Bryan Leyva

Implementation science in cancer prevention and control: a decade of grant funding by the National Cancer Institute and future directions

BackgroundThe National Cancer Institute (NCI) has supported implementation science for over a decade. We explore the application of implementation science across the cancer control continuum, including prevention, screening, treatment, and survivorship.MethodsWe reviewed funding trends of implementation science grants funded by the NCI between 2000 and 2012. We assessed study characteristics including cancer topic, position on the T2–T4 translational continuum, intended use of frameworks, study design, settings, methods, and replication and cost considerations.ResultsWe identified 67 NCI grant awards having an implementation science focus. R01 was the most common mechanism, and the total number of all awards increased from four in 2003 to 15 in 2012. Prevention grants were most frequent (49.3%) and cancer treatment least common (4.5%). Diffusion of Innovations and Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) were the most widely reported frameworks, but it is unclear how implementation science models informed planned study measures. Most grants (69%) included mixed methods, and half reported replication and cost considerations (49.3%).ConclusionsImplementation science in cancer research is active and diverse but could be enhanced by greater focus on measures development, assessment of how conceptual frameworks and their constructs lead to improved dissemination and implementation outcomes, and harmonization of measures that are valid, reliable, and practical across multiple settings.

Pathways between acculturation and health behaviors among residents of low-income housing: The mediating role of social and contextual factors

Acculturation may influence health behaviors, yet mechanisms underlying its effect are not well understood. In this study, we describe relationships between acculturation and health behaviors among low-income housing residents, and examine whether these relationships are mediated by social and contextual factors. Residents of 20 low-income housing sites in the Boston metropolitan area completed surveys that assessed acculturative characteristics, social/contextual factors, and health behaviors. A composite acculturation scale was developed using latent class analysis, resulting in four distinct acculturative groups. Path analysis was used to examine interrelationships between acculturation, health behaviors, and social/contextual factors, specifically self-reported social ties, social support, stress, material hardship, and discrimination. Of the 828 respondents, 69% were born outside of the U.S. Less acculturated groups exhibited healthier dietary practices and were less likely to smoke than more acculturated groups. Acculturation had a direct effect on diet and smoking, but not physical activity. Acculturation also showed an indirect effect on diet through its relationship with material hardship. Our finding that material hardship mediated the relationship between acculturation and diet suggests the need to explicate the significant role of financial resources in interventions seeking to promote healthy diets among low-income immigrant groups. Future research should examine these social and contextual mediators using larger, population-based samples, preferably with longitudinal data.

Religious Beliefs and Cancer Screening Behaviors among Catholic Latinos: Implications for Faith- based Interventions

Although most U.S. Latinos identify as Catholic, few studies have focused on the influence of this religious tradition on health beliefs among this population. This study explores the role of Catholic religious teachings, practices, and ministry on cancer screening knowledge, attitudes, and behaviors among Latinos. Eight focus groups were conducted with 67 Catholic Latino parishioners in Massachusetts. Qualitative analysis provided evidence of strong reliance on faith, God, and parish leaders for health concerns. Parishes were described as vital sources of health and social support, playing a central role in the community’s health. Participants emphasized that their religious beliefs promote positive health behaviors and health care utilization, including the use of cancer screening services. In addition, they expressed willingness to participate in cancer education programs located at their parishes and provided practical recommendations for implementing health programs in parishes. Implications for culturally appropriate health communication and faith-based interventions are discussed.

Religion, Fatalism, and Cancer Control: A Qualitative Study among Hispanic Catholics

OBJECTIVES To assess cancer perceptions among churchgoers and to examine the potential influence of fatalism and religious beliefs on the use of cancer screening tests. METHODS Eight semi-structured focus groups were conducted among 67 Hispanic Catholics in Massachusetts. RESULTS In this sample, there were few references to fatalistic beliefs about cancer and nearly universal endorsement of the utility of cancer screening for cancer early detection. Most participants reported that their religious beliefs encouraged them to use health services, including cancer-screening tests. Although participants agreed that God plays an active role in health, they also affirmed the importance of self-agency in determining cancer outcomes. CONCLUSIONS Our findings challenge the assumption that fatalism is an overriding perspective among Hispanics. Catholic religious beliefs may contribute to positive health attitudes and behaviors.

Why do People Avoid Medical Care? A Qualitative Study Using National Data

BackgroundMany studies have examined barriers to health care utilization, with the majority conducted in the context of specific populations and diseases. Less research has focused on why people avoid seeking medical care, even when they suspect they should go.ObjectiveThe purpose of the study was to present a comprehensive description and conceptual categorization of reasons people avoid medical care.DesignData were collected as part of the 2008 Health Information National Trends Survey, a cross-sectional national survey.ParticipantsParticipant-generated reasons for avoiding medical care were provided by 1,369 participants (40% male; Mage=48.9; 75.1% non-Hispanic white, 7.4% non-Hispanic black, 8.5% Hispanic or Latino/a).Main MeasuresParticipants first indicated their level of agreement with three specific reasons for avoiding medical care; these data are reported elsewhere. We report responses to a follow-up question in which participants identified other reasons they avoid seeking medical care. Reasons were coded using a general inductive approach.Key ResultsThree main categories of reasons for avoiding medical care were identified. First, over one-third of participants (33.3% of 1,369) reported unfavorable evaluations of seeking medical care, such as factors related to physicians, health care organizations, and affective concerns. Second, a subset of participants reported low perceived need to seek medical care (12.2%), often because they expected their illness or symptoms to improve over time (4.0%). Third, many participants reported traditional barriers to medical care (58.4%), such as high cost (24.1%), no health insurance (8.3%), and time constraints (15.6%). We developed a conceptual model of medical care avoidance based on these results.ConclusionsReasons for avoiding medical care were nuanced and highly varied. Understanding why people do not make it through the clinic door is critical to extending the reach and effectiveness of patient care, and these data point to new directions for research and strategies to reduce avoidance.

Is Religiosity Associated with Cancer Screening? Results from a National Survey

This study examined the following: (1) relationships between religiosity—as measured by religious service attendance—and screening for breast, cervical, and colorectal cancers; (2) the potential mediating role of social support; and (3) the potential moderating effect of race/ethnicity. Statistical analyses showed that religiosity was associated with greater utilization of breast, cervical, and colorectal cancer screening. Social support fully mediated the relationship between religiosity and Pap screening, and partially mediated the relationship between religiosity and colorectal screening, but had no effect on the relationship between religiosity and mammography screening. Race/ethnicity moderated the relationship between religiosity and social support in the cervical cancer screening model, such that the positive association between religiosity and social support was stronger for non-Hispanic Blacks than it was for non-Hispanic Whites. These findings have implications for the role of social networks in health promotion and can inform cancer screening interventions in faith-based settings.

Quality of Care for White and Hispanic Medicare Advantage Enrollees in the United States and Puerto Rico

IMPORTANCE Geographic, racial, and ethnic variations in quality of care and outcomes have been well documented among the Medicare population. Few data exist on beneficiaries living in Puerto Rico, three-quarters of whom enroll in Medicare Advantage (MA). OBJECTIVE To determine the quality of care provided to white and Hispanic MA enrollees in the United States and Puerto Rico. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of MA enrollees in 2011 was conducted, including white enrollees in the United States (n = 6 289 374), Hispanic enrollees in the United States (n = 795 039), and Hispanic enrollees in Puerto Rico (n = 267 016). The study was conducted from January 1, 2011, to December 31, 2011; data analysis took place from January 19, 2015, to January 2, 2016. MAIN OUTCOMES AND MEASURES Seventeen performance measures related to diabetes mellitus (including hemoglobin A1c control, retinal eye examination, low-density lipoprotein cholesterol control, nephropathy screening, and blood pressure control), cardiovascular disease (including low-density lipoprotein cholesterol control, blood pressure control, and use of a β-blocker after myocardial infarction), cancer screening (colorectal and breast), and appropriate medications (including systemic corticosteroids and bronchodilators for chronic obstructive pulmonary disease [COPD] and disease-modifying antirheumatic drugs). RESULTS Of the 7.35 million MA enrollees in the United States and Puerto Rico in our study, 1.06 million (14.4%) were Hispanic. Approximately 25.1% of all Hispanic MA enrollees resided in Puerto Rico, which was more than those residing in any state. For 15 of the 17 measures assessed, Hispanic MA enrollees in Puerto Rico received worse care compared with Hispanics in the United States, with absolute differences in performance rates ranging from 2.2 percentage points for blood pressure control in diabetes mellitus (P = .03) to 31.3 percentage points for use of disease-modifying antirheumatic drug therapy (P < .01). Adjusted performance differences between Hispanic MA enrollees in Puerto Rico and Hispanic MA enrollees in the United States exceeded 20 percentage points for 3 measures: use of disease-modifying antirheumatic drug therapy (-23.8 percentage points [95% CI, -30.9 to -16.8]), use of systemic corticosteroid in COPD exacerbation (-21.3 percentage points [95% CI, -27.5 to -15.1]), and use of bronchodilator therapy in COPD exacerbation (-22.7 percentage points [95% CI, -27.7 to -17.6]). CONCLUSIONS AND RELEVANCE We found modest differences in care between white and Hispanic MA enrollees in the United States but substantially worse care for enrollees in Puerto Rico compared with their US counterparts. Major efforts are needed to improve care delivery on the island to a level equivalent to the United States.

Enhancing organizational capacity to provide cancer control programs among Latino churches: Design and baseline findings of the CRUZA Study

BackgroundFaith-based organizations (FBOs) have been successful in delivering health promotion programs for African Americans, though few studies have been conducted among Latinos. Even fewer have focused on organizational change, which is required to sustain community-based initiatives. We hypothesized that FBOs serving Latinos would be more likely to offer evidence-based strategies (EBS) for cancer control after receiving a capacity enhancement intervention to implement health programs, and designed the CRUZA trial to test this hypothesis. This paper describes the CRUZA design and baseline findings.MethodsWe identified Catholic parishes in Massachusetts that provided Spanish-language mass (n = 65). A baseline survey assessed organizational characteristics relevant to adoption of health programs, including readiness for adoption, “fit” between innovation and organizational mission, implementation climate, and organizational culture. In the next study phase, parishes that completed the baseline assessment will be recruited to a randomized cluster trial, with the parish as the unit of analysis. Both groups will receive a Program Manual and Toolkit. Capacity Enhancement parishes will also be offered technical support, assistance forming health committees and building inter-institutional partnerships, and skills-based training.ResultsOf the 49 parishes surveyed at baseline (75%), one-third (33%) reported having provided at least one health program in the prior year. However, only two program offerings were cancer-specific. Nearly one-fifth (18%) had an active health ministry. There was a high level of organizational readiness to adopt cancer control programs, high congruence between parish missions and CRUZA objectives, moderately conducive implementation climates, and organizational cultures supportive of CRUZA programming. Having an existing health ministry was significantly associated with having offered health programs within the past year. Relationships between health program offerings and other organizational characteristics were not statistically significant.ConclusionsFindings suggest that many parishes do not offer cancer control programs, yet many may be ready to do so. However, the perceptions about existing organizational practices and policies may not be conducive to program initiation. A capacity enhancement intervention may hold promise as a means of increasing health programming. The efficacy of such an intervention will be tested in phase two of this study.

Recruiting and Surveying Catholic Parishes for Cancer Control Initiatives: Lessons Learned From the CRUZA Implementation Study.

Background. We describe activities undertaken to conduct organizational surveys among faith-based organizations in Massachusetts as part of a larger study designed to promote parish-based cancer control programs for Latinos. Method. Catholic parishes located in Massachusetts that provided Spanish-language mass were eligible for study participation. Parishes were identified through diocesan records and online directories. Prior to parish recruitment, we implemented a variety of activities to gain support from Catholic leaders at the diocesan level. We then recruited individual parishes to complete a four-part organizational survey, which assessed (A) parish leadership, (B) financial resources, (C) involvement in Hispanic Ministry, and (D) health and social service offerings. Our goal was to administer each survey component to a parish representatives who could best provide an organizational perspective on the content of each component (e.g., A = pastors, B = business managers, C = Hispanic Ministry leaders, and D = parish nurse or health ministry leader). Here, we present descriptive statistics on recruitment and survey administration processes. Results. Seventy-five percent of eligible parishes responded to the survey and of these, 92% completed all four components. Completed four-part surveys required an average of 16.6 contact attempts. There were an average of 2.1 respondents per site. Pastoral staff were the most frequent respondents (79%), but they also required the most contact attempts (M = 9.3, range = 1-27). While most interviews were completed by phone (71%), one quarter were completed during in-person site visits. Conclusions. We achieved a high survey completion rate among organizational representatives. Our lessons learned may inform efforts to engage and survey faith-based organizations for public health efforts.

Mode Effects in Assessing Cancer Worry and Risk Perceptions: Is Social Desirability Bias at Play?

Background. Risk perceptions and worry are important determinants of health behavior. Despite extensive research on these constructs, it is unknown whether people’s self-reports of perceived risk and worry are biased by their concerns about being viewed negatively by others (social desirability). Methods. In this study, we examined whether reports of perceived risk and worry about cancer varied across survey modes differing in the salience of social desirability cues. We used data from the National Cancer Institute’s 2007 Health Information National Trends Survey, which assessed perceived cancer risk and worry in 1 of 2 survey modes: an interviewer-administered telephone survey (higher likelihood of socially desirable responding; n = 3678) and a self-administered mail survey (lower likelihood of socially desirable responding; n = 3445). Data were analyzed by regressing perceived risk and worry on survey mode and demographic factors. Results. Analyses showed no effect of survey mode on cancer risk perceptions (B = 0.02, P = 0.55, d = 0.02). However, cancer worry was significantly higher in the self-administered mode than in the interviewer-administered mode (B = 0.24, P < 0.001, d = 0.26). Education moderated this effect, with respondents lower in education exhibiting a stronger mode effect. When cancer worry was dichotomized, the odds of reporting cancer worry were approximately twice as high in the self-administered mode compared with the interviewer-administered mode (OR = 2.13, P < 0.001). Conclusions. These results bolster the veracity of self-reported cancer risk perceptions. They also suggest that interviewer-administered surveys may underestimate the frequency of cancer worry, particularly for samples lower in socioeconomic status. Studies are needed to test for this effect in clinical contexts.