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author:("lignan, Mark")
1.  Inconsistencies Between Medical Records and Patient-Reported Recommendations for Follow-Up After Abnormal Pap Tests 
Journal of Women's Health  2013;22(2):147-152.
Adherence with recommended follow-up after an abnormal Pap test is a critical step in the prevention of cervical cancer. Here, we focused on identifying inconsistencies between self-reported and health department record recommendations for follow-up.
Self-reported recommendations for follow-up were collected by questionnaire from 519 women with abnormal Pap tests in rural Appalachia as part of a trial of the efficacy of patient navigation. Health department medical records were reviewed to collect healthcare provider recommendations. Measures of inconsistency (discordance) were calculated for overall recommendations and each of three particular follow-up recommendations: repeat Pap test, referral for further tests, and other gynecologist referral.
The inconsistencies between the recommendation from the health department records and self-reports ranged from 15.0% (repeat Pap test) to 35.3% (gynecologist referral). Inconsistencies were most common among women with a history of abnormal Pap tests and those with more severe initial results. Recommendations for repeat Pap tests were correctly reported most often when the women recalled receiving a letter stating the results. Of greatest concern were the inconsistencies regarding recommendations for referral to a gynecologist. The more severe the Pap test result, the greater the odds of inaccurate self-reports of receiving a referral to a gynecologist for follow-up, p<0.001.
Clinicians should be aware that patients with a history of abnormal results and severe Pap test abnormalities are at risk of misreporting recommendations for follow up.
PMCID: PMC3573725  PMID: 23145889
2.  Sustainability of the Dissemination of an Occupational Sun Protection Program in a Randomized Trial 
The sustainability of an occupational sun safety program, Go Sun Smart (GSS), was explored in a randomized trial, testing dissemination strategies at 68 U.S. and Canadian ski areas in 2004-2007. All ski areas received GSS from the National Ski Areas Association through a Basic Dissemination Strategy (BDS) using conference presentations and free materials. Half of the ski areas were randomly assigned to a theory-based Enhanced Dissemination Strategy (EDS) with personal contact supporting GSS use. Use of GSS was assessed at immediate and long-term follow-up posttests by on-site observation. Use of GSS declined from the immediate (M=5.72) to the long-term follow-up (M=6.24), F[1,62]=6.95, p=.01, but EDS ski areas (M=6.53) continued to use GSS more than BDS ski areas (M=4.49), F(1,62)=5.75, p=0.02, regardless of observation, F(1,60)=0.05, p=.83. Despite declines over time, a group of ski areas had sustained high program use and active dissemination methods had sustained positive effects on GSS implementation.
PMCID: PMC3463403  PMID: 22102323
3.  Enhancing Industry-based Dissemination of an Occupational Sun Protection Program with Theory-based Strategies Employing Personal Contact 
Industry-based strategies for dissemination of an evidence-based occupational sun protection program, Go Sun Smart (GSS), were tested.
Two dissemination strategies were compared in a randomized trial in 2004 – 2007.
The North American ski industry.
Ski areas in the United States and Canada (n=69) and their senior managers (n=469).
Employers received GSS through a Basic Dissemination Strategy (BDS) from the industry’s professional association which included conference presentations and free starter kits. Half of the areas also received the Enhanced Dissemination Strategy (EDS), in which project staff met face-to-face with managers and made ongoing contacts to support program use.
Observation of program materials in use and managers’ reports on communication about sun protection.
The effects of two alternative dissemination strategies were compared on program use using PROC MIXED in SAS, adjusted for covariates using 1-tailed p-values.
Ski areas receiving the EDS used more GSS materials (M=7.36) than those receiving the BDS (M=5.17; F=7.82, p<.01). Managers from more areas receiving the EDS reported communicating about sun protection in employee newsletters/flyers (M=0.97, p=.04), in guest email messages (M=0.75, p=.02), and on ski area websites (M=0.38, p=.02) than those receiving the BDS (M=0.84, 0.50, 0.15, respectively).
Industry professional associations play an important role in disseminating prevention programs; however, active personal communication may be essential to ensure increased implementation fidelity.
PMCID: PMC3390757  PMID: 22747318
sun protection; dissemination; implementation; occupational
4.  Men’s Knowledge and Beliefs about Colorectal Cancer and Three Screenings: Education, Race and Screening Status 
This study compared how education, race, and screening status affected men’s knowledge about colorectal cancer, and their views of three screenings, the fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy.
In-depth interviews were conducted with 65 African-American and white men with diverse education backgrounds with similar numbers screened and unscreened.
Education was associated with knowledge about colorectal cancer and the colonoscopy. Screening status and education were related to FOBT knowledge. Men knew little about the sigmoidoscopy.
Intervention programs should tailor education about colorectal cancer and screening by educational attainment levels, not by race.
PMCID: PMC3670612  PMID: 22040614
colorectal cancer; colorectal cancer screening; health disparities; African-American
5.  A community-based randomized trial of a faith-placed intervention to reduce cervical cancer burden in Appalachia 
Preventive Medicine  2012;54(6):408-414.
Faith Moves Mountains assessed the effectiveness of a faith-placed lay health advisor (LHA) intervention to increase Papanicolaou (Pap) test use among middle-aged and older women in a region disproportionately affected by cervical cancer and low screening rates (regionally, only 68% screened in prior 3 years).
This community-based RCT was conducted in four Appalachian Kentucky counties (December 2005 – June 2008). Women aged 40–64 and overdue for screening were recruited from churches and individually randomized to treatment (n=176) or wait-list control (n=169). The intervention provided LHA home visits and newsletters addressing barriers to screening. Self-reported Pap test receipt was the primary outcome.
Intention-to-treat analyses revealed that treatment group participants (17.6% screened) had over twice the odds of wait-list controls (11.2% screened) of reporting Pap test receipt post-intervention, OR=2.56, 95%CI: 1.03–6.38, p=0.04. Independent of group, recently screened participants (last Pap >1 but <5 years ago) had significantly higher odds of obtaining screening during the study than rarely or never screened participants (last Pap ≥5 years ago), OR=2.50, 95%CI: 1.48–4.25, p=0.001.
The intervention was associated with increased cervical cancer screening. The faith-placed LHA addressing barriers comprises a novel approach to reducing cervical cancer disparities among Appalachian women.
PMCID: PMC3368037  PMID: 22498022
cervical cancer screening; randomized controlled trial; faith-placed; Appalachia
6.  Mobile Mammography in Underserved Populations: Analysis of Outcomes of 3,923 Women 
Journal of Community Health  2013;38:900-906.
Mobile health units are increasingly utilized to address barriers to mammography screening. Despite the existence of mobile mammography outreach throughout the US, there is a paucity of data describing the populations served by mobile units and the ability of these programs to reach underserved populations, address disparities, and report on outcomes of screening performance. To evaluate the association of variables associated with outcomes for women undergoing breast cancer screening and clinical evaluation on a mobile unit. Retrospective analysis of women undergoing mammography screening during the period 2008–2010. Logistic regression was fitted using generalized estimating equations to account for potential repeat annual visits to the mobile unit. In total, 4,543 mammograms and/or clinical breast exams were conducted on 3,923 women with a mean age of 54.6, 29 % of whom had either never been screened or had not had a screening in 5 years. Age < 50 years, lack of insurance, Hispanic ethnicity, current smoking, or having a family relative (<50 years of age) with a diagnosis of cancer were associated with increased odds of a suspicious mammogram finding (BIRADS 4,5,6). Thirty-one breast cancers were detected. The mobile outreach initiative successfully engaged many women who had not had a recent mammogram. Lack of insurance and current smoking were modifiable variables associated with abnormal screens requiring follow up.
PMCID: PMC3765844  PMID: 23674194
Breast cancer; Mobile mammography; Underserved populations; Outcomes; Disparities
7.  Assessment of Cancer Education Seminars for Appalachian Populations 
Cancer education seminars for Appalachian populations were conducted to: (1) increase knowledge of existing cancer disparities, (2) disseminate findings from Appalachian community-based participatory research (CBPR) projects, and (3) foster CBPR capacity building among community members by promoting social networking. Evaluation of the seminars was completed by: (1) using pre–post-surveys to assess changes in knowledge and attitudes at three regional and one national seminar and (2) measuring a change in the social network patterns of participants at a national seminar by analyzing the names of individuals known at the beginning and at the end of the seminar by each participant. Among participants, there was a significant increase in knowledge of Appalachian cancer disparities at two seminars [national, t(145)=3.41, p=0.001; Pennsylvania, t(189)=3.00, p=0.003] and a change in attitudes about Appalachia at one seminar [Ohio t(193)=−2.80, p=0.006]. Social network analysis, operationally defined for this study as familiarity with individuals attending the conference, showed participation in the national seminar fostered capacity building for future CBPR by the development of new network ties. Findings indicate that short-term outcomes of the seminars were accomplished. Future educational seminars should consider using social network analysis as a new evaluation methodology.
PMCID: PMC3650897  PMID: 22131064
Appalachian region; Health disparities; Cancer
8.  Evaluating Allied Health Inpatient Rehabilitation Educational Materials in Terms of Health Literacy 
Journal of allied health  2012;41(2):e33-e37.
The purpose of this project was to assess and adapt inpatient rehabilitation educational materials in terms of reading level. Low health literacy has been shown to negatively impact health. Little health literacy research has been focused on rehabilitation settings. Written patient education materials were collected then analyzed for reading level. Focus groups were held with allied health practitioners to develop a plan to adapt them. A final focus group of former inpatient rehabilitation users was conducted to explore the end users perceptions of the original and revised materials. 90 pieces of patient education material were assessed. The average reading level of the original materials was 16th grade. A subset of 20 documents was chosen for revision. The average reading level was lowered to 5th grade with a range from 2nd to 8th. Clear communication for patient educational materials is a crucial first step to providing the best client-centered rehabilitation care. Vocabulary words, text formatting and “need to know” versus “nice to know” information were the most common problems in the original documents.
PMCID: PMC3612926  PMID: 22735823
9.  Expanding occupational sun safety to an outdoor recreation industry: a translational study of the Go Sun Smart program 
A successful occupational sun-protection program was translated to 67 ski areas where the effectiveness of two dissemination strategies was assessed. An industry professional association distributed materials to the resorts. Half of the resorts received the basic dissemination strategy (BDS) in which the materials were simply distributed to the resorts. In a randomized trial, the BDS was compared with an enhanced dissemination strategy (EDS) that added interpersonal contact with managers. Employees (n=2,228) at worksites that received the EDS had elevated program exposure (74.0% at EDS vs. 57.5% at BDS recalled a message). Exposure increased at two levels of program use: from less than four (55% exposed) to four to eight (68%) and to nine or more (82%) program items in use. More employees exposed to messages engaged in sun-safety behaviors than those unexposed. At worksites using nine or more items (versus 4–8 or <4), employees engaged in additional sun-safety behaviors. Program effects were strongly mediated by increased self-efficacy. Partnerships with industry associations facilitate dissemination of evidence-based programs. Dissemination methods are needed to maximize implementation and exposure to reduce health risk behaviors.
PMCID: PMC3480017  PMID: 23105954
Sun safety; Translational research; Health communication campaign; Skin cancer prevention; Diffusion of innovation; Occupational health
10.  A Comparison of Two Native American Navigator Formats: Face-to-Face and Telephone 
The study was designed to test the relative effectiveness of a Navigator intervention delivered face-to-face or by telephone to urban Native American women. The effectiveness of the intervention was evaluated using a design that included a pretest, random assignment to face-to-face or telephone group, and posttest. The Social Cognitive Theory-based intervention was a tailored education program developed to address individual risk factors for breast cancer. At posttest, self-reported mammograms in the past year increased from 29% to 41.3% in the telephone group and from 34.4%: to 45.2% in the face-to-face group. There was no difference in change from pretest to posttest between the telephone and face-to-face groups. Navigators can be effective in increasing adherence to recommendations for screening mammography among urban American Indian women.
PMCID: PMC3544403  PMID: 16327748
11.  Breast Screening Navigator Programs within Three Settings that Assist Underserved Women 
Medically underserved women in the Greater Denver Metropolitan Area had low rates of routine repeat mammograms in the latter 1990s. “Increasing Mammography Adherence among Medically Underserved Women” was designed to increase annual rescreening among medically underserved populations living in this area. Four community-based organizations collaborated to implement this 5-year study. A culturally modified navigator model including both face-to-face and telephone formats was used to facilitate mammography for African Americans, Latinas, Native Americans, and poor White women who had not been rescreened in more than 18 months. The navigator-implemented intervention was statistically significant at the 0.05 level for increasing rescreening.
PMCID: PMC3544404  PMID: 20300914
Navigators; Community-based participatory research; Breast cancer; Medically underserved; Screening; Early detection; Intervention; American Indians; Latinas; Poor White women; African-American women
12.  A Comparison of Quality of Life Between Native and Non-Native Cancer Survivors 
This paper compares quality of life (QOL) outcomes between Native American and non-Native cancer survivors. Native Patient Navigators helped Native cancer patients complete a 114-item QOL survey and access survivorship information available on the NACES website. The survey was modified from Ferrell et. al’s QOL measure and assessed the four domains of cancer survivorship: physical, psychological, social, and spiritual [1]. Findings from Native survivors were compared to Ferrell’s findings. This is the first time that QOL outcomes have been compared between Native and Non-Native cancer survivors. Natives scored lower for physical and social QOL, the same for psychological QOL, and higher for spiritual QOL in comparison to non-Natives. Overall QOL scores were the same. Although this is the largest sample of Native cancer survivors reported in peer-reviewed manuscripts, these Native survivorship data are based on a self-selected group and it is unknown if the findings are generalizable to others.
PMCID: PMC3544405  PMID: 22302431
American Indian; Native American; Cancer; Survivors; Psychosocial; Quality of life
13.  Compliance with Sunscreen Advice in a Survey of Adults Engaged in Outdoor Winter Recreation at High Elevation Ski Areas 
Adults are advised to wear sunscreen with a sun protection factor of 15+, apply it up to 30 minutes prior to sun exposure, and reapply it after two hours to reduce exposure to ultraviolet (UV) radiation in sunlight for the prevention of skin cancer.
This study investigated the extent to which adults comply with sunscreen advice.
A survey was conducted with 4,837 adult skiers and snowboarders at 28 high-altitude ski areas in Western North America in January – April 2001-02. Respondents self reported use of sunscreen, its SPF, time of first application, and reapplication.
Only 4.4% (95% CI=±0.6) of adults were in full compliance with all sunscreen advice. Half (49.8% [95% CI=±1.4]) complied with SPF 15+ advice. Of those wearing sunscreen, 73.2% (95% CI=±1.8) applied the sunscreen 30 minutes before beginning skiing/snowboarding, but only 20.4% (95% CI=±2.0) complied with advice to reapply it after 2 hours. Total compliance was lowest during inclement weather, on low-UV days, by males, and among respondents who believed skin cancer was unimportant and with low sun sensitive skin. It was positively associated with wearing lip balm and hats with a brim.
The sample was predominantly male and of high socio-economic status; the results apply most to winter recreation when UV radiation levels are low, and sunscreen use was assessed by self-report.
While the recommendation to use SPF 15+ sunscreen has reached many adults, the reapplication advice is heeded by few adults and needs to be highlighted in future sun safety promotions.
PMCID: PMC3193866  PMID: 21742410
sunscreen; sunscreen reapplication; adults; outdoor recreation; sun protection; ultraviolet radiation
14.  Telenovela: an innovative colorectal cancer screening health messaging tool 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.21301.
Alaska Native people have nearly twice the rate of colorectal cancer (CRC) incidence and mortality as the US White population.
Building upon storytelling as a culturally respectful way to share information among Alaska Native people, a 25-minute telenovela-style movie, What's the Big Deal?, was developed to increase CRC screening awareness and knowledge, role-model CRC conversations, and support wellness choices.
Alaska Native cultural values of family, community, storytelling, and humor were woven into seven, 3–4 minute movie vignettes. Written post-movie viewing evaluations completed by 71.3% of viewers (305/428) were collected at several venues, including the premiere of the movie in the urban city of Anchorage at a local movie theater, seven rural Alaska community movie nights, and five cancer education trainings with Community Health Workers. Paper and pencil evaluations included check box and open-ended questions to learn participants' response to a telenovela-style movie.
On written-post movie viewing evaluations, viewers reported an increase in CRC knowledge and comfort with talking about recommended CRC screening exams. Notably, 81.6% of respondents (249/305) wrote positive intent to change behavior. Multiple responses included: 65% talking with family and friends about colon screening (162), 24% talking with their provider about colon screening (59), 31% having a colon screening (76), and 44% increasing physical activity (110).
Written evaluations revealed the telenovela genre to be an innovative way to communicate colorectal cancer health messages with Alaska Native, American Indian, and Caucasian people both in an urban and rural setting to empower conversations and action related to colorectal cancer screening. Telenovela is a promising health communication tool to shift community norms by generating enthusiasm and conversations about the importance of having recommended colorectal cancer screening exams.
PMCID: PMC3736451  PMID: 23930245
storytelling; Alaska Native; telenovela; colorectal cancer screening; health communication; Community Health Workers
15.  Bridging storytelling traditions with digital technology 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.20717.
The purpose of this project was to learn how Community Health Workers (CHWs) in Alaska perceived digital storytelling as a component of the “Path to Understanding Cancer” curriculum and as a culturally respectful tool for sharing cancer-related health messages.
A pre-course written application, end-of-course written evaluation, and internet survey informed this project.
Digital storytelling was included in seven 5-day cancer education courses (May 2009–2012) in which 67 CHWs each created a personal 2–3 minute cancer-related digital story. Participant-chosen digital story topics included tobacco cessation, the importance of recommended cancer screening exams, cancer survivorship, loss, grief and end-of-life comfort care, and self-care as patient care providers. All participants completed an end-of-course written evaluation. In July 2012, contact information was available for 48 participants, of whom 24 completed an internet survey.
All 67 participants successfully completed a digital story which they shared and discussed with course members. On the written post-course evaluation, all participants reported that combining digital storytelling with cancer education supported their learning and was a culturally respectful way to provide health messages. Additionally, 62 of 67 CHWs reported that the course increased their confidence to share cancer information with their communities. Up to 3 years post-course, all 24 CHW survey respondents reported they had shown their digital story. Of note, 23 of 24 CHWs also reported change in their own behavior as a result of the experience.
All CHWs, regardless of computer skills, successfully created a digital story as part of the cancer education course. CHWs reported that digital stories enhanced their learning and were a culturally respectful way to share cancer-related information. Digital storytelling gave the power of the media into the hands of CHWs to increase their cancer knowledge, facilitate patient and community cancer conversations, and promote cancer awareness and wellness.
PMCID: PMC3752288  PMID: 23984267
digital storytelling; Alaska Native; cancer education; Community Health Workers; health communications
16.  Disparities in Underserved White Populations: The Case of Cancer-Related Disparities in Appalachia 
The Oncologist  2011;16(8):1072-1081.
Cancer-related disparities in the Appalachian region of the U.S. are described as an example of the disparities experienced by underserved predominantly white, rural populations. Appalachia Community Cancer Network activities designed to intervene on these disparities are presented.
There are meaningful cancer-related disparities in the Appalachian region of the U.S. To address these disparities, the Appalachia Community Cancer Network (ACCN), a collaboration of investigators and community partners in five states (Kentucky, Ohio, Pennsylvania, Virginia, and West Virginia), is involved in increasing cancer education and awareness, conducting community-based participatory research (CBPR), and creating mentorship and training opportunities. The primary objective of this paper is to describe cancer-related disparities in the Appalachian region of the U.S. as an example of the disparities experienced by underserved, predominantly white, rural populations, and to describe ACCN activities designed to intervene regarding these disparities. An ACCN overview/history and the diverse activities of ACCN-participating states are presented in an effort to suggest potential useful strategies for working to reduce health-related disparities in underserved white populations. Strengths that have emerged from the ACCN approach (e.g., innovative collaborations, long-standing established networks) and remaining challenges (e.g., difficulties with continually changing communities, scarce resources) are described. Important recommendations that have emerged from the ACCN are also presented, including the value of allowing communities to lead CBPR efforts. Characteristics of the community-based work of the ACCN provide a framework for reducing health-related disparities in Appalachia and in other underserved white and rural populations.
PMCID: PMC3228155  PMID: 21873582
Disparities; Appalachia; Cancer
17.  How do Rural Health Care Providers and Patients View Barriers to Colorectal Cancer Screening? Insights from Appalachian Kentucky 
This paper reports findings from a qualitative study that explored the attitudes and beliefs concerning colorectal cancer screening (CRC) among patients and health care providers in Appalachian Kentucky. We report results from five focus groups; three with primary care providers and two with patients. Providers discussed patient characteristics, financial issues and health care delivery system factors as challenges to screening. Participants reported fear, embarrassment, financial issues, lack of perceived need, qualities of the test, lack of provider recommendation, and health care delivery barriers. Although there were some areas of agreement, there are marked differences between the perceptions of Appalachian health care providers and participants regarding colorectal cancer screening. This paper compares and contrasts those perceptions and provides suggestions for culturally competent practice and culturally relevant research to improve CRC screening in this vulnerable population.
PMCID: PMC3086300  PMID: 21501729
Appalachian Kentucky; colorectal cancer; colonoscopy; rural
18.  Environmental Cues to Ultraviolet Radiation and Personal Sun Protection In Outdoor Winter Recreation 
Archives of Dermatology  2010;146(11):1241-1247.
The prevalence of ultraviolet radiation (UV) at North American ski resorts was predicted using temporal, seasonal, altitudinal, and meteorological factors and associated with a set of adult sun protection behaviors.
UV observations and cross-sectional survey of adults on sun protection were collected.
Data were collected at 32 high-altitude ski areas located in Western North America in 2001–03.
The sample consisted of 3,937 adult skier or snowboarders.
Main Outcome Measures
Measurements of direct, reflected, and diffuse UV were performed at 487 measurement points using handheld meters and combined with self-reported and observed sun protection assessed for adults interviewed on chair lifts.
The strongest predictors of UV were temporal proximity to noon, deviation from winter solstice, and clear skies. By contrast, altitude and latitude had more modest associations with UV and temperature had a small positive relationship with UV. Guest sun safety was inconsistently associated with UV: UV was positively related to adults wearing more sunscreen, reapplying it after two hours, and wearing protective eyewear but fewer adults exhibited many of the other sun protection behaviors, such as hats, protective clothing or lip balm, on days when UV was elevated. Guests took more sun safety precautions on clear-sky days but took steps to maintain body warmth on inclement days.
In future sun safety promotions, adults should be encouraged to wear sunscreen on cloudy days because UV is still high and conditions can change rapidly. They need reminders to rely more on season and time of day when judging UV and the need for sun safety.
PMCID: PMC3364536  PMID: 21079060
19.  Expanding occupational sun safety to an outdoor recreation industry: a translational study of the Go Sun Smart program 
A successful occupational sun-protection program was translated to 67 ski areas where the effectiveness of two dissemination strategies was assessed. An industry professional association distributed materials to the resorts. Half of the resorts received the basic dissemination strategy (BDS) in which the materials were simply distributed to the resorts. In a randomized trial, the BDS was compared with an enhanced dissemination strategy (EDS) that added interpersonal contact with managers. Employees (n = 2,228) at worksites that received the EDS had elevated program exposure (74.0% at EDS vs. 57.5% at BDS recalled a message). Exposure increased at two levels of program use: from less than four (55% exposed) to four to eight (68%) and to nine or more (82%) program items in use. More employees exposed to messages engaged in sun-safety behaviors than those unexposed. At worksites using nine or more items (versus 4–8 or <4), employees engaged in additional sun-safety behaviors. Program effects were strongly mediated by increased self-efficacy. Partnerships with industry associations facilitate dissemination of evidence-based programs. Dissemination methods are needed to maximize implementation and exposure to reduce health risk behaviors.
PMCID: PMC3480017  PMID: 23105954
Sun safety; Translational research; Health communication campaign; Skin cancer prevention; Diffusion of innovation; Occupational health
20.  A Pilot Study for Using Fecal Immunochemical Testing to Increase Colorectal Cancer Screening in Appalachia, 2008-2009 
The Appalachian region of the United States has disproportionately high colorectal cancer (CRC) death rates and low screening rates. The purpose of this pilot study was to assess acceptability of a take-home fecal immunochemical test (FIT) and the effect of follow-up telephone counseling for increasing CRC screening in rural Appalachia.
We used a prospective, single-group, multiple-site design, with centralized laboratory reports of screening adherence and baseline and 3-month questionnaires. Successive patients, aged 50 or older, at average CRC risk and due for screening were enrolled during a routine visit to 3 primary care practices in rural Appalachian Pennsylvania and received a free take-home FIT and educational brochure. Those who had not returned the test 2 weeks later were referred for telephone counseling.
Of 232 patients approached, 200 (86.2%) agreed to participate. Of these, 145 (72.5%) completed the FIT as recommended (adherent) and 55 (27.5%) were referred for telephone counseling (nonadherent), of whom 23 (41.8%) became adherent after 1 to 2 counseling sessions, an 11.5 percentage-point increase in screening after telephone counseling and 84% FIT adherence overall. Lack of CRC-related knowledge and perceived CRC risk were the screening barriers most highly associated with nonadherence. Although not statistically significant, the rate of conversion to screening adherence was higher among participants who received telephone counseling compared to an answering machine reminder.
If confirmed in future randomized trials, provider-recommended take-home FIT and follow-up telephone counseling may be methods to increase CRC screening in Appalachia.
PMCID: PMC3392085  PMID: 22482136
21.  Perspectives on Pap Test Follow Up Care Among Rural Appalachian Women 
Women & health  2010;50(6):580-597.
Approximately one to three quarters of women notified of abnormal Pap test results do not receive appropriate follow up care, dramatically elevating their risk for invasive cervical cancer (ICC). We explored barriers to/facilitators of follow up care for women in two counties in Appalachian Kentucky, where ICC incidence and mortality are significantly higher than the national average. In-depth interviews were conducted among 27 Appalachian women and seven local health department personnel. Those who had been told of an atypical Pap test result tended to have one of three reactions; (1) not alarmed and generally did not obtain follow-up care; (2) alarmed and obtained follow up care; or (3) alarmed, but did not obtain care. Each of these typologies appeared to be shaped by a differing set of three categories of influences: personal factors; procedure/provider/system factors; and ecological/community factors. Recommendations to increase appropriate follow up care included pursuing research on explanations for these typologies and developing tailored interventions specific to women in each of the response types.
PMCID: PMC2967444  PMID: 20981638
abnormal findings; cancer screenings; cancer of the cervix; public health; health services
22.  Cervical Cancer Prevention: New Tools and Old Barriers 
Cancer  2010;116(11):2531-2542.
Cervical cancer is the second most common female tumor worldwide and its incidence is disproportionately high (>80%) in the developing world. In the U.S., where Pap tests have reduced the annual incidence to approximately 11,000 cervical cancers, more than 60% of cases occur in medically-underserved populations as part of a complex of diseases linked to poverty, race/ethnicity, and/or health disparities. Because carcinogenic human papillomavirus (HPV) infections cause virtually all cervical cancer, two new approaches for cervical cancer prevention have emerged: 1) HPV vaccination to prevent infections in younger women (≤18 years old) and 2) carcinogenic HPV detection in older women (≥30 years old). Together, HPV vaccination and testing, if used in an age-appropriate manner, have the potential to transform cervical cancer prevention particularly among underserved populations. Yet significant barriers of access, acceptability, and adoption to any cervical cancer prevention strategy remain. Without understanding and addressing these obstacles, these promising new tools for cervical cancer prevention may be futile. We share our experiences in the delivery of cervical cancer prevention strategies to U.S. populations experiencing high cervical cancer burden: African-American women in South Carolina, Alabama, Mississippi; Haitian immigrant women in Miami; Hispanic women in the U.S.-Mexico Border; Sioux/Native American women in the Northern Plains; white women in the Appalachia; and Vietnamese-American women in Pennsylvania and New Jersey. Our goal is to inform future research and outreach efforts to reduce the burden of cervical cancer in underserved populations.
PMCID: PMC2876205  PMID: 20310056
23.  Academic detailing to increase colorectal cancer screening by primary care practices in Appalachian Pennsylvania 
In the United States, colorectal cancer (CRC) is the third most frequently diagnosed cancer and second leading cause of cancer death. Screening is a primary method to prevent CRC, yet screening remains low in the U.S. and particularly in Appalachian Pennsylvania, a largely rural area with high rates of poverty, limited health care access, and increased CRC incidence and mortality rates. Receiving a physician recommendation for CRC screening is a primary predictor for patient adherence with screening guidelines. One strategy to disseminate practice-oriented interventions is academic detailing (AD), a method that transfers knowledge or methods to physicians, nurses or office staff through the visit(s) of a trained educator. The objective of this study was to determine acceptability and feasibility of AD among primary care practices in rural Appalachian Pennsylvania to increase CRC screening.
A multi-site, practice-based, intervention study with pre- and 6-month post-intervention review of randomly selected medical records, pre- and post-intervention surveys, as well as a post-intervention key informant interview was conducted. The primary outcome was the proportion of patients current with CRC screening recommendations and having received a CRC screening within the past year. Four practices received three separate AD visits to review four different learning modules.
We reviewed 323 records pre-intervention and 301 post-intervention. The prevalence of being current with screening recommendation was 56% in the pre-intervention, and 60% in the post-intervention (p = 0. 29), while the prevalence of having been screened in the past year increased from 17% to 35% (p < 0.001). Colonoscopies were the most frequently performed screening test. Provider knowledge was improved and AD was reported to be an acceptable intervention for CRC performance improvement by the practices.
AD appears to be acceptable and feasible for primary care providers in rural Appalachia. A ceiling effect for CRC screening may have been a factor in no change in overall screening rates. While the study was not designed to test the efficacy of AD on CRC screening rates, our evidence suggests that AD is acceptable and may be efficacious in increasing recent CRC screening rates in Appalachian practices which could be tested through a randomized controlled study.
PMCID: PMC3128846  PMID: 21600059
24.  Intraclass Correlation Estimates for Cancer Screening Outcomes: Estimates and Applications in the Design of Group-Randomized Cancer Screening Studies 
Screening has become one of our best tools for early detection and prevention of cancer. The group-randomized trial is the most rigorous experimental design for evaluating multilevel interventions. However, identifying the proper sample size for a group-randomized trial requires reliable estimates of intraclass correlation (ICC) for screening outcomes, which are not available to researchers. We present crude and adjusted ICC estimates for cancer screening outcomes for various levels of aggregation (physician, clinic, and county) and provide an example of how these ICC estimates may be used in the design of a future trial.
Investigators working in the area of cancer screening were contacted and asked to provide crude and adjusted ICC estimates using the analysis of variance method estimator.
Of the 29 investigators identified, estimates were obtained from 10 investigators who had relevant data. ICC estimates were calculated from 13 different studies, with more than half of the studies collecting information on colorectal screening. In the majority of cases, ICC estimates could be adjusted for age, education, and other demographic characteristics, leading to a reduction in the ICC. ICC estimates varied considerably by cancer site and level of aggregation of the groups.
Previously, only two articles had published ICCs for cancer screening outcomes. We have complied more than 130 crude and adjusted ICC estimates covering breast, cervical, colon, and prostate screening and have detailed them by level of aggregation, screening measure, and study characteristics. We have also demonstrated their use in planning a future trial and the need for the evaluation of the proposed interval estimator for binary outcomes under conditions typically seen in GRTs.
PMCID: PMC2924625  PMID: 20386058

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