Education, not race or screening status, was associated with knowledge about the prostate gland, prostate cancer symptoms and screening tests, and fear of prostate cancer. The exception was knowledge about the prostate-specific antigen blood test, which was associated with education and screening status.

CONCLUSION

This study suggests that education may be associated with prostate cancer and screening knowledge. Interventions should focus on all men with low education to correct their misconceptions about prostate cancer and to engage them in shared decision-making about screening.

Parallels between the development of therapeutic drugs and cancer health disparity programs: implications for Disparities Reduction

BACKGROUND

There are analogies between the development of therapeutic drugs for cancer and the development of interventions for reducing cancer health disparities. In both cases, it can take between 12 and 15 years for the benefits to become apparent.

METHODS

The initial preclinical phase of drug development is analogous to the development of community partnerships and helping the community learn about cancer. The preclinical phase of in vitro and in vivo testing is analogous to identifying the disparities in the community. Then clinical testing begins with phase 1, toxicity, and dose-establishing studies. Analogously, community-based participatory research is used to develop disparities-reducing interventions (DRIs) within the community.

RESULTS

The phase 2 clinical studies to determine whether the drug has activity are analogous to the DRI being implemented in the community to determine whether it can cause behavioral changes that will reduce cancer health disparities. If a drug passes phase 1 and 2 studies, phase 3 clinical trials are initiated. These are controlled studies to examine the efficacy of the drug. The similar activity for disparities research is to determine whether the DRI is better than the current standard/usual practice in controlled trials. If the drug is beneficial, the final phase is the dissemination and adoption of the drug. Analogously in disparities, if the DRI is beneficial, it is disseminated and is culturally adapted to other racial/ethnic groups and finally adopted as standard practice.

CONCLUSIONS

The process of creating an effective DRI can be envisioned to have 4 stages, which can be used to aid in measuring the progress being made in reducing cancer health disparities.

Go Sun Smart

This is the story of Go Sun Smart, a worksite wellness program endorsed by the North American Ski Area Association and funded by the National Cancer Institute. Between 2000 and 2002 we designed and implemented a large-scale worksite intervention at over 300 ski resorts in North America with the objective of reducing ski area employees and guests risk for skin cancer by adopting sun safe practices. The following narrative describes the intervention in toto from its design and implementation through assessment. Our theory driven, experimentally tested intervention was successful in reducing employees' risks for skin cancer during and after the ski season. We also succeeded in making ski area guests more aware of the need to take sun safe precautions with both themselves and their children.

Appalachian women's perceptions of their community's health threats

CONTEXT

Decades of behavioral research suggest that awareness of health threats is a necessary precursor to engage in health promotion and disease prevention, findings that can be extended to the community level.

PURPOSE

We sought to better understand local perspectives on the main health concerns of rural Appalachian communities in order to identify the key health priorities. While Kentucky Appalachian communities are often described as suffering from substandard health, resource, and socioeconomic indicators, strong traditions of community mobilization make possible positive, home-grown change.

METHODS

To assess what women, the key health gatekeepers, perceive as the most significant health threats to their rural communities, 10 focus groups were held with 52 Appalachian women from diverse socioeconomic backgrounds. Tape-recorded narratives were content analyzed and a codebook was developed. Measures designed to increase data trustworthiness included member checks, negative case evidence, and multiple coding.

FINDINGS

The following rank-ordered conditions emerged as posing the greatest threat to the health of rural Appalachian communities: (1) drug abuse/medication dependence; (2) cancer; (3) heart disease and diabetes (tied); (4) smoking; (5) poor diet/overweight; (6) lack of exercise; and (7) communicable diseases. These health threats were described as specific to the local environment, deriving from broad ecological problems and were connected to one another.

CONCLUSION

Drawing on participants' community-relevant suggestions, we suggest ways in which rural communities may begin to confront these health concerns. These suggestions range from modest, individual-level changes to broader structural-level recommendations.

Testing the risk compensation hypothesis for safety helmets in alpine skiing and snowboarding

OBJECTIVE

The prevalence of helmet use by alpine skiers and snowboarders was estimated and self-reports on risk taking were assessed to test for potential risk compensation when using helmets in these sports.

SETTING

Skiers and snowboarders were observed and interviewed at 34 resorts in the western United States and Canada.

SUBJECTS

Respondents were 1779 adult skiers and snowboarders in the 2003 ski season.

OUTCOME MEASURES

Observations of helmet use and questions about perceived speed and degree of challenge when not wearing a helmet (helmet wearers) or in previous ski seasons (non-helmet wearers).

RESULTS

Helmet wearers reported that they skied/snowboarded at slower speeds (OR = 0.64, p<0.05) and challenged themselves less (OR = 0.76, p<0.05) than non-helmet wearers. Adoption of safety helmets in 2003 (23%) continued to increase over 2002 (OR = 0.46, p<0.05) and 2001 (OR = 0.84, p<0.05).

CONCLUSIONS

No evidence of risk compensation among helmet wearers was found. Decisions to wear helmets may be part of a risk reduction orientation. Helmet use continues to trend upwards but adoption may be slowing.

Factors associated with imaging and procedural events used to detect breast cancer after screening mammography

OBJECTIVE

The purpose of this study was to characterize the type and frequency of diagnostic evaluations after screening mammography and to summarize their association with the likelihood of biopsy and subsequent breast cancer diagnosis.

MATERIALS AND METHODS

The data source was 584,470 women with no previous breast cancer from six states in the Breast Cancer Surveillance Consortium. In this observational study, we linked data from 1,207,631 routine screening mammograms performed between January 1, 1996, and December 31, 2002, to data on additional imaging, interventional procedures, and biopsy outcome (benign or malignant). Additional examinations were categorized into diagnostic mammography, sonography, or both. Events were further subdivided by whether they were performed on the same day as the screening examination and whether patients reported breast symptoms. Logistic regression analysis was used to examine the association between additional evaluation performed and the likelihood of biopsy and the likelihood of subsequent breast cancer diagnosis after adjustment for patient and screening mammographic characteristics.

RESULTS

Most (92%) of the screening examinations did not include additional imaging. The probability of biopsy ranged from 0.4% for examinations with no follow-up to 20.1% for those with diagnostic mammography and sonography on the same day as screening among women without symptoms and from 2.1% for those with no follow-up to 18.9% for those with diagnostic mammography and sonography on a day different from screening among women with symptoms. Thirty percent of women without symptoms who underwent biopsy had cancer, whereas 27.1% of women with symptoms who underwent biopsy had cancer. Women who underwent biopsy after screening mammography with diagnostic mammography and sonography on the same day had the highest probability of breast cancer (37.6% among women without symptoms, 36.4% among women with symptoms), whereas those who underwent only sonography performed at a later date had the lowest probability of breast cancer (11.9% among women without symptoms, 17.1% among women with symptoms).

CONCLUSION

Women who undergo screening mammography followed by diagnostic mammography and sonography have a high probability of undergoing biopsy and having the biopsy result of breast cancer when follow-up imaging is performed on the same day as screening mammography whether or not breast symptoms are present. Biopsy performed after sonography in the absence of diagnostic mammography had a low yield of breast cancer.