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1.  Family/friend recommendations and mammography intentions: the roles of perceived mammography norms and support 
Health Education Research  2015;30(5):797-809.
Identifying factors that increase mammography use among Latinas is an important public health priority. Latinas are more likely to report mammography intentions and use, if a family member or friend recommends that they get a mammogram. Little is known about the mechanisms underlying the relationship between social interactions and mammography intentions. Theory suggests that family/friend recommendations increase perceived mammography norms (others believe a woman should obtain a mammogram) and support (others will help her obtain a mammogram), which in turn increase mammography intentions and use. We tested these hypotheses with data from the ¡Fortaleza Latina! study, a randomized controlled trial including 539 Latinas in Washington State. Women whose family/friend recommended they get a mammogram within the last year were more likely to report mammography intentions, norms and support. Perceived mammography norms mediated the relationship between family/friend recommendations and intentions, Mediated Effect = 0.38, 95%CI [0.20, 0.61], but not support, Mediated Effect = 0.002, 95%CI [−0.07, 0.07]. Our findings suggest perceived mammography norms are a potential mechanism underlying the effect of family/friend recommendations on mammography use among Latinas. Our findings make an important contribution to theory about the associations of social interactions, perceptions and health behaviors.
doi:10.1093/her/cyv040
PMCID: PMC4654755  PMID: 26324395
2.  Health Policy to Promote Colorectal Cancer Screening: Improving Access and Aligning Federal and State Incentives 
Since implementation of the Affordable Care Act, 7 million+ individuals are newly covered on state-managed Medicaid programs and millions more on subsidized commercial insurance plans. We describe Oregon's experience in including colorectal cancer (CRC) screening as a measure for the state's new pay-for-performance Medicaid program. Using Oregon Health Authority data, we present 1) frequencies of Medicaid enrollees age-eligible for CRC screening, before and after Medicaid expansion; 2) CRC screening rates for 2011 and 2013; and 3) stakeholder perceptions about incentivizing CRC screening. Between December 2013 and June 2014, the size of the Medicaid-enrolled population age-eligible for CRC screening increased by 55% (104,920 to 163,078). Between 2011 and 2013, CRC screening rates improved by more than three percent for 6/15 (40%) CCOs; the majority of stakeholders surveyed (70%) supported the CRC screening metric. Inclusion of CRC screening as a Medicaid quality metric may present a unique opportunity to raise rates among historically underserved populations.
doi:10.14524/CR-14-0044
PMCID: PMC4847543  PMID: 27135047
3.  Clinical Perspectives on Colorectal Cancer Screening at Latino-Serving Federally Qualified Health Centers 
Purpose
Colorectal cancer is the second most common cause of cancer death in the United States, and rates of screening for colorectal cancer are low. We sought to gather the perceptions of clinic personnel at Latino-serving Federally Qualified Health Centers (operating 17 clinics) about barriers to utilization of screening services for colorectal cancer.
Method
We conducted one-on-one interviews among 17 clinic personnel at four Latino-serving Federally Qualified Health Center networks in Oregon. All interviews were recorded, transcribed, and coded, and themes were grouped by influences at three levels: the patient, the organization, and the external environment.
Results
Estimated proportions of eligible patients who are underscreened for colorectal cancer ranged from 20% to 70%. Underscreening was thought to occur among low-income, underinsured, and undocumented patients and patients having multiple health concerns. Limited funding to pay for follow-up testing in patients with positive screens was cited as the key factor contributing to underscreening.
Conclusions
We identified health care provider perceptions about the underutilization of screening services for colorectal cancer; our findings may inform future efforts to promote guideline-appropriate cancer screening.
doi:10.1177/1090198114537061
PMCID: PMC4745651  PMID: 24952378
4.  Use of PRECIS ratings in the National Institutes of Health (NIH) Health Care Systems Research Collaboratory 
Trials  2016;17:32.
Background
The National Institutes of Health (NIH) Health Care Systems Research Collaboratory (NIH Collaboratory) seeks to produce generalizable knowledge about the conduct of pragmatic research in health systems. This analysis applied the PRECIS-2 pragmatic trial criteria to five NIH Collaboratory pragmatic trials to better understand 1) the pragmatic aspects of the design and implementation of treatments delivered in real world settings and 2) the usability of the PRECIS-2 criteria for assessing pragmatic features across studies and across time.
Methods/Design
Using the PRECIS-2 criteria, five pragmatic trials were each rated by eight raters. For each trial, we reviewed the original grant application and a required progress report written at the end of a 1-year planning period that included changes to the protocol or implementation approach. We calculated median scores and interrater reliability for each PRECIS domain and for the overall trial at both time points, as well as the differences in scores between the two time points. We also reviewed the rater comments associated with the scores.
Results
All five trials were rated to be more pragmatic than explanatory, with comments indicating that raters generally perceived them to closely mirror routine clinical care across multiple domains. The PRECIS-2 domains for which the trials were, on average, rated as most pragmatic on the 1 to 5 scale at the conclusion of the planning period included primary analysis (mean = 4.7 (range = 4.5 to 4.9)), recruitment (4.3 (3.6 to 4.8)), eligibility (4.1 (3.4 to 4.8)), setting (4.1 (4.0 to 4.4)), follow-up (4.1 (3.4 to 4.9)), and primary outcome (4.1 (3.5 to 4.9)). On average, the less pragmatic domains were organization (3.3 (2.6 to 4.4)), flexibility of intervention delivery (3.5 (2.1-4.5)), and flexibility of intervention adherence (3.8 (2.8-4.5)). Interrater agreement was modest but statistically significant for four trials (Gwet’s AC1 statistic range 0.23 to 0.40) and the intraclass correlation coefficient ranged from 0.05 to 0.31. Rating challenges included assigning a single score for domains that may relate to both patients and care settings (that is, eligibility or recruitment) and determining to what extent aspects of complex research interventions differ from usual care.
Conclusions
These five trials in diverse healthcare settings were rated as highly pragmatic using the PRECIS-2 criteria. Applying the tool generated insightful discussion about real-world design decisions but also highlighted challenges using the tool. PRECIS-2 raters would benefit from additional guidance about how to rate the interwoven patient and practice-level considerations that arise in pragmatic trials.
Trial registrations
Clinicaltrials.gov trial registrations: NCT02019225, NCT01742065, NCT02015455, NCT02113592, NCT02063867.
doi:10.1186/s13063-016-1158-y
PMCID: PMC4715340  PMID: 26772801
5.  Analytic Challenges Arising from the STOP CRC Trial: Pragmatic Solutions for Pragmatic Problems 
eGEMs  2015;3(1):1200.
Context:
Pragmatic trials lack the relatively tight quality control of traditional efficacy studies and hence may pose added analytic challenges owing to the practical realities faced in carrying them out.
Case Description:
STOP CRC is a cluster randomized trial testing the effectiveness of automated, electronic medical record (EMR)-driven strategies to raise colorectal cancer (CRC) screening rates in safety net clinics. Screen-eligible participants were accrued during year 1 and followed for 12 months (measurement window) to assess completion of a fecal screening test. Control clinics implemented the intervention in year 2.
Implementation Challenges/Analytic Issues:
Due to limitations on how we could build the intervention tools, the overlap of the year 1 measurement windows with year 2 intervention rollout posed a potential for contamination of the primary outcome for control participants. In addition, a variety of factors led to a lack of synchronization of the measurement windows with actual intervention delivery. In both cases, the net impact of these factors would be to diminish the estimated impact of the intervention.
Proposed Solutions:
We dealt with the overlap issue by delaying the start of intervention rollout to control clinics in year 2 by 6 months and by truncating the measurement windows for intervention and control participants at this point. In addition we formulated three sensitivity analyses to help address the issue of asynchronization.
Conclusion:
This case study might help other investigators facing similar challenges think about such issues and the pros and cons of various strategies for dealing with them.
doi:10.13063/2327-9214.1200
PMCID: PMC4708092  PMID: 26793738
pragmatic trials; data analysis; methodology; colorectal cancer screening; cluster-randomized study; 2014 Group Health Seattle Symposium; Electronic Health Records; Quality Inprovement
6.  AMIGAS: A Multicity, Multicomponent Cervical Cancer Prevention Trial Among Mexican American Women 
Cancer  2012;119(7):1365-1372.
BACKGROUND
Considerable efforts have been undertaken in the United States to reduce cervical cancer incidence and mortality by increasing screening; however, disparities in screening rates continue to exist among certain racial and ethnic minority groups. The objective of the current study was to determine the effectiveness of a lay health worker-delivered intervention—AMIGAS (Ayudando a las Mujeres con Informacion, Guia, y Amor para su Salud [helping women with information, guidance, and love for their health])—to increase Papanicolaou (Pap) test screening among 3 populations of women of Mexican origin.
METHODS
Six hundred thirteen women of Mexican origin in 3 treatment sites were randomized among 4 study arms: the full AMIGAS program with a video and a flip chart (n = 151), the AMIGAS program without the video (n = 154), the AMIGAS program without the flip chart (n = 155), and a usual care control group (n = 153). Six months after enrollment, women were surveyed and reported whether or not they had been screened.
RESULTS
Women in any of the intervention arms were statistically significantly more likely to report being screened than those in the usual care group in both an intent-to-treat analysis and a per-protocol analysis. In the intent-to-treat analysis, 25% of women in the control group and 52% in the full AMIGAS program group reported having had Pap tests (P < .001); in the per-protocol analysis, the percentages were 29% and 62%, respectively (P < .001).
CONCLUSIONS
AMIGAS was effective in increasing Pap test screening among women of Mexican descent when used in a 1-to-1 setting. Future research should compare the 1-on-1 intervention with the group-based intervention.
doi:10.1002/cncr.27926
PMCID: PMC4603549  PMID: 23280399
uterine cervical cancer screening; Mexican origin; clinical trial; health education; Hispanic women
7.  Strategies and Opportunities to STOP Colon Cancer in Priority Populations: Design of a Cluster-Randomized Pragmatic Trial 
Contemporary clinical trials  2014;38(2):344-349.
Background
Colorectal cancer is the second-leading cause of cancer deaths in the United States. The Strategies and Opportunities to Stop Colorectal Cancer (STOP CRC) in Priority Populations study is a pragmatic trial and a collaboration between two research institutions and a network of more than 200 safety net clinics. The study will assess effectiveness of a systems-based intervention designed to improve rates of colorectal-cancer screening using fecal immunochemical testing (FIT) in federally qualified health centers in Oregon and Northern California.
Material and Methods
STOP CRC is a cluster-randomized comparative-effectiveness pragmatic trial enrolling 26 clinics. Clinics will be randomized to one of two arms. Clinics in the intervention arm (1) will use an automated, data-driven, electronic health record-embedded program to identify patients due for colorectal screening and mail FIT kits (with pictographic instructions) to them; (2) will conduct an improvement process (e.g. Plan-Do-Study-Act) to enhance the adoption, reach, and effectiveness of the program. Clinics in the control arm will provide opportunistic colorectal-cancer screening to patients at clinic visits. The primary outcomes are: proportion of age– and screening-eligible patients completing a FIT within 12 months; and cost, cost-effectiveness, and return on investment of the intervention.
Conclusions
This large-scale pragmatic trial will leverage electronic health record information and existing clinic staff to enroll a broad range of patients, including many with historically low colorectal-cancer screening rates. If successful, the program will provide a model for a cost-effective and scalable method to raise colorectal-cancer screening rates.
doi:10.1016/j.cct.2014.06.006
PMCID: PMC4226652  PMID: 24937017
Colorectal cancer screening; fecal immunochemical test; pragmatic study; cluster-randomized study
8.  Navigating the Murky Waters of Colorectal Cancer Screening and Health Reform 
American journal of public health  2014;104(6):982-986.
The Affordable Care Act (ACA) mandates that both Medicaid and insurance plans cover life-saving preventive services recommended by the US Preventive Services Task Force, including colorectal cancer (CRC) screening and choice between colonoscopy, flexible sigmoidoscopy, and fecal occult blood testing (FOBT).
People who choose FOBT or sigmoidoscopy as their initial test could face high, unexpected, out-of-pocket costs because the mandate does not cover needed follow-up colonoscopies after positive tests. Some people will have no coverage for any CRC screening because of lack of state participation in the ACA or because they do not qualify (e.g., immigrant workers).
Existing disparities in CRC screening and mortality will worsen if policies are not corrected to fully cover both initial and follow-up testing.
doi:10.2105/AJPH.2014.301877
PMCID: PMC4062021  PMID: 24825195
9.  Advantages of Wordless Instructions on how to Complete a Fecal Immunochemical Test: Lessons from Patient Advisory Council Members of a Federally Qualified Health Center 
Some patients face difficulty understanding Instructions for completing the fecal immunochemical test (FIT), a self-administered test to screen for colorectal cancer. We sought to develop and test low-literacy instructions for completing the FIT. Working in partnership with a Latino-serving Federally Qualified Health Center (FQHC) in the Portland Metro area, we developed and tested low literacy instructions for completing the FIT; the instructions contained 7 words [Mail within 3 days; Devolver dentro de 3 dias]. We conducted focus groups of Spanish-speaking patients on the advisory council of our partnering FQHC organization, and we gathered feedback from the project’s advisory board members and clinic staff. We mailed a FIT kit to each patient, along with either (a) instructions written in English and Spanish, consisting of 415 words; or (b) low-literacy “wordless” instructions. We asked patients to complete the test before providing feedback. Our qualitative assessment showed that the wordless instructions were preferred over instructions consisting of words. Wordless instructions might aid efforts to raise the rates of colorectal cancer screening among low-literacy and non-English-speaking populations.
doi:10.1007/s13187-013-0551-4
PMCID: PMC3946071  PMID: 24057692
10.  Variability in the Take-Home Pathway: Farmworkers and Non-farmworkers and their Children 
Background
Organophosphate pesticides (OPs) are related to ill health among adults including farmworkers who are exposed to OPs as part of their regular work. Children of both farmworkers and non-farmworkers in agricultural communities may also be affected by pesticide exposure.
Methods
Study groups of 100 farmworkers with a referent child (aged 2 to 6 years) and 100 non-farmworkers with a referent child were recruited to participate in three data collection periods over the course of a year. At each collection, participants provided three urine samples within 5 days, and homes and vehicles were vacuumed to collect pesticide residues in dust.
Results
In thinning and harvest seasons, farmworkers and their children had higher dimethyl urinary metabolites than non-farmworkers and their children. During the non-spray season, the urinary metabolites levels decreased among farmworkers to a level comparable to non-farmworkers. Farmworkers consistently had higher pesticide residues in their home and vehicle dust.
Conclusions
Differences exist between farmworkers and non-farmworkers in urinary metabolites and the differences extended throughout the agricultural seasons. OP metabolites are seen at much higher levels for farmworkers and their children than non-farmworkers and their children during agricultural seasons when OPs are in use. These metabolite levels were significantly higher than the nationwide NHANES IV survey and up to 10 fold higher than other rural agricultural studies.
doi:10.1038/jes.2014.12
PMCID: PMC4141015  PMID: 24594649
organophosphate pesticides; child exposure/health; population based studies; environmental monitoring
11.  Reasons for non-response to a direct-mailed FIT kit program: lessons learned from a pragmatic colorectal-cancer screening study in a federally sponsored health center 
Colorectal cancer screening rates are below optimal. As part of a pilot clinic-based pragmatic study aiming to raise rates of colorectal-cancer screening, we explored patients’ reasons for not responding to a direct-mailed screening invitation. We conducted telephone interviews with patients who were mailed a fecal immunochemical test (FIT) but who did not return it to the lab. Interviews were audio-recorded, transcribed, and coded for thematic analysis. We met our goal of 20 interviews (10 in English and 10 Spanish; 75 % female). Reasons for not completing tests were fear of results or cost of follow-up colonoscopy (n = 9); not having received the test in the mail (n = 7); concerns about mailing fecal matter or that test results could be mixed up (n = 6); and being busy or forgetful (n = 4). Efforts to improve uptake of colorectal cancer screening in a direct-mailed program ought to address concerns identified in our study.
Electronic supplementary material
The online version of this article (doi:10.1007/s13142-014-0276-x) contains supplementary material, which is available to authorized users.
doi:10.1007/s13142-014-0276-x
PMCID: PMC4332898  PMID: 25729454
Colorectal cancer screening; Direct-mailed fecal testing; Federally qualified health centers; Implementation; Pragmatic research; Qualitative interviews
12.  “BeneFITs” to Increase Colorectal Cancer Screening in Priority Populations 
JAMA internal medicine  2014;174(8):1242-1243.
doi:10.1001/jamainternmed.2014.730
PMCID: PMC4217574  PMID: 24934255
15.  Using an Automated Data-driven, EHR-Embedded Program for Mailing FIT kits: Lessons from the STOP CRC Pilot Study 
Background
The Strategies and Opportunities to Stop Colorectal Cancer (STOP CRC) study is collaboration among two research institutions and health-systems partners. The main study, scheduled to begin in 2014, will assess effectiveness of an intervention program using electronic health record (EHR) clinical decision support (CDS) tools to improve rates of colorectal-cancer screening in federally qualified health centers (FQHCs). Very few studies, and no large studies, aimed at raising CRC screening rates have utilized an EHR-embedded system.
Study design
We piloted the use of an EHR-embedded real-time patient registry reporting tool in a pilot study undertaken prior to beginning our main CRC screening study. The pilot study goal was to assess feasibility and effectiveness of two clinic-based approaches to raising rates of colorectal cancer screening among selected patients aged 50–74 who were not up-to-date with colorectal-cancer screening guidelines. We used work sessions and qualitative interviews with clinic personnel to assess performance of the tool, as well as to identify specific elements of the tool’s functionality needing refinement.
Results
Two critical elements of the EHR tool allowed us to mail FIT kits efficiently to appropriate patients: (1) having a direct interface with the laboratory that processed the FITs, thus allowing for real-time updates to the registry; and (2) being able to place lab orders from a list of selected patients. We identified the following elements that needed refining: the use of Health Maintenance (EHR function for tracking screening eligibility and due dates incorporating STOP CRC inclusion and exclusion criteria), and the development of report templates for identifying patients eligible for each step.
Conclusion
We found that most elements of our EHR-embedded program worked well and that specific refinement may improve the accuracy of identifying patients at each step. Our findings can inform future efforts to build EHR-embedded CDS tools for preventive services.
doi:10.4172/2329-9126.1000141
PMCID: PMC4233714  PMID: 25411657
Electronic health record; Colorectal cancer screening; Reporting workbench; Patient registry; Clinical decision support; Fecal immunochemical (FIT) kit
16.  Cancer Screening at a Federally Qualified Health Center: A qualitative study on organizational challenges in the era of health care reform 
Background
Federally Qualified Health Centers (FQHCs) serve uninsured and minority populations, who have low cancer screening rates. The patient-centered medical home (PCMH) model aims to provide comprehensive preventive services, including cancer screening, to these populations. Little is known about organizational factors influencing the delivery of cancer screening in this context.
Methods
We conducted 18 semi-structured interviews with clinic personnel at four FQHC clinics in Washington State. All interviews were recorded and transcribed verbatim and analyzed by two bilingual coders to identify salient themes.
Results
We found that screening on-site, scheduling separate visits for preventive care, and having non-provider staff recommend and schedule screening services facilitated the delivery of cancer screening. We found work overload to be a barrier to screening.
Conclusions
To successfully implement screening strategies within the PCMH model, FQHCs must enhance facilitators and address organizational gaps in their cancer screening processes.
doi:10.1007/s10903-012-9701-8
PMCID: PMC3530661  PMID: 22878911
cancer prevention; cancer screening; Latinos; uninsured; primary care medical home; organizational change
17.  Utilizing Pyrosequencing and Quantitative PCR to Characterize Fungal Populations among House Dust Samples 
Molecular techniques are replacing culturing and counting methods in quantifying indoor fungal contamination. Pyrosequencing offers the possibility of identifying unexpected indoor fungi. In this study, 50 house dust samples were collected from homes in the Yakima Valley, WA. Each sample was analyzed by quantitative PCR (QPCR) for 36 common fungi and by fungal tag-encoded flexible (FLX) amplicon pyrosequencing (fTEFAP) for these and additional fungi. Only 24 of the samples yielded amplified results using fTEFAP but QPCR successfully amplified all 50 samples. Over 450 fungal species were detected by fTEFAP but most were rare. Twenty-two fungi were found by fTEFAP to occur with at least an average of ≥ 0.5% relative occurrence. Many of these fungi seem to be associated with plants, soil or human skin. Combining fTEFAP and QPCR can enhance studies of fungal contamination in homes.
doi:10.1039/c2em30229b
PMCID: PMC4079115  PMID: 22767010
18.  Evaluation of a Radionovela to Promote HPV Vaccine Awareness and Knowledge Among Hispanic Parents 
Journal of community health  2011;36(6):957-965.
Hispanic women have more than a 1.5-fold increased cervical cancer incidence and mortality compared to non-Hispanic white women in the United States. The Centers for Disease Control recommends the HPV vaccine for females at ages 11 and 12 years, though it is approved for females aged 9–26 to protect against the primary types of high-risk HPV (HPV-16 and HPV-18) that cause approximately 70% of cervical cancer cases. Few culturally-tailored Spanish HPV vaccine awareness programs have been developed. This study evaluates the efficacy of a Spanish radionovela as an educational tool. Rural Hispanic parents of daughters aged 9–17 (n = 88; 78 mothers and 10 fathers) were randomized to listen to the HPV vaccine radionovela or to another public service announcement. Participants completed a 30 min pretest posttest questionnaire. Parents who listened to the HPV radionovela (intervention group) scored higher on six knowledge and belief items. They were more likely to confirm that HPV is a common infection (70% vs. 48%, P = .002), to deny that women are able to detect HPV (53% vs. 31%, P = .003), to know vaccine age recommendations (87% vs. 68%, P = .003), and to confirm multiple doses (48% vs. 26%, P = .03) than control group parents. The HPV vaccine radionovela improved HPV and HPV vaccine knowledge and attitudes. Radionovela health education may be an efficacious strategy to increase HPV vaccine awareness among Hispanic parents.
doi:10.1007/s10900-011-9395-1
PMCID: PMC4065612  PMID: 21452030
Rural Hispanic parents; HPV vaccine education; Cervical cancer prevention; Efficacy evaluation
19.  Having a Diagnosis of Diabetes Is Not Associated With General Diabetes Knowledge in Rural Hispanics 
Purpose
The prevalence of diabetes among Hispanics in Washington State is 30% greater than it is for non-Hispanic Whites. Hispanics also have higher rates of diabetes-related complication and mortality due to the disease. Although interventions have been developed for the Hispanic community, studies in rural settings are limited. To address this we conducted a study to identify factors associated with general diabetes knowledge in a rural Hispanic population.
Methods
This study was conducted as part of a larger project in partnership with a local community hospital in Washington State’s Lower Yakima Valley. Diabetes knowledge was assessed as part of a screening survey using 5-statements selected from the Diabetes Knowledge Questionnaire. Men and women (N=1297) between the ages of 18–92 attending community-oriented events took part in the survey. Gender, education, age, birthplace, diabetic status and family history of diabetes were tested as predictors of diabetes knowledge.
Findings
Overall, general knowledge was high with 71–84% of participants responding correctly to 4 of 5 statements, while only 17% of participants responded correctly to a 5th statement. Although, no variable was associated with all statements, family history, gender and education were most frequently associated with knowledge. Diabetic status, age, and birthplace were less often or not associated with the knowledge statements.
Conclusion
Contrary to expectations having a diagnosis of diabetes was not among the factors most frequently associated with diabetes knowledge. Future research should investigate the roles of family history, gender and diabetic status as conduits of diabetes education among rural Hispanics.
doi:10.1111/j.1748-0361.2010.00299.x
PMCID: PMC4022479  PMID: 21029169
diabetes; health promotion; Hispanic; rural; social determinants of health
20.  Strategies for Increasing Mammography Screening in Primary Care in Chile: Results of a Randomized Clinical Trial 
Background
Breast cancer is the cancer with the highest incidence among women in Chile and in many Latin American countries. Breast cancer screening has very low compliance among Chilean women.
Methods
We compare the effects on mammography screening rates of standard care, of a low intensity intervention based on mail contact, and of a high intensity intervention based on mail plus telephone or personal contact. A random sample of 500 women 50 to 70 years registered at a community clinic in Santiago who had not had a mammogram in the past two years were randomly assigned to one of the three intervention groups. Six months after randomization, participants were re-evaluated for their compliance with mammography screening. The outcome was measured by self report and by electronic clinical records. An intention to treat model was used to analyze the results.
Results
Between 92% and 93% of participants completed the study. Based on electronic records, mammography screening rates increased significantly from 6% in the control group to 51.8% in the low intensity group, and 70.1% in the high intensity group. About 14% of participants in each group received opportunistic advice, 100% of participants in the low and high intensity groups received the mail contact, and 50% in the high intensity group received a telephone or personal contact.
Conclusion
A primary care intervention based on mail or brief personal contact could significantly improve mammogram screening rates.
Impact
A relatively simple intervention could have a strong impact in breast cancer prevention in underserved communities.
doi:10.1158/1055-9965.EPI-10-0313
PMCID: PMC3985495  PMID: 20826832
21.  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.
Methods
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 (June–July); harvest (September–October); and, non-spray (December–January).
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 ought to consider the seasonal variation in consumption patterns, especially in agricultural communities.
doi:10.1016/j.jada.2008.10.007
PMCID: PMC3983846  PMID: 19103322
fruit and vegetable consumption; agricultural season; Hispanic
22.  A systematic review of special events to promote breast, cervical and colorectal cancer screening in the United States 
BMC Public Health  2014;14:274.
Background
Special events are common community-based strategies for health promotion. This paper presents findings from a systematic literature review on the impact of special events to promote breast, cervical or colorectal cancer education and screening.
Methods
Articles in English that focused on special events involving breast, cervical, and/or colorectal cancer conducted in the U.S. and published between January 1990 and December 2011 were identified from seven databases: Ovid, Web of Science, CINAHL, PsycINFO, Sociological Abstract, Cochrane Libraries, and EconLit. Study inclusion and data extraction were independently validated by two researchers.
Results
Of the 20 articles selected for screening out of 1,409, ten articles on special events reported outcome data. Five types of special events were found: health fairs, parties, cultural events, special days, and plays. Many focused on breast cancer only, or in combination with other cancers. Reach ranged from 50–1732 participants. All special events used at least one evidence-based strategy suggested by the Community Guide to Preventive Services, such as small media, one-on-one education, and reducing structural barriers. For cancer screening as an outcome of the events, mammography screening rates ranged from 4.8% to 88%, Pap testing was 3.9%, and clinical breast exams ranged from 9.1% to 100%. For colorectal screening, FOBT ranged from 29.4% to 76%, and sigmoidoscopy was 100% at one event. Outcome measures included intentions to get screened, scheduled appointments, uptake of clinical exams, and participation in cancer screening.
Conclusions
Special events found in the review varied and used evidence-based strategies. Screening data suggest that some special events can lead to increases in cancer screening, especially if they provide onsite screening services. However, there is insufficient evidence to demonstrate that special events are effective in increasing cancer screening. The heterogeneity of populations served, event activities, outcome variables assessed, and the reliance on self-report to measure screening limit conclusions. This study highlights the need for further research to determine the effectiveness of special events to increase cancer screening.
doi:10.1186/1471-2458-14-274
PMCID: PMC3987802  PMID: 24661503
Cancer screening; Early detection of cancer; Health promotion; Community health education; Breast neoplasms; Cervical neoplasms; Colorectal neoplasms
23.  Racial/ethnic differences in use and duration of adjuvant hormonal therapy for breast cancer in the Women’s Health Initiative 
Background
Five-year breast cancer survival rates are lower among Hispanic and African American women than among Non-Hispanic White (NHW) women. Differences in breast cancer treatment likely play a role. Adjuvant hormonal therapies increase overall survival among women with hormone receptor-positive breast cancer.
Methods
We examined racial/ethnic differences in use and duration of adjuvant hormonal therapy among 3,588 postmenopausal women enrolled in the Women’s Health Initiative (WHI) Extension Study. Women diagnosed with hormone receptor-positive localized or regional stage breast cancer after study enrollment were surveyed between September 2009 and August 2010 and asked to recall prior use and duration of adjuvant hormonal breast cancer therapy. Odds ratios [OR] comparing self-reported use and duration by race/ethnicity (Hispanic, African American, Asian/Pacific Islander vs. NHW) were estimated using multivariable-adjusted logistic regression.
Results
Of the 3,588 women diagnosed from 1994–2009; 3,039 (85%) reported any use of adjuvant hormonal therapy and 67% of women reporting ever-use who were diagnosed prior to 2005 reported using adjuvant hormonal therapy for the optimal duration of ≥5 years. In adjusted analysis, no statistically significant differences in use or duration by race/ethnicity were observed.
Conclusions
This study did not find significant differences in use or duration of use of adjuvant hormonal therapy by race/ethnicity.
Impact
Findings should be confirmed in other population-based samples and potential reasons for discontinuation of therapy across all racial/ethnic groups should be explored.
doi:10.1158/1055-9965.EPI-12-1225
PMCID: PMC3596451  PMID: 23275187
postmenopausal breast cancer; adjuvant hormonal therapy; racial/ethnic disparities
24.  Strategies and opportunities to STOP colon cancer in priority populations: pragmatic pilot study design and outcomes 
BMC Cancer  2014;14:55.
Background
Colorectal-cancer is a leading cause of cancer death in the United States, and Latinos have particularly low rates of screening. Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) is a partnership among two research institutions and a network of safety net clinics to promote colorectal cancer screening among populations served by these clinics. This paper reports on results of a pilot study conducted in a safety net organization that serves primarily Latinos.
Methods
The study assessed two clinic-based approaches to raise rates of colorectal-cancer screening among selected age-eligible patients not up-to-date with colorectal-cancer screening guidelines. One clinic each was assigned to: (1) an automated data-driven Electronic Health Record (EHR)-embedded program for mailing Fecal Immunochemical Test (FIT) kits (Auto Intervention); or (2) a higher-intensity program consisting of a mailed FIT kit plus linguistically and culturally tailored interventions delivered at the clinic level (Auto Plus Intervention). A third clinic within the safety-net organization was selected to serve as a passive control (Usual Care). Two simple measurements of feasibility were: 1) ability to use real-time EHR data to identify patients eligible for each intervention step, and 2) ability to offer affordable testing and follow-up care for uninsured patients.
Results
The study was successful at both measurements of feasibility. A total of 112 patients in the Auto clinic and 101 in the Auto Plus clinic met study inclusion criteria and were mailed an introductory letter. Reach was high for the mailed component (92.5% of kits were successfully mailed), and moderate for the telephone component (53% of calls were successful completed). After exclusions for invalid address and other factors, 206 (109 in the Auto clinic and 97 in the Auto Plus clinic) were mailed a FIT kit. At 6 months, fecal test completion rates were higher in the Auto (39.3%) and Auto Plus (36.6%) clinics compared to the usual-care clinic (1.1%).
Conclusions
Findings showed that the trial interventions delivered in a safety-net setting were both feasible and raised rates of colorectal-cancer screening, compared to usual care. Findings from this pilot will inform a larger pragmatic study involving multiple clinics.
Trial registration
ClinicalTrial.gov: NCT01742065
doi:10.1186/1471-2407-14-55
PMCID: PMC3936821  PMID: 24571550
Colorectal cancer screening; Fecal testing; Latinos; Hispanics; Safety net clinic; Federally qualified health center; Pragmatic study
25.  Do workplace and home protective practices protect farm workers? Findings from the For Healthy Kids Study 
Objective
To assess associations of protective workplace and home practices to pesticide exposure levels.
Methods
Using data from orchard workers in the Yakima Valley, Washington, we examined associations of workplace and home protective practices to (1) urinary metabolite concentrations of dimethylthiophosphate (DMTP) in adults and children aged 2–6; and (2) azinphos-methyl levels in house and vehicle dust.
Results
Data were from 95 orchard workers and 94 children. Contrary to expectation, adult farm workers who wore boots or washed hands using hand sanitizer had higher concentrations of DMTP than those who did not. Children who attended daycare had higher DMTP concentrations than children who did not.
Conclusions
Few workplace or home practices were associated with pesticide exposure levels; workers who used hand sanitizer had higher concentrations of DMTP, as did children who attended daycare.
doi:10.1097/JOM.0b013e31825902f5
PMCID: PMC3866960  PMID: 22772953
Pesticides; agriculture; United States Environmental Protection Agency Worker Protection Standard; home practices; workplace practices

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