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1.  Is “Active Surveillance” an Acceptable Alternative? A Qualitative Study of Couples’ Decision Making about Early-Stage, Localized Prostate Cancer 
The objective of our study was to describe decision making by men and their partners regarding active surveillance (AS) or treatment for early-stage, localized prostate cancer. Fifteen couples were recruited from a Cancer center multispecialty clinic, which gave full information about all options, including AS. Data were collected via individual, semi-structured telephone interviews. Most patients were white, non-Hispanic, had private insurance, had completed at least some college, and were aged 49–72 years. Ten chose AS. All partners were female, and couples reported strong marital satisfaction and cohesion. All couples described similar sequences of a highly emotional initial reaction and desire to be rid of the cancer, information seeking, and decision making. The choice of AS was built on a nuanced evaluation of the man's condition in which the couple differentiated prostate cancer from other cancers and early stage from later stages, wanted to avoid/delay side effects, and trusted the AS protocol to identify negative changes in time for successful treatment. Treated couples continued to want immediate treatment to remove the cancer. We concluded that having a partner's support for AS may help a man feel more comfortable with choosing and adhering to AS. Using decision aids that address both a man's and his partner's concerns regarding AS may increase its acceptability. Our research shows that some patients want to and do involve their partners in the decision-making process. Ethical issues are related to the tension between desire for partner involvement and the importance of the patient as autonomous decision-maker. The extended period of decision making, particularly for AS, is also an ethical issue that requires additional support for patients and couples in the making of fully informed choices that includes AS.
PMCID: PMC5176358  PMID: 27346824
Active Surveillance; Couples; Decision Making; Prostate Neoplasm; Qualitative
2.  Treatment Decisions for Localized Prostate Cancer: A Concept Mapping Approach 
Few decision aids emphasize active surveillance for localized prostate cancer. Concept mapping was used to produce a conceptual framework incorporating active surveillance and treatment.
54 statements about what men need to make a decision for localized prostate cancer were derived from focus groups with African American, Latino, and white men previously screened for prostate cancer and partners (n=80). In the second phase, 89 participants sorted and rated the importance of statements.
An 8 cluster map was produced for the overall sample. Clusters were labelled Doctor-patient exchange, Big picture comparisons, Weighing the options, Seeking and using information, Spirituality and inner strength, Related to active treatment, Side effects, and Family concerns. A major division was between medical and home-based clusters. Ethnic groups and genders had similar sorting, but some variation in importance. Latinos rated Big picture comparisons as less important. African Americans saw Spirituality and inner strength most important, followed by Latinos, then whites. Ethnic- and gender-specific concept maps were not analyzed because of high similarity in their sorting patterns.
We identified a conceptual framework for management of early stage prostate cancer that included coverage of active surveillance. Eliciting the conceptual framework is an important step in constructing decision aids which will address gaps related to active surveillance.
PMCID: PMC4128894  PMID: 24506829
3.  Using the Theory of Planned Behavior to Understand Cervical Cancer Screening among Latinas 
To reduce the high incidence of cervical cancer among Latinas in the United States it is important to understand factors that predict screening behavior. The aim of this study was to test the utility of theory of planned behavior (TPB) in predicting cervical cancer screening among a group of Latinas. A sample of Latinas (N= 614) completed a baseline survey about Pap test attitudes subjective norms, perceived behavioral control, and intention to be screened for cervical cancer. At six-months cervical cancer screening behavior was assessed. Structural equation modeling was used to test the theory. Model fit statistics indicated good model fit (χ2 (48) = 54.32, p-value = .246; CFI = .992; RMSEA = .015; WRMR =.687). Subjective norms (p = .005) and perceived behavioral control (p < .0001) were positively associated with intention to be screened for cervical cancer, and the intention to be screened predicted actual cervical cancer screening (p<.0001). The proportion of variance (R2) in intention accounted for by the predictors was .276 and the R2 in cervical cancer screening accounted for was .130. This study provides support for the use of the theory of planned behavior in predicting cervical cancer screening among Latinas. This knowledge can be used to inform the development of a TPB-based intervention to increase cervical cancer screening among Latinas and reduce the high incidence of cervical cancer in this group of women.
PMCID: PMC4932857  PMID: 25712240
cervical cancer screening; Latinas; theory of planned behavior; prevention; women's reproductive health
4.  AMIGAS: A Multicity, Multicomponent Cervical Cancer Prevention Trial Among Mexican American Women 
Cancer  2012;119(7):1365-1372.
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.
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.
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).
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.
PMCID: PMC4603549  PMID: 23280399
uterine cervical cancer screening; Mexican origin; clinical trial; health education; Hispanic women
5.  Designing normative messages about active surveillance for men with localized prostate cancer 
Journal of health communication  2015;20(9):1014-1020.
Active surveillance (AS) is increasingly recognized as a reasonable option for men with low-risk, localized prostate cancer, yet few men who might benefit from conservative management receive it. We examined the acceptability of normative messages about AS as a management option for patients with low-risk prostate cancer. Men with a diagnosis of localized prostate cancer who were recruited through prostate cancer support organizations completed a web-based survey (N=331). They rated messages about AS for believability, accuracy, and importance for men to hear when making treatment decisions. The message “you don’t have to panic…you have time to think about your options” was perceived as believable, accurate, and important by over 80% of the survivors. In contrast, messages about trust in the AS protocol and “knowing in plenty of time” if treatment is needed were rated as accurate by only about 36% of respondents. For AS to be viewed as a reasonable alternative, men will need reassurance that following an AS protocol is likely to allow time for curative treatment if the cancer progresses.
PMCID: PMC4784693  PMID: 26066011
cancer; oncology; prostate neoplasms; decision making
6.  Colorectal Cancer Screening Among Latinos in Three Communities on the Texas–Mexico Border 
To assess colorectal cancer screening (CRCS) prevalence and psychosocial predictors among Texas Latinos in South Texas.
Using multivariable analysis, we examined adjusted effects of perceived susceptibility, self-efficacy, pros and cons of CRCS, subjective norms, knowledge and fatalism on CRCS, in 544 Latinos (50 years and older).
In this socioeconomically disadvantaged population 40% had never heard of any CRCS test and only34% reported ever completing a CRCS test. Insurance status, perceived cons, and self-efficacy were significantly associated with CRCS.
CRCS interventions in this population should focus on improving access, increasing self-efficacy and decreasing negative perceptions of CRCS.
PMCID: PMC4214900  PMID: 24786793
colorectal cancer; cancer screening; Hispanic Americans
7.  Cervical Cancer Screening with AMIGAS 
Hispanic women have a higher incidence of cervical cancer than all other races and ethnicities. In Hispanic subgroups, Mexican American women were among the least likely to have received cervical cancer screening. In a recent RCT, Ayudando a las Mujeres con Información, Guia, y Amor para su Salud (AMIGAS) was shown to increase cervical cancer screening rates among women of Mexican descent at 6 months in all intervention arms compared to the control arm. Limited information exists about the economics of interventions to increase cervical cancer screening rates among women of Mexican descent.
This study aims to estimate the cost-effectiveness of the alternative AMIGAS intervention methods for increasing cervical cancer screening among low-income women of Mexican descent in three U.S. communities.
Cost data were collected from 2008 to 2011 alongside the AMIGAS study of 613 women. Receipt of Pap test within 6 months of intervention was the primary outcome measure in the cost-effectiveness analysis, conducted during 2012–2013.
The cost per additional woman screened comparing the video-only intervention to usual care was $980. The cost increased to $1,309 with participant time cost included. With an additional cost per participant of $3.90 compared to flipchart only, the full AMIGAS program (video plus flipchart) yielded 6.8% additional women screened.
Results on the average and incremental cost-effectiveness of the AMIGAS program elements may assist health policymakers and program managers to select and appropriately budget for interventions shown to increase cervical cancer screening among low-income women of Mexican descent.
PMCID: PMC4603553  PMID: 24842738
8.  AMIGAS: Building a Cervical Cancer Screening Intervention for Public Health Practice 
Journal of women's health (2002)  2013;22(9):718-723.
Many barriers to cervical cancer screening for Hispanic women have been documented, but few effective interventions exist. The Community Preventive Services Task Force recommends increasing cervical cancer screening through various methods. Building on this evidence, the Centers for Disease Control and Prevention funded the research and testing phases for an evidence-based and theoretically grounded intervention designed to increase cervical cancer screening among never and rarely screened Hispanic women of Mexican descent. In this article, we describe the development process of the AMIGAS (Ayudando a las Mujeres con Información, Guía, y Amor para su Salud) intervention, highlight the integration of scientific evidence and community-based participatory research principles, and identify opportunities for dissemination, adaptation, and implementation of this intervention.
The AMIGAS team was a collaboration among researchers, promotoras (community health workers), and program administrators. The multiyear, multiphase project was conducted in Houston, Texas; El Paso, Texas; and Yakima, Washington. The team completed several rounds of formative research, designed intervention materials and methodology, conducted a randomized controlled trial, created a guide for program administrators, and developed an intervention dissemination plan.
Trial results demonstrated that AMIGAS was successful in increasing cervical cancer screening among Hispanic women. Adaptation of AMIGAS showed minimal reduction of outcomes. Dissemination efforts are underway to make AMIGAS available in a downloadable format via the Internet.
Developing a community-based intervention that is evidence-based and theoretically grounded is challenging, time-intensive, and requires collaboration among multiple disciplines. Inclusion of key stakeholders—in particular program deliverers and administrators—and planning for dissemination and translation to practice are integral components of successful intervention design. By providing explicit directions for adaptation for program deliverers, relevant information for program administrators, and access to the intervention via the Internet, AMIGAS is available to help increase cervical cancer screening among Hispanic women and other women disproportionately affected by cervical cancer.
PMCID: PMC4603539  PMID: 23930983
9.  “It's Not Like You Just Had a Heart Attack”: Decision-Making about Active Surveillance by Men with Localized Prostate Cancer 
Psycho-oncology  2013;23(4):467-472.
Growing recognition that active surveillance (AS) is a reasonable management option for many men diagnosed with localized prostate cancer led us to describe patients’ conceptualizations of AS and reasons for their treatment decisions.
Men were patients of a multidisciplinary prostate cancer clinic at a large tertiary cancer center where patients are routinely briefed on treatment options, including AS. We conducted a thematic analysis of interviews with 15 men who had chosen AS and 15 men who received radiation or surgery.
Men who chose AS described it as an organized process with a rigorous and reassuring protocol of periodic testing, with potential for subsequent and timely decision making about treatment. AS was seen as prolonging their current good health and function with treatment still possible later. Rationales for choosing AS included trusting their physician's monitoring, “buying time” without experiencing adverse effects of treatment, waiting for better treatments, and seeing their cancer as very low risk. Men recognized the need to justify their choice to others because it seemed contrary to the impulse to immediately treat cancer. Descriptions of AS by men who chose surgery or radiation were less specific about the testing regimen. Getting rid of the cancer and having a cure were paramount for them.
Men fully informed of their treatment options for localized prostate cancer have a comprehensive understanding of the purpose of AS. Slowing the decision-making process may enhance the acceptability of AS.
PMCID: PMC3983844  PMID: 24243777
Cancer; Oncology; Prostate Neoplasms; Decision Making; Qualitative Research
10.  Dating Violence Among Urban, Minority, Middle School Youth and Associated Sexual Risk Behaviors and Substance Use 
The Journal of school health  2013;83(6):415-421.
Whereas dating violence among high school students has been linked with sexual risk-taking and substance use, this association has been understudied among early adolescents. We estimated the prevalence of physical and nonphysical dating violence in a sample of middle school students and examined associations between dating violence, sexual, and substance use behaviors.
Logistic regression models for clustered data from 7th grade students attending 10 Texas urban middle schools were used to examine cross-sectional associations between dating violence victimization and risk behaviors.
The sample (N = 950) was 48.5% African American, 36.0% Hispanic, 55.7% female, mean age 13.1 years (SD 0.64). About 1 in 5 reported physical dating violence victimization, 48.1% reported nonphysical victimization, and 52.6% reported any victimization. Adjusted logistic regression analyses indicated that physical, nonphysical, and any victimization was associated with ever having sex, ever using alcohol, and ever using drugs.
Over 50% of sampled middle school students had experienced dating violence, which may be associated with early sexual initiation and substance use. Middle school interventions that prevent dating violence are needed.
PMCID: PMC4372798  PMID: 23586886
dating violence; middle school; adolescent; sexual behaviors; alcohol and drug use; substance abuse
11.  A systematic review of special events to promote breast, cervical and colorectal cancer screening in the United States 
BMC Public Health  2014;14:274.
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.
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.
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.
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.
PMCID: PMC3987802  PMID: 24661503
Cancer screening; Early detection of cancer; Health promotion; Community health education; Breast neoplasms; Cervical neoplasms; Colorectal neoplasms
12.  Cervical cancer screening and adherence to follow-up among Hispanic women study protocol: a randomized controlled trial to increase the uptake of cervical cancer screening in Hispanic women 
BMC Cancer  2012;12:170.
In the US, Hispanic women have a higher incidence of, and mortality from, cervical cancer than non-Hispanic white women. The reason for this disparity may be attributable to both low rates of screening and poor adherence to recommended diagnostic follow-up after an abnormal Pap test. The 'Cervical Cancer Screening and Adherence to Follow-up Among Hispanic Women' study is a collaboration between a research institution and community partners made up of members from community based organizations, the Yakima Valley Farm Workers Clinic and the Breast, Cervical, and Colon Health Program of the Yakima District . The study will assess the efficacy of two culturally-appropriate, tailored educational programs designed to increase cervical cancer screening among Hispanic women, based in the Yakima Valley, Washington, US.
A parallel randomized-controlled trial of 600 Hispanic women aged 21–64, who are non-compliant with Papanicolau (Pap) test screening guidelines. Participants will be randomized using block randomization to (1) a control arm (usual care); (2) a low-intensity information program, consisting of a Spanish-language video that educates women on the importance of cervical cancer screening; or (3) a high-intensity program consisting of the video plus a ‘promotora’ or lay-community health educator-led, home based intervention to encourage cervical cancer screening. Participants who attend cervical cancer screening, and receive a diagnosis of an abnormal Pap test will be assigned to a patient navigator who will provide support and information to promote adherence to follow-up tests, and any necessary surgery or treatment. Primary endpoint: Participants will be tracked via medical record review at community-based clinics, to identify women who have had a Pap test within 7 months of baseline assessment. Medical record reviewers will be blinded to randomization arm. Secondary endpoint: An evaluation of the patient navigator program as a method to improve adherence and reduce time to follow-up among participants who receive an abnormal Pap test result. An additional secondary endpoint is the cost-effectiveness of the two different intensity intervention programs.
This culturally sensitive intervention aims to increase compliance and adherence to cervical screening in a Hispanic population. If effective, such interventions may reduce incidence of cervical cancer.
Trial registration
PMCID: PMC3407514  PMID: 22559251
Hispanic women; Pap test; Cervical cancer screening; Cancer disparities

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