Adaptation of an evidence-based intervention to promote colorectal cancer screening: a quasi-experimental study

Background

To accelerate the translation of research findings into practice for underserved populations, we investigated the adaptation of an evidence-based intervention (EBI), designed to increase colorectal cancer (CRC) screening in one limited English-proficient (LEP) population (Chinese), for another LEP group (Vietnamese) with overlapping cultural and health beliefs.

Methods

Guided by Diffusion of Innovations Theory, we adapted the EBI to achieve greater reach. Core elements of the adapted intervention included: small media (a DVD and pamphlet) translated into Vietnamese from Chinese; medical assistants distributing the small media instead of a health educator; and presentations on CRC screening to the medical assistants. A quasi-experimental study examined CRC screening adherence among eligible Vietnamese patients at the intervention and control clinics, before and after the 24-month intervention. The proportion of the adherence was assessed using generalized linear mixed models that account for clustering under primary care providers and also within-patient correlation between baseline and follow up.

Results

Our study included two cross-sectional samples: 1,016 at baseline (604 in the intervention clinic and 412 in the control clinic) and 1,260 post-intervention (746 in the intervention and 514 in the control clinic), including appreciable overlaps between the two time points. Pre-post change in CRC screening over time, expressed as an odds ratio (OR) of CRC screening adherence by time, showed a marginally-significant greater increase in CRC screening adherence at the intervention clinic compared to the control clinic (the ratio of the two ORs = 1.42; 95% CI 0.95, 2.15). In the sample of patients who were non-adherent to CRC screening at baseline, compared to the control clinic, the intervention clinic had marginally-significant greater increase in FOBT (adjusted OR = 1.77; 95% CI 0.98, 3.18) and a statistically-significantly greater increase in CRC screening adherence (adjusted OR = 1.70; 95% CI 1.05, 2.75).

Conclusions

Theoretically guided adaptations of EBIs may accelerate the translation of research into practice. Adaptation has the potential to mitigate health disparities for hard-to-reach populations in a timely manner.

Hypertension identification via emergency responders: a randomized controlled intervention study

OBJECTIVE

The objective was to test the effectiveness of a mail campaign that included blood pressure (BP) measurements from patients treated by emergency medical technicians (EMTs) to motivate them to (re)check their BP at a fire station. The mailing used a 2×2 research design tailoring on risk and source personalization.

METHOD

In this randomized controlled trial, participants were randomized into a control group or one of four experimental groups. Participants residing in one of four fire departments in a Pacific Northwest metropolitan area were eligible if they had a systolic BP≥160 mm Hg and/or diastolic BP≥100 mm Hg when seen by EMTs during the study period (July 2007-September 2009).

RESULTS

Of 7106 eligible participants, 40.7% were reached for a follow-up interview. Multivariable logistic regression analysis showed that although the absolute number of fire station BP checks was low (4%), participants who received any mailed intervention had a 3 to 5-fold increase in the odds of reporting a fire station BP check over controls. Fire station visits did not differ by type of tailored mailing.

CONCLUSION

Partnering with Emergency Medical Services is an innovative way to identify high-risk community members for population health interventions.

Improving low-wage, midsized employers' health promotion practices: a randomized controlled trial

BACKGROUND

The Guide to Community Preventive Services (Community Guide) offers evidence-based intervention strategies to prevent chronic disease. The American Cancer Society (ACS) and the University of Washington Health Promotion Research Center co-developed ACS Workplace Solutions (WPS) to improve workplaces' implementation of Community Guide strategies.

PURPOSE

To test the effectiveness of WPS for midsized employers in low-wage industries.

DESIGN

Two-arm RCT; workplaces were randomized to receive WPS during the study (intervention group) or at the end of the study (delayed control group).

SETTING/PARTICIPANTS

Forty-eight midsized employers (100-999 workers) in King County WA.

INTERVENTION

WPS provides employers one-on-one consulting with an ACS interventionist via three meetings at the workplace. The interventionist recommends best practices to adopt based on the workplace's current practices, provides implementation toolkits for the best practices the employer chooses to adopt, conducts a follow-up visit at 6 months, and provides technical assistance.

MAIN OUTCOME MEASURES

Employers' implementation of 16 best practices (in the categories of insurance benefits, health-related policies, programs, tracking, and health communications) at baseline (June 2007-June 2008) and 15-month follow-up (October 2008-December 2009). Data were analyzed in 2010-2011.

RESULTS

Intervention employers demonstrated greater improvement from baseline than control employers in two of the five best-practice categories; implementing policies (baseline scores: 39% program, 43% control; follow-up scores: 49% program, 45% control; p=0.013) and communications (baseline scores: 42% program, 44% control; follow-up scores: 76% program, 55% control; p=0.007). Total best-practice implementation improvement did not differ between study groups (baseline scores: 32% intervention, 37% control; follow-up scores: 39% intervention, 42% control; p=0.328).

CONCLUSIONS

WPS improved employers' health-related policies and communications but did not improve insurance benefits design, programs, or tracking. Many employers were unable to modify insurance benefits and reported that the time and costs of implementing best practices were major barriers.

TRIAL REGISTRATION

This study is registered at clinicaltrials.gov NCT00452816.

Predictors of recruited melanoma families into a behavioral intervention project

BACKGROUND

Examination of families represents an important priority in health research. In this paper we report on individual and family-level factors associated with enrollment in a cancer prevention research project. We approached families affected by melanoma for possible participation in a randomized controlled trial of a web-based communication and support intervention.

METHODS

We recruited three family members per family for assessment - the melanoma case, a first-degree relative (FDR), and a relative who is a parent of a child age 18 or younger. Recruitment involved three steps: requesting the physician's consent to approach the melanoma case, approaching the case to request their participation and family contact information, and they approaching the FDRs and parents.

RESULTS

Of the 1380 families approached, 313 were enrolled, 263 were excluded because we could not find or contact a family member (FDR or parent), 331 did not have eligible family members, and 473 refused. The most frequently noted reason for refusal was being too busy or having no time. The primary predictors of participation for cases (OR=1.6; CI=1.01-2.51) and FDRs (OR=2.15; CI=1.11-4.13) included higher educational attainment. FDRs were more likely to enroll if they were female (OR=1.77; CI=1.1-.85) and parents were more likely to enroll if the case had been diagnosed more recently (OR=3.3; CI=1.9-5.93), if the parent was partnered (OR=4.37; CI=1.86-10.26), and if the parent lived in the same city as the case (OR=2.88; CI=1.08-7.68).

CONCLUSIONS

The results can provide information on potential directions for future family recruitment.

Using a family systems approach to investigate cancer risk communication within melanoma families

OBJECTIVE

The family provides an important communication nexus for information and support exchange about family cancer history, and adoption of family-wide cancer risk reduction strategies. The goals of this study were to (1) use the family systems theory to identify characteristics of this sample of families at increased risk of developing melanoma and (2) to relate familial characteristics to the frequency and style of familial risk communication.

METHODS

Participants were first-degree relatives (n=313) of melanoma patients, recruited into a family web-based intervention study. We used multivariable logistic regression models to analyze the association between family functioning and family communication.

RESULTS

Most participants were female (60%), with an average age of 51 years. Fifty percent of participants reported that they spoke to their relatives about melanoma risk and people were more likely to speak to their female family members. Familial adaptation, cohesion, coping, and health beliefs were strongly associated with an open style of risk communication within families. None were associated with a blocked style of risk communication. Only cohesion and adaptation were associated with the amount of risk communication that occurred within families.

CONCLUSIONS

Overall, individuals who came from families that were more highly cohesive, adaptable, and shared strong beliefs about melanoma risk were more likely to communicate openly about melanoma. The fact that this association was not consistent across blocked communication and communication frequency highlights the multifaceted nature of this process. Future research should focus on the interplay between different facets of communication.

Weight loss and changes in generic and weight-specific quality of life in obese adolescents

PURPOSE

To investigate how weight loss correlates with changes in generic and weight-specific quality of life (QoL).

METHODS

Youth generic (YQOL-S) and weight-specific instruments (YQOL-W) from 133 youth age 11-19 were analyzed at the beginning and end of 4-week immersion camp sessions known to produce weight loss. Paired samples t tests were used to test mean difference between baseline and final Body Mass Index (BMI) and YQOL-S and YQOL-W scores. YQOL-S and YQOL-W scores were transformed to values between 0 and 100, with higher values indicating better QOL. Cohen's d effect sizes were calculated to assess magnitude of effects. Percent weight loss (as % of baseline weight), change in BMI (baseline kg/m²-follow-up kg/m²), and change in % overweight ((BMI-50th% BMI for age and sex)/50th% BMI for age and sex × 100) were calculated. Multiple regressions were used to model final YQOL scores in the 11-14 and 15-19 age groups as functions of each measure of weight change, sex, age, and baseline YQOL score.

RESULTS

Youth experienced significant reductions in BMI (Mean change = 3.7, SD = 1.4, t = 34.1, P < 0.001) and in the other measures of weight change. YQOL-S and YQOL-W scores improved significantly (P < 0.001), and effect sizes were 0.61 and 0.66, respectively.

CONCLUSION

Changes in generic and weight-specific quality of life scores are associated with weight loss. The weight-specific measure is slightly more sensitive to weight changes; however, when controlling for modifiers, the YQOL-W remained significantly associated with weight loss, while the generic QoL measure did not.

Process Evaluation Results from the Eating for a Healthy Life Study

Purpose.

Conduct a process evaluation of a low-fat, high-fruit/vegetable dietary intervention in religious organizations (ROs). The purpose of this process evaluation was to explore differences in healthy eating activities between the intervention and delayed control ROs and among the intervention ROs to identify the intervention activities most associated with dietary change.

Methods.

Process data were collected via phone surveys and participation logs. A 12-month follow-up phone survey was conducted with an RO representative from intervention and delayed control ROs. The survey asked about healthy eating activities. Eating for a Healthy Life staff maintained participation logs of intervention RO participation in intervention activities: advisory board meetings, volunteer activities, healthy eating sessions, social events, dietary change mailings, print advertisements, and motivational messages. We used a stepwise regression model to determine which intervention activities were associated with changes in fat-and fiber-related dietary behaviors.

Results.

RO member participation in advisory board meetings, social activities, and healthy eating sessions were associated with healthier fat- and fiber-related dietary behaviors. Greater RO attendance at advisory board meetings and greater numbers of healthy eating sessions at the RO were associated with decreased fat-related dietary behaviors (p ≤ .05). Member participation in social activities was associated with more favorable fat, fruit, and vegetable intake.

Conclusion.

We successfully delivered an increased number of healthy activities at the intervention ROs and improved dietary-related behaviors.

Seasonal variation in fruit and vegetable consumption in a rural agricultural community

BACKGROUND

Seasonal variation in fruit and vegetable consumption has been documented in a limited number of previous investigations and is important for the design of epidemiologic investigations and in the evaluation of intervention programs.

OBJECTIVE

This study investigates fruit and vegetable consumption behaviors among Hispanic farmworkers and non-farmworkers in a rural agricultural community.

DESIGN

A larger study recruited 101 farmworker families and 100 non-farmworker families from the Yakima Valley in Washington State between December 2004 and October 2005. All families were Hispanic. An in-person administered questionnaire collected information on consumption of locally grown fruits and vegetables and sources of obtaining fruits and vegetables. Data on dietary intake asked whether or not the respondent had consumed a given fruit or vegetable in the past month. Data were collected longitudinally, coinciding with three agricultural seasons: thinning (summer), harvest (fall), and nonspray (winter).

STATISTICAL ANALYSES PERFORMED

Generalized estimating equations were used to test for statistical significance between proportions of the population who consumed a given fruit or vegetable across agricultural seasons. Multivariable logistic regression was performed and corresponding odds ratios and 95% confidence intervals are reported.

RESULTS

The proportion of respondents who ate apples, pears, plums, peaches, apricots, peppers, corn, and cucumbers was highest in the fall harvest season, whereas the proportions of those who ate cherries and asparagus were highest in the summer thinning season. Compared to non-farmworkers, a higher proportion of farmworkers reported having eaten peaches, apricots, cherries, green beans, carrots, peppers, corn, pumpkin, squash, and onions, in the past month.

CONCLUSIONS

Epidemiologic investigations and public health interventions that examine the consumption of fruits and vegetables should consider seasonal variation in consumption patterns, especially in agricultural communities.

Employer adoption of evidence-based chronic disease prevention practices: a pilot study

BACKGROUND

We conducted a pilot test of American Cancer Society Workplace Solutions, an intervention that takes a marketing approach to increasing employers' adoption of evidence-based practices to prevent and control chronic diseases among their employees.

CONTEXT

We delivered the intervention and assessed the changes in practices of 8 large employers in the Pacific Northwest.

METHODS

Workplace Solutions recommends 15 employer practices in 5 categories: 1) health insurance benefits, 2) policies, 3) workplace programs, 4) health-promoting communication, and 5) tracking of employee health behaviors to measure progress. The intervention includes 4 meetings with employers over 2 months and begins with a questionnaire-based assessment of employer practices. Tailored recommendations follow, along with practice-specific implementation assistance on requested topics. We tested the intervention in a before-after study without a comparison group.

CONSEQUENCES

The employers ranged in size from 7500 to 115,522 employees and included private companies and public employers. Seven of the eight employers implemented more of the recommended practices at follow-up (an average of 13 months after the intervention) than at baseline. Overall, implementation of the practices increased from 38% at baseline to 61% at follow-up (P = .02).

INTERPRETATION

Workplace Solutions is a promising new approach to bringing evidence-based best practices for preventing chronic disease to large numbers of adults.

Disseminating a successful dietary intervention to faith communities: feasibility of using staff contact and encouragement to increase uptake

OBJECTIVE

To test the feasibility of a dissemination strategy to increase faith communities' (FCs) adoption and implementation of a tested dietary intervention.

DESIGN

The study was a randomized, controlled trial that took place over a 9-month period.

SETTING

Seattle, Washington, metropolitan area.

PARTICIPANTS

Seven FCs assigned to an intervention group and five to a comparison group.

INTERVENTION

All FCs received intervention materials, monetary support, and a Healthy Eating Coordinator (HEC), who was available to answer questions or provide assistance. Intervention FCs additionally received monthly contact from the HEC.

MAIN OUTCOME MEASURE

The main outcome measure was the number of intervention activities the FCs reported over the intervention period.

ANALYSIS

The authors performed descriptive analyses and compared median number of activities performed by intervention and control FCs with Wilcoxon rank-sum tests.

RESULTS

Intervention FCs implemented a median of 3 intervention activities, whereas control FCs implemented a median of 0 intervention activities (P = .05).

CONCLUSIONS AND IMPLICATIONS

These findings indicate that regular contact from HECs is a feasible dissemination strategy for FCs. Further research is needed to determine how to improve the effectiveness of this contact.

The relationship between the social environment within religious organizations and intake of fat versus fruits and vegetables

The authors explored associations of social environment with dietary behavior among participants in the Eating for a Healthy Life study, a randomized, low-fat, high-fruit-and-vegetable dietary intervention trial in religious organizations. Data in this report are from baseline telephone surveys of 1,520 persons that assessed dietary behaviors (Fat- and Fiber-Related Diet Behavior Questionnaire) and social environment (Moos Group Environment Scale). After adjusting for demographic characteristics, higher scores on the Cohesion and Order/Organization subscales were associated with higher fruit/vegetable scores (indicating higher fruit and vegetable consumption). Higher scores on the Cohesion, Leader Support, and Order/Organization subscales were also associated with lower fat scores (indicating lower fat intake). Dietary behaviors within religious organizations may be related to positive perceptions of the social environment. These results support further exploration of the potential influence of religious organizations' social environment on health behaviors and its applicability to dietary change interventions.

Psychometric properties of a tool for measuring hormone-related symptoms in breast cancer survivors

Hormone-related symptoms are common in breast cancer survivors and many aspects of these symptoms are currently under study. Reliable and valid assessment tools are needed to successfully study hormone-related symptoms in breast cancer survivors; however, no gold standard currently exists for measuring these symptoms. This study evaluated the psychometric properties of a shortened version of the Breast Cancer Prevention Trial (BCPT) symptom checklist in a sample of 803 breast cancer survivors. Principal factor analysis with Promax oblique rotation revealed a five-factor structure, identifying five separate hormone-related symptoms scales: vasomotor symptoms, urinary incontinence, cognitive/mood changes, vaginal symptoms, and weight gain/appearance concern. Hormone-related symptom scale scores differed by demographic and clinical characteristics according to expectations, suggesting that these five scales from the shortened BCPT checklist are reasonably reliable and valid. Symptom scale scores were only weakly correlated with health-related quality of life scores; however, the pattern of results generally supported the validity of the symptom scales. This study adds to the evidence that breast cancer survivors experience a significant number of hormone-related symptoms. Future clinical trials and quality of life and symptom management intervention studies would benefit from accurate assessment of hormone-related symptoms with the five scales from the shortened BCPT checklist.

Possible socioeconomic and ethnic disparities in quality of life in a cohort of breast cancer survivors

BACKGROUND

This paper describes the ethnic and socioeconomic correlates of functioning in a cohort of long-term nonrecurring breast cancer survivors.

METHODS

Participants (n = 804) in this study were women from the Health, Eating, Activity, and Lifestyle (HEAL) Study, a population-based, multicenter, multiethnic, prospective study of women newly diagnosed with in situ or Stages I to IIIA breast cancer. Measurements occurred at three timepoints following diagnosis. Outcomes included standardized measures of functioning (MOS SF-36).

RESULTS

Overall, these long-term survivors reported values on two physical function subscales of the SF-36 slightly lower than population norms. Black women reported statistically significantly lower physical functioning (PF) scores (P = 0.01), compared with White and Hispanic women, but higher mental health (MH) scores (P < 0.01) compared with White and Hispanic women. In the final adjusted model, race was significantly related to PF, with Black participants and participants in the "Other" ethnic category reporting poorer functioning compared to the White referent group (P < 0.01, 0.05). Not working outside the home, being retired or disabled and being unemployed (on leave, looking for work) were associated with poorer PF compared to currently working (both P < 0.01).

CONCLUSION

These data indicate that race/ethnicity influences psychosocial functioning in breast cancer survivors and can be used to identify need for targeted interventions to improve functioning.

Psychometric evaluation of the Brief Cancer Impact Assessment among breast cancer survivors

OBJECTIVES

The increasing number of cancer survivors brings greater attention to the biopsychosocial impact of surviving cancer. Instruments exist that measure quality of life (QOL), symptoms, and specific types of functioning after cancer; however, a reliable and valid assessment of the perceived impact of cancer (IOC) on the life plans and activities of cancer survivors has been missing. This study evaluated the psychometric properties of the 16-item Brief Cancer Impact Assessment (BCIA).

METHODS

Factor analysis with Promax oblique rotation established the factor structure of the BCIA in 783 ethnically diverse breast cancer survivors, >or=2 years after diagnosis. Construct validity was assessed by comparing factor-based scale means by demographic and treatment characteristics, and correlating scales with psychosocial and health-related QOL scales.

RESULTS

Factor analysis revealed four factors measuring the IOC on caregiving and finances, exercise and diet behaviors, social and emotional functioning, and religiosity. Scale scores differed by demographic and treatment characteristics according to expectations, and the pattern of correlations with psychosocial and health-related QOL generally supported the construct validity of the scales.

CONCLUSION

Including the BCIA with measures of QOL, symptoms, and functioning will allow researchers to gain a more comprehensive assessment of the biopsychosocial IOC in survivors.

Self-report of prostatitis and its risk factors in a random sample of middle-aged men

OBJECTIVES

To determine the risk factors for the self-reported history of prostatitis and to determine whether a self-reported history of prostatitis is related to the diagnosis of prostate cancer.

METHODS

Random digit dialing was used to select a group of controls aged 40 to 64 years without prostate cancer matched by age with a group of patients with prostate cancer in a study on the epidemiology of prostate cancer. Controls were divided into those who reported a diagnosis of prostatitis (cases) and those who denied ever having had prostatitis (controls). We adjusted for the time from a prostatitis diagnosis to the in-person interview. We also compared the number of men with a prostatitis diagnosis to the number of men diagnosed and not diagnosed with prostate cancer.

RESULTS

Of the 645 control men without a history of prostate cancer, 58 (9.0%) reported a diagnosis of prostatitis. The men with prostatitis had a mean age of 39.5 years at diagnosis. The urinary symptoms among prostatitis cases and controls was similar. Prostatitis cases more frequently reported urinary (P < or =0.05) or urethral infections (P < or =0.01) before diagnosis. Men with prostatitis were more likely to have procedures aimed at diagnosing both prostatic and other diseases. Men with prostate cancer reported a diagnosis of prostatitis more often than the noncancer controls (13.6% versus 9.0%). After controlling for the number of prostate-specific antigen tests this difference disappeared.

CONCLUSIONS

Nine percent of a randomly selected group of middle-aged men reported they had been diagnosed with prostatitis. The prevalence of a prostatitis diagnosis is similar in men with and without prostate cancer.

Recruitment of religious organisations into a community-based health promotion programme

Programmes concerned with health promotion activities frequently rely on community organisations to deliver health behaviour change interventions. This paper presents data on the recruitment of religious organisations (ROs) into a research project focused on dietary change. The authors contacted the membership list of a local multi-denominational religious umbrella organisation by mail. The recruitment process consisted of a screening survey followed by an informational meeting with RO representatives, with additional meetings as necessary. The ROs were surveyed by telephone, and the initial and follow-up meetings were held at a location convenient to the RO representatives, often the RO's building. For this paper, the unit of analysis is the RO. The ROs approached during the recruitment process were of a variety of faiths and denominations. All were located within the metropolitan area of Seattle, WA, USA. The screening survey was used to determine RO eligibility, and collect further information on the RO and its membership. The survey included questions adapted from previous RO surveys and questions developed by the project team. The recruitment strategy yielded a 26% enrollment rate of eligible ROs. In comparison to eligible ROs, those that did not meet the eligibility criteria were less stable, smaller and had a membership that was less white, less college-educated and more working class. The size of the RO and the number of years that the religious leader had been with the RO were the strongest predictors of the RO's interest in participating in the project. These data will be helpful in recruiting community organisations into health promotion programmes.

Screening mammography among Chinese Canadian women

BACKGROUND

Though breast cancer is the most common malignancy among Chinese women, screening mammography is underutilized. This study examined barriers and facilitators of screening mammography among Chinese Canadian women.

METHODS

Using community-based sampling, Chinese women in British Columbia were interviewed in 1999 about multiple preventive health behaviours. We included 213 women in the mammography analysis; main outcome measures were ever having a mammogram and routine mammography.

RESULTS

Seventy-five percent of women 50 to 79 years old reported ever having had a mammogram, and 53% had two or more mammograms within the last five years. Receiving a recommendation for a mammogram from medical personnel or from a family member, and believing that cancer cannot be prevented by faith were independently associated with both screening outcomes.

CONCLUSIONS

A multifaceted approach to screening mammography promotion in Chinese Canadian women is suggested. Interventions that include education of and by medical providers and family members should be considered.

Hepatitis B knowledge and practices among Chinese Canadian women in Vancouver, British Columbia

INTRODUCTION

Liver cancer rates are higher in North American Chinese than non-Asian ethnic/racial groups, largely due to chronic hepatitis B virus (HBV) infection.

METHODS

A community-based survey of Chinese women (n = 147) was completed during 1999 to examine HBV knowledge and practices in Vancouver, British Columbia.

RESULTS

Most women had heard of HBV (85%) but smaller proportions knew about some routes of transmission (e.g., sexual intercourse) and sequelae of infection. Knowledge about HBV was significantly associated with education level (p = 0.005), English fluency (p < 0.001) and household income (p = 0.007). Previous serologic testing for HBV infection was significantly associated with education level (p = 0.04), English fluency (p = 0.01), and level of knowledge about HBV (p < 0.001).

CONCLUSIONS

Efforts to increase knowledge about HBV infection in this community should consider targeting less educated and less acculturated individuals.

General quality of life 2 years following treatment for prostate cancer: what influences outcomes? Results from the prostate cancer outcomes study

PURPOSE

The goal of this study was to determine the relationship between primary treatment, urinary dysfunction, sexual dysfunction, and general health-related quality of life (HRQOL) in prostate cancer.

METHODS

A sample of men with newly diagnosed prostate cancer between 1994 and 1995 was randomly selected from six population-based Surveillance, Epidemiology, and End Results registries. A baseline survey was completed by 2,306 men within 6 to 12 months of diagnosis, and these men also completed a follow-up HRQOL survey 2 years after diagnosis. Logistic regression models were used to determine whether primary treatment, urinary dysfunction, and sexual dysfunction were independently associated with general HRQOL outcomes approximately 2 years after diagnosis as measured by the Medical Outcomes Study 36-item Short Form Health Survey. The magnitude of this effect was estimated using least square means models.

RESULTS

After adjustment for potential confounders, primary treatment was not associated with 2-year general HRQOL outcomes in men with prostate cancer. Urinary function and bother were independently associated with worse general HRQOL in all domains. Sexual function and bother were also independently associated with worse general HRQOL, although the relationship was not as strong as in the urinary domains.

CONCLUSION

Primary treatment is not associated with 2-year general HRQOL outcomes in prostate cancer. Although both sexual and urinary function and bother are associated with quality of life, men who are more bothered by their urination or impotence are more likely to report worse quality of life. This implies that future research should be directed toward finding ways to improve treatment-related outcomes or help patients better cope with their posttreatment urinary or sexual dysfunction.

Facilitators and barriers to cervical cancer screening among Chinese Canadian women

BACKGROUND

Chinese Canadian women have higher cervical cancer incidence, and lower Pap testing, rates than the general Canadian population. Predisposing, enabling and reinforcing factors associated with ever having a Pap test, and having a recent Pap test within the last 2 years, were assessed in Chinese women in British Columbia using the PRECEDE-PROCEED model.

METHOD

Chinese women (n=512) between the ages of 20 and 79 years and residing in Greater Vancouver were interviewed about Pap testing, health care, traditional health beliefs, acculturation and sociodemographic characteristics. Two analyses were done, comparing women who had ever and never had a Pap test, and comparing women who had and had not received a recent Pap test. Focus groups and qualitative interviews ensured cultural sensitivity in the survey questionnaire.

RESULTS

Seventy-six percent reported ever having a Pap test and 57% reported having a Pap test within the last 2 years. Traditional health beliefs were not associated with ever or recent Pap testing. However, belief that Pap testing prevented cancer and general knowledge about the Pap test were associated with screening. Concern about pain/discomfort with the test, availability of time, culturally sensitive health care services and recommendation for Pap testing by a physician were also associated with screening. Factors differed for ever, and recently, having a Pap test.

INTERPRETATION

Pap testing is less common among Chinese Canadian women. Continuing education about Pap testing is recommended for physicians serving underscreened Chinese women. Culturally and linguistically appropriate educational materials are needed for the Chinese community.

Knowledge of cervical cancer risk factors among Chinese immigrants in Seattle

Chinese American immigrants are a growing part of the United States population. Cervical cancer is a significant cause of morbidity and mortality among Chinese Americans. Pap smear testing is less common in Chinese American immigrants than in the general population. During 1999, we conducted a community-based survey of Chinese American women living in Seattle. We assessed knowledge of cervical cancer risk factors and history of Pap smear testing along with socioeconomic and acculturation characteristics. The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample included 472 women. Most cervical cancer risk factors were recognized by less than half of our participants. Factors independently associated with knowledge of cervical cancer risk factors included marital status, employment, and education. Respondents with the highest knowledge had greater odds of ever receiving a Pap smear, compared to those respondents with the lowest knowledge (OR 2.5; 95% CI: 1.1,5.8). Our findings suggest a need for increased recognition of cervical cancer risk factors among Chinese American immigrants. Culturally and linguistically appropriate educational interventions for cervical cancer risk factors should be developed, implemented and evaluated.

Hepatitis B knowledge and practices among Cambodian American women in Seattle, Washington

Southeast Asians have higher liver cancer rates than any other racial/ethnic group in the US. Approximately 80 percent of liver cancers are etiologically associated with hepatitis B virus (HBV) infection which is endemic in Southeast Asia. An in-person survey of Cambodian women (n = 320) was conducted in Seattle, Washington, during 1999. The questionnaire included items about HBV knowledge, beliefs, and practices. Prior to being provided with a description of the disease, only about one-half (56 percent) of our respondents had heard of HBV infection. Less than one-quarter (23 percent) of the study group thought that asymptomatic individuals can transmit the disease to others. Most thought that HBV infection can cause liver cancer (54 percent) and death (72 percent). However, a minority thought that infection can be lifelong (24 percent) and incurable (15 percent). Only 38 percent reported they had been serologically tested for HBV. Finally, of those who had been tested and thought they were susceptible, two-thirds (67 percent) had not been vaccinated. Lower levels of education were associated with lower levels of HBV knowledge and serologic testing. Our findings suggest that Cambodian immigrants have low levels of HBV knowledge, serologic testing, and vaccination; and demonstrate a need for targeted educational interventions aimed at reducing HBV-related liver cancer mortality among Southeast Asian communities.

A randomized controlled trial of interventions to promote cervical cancer screening among Chinese women in North America

BACKGROUND

North American Chinese women have lower levels of Papanicolaou (Pap) testing than other population subgroups. We conducted a randomized controlled trial to evaluate the effectiveness of two alternative cervical cancer screening interventions for Chinese women living in North America.

METHODS

Four hundred and eighty-two Pap testing underutilizers were identified from community-based surveys of Chinese women conducted in Seattle, Washington, and Vancouver, British Columbia. These women were randomly assigned to one of two experimental arms or control status. Several Chinese-language materials were used in both experimental arms: an education-entertainment video, a motivational pamphlet, an educational brochure, and a fact sheet. Women in the first experimental group (outreach worker intervention) received the materials, as well as tailored counseling and logistic assistance, during home visits by trilingual, bicultural outreach workers. Those in the second experimental group (direct mail intervention) received the materials by mail. The control group received usual care. Follow-up surveys were completed 6 months after randomization to ascertain participants' Pap testing behavior. All statistical tests were two-sided.

RESULTS

A total of 402 women responded to the follow-up survey (83% response rate). Of these women, 50 (39%) of the 129 women in the outreach group, 35 (25%) of the 139 women in the direct mail group, and 20 (15%) of the 134 women in the control group reported Pap testing in the interval between randomization and follow-up data collection (P<.001 for outreach worker versus control, P =.03 for direct mail versus control, and P =.02 for outreach worker versus direct mail). Intervention effects were greater in Vancouver than in Seattle.

CONCLUSION

Culturally and linguistically appropriate interventions may improve Pap testing levels among Chinese women in North America.

Information women receive about heart attacks and how it affects their knowledge, beliefs, and intentions to act in a cardiac emergency

In this study we investigate (a) what information women receive on acute myocardial infarction (AMI) from different information sources, (b) how women evaluate this information, and (c) how information acquisition is related to women's knowledge of AMI, personal risk perceptions, and behavioral intentions regarding a cardiac emergency. A random sample of 844 women 50 years and over were telephoned in the state of Washington. Repeated measures regression analyses showed that women receive most of their information on AMI from the mass media, even though they evaluated the media as less believable, less useful, less clear, and making less of an impression than information received from health care providers. Logistic regression analyses showed that the total number of information sources from which heart attack information was received in the past year was positively related to knowledge of AMI symptoms, beliefs about AMI, and personal risk perceptions. The results are discussed in terms of their pragmatic implications.

Awareness of genetic testing for breast cancer risk among women with a family history of breast cancer: effect of women's information sources on their awareness

The purpose of this study was to relate women's awareness of breast cancer risk genetic testing to the sources of information used by women for obtaining information about breast health. A sample of 354 women with a family history of breast or ovarian cancer was interviewed. Study variables included women's information sources for breast health, personal risk perceptions, family history of breast cancer, personal experience (i.e., having had a biopsy), awareness of genetic testing, and demographic variables. Regression analyses were conducted to assess the relationships among the variables. Only approximately one-third of the study participants were moderately aware of genetic testing for breast cancer risk. The Internet Web was the only information source significantly related to awareness of genetic testing. Having had a biopsy, being more highly educated, and being married also were significant predictors of awareness of genetic testing. Study participants were not uniformly aware of genetic testing. If the diffusion of Web technology continues, the Web may be a promising source for increasing awareness on genetic testing for breast cancer risk.

Breast cancer screening: stages of adoption among Cambodian American women

BACKGROUND

Little information is available on the breast cancer screening behavior of Cambodian American women.

METHODS

We identified households from multiple sources using Cambodian surnames and conducted a cross-sectional survey, administered by bilingual and bicultural interviewers. Breast cancer screening stages of adoption were examined based on concepts from the transtheoretical model of behavioral change.

RESULTS

Our response rate was 73% (398 women in clinical breast exam (CBE) analysis, and 248 in mammography analysis) with approximately 25% each in the maintenance stage. We found significant associations between screening stage with physician characteristics. Asian American female physician increased the likelihood of being in the maintenance stage (CBE, OR = 10.1, 95% CI 2.8-37.1; mammogram, OR = 74.7,95% CI 8.3-674.6), compared to Asian American male physician with precontemplation/contemplation stage as our referent outcome.

CONCLUSION

Results from this study support the need to promote regular breast cancer screening among Cambodian American women.

Cervical cancer screening among Chinese Americans

STUDY PURPOSE

Chinese women in North America have high rates of invasive cervical cancer and low levels of Papanicolaou (Pap) testing use. This study examined Pap testing barriers and facilitators among Chinese American women.

BASIC PROCEDURES

A community-based, in-person survey of Chinese women was conducted in Seattle, Washington during 1999. Four hundred and thirty-two women in the 20-79 years age-group were included in this analysis. The main outcome measures were a history of at least one previous Pap smear and Pap testing within the last 2 years.

MAIN FINDINGS

Nineteen percent of the respondents had never received cervical cancer screening and 36% had not been screened in the previous 2 years. Eight characteristics were independently associated with a history of at least one Pap smear: being married, thinking Pap testing is necessary for sexually inactive women, lack of concerns about embarrassment or cancer being discovered, having received a physician or family recommendation, having obtained family planning services in North America, and having a regular provider. The following characteristics were independently associated with recent screening: thinking Pap testing is necessary for sexually inactive women, lack of concern about embarrassment, having received a physician recommendation, having obtained obstetric services in North America, and having a regular provider.

PRINCIPAL CONCLUSIONS

Pap testing levels among the study respondents were well below the National Cancer Institute's Year 2000 goals. The findings suggest that cervical cancer control interventions for Chinese are more likely to be effective if they are multifaceted.

Hepatitis B knowledge and practices among Chinese American women in Seattle, Washington

BACKGROUND

Chinese Americans have higher rates of chronic hepatitis B virus (HBV) infection, resulting in higher incidences of liver cancer, compared with the general population.

METHODS

The authors conducted a community-based survey of HBV knowledge and preventive practices among Chinese American women in Seattle, Washington, during 1999.

RESULTS

Less than half (46%) of the respondents knew that HBV could cause liver cancer. Only 35% reported that they had been serologically tested for HBV, and most of those who knew they were susceptible (61%) had not been vaccinated.

CONCLUSIONS

The findings indicate low levels of HBV knowledge, screening, and vaccination among Chinese immigrants. Targeted interventions are needed to reduce the burden of HBV infection and liver cancer in this community.

Evaluation of an outreach intervention to promote cervical cancer screening among Cambodian American women

INTRODUCTION

Southeast Asian women have low levels of Papanicolaou (Pap) testing participation. We conducted a group-randomized controlled trial to evaluate a cervical cancer screening intervention program targeting Seattle's Cambodian refugee community.

METHODS

Women who completed a baseline, community-based survey were eligible for the trial. Neighborhoods were the unit of randomization. Three hundred and seventy survey participants living in 17 neighborhoods were randomized to intervention or control status. Intervention group women received home visits by outreach workers and were invited to group meetings in neighborhood settings. The primary outcome measure was self-reported Pap testing in the year prior to completing a follow-up survey.

RESULTS

The proportion of women in the intervention group reporting recent cervical cancer screening increased from 44% at baseline to 61% at follow-up (+17%). The corresponding proportions among the control group were 51 and 62% (+11%). These temporal increases were statistically significant in both the intervention (P < 0.001) and control (P = 0.027) groups.

DISCUSSION

This study was unable to document an increase in Pap testing use specifically in the neighborhood-based outreach intervention group; rather, we found an increase in both intervention and control groups. A general awareness of the project among women and their health care providers as well as other ongoing cervical cancer screening promotional efforts may all have contributed to increases in Pap testing rates.

Measurement characteristics of 2 different self-monitoring tools used in a dietary intervention study

OBJECTIVE

To examine the measurement characteristics of 2 self-monitoring tools, a food diary and fat scan, used in the dietary intervention of the Women's Health Trial: Feasibility in Minority Populations study.

DESIGN

Comparison of fat intake reported on the self-monitoring tools to a criterion measure of fat intake, specifically the mean of a food frequency questionnaire and a 4-day food record. The main outcome measures were differences in fat grams and correlations between each of the self-monitoring tools and the criterion measure.

SUBJECTS/SETTING

Six-month postrandomization data from 313 women aged 50 to 79 years who participated in the intervention group of the Women's Health Trial: Feasibility in Minority Populations study.

RESULTS

Both self-monitoring tools underestimated fat intake compared to the criterion measure, the food diary by 9 g and the fat scan by 6 g. The self-monitoring instruments were better than chance at detecting a low-fat dietary pattern, however, and did not differ from each other in their ability to do so.

APPLICATIONS/CONCLUSIONS

The self-monitoring tools were modestly precise as measures of fat intake, but neither was sufficiently accurate to be reliable as a sole assessment of dietary adherence. Dietetics professionals are encouraged to assess the measurement properties of self-monitoring tools to use them appropriately in supporting dietary changes.

Breast cancer screening among Cambodian American women

Our aim was to describe and identify factors associated with breast cancer screening among Cambodian American women. We conducted a cross-sectional survey of 1,365 households using bilingual and bicultural interviewers. We found that low proportions of Cambodian American women were up to date on their clinical breast examinations (CBE; 42%) and mammograms (40%). More than 80% of women with female physicians have had at least one prior screening, and 52% have had the tests recently. Women with male Asian American physicians were less likely to have had screening as compared to women with female non-Asian physicians: ever had CBE (odds ratio [OR], 0.26); recent CBE (OR, 0.39); ever had mammogram (OR, 0.36); and recent mammogram (OR, 0.22). Breast cancer screening among Cambodian American women lags behind the general U.S. population. Tailored promotion efforts should address barriers and promote cancer screening by physicians, staff, and organizations serving this population.

Comparisons of two breast cancer risk estimates in women with a family history of breast cancer

There is an increasing need for accurate prediction methods of assessing individual risk for breast cancer for both clinical and research purposes. The purpose of this study is to compare the Gail and Claus model risk estimates of breast cancer among women with a family history of breast cancer. This study presents risk estimates from two models of breast cancer risk in 491 women 18 to 74 years of age with a family history of breast cancer who were recruited to risk counseling clinical trials in Seattle, Washington between 1996 and 1997. These trials included women from the general population and additional samples of Ashkenazi Jewish, African-American, and lesbian women. We estimated and compared lifetime (to age 79) and 5-year risk for developing breast cancer using the National Surgical Adjuvant Breast and Bowel Project adaptation of the Gail model and the Claus model. About one-quarter of participants fell into the Gail "high" risk category (> or =1.7% risk of developing breast cancer in the next 5 years). The average lifetime risk was estimated at 13.2% by the Gail model and 11.2% by the Claus model. Estimates from the two models were moderately and positively correlated (r = 0.55) with the Gail model yielding a higher estimate than the Claus model for most participants. If women with a family history of breast cancer are being counseled regarding decisions on genetic testing, tamoxifen use, or other preventive measures, presenting both Claus and Gail estimates may be the best option.

Results of a volunteer program to conduct dietary intervention research for women

The American Cancer Society (ACS) initiated the Breast Cancer Dietary Intervention Project (BCDIP) to involve community volunteers in cancer-related intervention research activities focused on dietary fat reduction in women with breast cancer. This article presents data on the volunteer aspects of the project, with two aims: (a) to describe the volunteer recruitment and intervention designed for the BCDIP, conducted jointly by the American Cancer Society and the Fred Hutchinson Cancer Research Center, and (b) to present baseline characteristics and predictors of retention of the BCDIP volunteers. There were five types of volunteers, called volunteer adjunct researchers or VARs, in the BCDIP. VARs were recruited using a variety of approaches, including electronic media alerts, flyers in oncology clinics, and notices in the newsletters of state nursing and nutritional professional organizations. Over half of all VARs came from two main sources: the media (television, radio, newspapers) and from work-related sources. Over half (58%) of the VARs had professional licenses in nursing or dietetics, and 46% were employed full-time. Several types of motivations for participating in the BCDIP, including altruistic reasons (want to help others, help people with cancer), health concerns (family/friend with breast cancer, have had cancer), and work-related reasons (gain professional skills) were important. Sixty-eight percent of VARs remained with the project for its entirety. Predictors of retention in the VAR program included previous ACS volunteer experience with initial motivations to volunteer and the interaction of employment status and professional nursing training. In future research and community-based projects, better recruitment and volunteer coordination procedures should be used to reduce dropout rates and maintain volunteer commitment and participation.

The effectiveness of mammography promotion by volunteers in rural communities

INTRODUCTION

The Community Trial of Mammography Promotion assessed the effectiveness of mammography promotion by community volunteer groups in rural areas. Three interventions were tested. One used an individual counseling strategy, one used a community activities strategy, and a third combined the two strategies.

METHODS

The effects of the interventions were tested by randomizing 40 communities either to the study interventions or to a control group. A cohort of 352 women from each community was randomly selected and used to evaluate the interventions' effectiveness. Of these, 6592 women were eligible for screening mammography at baseline and follow-up and were successfully interviewed prior to and after study intervention activities.

RESULTS

Although the interventions did not significantly increase women's overall use of mammography, the community activities intervention increased use at follow-up by regular users over baseline by 2.9% (p = 0.01). Intervention appears to have increased the use of mammography among certain groups of women who were not regular users at baseline, including those in communities without female physicians (10% to 16%; p < 0.05), and among women with no health insurance (10% to 23%; p </= 0.05).

CONCLUSION

Volunteers can effectively promote mammography in rural communities.

Pap Testing Stages of Adoption among Cambodian Immigrants

PURPOSE

We examined levels of Pap testing and factors associated with screening participation among Cambodian refugees.

METHODS

A community-based, in-person survey was conducted in Seattle during late 1997 and early 1998. Interviews were completed by 413 women; the estimated response rate was 73%. We classified respondents into four Pap testing stages of adoption: precontemplation/contemplation (never screened), relapse (ever screened but did not plan to be screened in the future), action (ever screened and planned to be screened in the future), and maintenance (recently screened and planned to be screened in the future). Bivariate and multivariate techniques were used to examine various factors.

FINDINGS

About one-quarter (24%) of the respondents has never been screened, and a further 22% had been screened but did not plan to obtain Pap tests in the future. Fifteen percent were in the action stage and 39% were in the maintenance stage. The following factors were independently associated with cervical cancer screening stages: previous physician recommendation; younger age; beliefs about Pap testing for post-menopausal women, screening for sexually inactive women, and regular checkups; provider ethnicity; prenatal care in the US; and problems finding interpreters.

CONCLUSIONS

Our findings confirm low Pap testing rates among Cambodian immigrants, and suggest that targeted interventions should be multifaceted.

How women label and respond to symptoms of acute myocardial infarction: responses to hypothetical symptom scenarios

OBJECTIVE

To investigate how women label and intend to respond to common and less common symptoms of acute myocardial infarction (AMI).

DESIGN

Telephone interviews were conducted with 862 women older than age 50 years in the state of Washington.

OUTCOME MEASURES

Intended coping strategies, labeling of hypothetical symptoms, perceived risk of AMI, knowledge of AMI symptoms, medical and family history of AMI and demographics.

RESULTS

Women who labeled common or less common symptoms as a heart attack (65% and 36%, respectively) were more likely to report they would call 911 or go to a hospital right away than women who labeled these symptoms as something else. The results of a multiple logistic regression analysis suggests that knowledge of less common AMI symptoms, AMI information seeking, and personal risk perceptions were significant predictors of labeling less common symptoms as a heart attack.

CONCLUSIONS

The findings suggest that many women might be in danger of mislabeling their symptoms and not taking appropriate action. Women need to be educated about the less common symptoms of AMI and need to be encouraged to seek out information regarding AMI.

Cervical cancer screening among Cambodian-American women

Southeast Asian women have higher invasive cervical cancer incidence rates and lower Pap testing frequencies than most other racial/ethnic groups in the United States. However, there is little information about the cervical cancer screening behavior of Cambodian-American women. Cambodian residents of Seattle were surveyed in person during late 1997 and early 1998. The PRECEDE model was used to guide the development of items that assessed predisposing, reinforcing, and enabling factors associated with cervical cancer screening participation. The estimated overall survey response was 72%. Four hundred thirteen women completed our questionnaire. Approximately one-quarter (24%) of the respondents had never had a Pap test, and over one-half (53%) had not been screened recently. The following variables were positively associated with a history of at least one Pap smear: younger age, greater number of years since immigration, belief about Pap testing for postmenopausal women, prenatal care in the United States, and physician recommendation. Women who believed in karma were less likely to have ever been screened for cervical cancer than those who did not. Six variables independently predicted recent screening: age; beliefs about regular checkups, cervical cancer screening for sexually inactive women, and the prolongation of life; having a female doctor; and a previous physician recommendation for Pap testing. The study findings indicate that culturally specific approaches might be effective in modifying the cervical cancer screening behavior of immigrant women. Programs targeting Cambodian-Americans are likely to be more effective if they are multifaceted and simultaneously address predisposing, reinforcing, and enabling factors.

Durability, dissemination, and institutionalization of worksite tobacco control programs: Results from the working well trial

Durability, dissemination and institutionalization o f tobacco control activities are reported, based on the Working Well worksite cancer control intervention study (n = 83 worksites). Tobacco control activities increased significantly in intervention worksites as a result of research-supported activities but were not sustained 2 years after the conclusion of the intervention. Intervention sites were more likely than control sites to initiate and maintain structures for institutionalizing programs, such as assigning a committee responsibility for health-promotion programs or providing a budget for health-promoting activities. Dissemination of the program to control worksites had little impact on the level of smoking control activities in control worksites. Although program durability was not a primary aim of this intervention study, these analyses provide an important assessment of program maintenance beyond a funded intervention and underscore the need for additional research to identify effective organizational strategies for institutionalization of worksite health-promotion programs.

A health priorities model: application to mammography screening

This study describes and empirically tests a health priorities model. This model predicts underuse of regular mammography screening among adult women within the larger health context in which such decisions are made. The model incorporates women's comparative illness threats, comparative importance of health behaviors, and demographic variables. A telephone survey was conducted with a sample of women (N = 887) older than 50, in 40 rural communities in the state of Washington. Logistic regression analyses showed that women who perceived themselves at low risk for getting breast cancer and/or who perceived another disease (i.e. heart attack) as an equal or greater threat than breast cancer were less likely to be regular screeners of mammography. In addition, women who perceived other health behaviors as more important than regular mammography screening were less likely to be regular screeners than those women who perceived regular mammography screening as more important. Current or anticipated health problems were not related to screening behavior. The results are discussed in light of the practical, theoretical, and empirical implications.