Carol White

Seeking health advice from social networks in low-income urban neighborhoods.

OBJECTIVES To examine how individuals residing in low-income neighborhoods use their social networks for health advice. METHODS Secondary data analysis of 363 individuals living in low-income neighborhoods was conducted using social network analysis and logistic regression techniques. RESULTS Findings suggest that residents typically seek health advice from one or 2 friends and family members rather than a health professional. Age and family history of illness increased the likelihood that one would seek support whereas the combination of anxiety and depression decreased advice seeking. CONCLUSIONS Findings support the need for multidisciplinary strategies for disseminating health information through informal social networks.

Inconsistencies Between Medical Records and Patient-Reported Recommendations for Follow-Up After Abnormal Pap Tests

PURPOSE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

Effectiveness of an Intervention for Adherence to Follow-up Recommendations for Abnormal Pap Tests in Appalachian Kentucky

OBJECTIVE In collaboration with rural county health departments (CHDs), we developed a patient navigation intervention to increase adherence to follow-up recommendations for women with abnormal Pap tests. METHODS Local women were recruited, trained and placed in CHDs. Navigation was tailored to the follow-up care recommended. Effectiveness was evaluated in a quasi-experimental trial that included 13 intervention CHDs and 13 comparison group CHDs. Participants were enrolled from September 2008 through July 2010. RESULTS A total of 478 participants were enrolled. The proportion that received recommended follow-up care was greater in the intervention CHDs (91.6%) than in the comparison group CHDs (80.8%) (p = .01). CONCLUSIONS These results suggest that development of policy to promote navigation with rural health care delivery systems has great potential to improve patient outcomes.

Abstract C12: Cancer navigation programs: Identifying barriers and addressing health disparities in Appalachia

The Appalachian region includes 13 states comprising 420 counties, beginning in the north in southern New York and following the Appalachian Mountains to Mississippi. The region has unique natural beauty and a heterogeneous population that shares distinct cultural characteristics but with high rates of unemployment, low income, and high rates of chronic disease, including cancer. Patient Navigation (PN) can address barriers and enhance access to cancer screening and care through the use of individual navigators who are sensitive to the needs, interests, and values of the community. Although there are numerous PN training programs available, there are no known programs specific to the Appalachian population. An electronic survey was distributed in 2011 and again in 2015/16 to better understand the cancer navigation programs in all 13 states of the Appalachian states and how they serve the regional population. In both waves of the survey over 150 responses were received from navigators, program directors, and supervisors. Survey results identify where cancer navigation programs take place (hospitals, health centers, and cancer centers), which health professionals fill the role of navigators (social workers, nurses, health educators), where navigation programs reside in health organizations (breast care centers, infusion centers, social services, and cancer centers), what aspects of the cancer continuum are addressed (prevention, screening, treatment to survivorship), and what range of services are provided by navigation programs (from education, referrals, to financial and spiritual support). A summary and comparison of quantitative data will be reported supplemented with qualitative findings and open-ended responses. Citation Format: Sharon Dwyer, Elizabeth Rohan, Dana White, Eric Stockton, Georgina Castro, Reda Wilson, Carol White, Mark Dignan. Cancer navigation programs: Identifying barriers and addressing health disparities in Appalachia [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C12.

Abstract B14: Effectiveness of patient navigation for follow-up for abnormal pap tests in Appalachian Kentucky

Introduction. Residents of Appalachian Kentucky experiences significant cancer disparities. The population is characterized, in general, as largely rural with high poverty rates, high unemployment and limited access to health care. Lung and colorectal cancer incidence and mortality rates in this area are among the highest in the nation and although cervical cancer mortality has decreased over recent decades, data from the Surveillance, Epidemiology, and End Results (SEER) program reveals that mortality rates in Kentucky are substantially higher than the national average. In 2003, when this project began, the US cervical cancer mortality rate was 2.7 per 100,000 (95% confidence interval = 2.6-2.7). During the same period, the rate in Kentucky was 3.2 per 100,000 (2.9-3.6). In the 54 Appalachian counties in the state, the rate was even higher, 3.7 per 100,000 (3.5-4.0). Death from cervical cancer is preventable in nearly all cases with screening by the Pap test and adherence with recommendations to obtain follow-up care when abnormalities are detected. Methods. To address the problem of elevated cervical cancer incidence and mortality experienced by rural Appalachian women, a patient navigation intervention program was developed with the goal of increasing adherence with recommendations for follow-up for women with abnormal Pap test results. The intervention was implemented in partnership with county health departments. Intervention effectiveness was evaluated in a quasi-experimental trial that included intervention county health departments (n=13) that provided patient navigation services and a comparison group of county health departments (n=13) that provided usual care. Women with abnormal Pap test results were enrolled in the intervention group county health departments and patient navigation was tailored to the type of follow-up care recommended. Study outcome data were collected from medical records. Participants were enrolled from September 2008 through July 2010. A total of 774 medical record reviews are included in the analysis (230 women in intervention and 544 women in comparison county health departments). Recommendations for follow-up, which were based on the type of abnormality and the age of the patient, included returning to the health department to obtain a repeat Pap test or making an appointment with a community gynecologist under contract with the health department. Key Findings. The proportion of participants that received their recommended follow-up care was greater in the intervention group (91.6%) than in the comparison group (80.8%) (p=.01). The effect of the patient navigation intervention was strongest among women who received follow-up care from the health department as opposed to community gynecologists under contract with the health departments. Conclusions. The results demonstrate the effectiveness of the patient navigation intervention and also provide evidence suggesting that development of policy to promote integration of navigation with rural health care delivery systems has great potential to improve patient outcomes. Citation Format: Mark Dignan, Brent Shelton, Nancy E. Schoenberg, Carol R. White, Stacey A. Slone, Emily Van Meter, Frances J. Feltner, Gretchen Ely, Christopher DeSimone. Effectiveness of patient navigation for follow-up for abnormal pap tests in Appalachian Kentucky. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr B14.

Abstract B30: Patient navigation for cervical cancer in Kentucky: Baseline results

Background: Although morbidity and mortality rates are low compared to other types of cancer, cervical cancer remains a high priority for the following reasons: 1) invasive cervical cancer is a disease that could be prevented in nearly all cases, with greater use of the Pap test; 2) the Pap test is a well‐established, low cost, widely available screening test that should present minimal barriers to its use; and 3) despite our ability to prevent and treat cervical cancer, the burden of cervical cancer morbidity and mortality continues to be higher among low‐income women with limited education, many of whom reside in rural areas. Despite public health recommendations for cervical cancer screening and follow‐up of abnormal Pap test results, adherence is still low among rural Appalachian women in Kentucky. In response to this concern, the University of Kentucky Prevention Research Center is implementing a National Cancer Institute‐funded project that is integrating patient navigators (PN) in cervical cancer screening programs in several rural health departments. Goal: To reduce the disproportionate burden of cervical cancer experienced by rural Appalachian women in Kentucky. Objectives: To: 1) improve our understanding of the barriers to follow‐up; 2) recruit, train, and utilize lay health workers as PNs in cervical cancer screening programs; 3) increase the proportion of women who adhere to recommended follow‐up; and 4) evaluate the efficacy of the intervention. Method: Intervention activities are as follows: 1) nurse case managers refer patients with abnormal pap tests to PNs in selected local health departments in Big Sandy, Lake Cumberland, and Kentucky River Area Development Districts; 2) PNs enroll patients in the study; 3) study participants complete a baseline interview; 4) PNs provide navigation services including outreach, education, and support; 5) PNs conduct follow‐up interviews; and 6) PNs document follow‐up recommendations, barriers, patient needs, and specific actions taken to ensure adherence to follow‐up recommendations. Evaluation: To assess the efficacy of the intervention, outcome data will be collected from health department records in intervention and control counties. Findings: The total number of referrals to date is 600. Among the referrals: 82 (14%) were ineligible (patient less than 18 years, refused services, dropped by health department for non‐compliance, or lost to follow‐up); 379 (63%) were offered enrollment; and enrollment is pending for 139 (23%). Among those offered enrollment, 297 (78%) agreed to participate in the study. Additional preliminary findings will be presented including reason for referral, characteristics of women enrolled, patient needs, adherence to follow‐up, etc. Conclusions: The program creates a unique opportunity to support rural cervical cancer screening programs, ensuring women obtain their recommended follow‐up care through the support of PNs. Citation Information: Cancer Prev Res 2010;3(1 Suppl):B30.