An RCT to Increase Breast and Colorectal Cancer Screening

INTRODUCTION

Adherence to breast and colorectal cancer screenings reduce mortality from these cancers, yet screening rates remain suboptimal. This 2 × 2 RCT compared 3 theory-based interventions to usual care to simultaneously increase breast and colon cancer screening in women who were nonadherent to both screenings at study entry.

DESIGN

RCT.

SETTING/PARTICIPANTS

Women (n=692) who were nonadherent to both breast and colon cancer screenings and aged 51-75 years were recruited. Enrollment, intervention delivery, and data collection were completed between 2013 and 2017, and data analyzed in 2018.

INTERVENTION

The randomized intervention included the following 4 groups: 3 intervention arms (personally tailored messages using a web-based intervention, phone delivery by a trained navigator, or both) compared with usual care. Women at an average risk for colon cancer were allowed to select either colonoscopy or stool test as their preferred colon cancer screening. Mammography was promoted for breast cancer screening.

MAIN OUTCOME MEASURES

Outcome data at 6 months included self-report and medical records for screening activity.

RESULTS

All intervention arms significantly increased receipt of either a mammogram or stool test compared with control (web: p<0.0249, phone: p<0.0001, web + phone: p<0.0001). When considering receipt of both mammogram and stool test, all intervention arms were significantly different from usual care (web: p<0.0249, phone: p<0.0003, web + phone: p<0.0001). In addition, women who were adherent to mammography had a 4.5 times greater odds of becoming adherent to colonoscopy.

CONCLUSIONS

The tailored intervention simultaneously supporting both breast and colon cancer screenings significantly improved rates of obtaining one of the screenings and increased receipt of both tests.

TRIAL REGISTRATION

This study is registered with the clinical trials identifier NCT03279198 at www.clinicaltrials.gov.

A Randomized Trial to Compare a Tailored Web-Based Intervention and Tailored Phone Counseling to Usual Care for Increasing Colorectal Cancer Screening

BACKGROUND

Colorectal cancer mortality could be decreased with risk-appropriate cancer screening. We examined the efficacy of three tailored interventions compared with usual care for increasing screening adherence.

METHODS

Women (n = 1,196) ages 51 to 74, from primary care networks and nonadherent to colorectal cancer guidelines, were randomized to (1) usual care, (2) tailored Web intervention, (3) tailored phone intervention, or (4) tailored Web + phone intervention. Average-risk women could select either stool test or colonoscopy, whereas women considered at higher than average risk received an intervention that supported colonoscopy. Outcome data were collected at 6 months by self-report, followed by medical record confirmation (attrition of 23%). Stage of change for colorectal cancer screening (precontemplation or contemplation) was assessed at baseline and 6 months.

RESULTS

The phone (41.7%, P < 0.0001) and combined Web + phone (35.8%, P < 0.001) interventions significantly increased colorectal cancer screening by stool test compared with usual care (11.1%), with ORs ranging from 5.4 to 6.8 in models adjusted for covariates. Colonoscopy completion did not differ between groups except that phone significantly increased colonoscopy completion compared with usual care for participants in the highest tertile of self-reported fear of cancer.

CONCLUSIONS

A tailored phone with or without a Web component significantly increased colorectal cancer screening compared with usual care, primarily through stool testing, and phone significantly increased colonoscopy compared with usual care but only among those with the highest levels of baseline fear.

IMPACT

This study supports tailored phone counseling with or without a Web program for increasing colorectal cancer screening in average-risk women.

Comparability and Short-Term Stability of Techniques to Assess Extension of Thinking about One's Personal Future

Three techniques for assessing extension of one's personal future (line-marking, open-ended report, life-events) were compared in a sample of 74 respondents. Two points of data collection were employed to examine short-term stability. At both administrations, correlations among indices suggested that techniques were only moderately comparable. Short-term stabilities were variable; correlations ranged from .42 to .79. Across subgroups of the sample, the direct, open-ended report of extension showed the greatest stability, while life-event extension showed the least. Apparently, extension of thinking about the future should be assessed by more than one technique to investigate potential relationships with other variables or changes over time in perspective about the future.

Late Life Health Behavior

This article outlines psychosocial model for studying health behavior in later adulthood. Fundamental elements from the Health Belief Model are integrated with concepts of temporal perspective, forming the basis of process-oriented stages which compose the proposed framework. Considerations relating to the older adult's family support network are incorporated at selected points in the decision-making process. Indications in theory and research suggest the potential feasibility of such an integration and its relevance for older adults. Provision for a focus upon long-term treatment of chronic conditions occurs through inclusion of feedback from successive contacts with the health care system. Special attention should be given to the perceived severity of a target condition, since actual or perceived time pressure to seek treatment may have significant impact on the complexity and scope of one's decision process.

Self-Assessments of Health and Mortality among Older Persons

Although several studies show an association between self-rated health and mortality among older persons, most have used only a single question to assess self-rated health. The present research used the 1984-1990 Longitudinal Study of Aging to examine whether self-ratings other than the traditional, National Health Interview Survey-type global self-assessment make independent contributions to predicting mortality. Four health assessments were selected in addition to the global rating (Activity Compared to Age Peers, Control over Future Health, Taking Care of One's Health, and Worry Due to Health in the past year). All five self-assessments, along with a composite measure, had bivariate associations with higher mortality as ratings became less favorable. However, only Activity Compared to Peers retained an association with mortality even with Global Self-Rated Health in the model. Subjective assessments based on peer comparison may be important additions to research in this area.

The Meaning and Practice of Self- Care by Older Adults

Drawing on material from qualitative interviews, this article examines self-care as a response to physical symptoms commonly experienced by older people. The analysis indicates that older persons approach, interpret, and treat their symptoms within both biomedical and psychosocial frameworks. Self-care responses appear to be learned early in life, reinforced throughout the life cycle, and formed in consultation with professional as well as lay persons. Symptom responses reflect and reinforce the meaning of social relations in individuals' lives, providing a symbolic medium for the assessment of present and past relationships, cross-generational connections, and past troubles and issues of personal identity. Findings suggest that categorizing sources of care into professional, informal, or self overly simplifies the symptom experience of older adults. Self-care goes beyond the acknowledgment of discomfort and subsequent treatment of symptoms; it involves the representation and interpretation of the self.

Predictors of Mortality among Elderly African-Americans

Older African-Americans face many barriers that impede access to formal support services. Therefore, informal social networks may be the only source of support for many elderly African-Americans. This study looked at three measures of informal social networks: contacts with family members, contacts with friends, and social involvement outside the home. Data were from the 1984-1988 Longitudinal Survey of Aging. Bivariate associations with lower mortality occurred for all three social network indices. When controlling for sociodemographic, physical health variables, and self-rated health in logistic regression, church attendance retained significance. Men appeared to be at high risk when social network was limited. Other significant factors were: cancer, activities of daily living, sex-specific body mass, and self-rated health.

Self-Management of Chronic Disease by Older Adults

This article summarizes the literature describing the at-home management of and psychosocial coping with five chronic diseases (heart disease, asthma, chronic obstructive pulmonary disease, arthritis, and diabetes) by the general population of adults. It also reviews the literature describing self-management of these chronic diseases by older adults. Conclusions drawn subsequent to the review are (a) that there are strong commonalities in the essential nature of tasks that exist across disease entities, (b) that the context for self-management of disease by the ill elderly is likely to differ somewhat from the context for other age groups. Questions for future research are posed.

The Association of Self-Rated Health with Two-Year Mortality in a Sample of Well Elderly

The 1984-1986 Longitudinal Study of Aging (LSOA) was used to investigate self-assessed health as a predictor of 2-year mortality in a subsample of 1,252 persons aged 70 and over. The LSOA sample was screened to exclude individuals reporting a high-risk medical condition or difficulty in instrumental activities of daily living. Logistic regression showed independent predictive effects with higher mortality for age (older), sex (male), less favorable self-rated health, and a family network variable (having no living children or siblings), and sex-specific body mass (highest quintile) was associated with lower mortality. Results therefore support prior studies showing that self-rated health predicts mortality, even in a very healthy elderly subsample, and with a follow-up period that is among the shortest reported to date.

Associations among Health Perceptions and Health Status within Three Age Groups

Using data from the 1984 Supplement on Aging to the National Health Interview Survey, the associations among five health perceptions and two indices of functional health status were investigated within each of three age groups (55-64, 65-79, 80+). Greater functional impairment was associated with less favorable health perceptions in all three age groups. However, the strength of association was not consistent for the five indices, leaving room for conflicting assessments of one's health. Efficacy at taking care of health and perceived control over health showed lower strengths of association with functional impairment, raising the possibility that the resilience of some perceptions may be studied in greater detail. Results for persons aged 80 and older were similar in some ways to those for persons aged 55-64; however, there was some evidence of stronger negative association with increasing functional limitation among persons aged 55-64, suggesting a possibly stronger impact of health problems in this group. Future research might usefully examine intraindividual consistency of health perceptions and behavior, in addition to looking for normative interindividual trends.

Stages of Adopting Regular Screening Mammography

This study examined whether distinct subgroups of women could be identified within stages of adoption for screening mammography. These subgroups may represent differential readiness to move to the next stage of the adoption continuum. Data were from a baseline survey of 1323 women between the ages of 50 and 74 years who were recruited through a staff- model HMO for an intervention study to increase rates of mammography. Multiple regression models were used to identify correlates of positive decisional balance within each of four stages of adoption, and an index of positive indicators was developed from the significant correlates for each stage. Analysis of variance showed that the number of positive indicators discriminated women within each stage. This information can be used to develop more effective tailored interventions to increase the percentage of women receiving mammograms on a regular schedule.

Continuum of mammography use among US women: classification tree analysis

OBJECTIVES

To identify women with low mammography utilization.

METHODS

We used Classification Tree Analysis among women aged 42-80 from the 2008 Behavioral Risk Factor Surveillance System (N = 169,427) to identify sub-groups along a continuum of screening.

RESULTS

Women with neither a primary care provider nor health insurance had the lowest utilization (33.9%) and were 2.8% of the sample. Non-smoking women aged 55-80, with a primary care provider, health insurance, and income of $75,000 or more had the highest utilization (90.7%) and comprised 5% of the sample.

CONCLUSION

As access to primary care providers and health insurance increases with the Affordable Care act, classification tree analyses may help to identify women of high priority for intervention.

Colorectal cancer screening: language is a greater barrier for Latino men than Latino women

Colorectal cancer screening (CRC) disparities between non-Latino Whites and Latinos remain, and may have increased. The goal of this analysis was to examine the association between Latino race/ethnicity, gender, and English-proficiency and CRC screening. Analysis of the CDC's BRFSS 2008 survey. We estimated crude and adjusted screening rates and odds ratios of respondents' reported CRC test receipt stratified by self-reported Latino ethnicity, gender, and limited English proficiency (LEP) as determined by language of survey response (English vs Spanish). Of 99,883 respondents included in the study populations, LEP Latino men had the lowest adjusted screening rates (48.2%) which were lower that all other Latinos subgroups including Latina women with LEP (56.2%). Compared to non-Latino White men, LEP Latino men were 0.47 times as likely to report receiving CRC screening tests (AOR 0.47; 95% CI 0.35-0.63). Disparities in CRC screening are most dramatic for LEP Latino men.

Examining whether lung screening changes risk perceptions: National Lung Screening Trial participants at 1-year follow-up

BACKGROUND

The National Lung Screening Trial (NLST) research team reported reduced lung cancer mortality among current and former smokers with a minimum 30 pack-year history who were screened with spiral computed tomography scans compared with chest x-rays. The objectives of the current study were to examine, at 1-year follow-up: 1) risk perceptions of lung cancer and smoking-related diseases and behavior change determinants, 2) whether changes in risk perceptions differed by baseline screening result; and 3) whether changes in risk perceptions affected smoking behavior.

METHODS

A 25-item risk perception questionnaire was administered to a subset of participants at 8 American College of Radiology Imaging Network/NLST sites before initial and 1-year follow-up screens. Items assessed risk perceptions of lung cancer and smoking-related diseases, cognitive and emotional determinants of behavior change, and knowledge of smoking risks.

RESULTS

Among 430 NLST participants (mean age, 61.0 years; 55.6% men; 91.9% white), half were current smokers at baseline. Overall, risk perceptions and associated cognitive and emotional determinants of behavior change did not change significantly from prescreen trial enrollment to 1-year follow-up and did not differ significantly by screening test result. Changes in risk perceptions were not associated with changes in smoking status (9.7% of participants quit, and 6.6% relapsed) at 1-year follow-up.

CONCLUSIONS

Lung screening did not change participants' risk perceptions of lung cancer or smoking-related disease. A negative screening test, which was the most common screening result, did not appear to decrease risk perceptions nor provide false reassurance to smokers.

Reversal of associations between Spanish language use and mammography and pap smear testing

Latina women are less likely to utilize cancer screening services than are non-Latina White women. The purpose of this study is to examine the relationship between preferred language (English vs. Spanish) and receipt of mammography and Pap-smear testing among US Latinas and non-Latinas. Cross-sectional analysis of the 2008 and 2010 Behavioral Risk Factor Surveillance System (BRFSS) surveys. While Latinas responding to the BRFSS in English or in Spanish had unadjusted lower odds of receiving mammography testing, in multivariable analysis Latinas responding-in-Spanish had 2.20 times the odds (OR = 2.20, 95 % CI, 1.90-2.55) of reporting mammography compared to non-Latinas. Similarly, Latinas responding-in- Spanish had lower unadjusted odds of receiving Pap-smear testing. However, Latinas responding-in-Spanish had 2.37 times the odds (OR = 2.37 CI, 2.04-2.75) of reporting having received Pap smear testing compared to non-Latinas in multivariate analysis. The results of this paper further confirm the "reversed associations" among Latinas and mammography and Pap smear testing described in previous studies and suggest that in addition to insurance status, preferred language may be a key variable contributing to the reversal phenomenon observed among Latinas.

Understanding reversals of association between cancer screening and race/ethnicity

BACKGROUND

We used a composite variable composed of insurance status, income, and race/ethnicity to investigate access-enhancing programs as a possible reason for "reversals of association" and large percent changes (LPC), between race/ethnicity and cancer screening, when comparing the unadjusted and adjusted ORs.

METHODS

Data were from women aged 40-64 years, using the combined 2008 and 2010 Behavioral Risk Factor Surveillance System surveys. Recent mammography was within the past 2 years, and recent Pap testing was within the past 3 years. Initial analyses using all variables singly were followed by analyses that used the composite variable with the remaining covariates.

RESULTS

Analyses with race/ethnicity singly indicated reversals of association for Hispanic women and higher estimated screening for black and Hispanic women than for white women. Analyses with the composite variable found no reversals of association, but there were several LPCs for Hispanic and black women, for lower income, and for uninsured women. White, uninsured, lower income women were among those with the lowest utilization.

CONCLUSIONS

Results were consistent with the possibility that access-enhancing programs for lower income, uninsured and often non-white women can lead to overestimates of screening, reversals of association, and LPCs in multivariable analyses. Attention should be given to identifying LPCs to unadjusted ORs. Lower income, uninsured, white women are also a group at risk of extremely low mammography and Pap test utilization.

IMPACT

Combining variables to create better-targeted population subgroups may help in the interpretation of analyses that produce reversals of association and LPCs for correlates of cancer screening utilization.

Evaluating the impact of non-response bias in the Behavioral Risk Factor Surveillance System (BRFSS)

BACKGROUND

Response rates of national health surveys are decreasing, which potentially can bias obtained prevalence estimates. The purpose of this study is to evaluate the extent to which non-response impacts the representativeness of the 2000 Behavioral Risk Factor Surveillance System (BRFSS) sample compared to the 2000 Decennial Census.

METHODS

The 2000 BRFSS had a median response rate of 48%, while the 2000 Decennial Census had a response rate of 67%. Representativeness of the BRFSS sample was evaluated on gender, race, ethnicity, age, household income and marital status. Prevalence of each factor in the BRFSS was compared to the prevalence found in the US Census on both the state and county levels. Prevalence differences between the BRFSS and Census were calculated and their association with response rates was evaluated using robust OLS regression and polytomous logistic regression. The relationship between prevalence differences and other survey design elements, such as data collection procedure and sampling fraction, was also explored.

RESULTS

The BRFSS prevalence estimates diverged from the Census estimates on several sociodemographic factors even after adjustment for non-response/non-coverage. This was found on both the state and county levels; however, smaller absolute differences between the BRFSS and Census prevalence estimates were found for factors included in the non-response/non-coverage adjustment weight. Lower response rates (<40%) were associated with the under-representation of racial/ethnic minorities, women and younger individuals in the BRFSS survey.

CONCLUSION

Future research should examine alternative approaches to increase response rate (eg, mixed mode) and to adjust for non-response (eg, multiple imputation).

Validity of the process of change for colorectal cancer screening among African Americans

BACKGROUND

Process of change (POC) is a construct of the transtheoretical model that proposes to promote healthy behaviors.

PURPOSE

African Americans participate in colorectal cancer (CRC) screening less often than whites, while disease onset is younger, and incidence and mortality from CRC are higher.

METHODS

POC items for CRC screening were administered to 158 African Americans, the majority of whom were female (75.9%) and were not employed (85.4%). Confirmatory factor analysis was used to validate four factors reflecting the POC sub-domains.

RESULTS

Support of the factor validity of the POC with internal consistency of standardized alpha for the four factors was found. A logistic regression showed predictive validity in predicting current screening stage for two of the four sub-domains.

CONCLUSION

These data support the application of the POC to prediction of CRC screening intention among African Americans.

Reversals of association for Pap, colorectal, and prostate cancer testing among Hispanic and non-Hispanic black women and men

BACKGROUND

Several studies have found that Hispanics and non-Hispanic blacks have statistically significantly higher adjusted OR for cancer screening tests compared to non-Hispanic whites, even though their crude percentages were lower than, or about equal to, those for the non-Hispanic whites. Most documentation is for mammography. This article investigates the prevalence of such unadjusted-to-adjusted "reversed associations" (RA) for Pap, colorectal, and prostate testing. We also investigate large percent changes (LPC) to the unadjusted ORs.

METHODS

Data were from the 2004/2006/2008 Behavioral Risk Factor Surveillance System (BRFSS) and the 2000/2003/2005/2008 National Health Interview Survey (NHIS). Analyses used a consistent set of covariates.

RESULTS

RAs were more common for non-Hispanic blacks than Hispanics, but Hispanics had a greater number of LPCs. RAs and LPCs occurred more often for Pap testing than colorectal and prostate testing. However, results from the BRFSS and NHIS were often not consistent.

CONCLUSIONS

Attention should be given to the National Breast and Cervical Cancer Early Detection Program, as well as public programs addressing other cancers, as possible contributors to RAs and LPCs. Hispanics may show more RAs in analyses of future data. Discrepancies between the BRFSS and the NHIS also must be recognized and explained.

IMPACT

This research highlights the need for vigilance regarding the results of analyses to identify race/ethnicity as a correlate of cancer screening. Results also direct attention to aspects of the results of multivariable analysis other than ORs and confidence intervals.

Prevalence and correlates of recent and repeat mammography among California women ages 55-79

OBJECTIVE

Data on repeat mammography rates are less available than for recent screening. Two large, population-based state surveys provide the opportunity to investigate repeat and recent mammography prevalence and correlates among California's diverse population.

METHODS

Data were from women aged 55-79, using the 2001 and 2005 California Health Interview Surveys. The study assessed the prevalence and correlates of recent mammography (within the past two years) and repeat mammography (mammogram within the past two years and 3-11 mammograms within the past six years).

RESULTS

Prevalence was 82.4% (recent) and 73.8% (repeat) in 2001, and 87.1% (recent) and 77.5% (repeat) in 2005. Correlates of lower rates were insurance status, no usual source of care, being a smoker, age 65-79, being Asian with no English proficiency, being never married, and lower absolute risk for breast cancer. Especially low ratios of repeat-to-recent mammography existed for the uninsured, and those using the emergency room or with no source of care. Unexpected findings in which unadjusted results were inconsistent with multivariable adjusted results occurred for Latinas with no English proficiency and women at 200-299% of poverty level.

CONCLUSIONS

Several groups of women in California remain at-risk of lower mammography utilization. However, investigators should also be alert for instances where multivariable analyses seem particularly discrepant with crude rates.

Construct validity of a mammography processes of change scale and invariance by stage of change

The development and use of validated processes of change (POC) measures have received little attention in the literature despite their importance in the Transtheoretical Model. Using survey data (N = 2909), we examined the construct validity of a 22-item mammography POC scale by testing for factorial validity and factorial invariance across stage of change. We also used MANOVA with Tukey post-hoc tests to confirm stage differences in POC use (concurrent validity). Our results confirm the a priori correlated four-factor structure of this scale and provide some support for the measurement equivalence of this scale across stage, supporting comparisons of POC use across stage.

Behavioral constructs and mammography in five ethnic groups

Intention, self-efficacy, perceived susceptibility, perceived benefits, and subjective norms are key constructs of health behavior theories; their predictive validity for cancer screening has not been ascertained in multiethnic populations. Participants were 1,463 African American, Chinese, Filipina, Latina, and White women aged 40 to 74 interviewed by telephone in their preferred languages. The relationship between baseline constructs and mammography 2 years later was assessed using multivariable logistic regression. Intention predicted mammography overall and among Whites (odds ratio [OR] = 5.0, 95% confidence interval [CI] = 2.4, 10), with racial/ethnic differences in association (p = .020). Self-efficacy predicted mammography overall and among Whites (OR = 3.5, 95% CI = 1.1, 11), with no racial/ethnic interaction. Perceived benefits and subjective norms were associated with screening overall and in some racial/ethnic groups. These results generally support cross-cultural applicability of four of the five constructs to screening with mixed predictive value of measures across racial/ethnic groups. Additional in-depth inquiry is required to refine assessment of constructs.

Social and cultural meanings of self-efficacy

This article describes the influences of social context on women's health behavior through illustration of the powerful influences of social capital (the benefits and challenges that accrue from participation in social networks and groups) on experiences and perceptions of self-efficacy. The authors conducted inductive interviews with Latino and Filipino academics and social service providers and with U.S.-born and immigrant Latinas and Filipinas to explore direct and indirect influences of social context on health behaviors such as mammography screening. Iterative thematic analysis identified themes (meanings of efficacy, spheres of efficacy, constraints on efficacy, sources of social capital, and differential access to and quality of social capital) that link the domain of social capital with the behavioral construct perceived self-efficacy. The authors conclude that social capital addresses aspects of social context absent in the current self-efficacy construct and that these aspects have important implications for scholars' and practitioners' understandings of health behavior and intervention development.

Behavioral theory in a diverse society: like a compass on Mars

The behavioral theory constructs most often used to study mammography utilization-perceived benefit, perceived susceptibility, self-efficacy, intention, and subjective norms-have neither been developed nor sufficiently tested among diverse racial/ethnic subgroups. The authors explored these constructs and their underlying assumptions relating to the social context of Filipina and Latina women. The mixed-methods study included testing construct measures in the multilingual surveys of a concurrent intervention study of 1,463 women from five ethnic groups. An intensive inductive investigation then targeted Latina and Filipina women to elucidate connections between social context and individual screening behavior. In-depth interviews were conducted with 11 key informant scholars, 13 community gatekeepers, and 29 lay women, and a supplemental study videotaped and interviewed 9 mother-daughter dyads. Three social context domains emerged: relational culture, social capital, and transculturation and transmigration. The meaning and appropriateness of the five behavioral constructs were analyzed in relation to these domains. In contradistinction to tenets of behavioral theory, the authors found that social context can influence behavior directly, circumventing or attenuating the influence of individual beliefs; contextual influences, synthesized from multiple perspectives, can operate at an unconscious level not accessible to the individual; and contextual influences are dynamic, contingent on distal and proximal forces coming together in a given moment and are thus not consistent with an exclusive focus at the individual level. This article describes the study methods, summarizes main findings, and preview the detailed results presented in the other articles in this issue.

The Getting-Out-of-Bed (GoB) scale: a measure of motivation and life outlook in older adults with cancer

OBJECTIVE

To develop and evaluate the psychometric properties of a measure of motivation and life outlook (Getting-Out-of-Bed [GoB]).

DESIGN

Secondary analysis of baseline and 6-month data from a longitudinal follow-up study of older breast cancer survivors.

PARTICIPANTS

Women (N = 660) diagnosed with primary breast cancer stage I-IIIA disease, age >or=65 years, and permission to contact from an attending physician in four geographic regions in the United States (city-based Los Angeles, California; statewide in Minnesota, North Carolina, and Rhode Island).

MEASUREMENT

Data were collected over 6-months of follow-up from consenting patients' medical records and telephone interviews with patients. Data collected included the 4-item GoB, health-related quality of life (HRQoL), breast cancer, sociodemographic, and health-related characteristics.

RESULTS

Factor analysis produced, as hypothesized, one principal component with eigen values of 2.74(baseline) and 2.91(6-months) which explained 68.6%(baseline) and 72.7%(6-months) of total variance. In further psychometric analyses, GoB exhibited good construct validity (divergent: low nonstatistically significant correlations with unrelated constructs; convergent: moderate statistically significant correlations with related constructs; discriminant: distinguished high HRQoL groups with a high level of significance), excellent internal reliability (Cronbach's alpha 0.84(baseline), 0.87(6-months)), and produced stable measurements over 6-months. Women with GoB scores >or=50 at baseline were more likely at 6-months to have good HRQoL, good self-perceived health, and report regular exercise, indicating good predictive ability.

CONCLUSION

GoB demonstrated overall good psychometric properties in this sample of older breast cancer survivors, suggestive of a promising tool for assessing motivation and life outlook in older adults. Nevertheless, because it was developed and initially evaluated in a select sample, using measures with similar but not exact content overlap further evaluation is needed before it can be recommended for widespread use.

Repeat mammography screening among unmarried women with and without a disability

OBJECTIVES

Unmarried women with disabilities may be a particularly vulnerable group for underutilization of repeat mammography screening. Our goal was to compare the breast cancer screening experiences of unmarried women with disabilities (WWD) versus women with no disabilities (WND), and determine whether these experiences are associated with adherence to repeat screening.

METHODS

We conducted a matched cohort study of 93 WWD and 93 WND to compare mammography experiences by disability status, examine rates of repeat mammography by disability status, and identify factors that are associated with repeat mammography.

RESULTS

WWD were less likely to be on-schedule than WND in univariable (54.8% vs. 71.0%; relative risk, 0.77; 95% confidence limits, 0.61, 0.97), but not multivariable, analyses. In multivariable analyses, there was a significant interaction between disability status and positive experiences as the reasons for returning to the same mammography facility. Among WND, repeat screening ranged from 59% to 86%, depending on the number of positive experiences endorsed (range, 1-5). In contrast, among WWD, screening rates were only 37% among those who did not report any positive experiences and increased to a maximum of 60% regardless of whether women endorsed one to four or all five positive experiences. Severity and type of disability were not associated with repeat screening.

CONCLUSION

WWD may be less likely than WND to remain on-schedule for mammography. WWD who do not report any positive experiences as reasons for returning to a mammography facility may be at particularly high risk of underutilization of screening.

Using small-area estimation to describe county-level disparities in mammography

INTRODUCTION

Breast cancer control efforts could benefit from estimating mammography prevalence at the substate level because studies have primarily analyzed health survey data at the national and state levels. The purpose of this study was to evaluate the extent to which geographic disparities exist in mammography use across counties in the contiguous United States.

METHODS

We estimated county-level prevalence of recent mammography (past 2 years) for women aged 40 to 79 years by using synthetic regression, a small-area estimation method. The 2000 Behavioral Risk Factor Surveillance System (BRFSS), 2000 Census, Area Resource File, and Food and Drug Administration mammography facility data were merged by BRFSS respondents' county of residence. We conducted separate analyses to produce county-level prevalence estimates for each race and age group.

RESULTS

Mammography use varied geographically, and the magnitude of geographic disparities differed by race and age. Nonwhite women showed the lowest prevalence of mammography and widest range in county-level estimates. Women aged 40 to 49 had generally lower prevalence than other age groups, while women aged 65 to 79 showed the greatest variation in county-level mammography estimates.

CONCLUSION

Small-area estimation using BRFSS data is advantageous for surveillance of mammography use at the county level. This method allows documentation of geographic disparities and improves our understanding of the spatial distribution of mammography prevalence. Future interventions should consider this county-level geographic variation, targeting women in the neediest counties.

Risk perceptions among participants undergoing lung cancer screening: baseline results from the National Lung Screening Trial

BACKGROUND

Lung cancer screening could present a "teachable moment" for promoting smoking cessation and relapse prevention. Understanding the risk perceptions of older individuals who undergo screening will guide these efforts.

PURPOSE

This paper examines National Lung Screening Trial (NLST) participants' perceptions of risk for lung cancer and other smoking-related diseases. We investigated (1) whether risk perceptions of lung cancer screening participants differed between current and former smokers and (2) which factors (sociodemographic, smoking and medical history, cognitive, emotional, and knowledge) were associated with these risk perceptions.

METHODS

We analyzed baseline data collected from 630 NLST participants prior to their initial screen. Participants were older (55-74 years), heavy (minimum 30 pack years) current or former smokers. A ten-item risk perception measure was developed to assess perceived lifetime risk of lung cancer and other smoking-related diseases.

RESULTS

The risk perception measure had excellent internal consistency (alpha = 0.93). Former smokers had lower risk perceptions compared to current smokers. Factors independently associated with high risk perceptions among current smokers included having a personal history of a smoking-related disease, higher lifetime maximum number of cigarettes smoked daily, having lived with a smoker, high worry, high perceived severity of lung cancer and smoking-related diseases, and accurate knowledge of tenfold increased risk of lung cancer for a one pack per day smoker. Factors independently associated with high risk perceptions among former smokers included being White, past history of smoking within 30 min of waking, high worry, and accurate knowledge of tenfold increased risk of lung cancer for a one pack per day smoker.

CONCLUSIONS

Using a comprehensive risk perception measurement, we found that current and former smokers held different risk perceptions. Former and current smokers' smoking and medical history, race, emotional concerns, behavior change cognitions, and knowledge should be considered during a prescreening risk communication session. We highlight the theoretical and risk communication implications for former and current smokers undergoing lung cancer screening.

Investigating reversals of association for utilization of recent mammography among Hispanic and Non-Hispanic Black women

OBJECTIVE

Several papers have found that Hispanic and Non-Hispanic Black women have higher adjusted odds ratios for recent mammography when compared with Non-Hispanic White women, even though their crude percentages were lower than, or about equal to, Non-Hispanic White women's. This paper investigates the existence of "reversals" of association for recent mammography and describes an analysis strategy for identifying variables that might produce them.

METHODS

We used every-other-year data for women aged 40-80 from the 1996-2006 Behavioral Risk Factor Surveillance System and the 1999, 2000, 2003, and 2005 National Health Interview Survey. A consistent set of covariates was used across all datasets.

RESULTS

Reversals were found in almost all survey years for Hispanic women. Non-Hispanic Black women often had unadjusted rates comparable to Non-Hispanic Whites, but their adjusted odds ratios were significantly higher in most surveys. A limited number of variables contributed strongly to reversals, and differed somewhat for Hispanic and Black women.

CONCLUSIONS

Reversed associations found in adjusted analyses present a challenge for interpretation, but could also denote success of programs to increase screening rates. Users of population-level surveys should be alert for reversals and attempt to find explanations.

Comprehensive cancer screening among unmarried women aged 40-75 years: results from the cancer screening project for women

OBJECTIVES

We explored self-reported rates of individual on-schedule breast, cervical, and colorectal cancer screenings, as well as an aggregate measure of comprehensive screenings, among unmarried women aged 40-75 years. We compared women who partner with women (WPW) or with women and men (WPWM) to women who partner exclusively with men (WPM). We also compared barriers to on-schedule cancer screenings between WPW/WPWM and WPM.

METHODS

Comparable targeted and respondent-driven sampling methods were used to enroll 213 WPW/WPWM and 417 WPM (n = 630). Logistic regression models were computed to determine if partner gender was associated with each measure of on-schedule screening after controlling for demographic characteristics, health behaviors, and cancer-related experiences.

RESULTS

Overall, 74.3% of women reported on-schedule breast screening, 78.3% reported on-schedule cervical screening, 66.5% reported on-schedule colorectal screening, and 56.7% reported being on-schedule for comprehensive screening. Partner gender was not associated with any of the measures of on-schedule screening in multivariable analyses. However, women who reported ever putting off, avoiding, or changing the place of screenings because of sexual orientation were less likely to be on-schedule for comprehensive screening. Women who reported barriers associated with taking time from work and body image concerns were also less likely to be on-schedule for comprehensive screening.

CONCLUSIONS

Barriers to cancer screening were comparable across types of examinations as well as between WPW/WPWM and WPM. Developing health promotion programs for unmarried women that address concomitant detection and prevention behaviors may improve the efficiency and effectiveness of healthcare delivery and ultimately assist in reducing multiple disease risks.

Development and validation of a cervical cancer screening self-efficacy scale for low-income Mexican American women

Although self-efficacy, a construct from social cognitive theory, has been shown to influence other screening behaviors, few measures currently exist for measuring Papanicolaou test self-efficacy. This article describes the development and psychometric testing of such a measure for Mexican American women. Data from two separate samples of Mexican American women ages>or=50 years, obtained as part of a study to develop and evaluate a breast and cervical cancer screening educational program, were used in the current study. Exploratory factor analysis indicated a single-factor solution and all item loadings were >0.73. Confirmatory analysis confirmed a single-factor structure with all standardized loadings>0.40 as hypothesized. The eight-item self-efficacy scale showed high internal consistency (Cronbach's alpha=0.95). As hypothesized, self-efficacy was correlated with knowledge, prior experience, and screening intention. Logistic regression supported the theoretical relationship that women with higher self-efficacy were more likely to have had a recent Papanicolaou test. Findings showed a significant increase in self-efficacy following the intervention, indicating that the measure has good sensitivity to change over time.

Lessons learned from developing a tailored print intervention: a guide for practitioners and researchers new to tailoring

Although some "how-to" guides have been written on tailored messaging, we found no reports on lessons learned from the process of developing a tailored intervention. Such lessons may be useful for practitioners and researchers who are new to tailored intervention development. The authors describe lessons gleaned from the process of developing a repeat mammography tailored print intervention. Lessons learned include the following: Selection of determinants appropriate for tailoring should be based on a theoretic framework and refined through assessment of the target population; researchers should anticipate threats to fidelity of intervention delivery because of incomplete or illogical survey data; fingerprinting enables assessment of intervention dose and how it relates to effectiveness of the tailored intervention; and a systematic process for conducting a systems test is needed to check for inconsistencies and errors before final tailored letter production. These lessons are discussed in the context of challenges and possible solutions for tailored health communication.

Body satisfaction effect on thorough skin self-examination

BACKGROUND

Melanoma and obesity have both increased in recent years. Given the propensity of body dissatisfaction among the obese, the objectives of this paper were to determine how body satisfaction might influence skin examination and to examine differences in this relationship by gender among the participants of Check-It-Out, a study to increase thorough skin self-examination (TSSE).

METHODS

Through primary care offices, 2126 participants were recruited from April 2000 to November 2001 for the baseline cross-sectional telephone data from the Check-It-Out study. TSSE was defined as the self-reported examination of all seven key areas of the body. Body satisfaction was reported based on the degree of disagreement or agreement with the statement I like the way my body looks. Analyses were conducted in 2005 and 2006.

RESULTS

Among participants, 18% reported performing TSSE, 34% were normal or underweight, 36% were overweight, and 30% were obese. Overall, 23% strongly agreed, 45% somewhat agreed, 19% somewhat disagreed, and 12% strongly disagreed with the statement I like the way my body looks. Body satisfaction was less common among women than men. The odds of conducting TSSE were 1.6 for the total sample (1.9 for women and 1.2 for men) for those with strong agreement that they like the way their body looks. In multivariate analysis, body satisfaction was associated with TSSE performance for women and both genders together, along with the availability of a partner (both genders together and men), the availability of a wall mirror, the advice of a physician, and the use of glasses or contacts(women only).

CONCLUSIONS

Body satisfaction is an important factor in TSSE performance, especially among women, and should be considered along with other risk factors.

Promoting regular mammography screening II. Results from a randomized controlled trial in US women veterans

BACKGROUND

Few health promotion trials have evaluated strategies to increase regular mammography screening. We conducted a randomized controlled trial of two theory-based interventions in a population-based, nationally representative sample of women veterans.

METHODS

Study candidates 52 years and older were randomly sampled from the National Registry of Women Veterans and randomly assigned to three groups. Groups 1 and 2 received interventions that varied in the extent of personalization (tailored and targeted vs targeted-only, respectively); group 3 was a survey-only control group. Postintervention follow-up surveys were mailed to all women after 1 and 2 years. Outcome measures were self-reported mammography coverage (completion of one postintervention mammogram) and compliance (completion of two postintervention mammograms). In decreasingly conservative analyses (intention-to-treat [ITT], modified intention-to-treat [MITT], and per-protocol [PP]), we examined crude coverage and compliance estimates and adjusted for covariates and variable follow-up time across study groups using Cox proportional hazards regression. For the PP analyses, we also used logistic regression.

RESULTS

None of the among-group differences in the crude incidence estimates for mammography coverage was statistically significant in ITT, MITT, or PP analyses. Crude estimates of compliance differed at statistically significant levels in the PP analyses and at levels approaching statistical significance in the ITT and MITT analyses. Absolute differences favoring the intervention over the control groups were 1%-3% for ITT analysis, 1%-5% for MITT analysis, and 2%-6% for the PP analysis. Results from Cox modeling showed no statistically significant effect of the interventions on coverage or compliance in the ITT, MITT, or PP analyses, although hazard rate ratios (HRRs) for coverage were consistently slightly higher in the intervention groups than the control group (range for HRRs = 1.05-1.09). A PP analysis using logistic regression produced odds ratios (ORs) that were consistently higher than the corresponding hazard rate ratios for both coverage and compliance (range for ORs = 1.15-1.29).

CONCLUSIONS

In none of our primary analyses did the tailored and targeted intervention result in higher mammography rates than the targeted-only intervention, and there was limited support for either intervention being more effective than the baseline survey alone. We found that adjustment for variable follow-up time produced more conservative (less favorable) intervention effect estimates.

Cancer prevention in primary care: predictors of patient counseling across four risk behaviors over 24 months

OBJECTIVE

Rates of preventive counseling remain below national guidelines. We explored physician and patient predictors of preventive counseling across multiple cancer risk behaviors in at-risk primary care patients.

METHODS

We surveyed 3557 patients, with at least one of four cancer risk behaviors: smoking, diet, sun exposure, and/or mammography screening, at baseline and 24 months. Patients reported receipt of 4A's (Ask, Advise, Assist, Arrange follow-up); responses were weighted and combined to reflect more thorough counseling (Ask=1, Advise=2, Assist=3, Arrange=4, score range 0-10) for each target behavior. A series of linear-regression models, controlling for office clustering, examined patient, physician and other situational predictors at 24 months.

RESULTS

Risk behavior topics were brought up more often for mammography (90%) and smoking (79%) than diet (56%) and sun protection (30%). Assisting and Arranging follow-up were reported at low frequencies across all behaviors. More thorough counseling for all behaviors was associated with multiple visits and higher satisfaction with care. Prior counseling predicted further counseling on all behaviors except smoking, which was already at high levels. Other predictors varied by risk behavior.

CONCLUSIONS

More thorough risk behavior counseling can be delivered opportunistically across multiple visits; doing so is associated with more satisfaction with care.

Differential response effects of data collection mode in a cancer screening study of unmarried women ages 40-75 years: a randomized trial

BACKGROUND

Little is known about the impact of data collection method on self-reported cancer screening behaviours, particularly among hard-to-reach populations. The purpose of this study is to examine the effects of data collection mode on response to indicators of cancer screenings by unmarried middle-aged and older women.

METHODS

Three survey methods were evaluated for collecting data about mammography and Papanicolaou (hereafter, Pap) testing among heterosexual and sexual minority (e.g., lesbian and bisexual) women. Women ages 40-75 were recruited from June 2003 - June 2005 in Rhode Island. They were randomly assigned to receive: Self-Administered Mailed Questionnaire [SAMQ; N = 202], Computer-Assisted Telephone Interview [CATI; N = 200], or Computer-Assisted Self-Interview [CASI; N = 197]. Logistic regression models were computed to assess survey mode differences for 13 self-reported items related to cancer screenings, adjusting for age, education, income, race, marital status, partner gender, and recruitment source.

RESULTS

Compared to women assigned to CATI, women assigned to SAMQ were less likely to report two or more years between most recent mammograms (CATI = 23.2% vs. SAMQ = 17.7%; AOR = 0.5, 95% CI = 0.3 - 0.8) and women assigned to CASI were slightly less likely to report being overdue for mammography (CATI = 16.5% vs. CASI = 11.8%; AOR = 0.5, 95% CI = 0.3 - 1.0) and Pap testing (CATI = 14.9% vs. CASI = 10.0%; AOR = 0.5, 95% CI = 0.2 - 1.0). There were no other consistent mode effects.

CONCLUSION

Among participants in this sample, mode of data collection had little effect on the reporting of mammography and Pap testing behaviours. Other measures such as efficiency and cost-effectiveness of the mode should also be considered when determining the most appropriate form of data collection for use in monitoring indicators of cancer detection and control.

Promoting regular mammography screening I. A systematic assessment of validity in a randomized trial

BACKGROUND

Most health promotion trials in cancer screening offer limited evidence of external validity. We assessed internal and external validity in a nationwide, population-based trial of an intervention to promote regular mammography screening.

METHODS

Beginning in September 2000, study candidates age 52 years and older (n = 23,000) were randomly selected from the National Registry of Women Veterans and sent an eligibility survey. Consistent with intention-to-treat principles for effectiveness trials, we randomly assigned eligible respondents and nonrespondents to one of five groups. We mailed baseline surveys to groups 1-3 followed by intervention materials of varying personalization to groups 1 and 2. We delayed mailing baseline surveys to two additional control groups to coincide with the mailing of postintervention follow-up surveys to groups 1-3 at year 1 (group 4) and year 2 (group 5). Mammography rates were determined from self-report and Veterans Health Administration records. To assess internal validity, we compared groups on participation and factors associated with mammography screening at each stage. To assess external validity, we compared groups 3, 4, and 5 on mammography rates at the most recent follow-up to detect any cueing effects of prior surveys and at the respective baselines to uncover any secular trends. We also compared nonparticipants with participants on factors associated with mammography screening at the trial's end.

RESULTS

We established study eligibility for 21,340 (92.8%) of the study candidates. Groups 1-3 were similar throughout the trial in participation and correlates of mammography screening. No statistically significant survey cueing effects or differences between nonparticipants and participants across groups were observed. Mammography screening rates over the 30 months preceding the respective baselines were lower in group 5 (82.3% by self-report) than in groups 1-4 (85.1%, P = .024, group 5 vs groups 1-4 combined), suggesting a decline over time similar to that reported for US women in general.

CONCLUSION

This systematic assessment provides evidence of the trial's internal and external validity and illustrates an approach to evaluating validity that is readily adaptable to future trials of behavioral interventions.

Effect of cost sharing on screening mammography in Medicare health plans

BACKGROUND

Policies that increase patients' share of health care expenses decrease the use of discretionary health services but also may reduce the use of important preventive care such as mammography.

METHODS

We reviewed coverage for mammography within 174 Medicare managed-care plans from 2001 through 2004. Among 550,082 individual-level observations for 366,475 women between the ages of 65 and 69 years, we compared rates of biennial breast-cancer screening in plans requiring cost sharing for mammography with screening rates in plans with full coverage. We also performed a longitudinal analysis of screening rates in plans that changed from full coverage to cost sharing for mammography as compared with rates in matched control plans that did not institute cost sharing.

RESULTS

The number of plans with cost sharing for mammography, which we defined as requiring a copayment of more than $10 or coinsurance of more than 10% for screening mammography, increased from 3 in 2001 (representing 0.5% of women) to 21 in 2004 (11.4% of women). Biennial screening rates were 8.3 percentage points lower in cost-sharing plans than in plans with full coverage, a difference that persisted in adjusted analyses (P<0.001). The effect of cost sharing was magnified among women residing in areas of lower income or educational levels (P<0.001 for each interaction). Screening rates decreased by 5.5 percentage points in plans that instituted cost sharing and increased by 3.4 percentage points in matched control plans that retained full coverage (P<0.001 for the adjusted analysis).

CONCLUSIONS

Relatively small copayments were associated with significantly lower mammography rates among women who should undergo screening mammography according to accepted clinical guidelines. For effective preventive services such as mammography, exempting elderly adults from cost sharing may be warranted.

Risk perceptions and worry about cancer: does gender make a difference?

Risk perceptions and worry are important constructs in many theoretical frameworks used to develop cancer screening interventions. Because most cancers for which we have early detection or prevention strategies are gender specific, few investigations have examined gender differences. We examined gender differences in the magnitude of, and associations with, perceived risk and worry by cancer type. Our sample included 939 men and 1,580 women >or= 50 years old with no history of relevant cancers from the 2003 Health Information National Trends Survey (HINTS). Dependent variables included absolute and comparative perceived risk and worry for gender-specific (breast/prostate) and colon cancers. We examined demographics, health status, health behaviors, cancer beliefs, and cancer communication variables as correlates. Linear regression analyses and pairwise contrasts were conducted with SUDAAN. Men reported greater comparative perceived risk for developing cancers, whereas women reported more frequent cancer worry. For both genders, perceived risk and worry were lowest for colon cancer. Correlates of perceived risk and worry varied, and several associations were moderated by gender. Different risk messages and intervention strategies may be needed to influence males' and females' perceived cancer risk and worry. All effect sizes were small, and future prospective research is needed to confirm our findings.

Factors associated with thorough skin self-examination for the early detection of melanoma

BACKGROUND

Regular thorough skin self-examination (TSSE) has potential for detecting melanoma early and reducing melanoma mortality.

OBJECTIVES

We sought to model factors associated with skin self-examination (SSE) and test whether efficacy and attitudes about SSE mediated these relationships.

PATIENTS/METHODS

The Check-It-Out project is a randomized trial of an intervention to encourage TSSE; 2126 participants were recruited from the practices of primary care physicians. Correlates predicting baseline TSSE included demographic variables, skin cancer risk, physician advice to examine skin, and appropriate conditions for conducting SSE (availability of partner to assist with self-examination, availability of a wall mirror, and use of contact lenses/glasses).

RESULTS

Those who were given physician advice, had a wall mirror, and had a partner available were more likely to perform TSSE.

LIMITATIONS

We identified the factors associated with concurrent TSSE practices. Further research is needed to determine if these same factors predict future behaviour. Our findings may not be applicable in geographical areas other than our recruitment area.

CONCLUSIONS

Primary care providers can recommend SSE and provide materials to increase ability to recognize skin problems. Providing instructions and aids for conducting TSSE may increase self-efficacy.

Correlates of repeat and recent mammography for women ages 45 to 75 in the 2002 to 2003 Health Information National Trends Survey (HINTS 2003)

BACKGROUND

Most national-level mammography data are for ever-had and most-recent screening. There are few national-level data on rates of repeat, on-schedule mammography, and on the prevalence and correlates of repeat mammography. It is also important to investigate the similarity of correlates for repeat and recent mammography.

METHODS

Analyses were from data for women ages 45 to 75 in the 2002 to 2003 Health Information and National Trends Survey (HINTS 2003; N = 1,581). The two dependent variables were self-report of repeat mammography (two exams on schedule, based on an every-other-year interval) and recent mammography only (one mammogram within the past 2 years).

RESULTS

The prevalence of recent mammography was 81.6% (95% confidence interval, 79.1-84.1) and for repeat mammography was 72.2% (95% confidence interval, 69.0-75.4). An access to care variable combining insurance coverage and regular source of care was the strongest sociodemographic correlate of both mammography indicators. Most other sociodemographic variables were not associated with mammography status. Five psychosocial/behavioral variables were associated with both mammography indicators (smoking status, attention to health information, knowledge of screening interval, worry about breast cancer, and recent mood status). Correlates were very similar for repeat and recent mammography.

CONCLUSIONS

Although access to care had the strongest association with mammography, psychosocial and behavioral variables did better as a group than the sociodemographic variables. A standard set of such variables should be considered for all national surveys.

Melanoma early detection with thorough skin self-examination: the "Check It Out" randomized trial

BACKGROUND

Monthly thorough skin self-examination (TSSE) is an important practice for early melanoma detection that is performed by a small minority of the population.

DESIGN

A randomized trial was conducted to determine whether a multicomponent intervention can increase TSSE performance and to describe the effects on performance of skin surgeries compared with a similar control intervention focused on diet.

SETTING/PARTICIPANTS

One thousand three hundred fifty-six patients attending a routine primary care visit in southeastern New England participated in this trial.

INTERVENTIONS

Participants received instructional materials, including cues and aids, a video, and a brief counseling session and (at 3 weeks) a brief follow-up phone call (from a health educator) and tailored feedback letters.

MEASURES

Performance of TSSE assessed by telephone interview and having a surgical procedure performed on the skin were confirmed by examining medical records.

RESULTS

TSSE was performed by substantially more participants at 2, 6, and 12 months in the intervention group than in the control group (55% vs 35%, p<0.0001 at 12 months). We also noted that a substantially higher proportion in the intervention group had skin surgery in the first 6 months (8.0% vs 3.6%, p=0.0005), but there was no difference at 6 to 12 months (3.9% vs 3.3%, p=0.5).

CONCLUSIONS

The TSSE intervention was effective in increasing performance of TSSE, in that it resulted in increased surgery on the skin, and that increase in skin procedures only persisted for 6 months. Intervention to increase TSSE may result in long-term benefit in early detection of melanoma while causing only a short-term excess of skin surgeries.

Traditionality and Cancer Screening Practices Among American Indian Women in Vermont

The study purpose was to examine the relationship between cancer screening and traditionality, using a culturally specific survey instrument. American Indian (AI) women were randomly selected from the Vermont Breast Cancer Surveillance System (VBCSS), a statewide mammography database. The 13 items that assessed traditionality examined identity, cultural beliefs, customs, and health practices. The sample of 115 was predominately married, educated, middle class, insured, and rural. Significant associations were found between traditionality and past mammography and clinical breast examination (CBE) behavior, as well as future mammography intention. Results suggest that traditionality scales can be useful for identifying differences in screening behavior, with further testing of traditionality items with other AI women recommended. International implications of the study findings are also addressed.

Colorectal cancer screening among low-income African Americans in East Harlem: a theoretical approach to understanding barriers and promoters to screening

African Americans (AAs) have the highest incidence rates of colorectal cancer (CRC) among all races in the US. These disparities may be attributed to lower participation in CRC prevention and control activities [e.g., flexible sigmoidoscopy (FS), fecal occult blood testing (FOBT)]. This is a current issue in East Harlem where less than half the residents in this area participate in CRC screening and mortality rates due to CRC are higher than the national average. We examined correlates of FS and FOBT screening among AAs based on the transtheoretical model (TTM) of behavior change. One hundred and eleven AA men and women, 50 years and older (51-92), low-income, and at average risk for CRC were recruited at an ambulatory care center in East Harlem. Assessments focused on sociodemographic, medical, psychosocial and TTM variables. The first logistic regression model showed that higher levels of education (p < 0.05), greater knowledge of FS (p < 0.05), and greater endorsements of Thinking Beyond Oneself (p < 0.05) were associated with adherence to FS screening guidelines. The second model showed that only greater knowledge of FOBT (p < 0.05) and receiving a physician's recommendation (p < 0.01) were significant correlates of adherence to FOBT screening guidelines. This study supported the application of components of the TTM for FS and FOBT screening among low-income AAs receiving care in an urban medical center and illustrated the need for interventions targeting both patients and their providers.

Development of a culturally specific instrument for mammography screening: an example with American Indian women in Vermont

This article presents the triangulation process for translating qualitative data about mammography screening from a grounded theory study with American Indian women in Vermont, into questionnaire items based on an existing model of behavior change, the Transtheoretical Model (TTM) Stages-of-Change. Qualitative data were used to derive a theory, Moving in Between Mammography, which suggested that traditionality influenced American Indian women's screening decisions. To examine the relationship between mammography and traditionality, new items were developed for each of three key TTM constructs: Pros, Cons, and Processes-of-Change. The process for developing the new TTM-based items, as well as traditionality items specific for American Indian women living off-reservation, are presented. This article provides one example of how an instrument can be developed within a culturally competent nursing framework.

Are there gender differences in colorectal cancer test use prevalence and correlates?

Despite evidence that screening tests reduce colorectal cancer incidence and mortality, screening prevalence is low. Gender differences in test uptake have been reported, but few studies examine correlates of test use by gender. Differences, if present, may inform strategies to increase test use. We examined gender differences in the prevalence and correlates of colorectal cancer test use [fecal occult blood test (FOBT) and endoscopy] using data from the 2002 to 2003 Health Information National Trends Survey. Male (n = 999) and female (n = 1687) respondents ages > or =50 years, without a personal history of colorectal cancer, were interviewed by telephone. Age-adjusted prevalence rates were reported for lifetime, recent, and repeat use by gender and test type. Multivariable logistic regression analyses were used to identify correlates of test use stratified by gender and colorectal cancer test type. More females reported only using FOBT in lifetime and in the past year, whereas more males reported repeat endoscopy use. The use of other tests or combinations of tests did not differ by gender. Consistent positive correlates of colorectal cancer test use for both genders included age, recent physician visits, recent breast or prostate cancer screening, and knowledge of test-specific screening intervals. Correlates that differed by gender included comparative perceived risk, belief that colorectal cancer testing was too expensive, fear of finding colorectal cancer if tested, and attention to and trust in media sources of health information. Such differences, if confirmed in future studies, may inform the use of gender-specific intervention strategies or messages to increase colorectal cancer test use.

The distribution and predictive validity of the stages of change for mammography adoption among Canadian women

OBJECTIVE

To examine the predictive validity of the transtheoretical model (TTM) stages of change for mammography participation in Canadian women.

METHOD

We examined the association between baseline TTM stage of mammography adoption and subsequent mammography participation in a representative sample of 3,125 Canadian women aged 40 and older from the longitudinal Canadian National Population Health Survey.

RESULTS

The likelihood of having a mammogram at follow-up (1998/1999) increased with progressive stages of change at baseline (1996/1997) even after adjusting for potential confounders. Relative to women in maintenance, women in precontemplation, relapse, contemplation, relapse risk, and action were significantly less likely to report a recent mammogram during follow-up (adjusted RR of 0.41, 0.50, 0.63, 0.75, and 0.92, respectively; P(trend) < 0.01). This pattern held for women within and outside of the 50-69 target age range, and for urban and to a lesser degree rural-dwelling women.

CONCLUSION

Our findings support the predictive validity of the TTM stages of mammography adoption construct and the inclusion of both relapse and relapse risk categories to improve the sensitivity of the predictive model. Interventions to promote the eventual maintenance of mammography screening should also benefit from further research that aims to understand the variables that promote progressive movement through the stages.