Emily M. Gillen

Regional variation in colorectal cancer testing and geographic availability of care in a publicly insured population.

Despite its demonstrated effectiveness, colorectal cancer (CRC) testing is suboptimal, particularly in vulnerable populations such as those who are publicly insured. Prior studies provide an incomplete picture of the importance of the intersection of multilevel factors affecting CRC testing across heterogeneous geographic regions where vulnerable populations live. We examined CRC testing across regions of North Carolina by using population-based Medicare and Medicaid claims data from disabled individuals who turned 50 years of age during 2003-2008. We estimated multilevel models to examine predictors of CRC testing, including distance to the nearest endoscopy facility, county-level endoscopy procedural rates, and demographic and community contextual factors. Less than 50% of eligible individuals had evidence of CRC testing; men, African-Americans, Medicaid beneficiaries, and those living furthest away from endoscopy facilities had significantly lower odds of CRC testing, with significant regional variation. These results can help prioritize intervention strategies to improve CRC testing among publicly insured, disabled populations.

Social Ecology of Asthma Engaging Stakeholders in Integrating Health Behavior Theories and Practice-Based Evidence Through Systems Mapping

This article describes a process for integrating health behavior and social science theories with practice-based insights using participatory systems thinking and diagramming methods largely inspired by system dynamics methods. This integration can help close the gap between research and practice in health education and health behavior by offering a systematic approach to bring together stakeholders across multiple domains. In this process we create a diagram using constructs from multiple health behavior theories at all levels of the social ecological framework as variables in causal loop diagrams. The goal of this process is to elucidate the reciprocal relationships between explanatory factors at various levels of the social ecological framework that render so many public health problems intractable. To illustrate, we detail a theory-based, replicable process for creating a qualitative diagram to enrich understanding of caregiver and provider behavior around adherence to pediatric asthma action plans. We describe how such diagramming can serve as the foundation for translating evidence into practice to address real-world challenges. Key insights gained include recognition of the complex, multilevel factors affecting whether, and how effectively, parents/caregivers and medical providers co-create an asthma action plan, and important “feedback” dynamics at play that can support or derail ongoing collaboration. Although this article applies this method to asthma action plan adherence in children, the method and resulting diagrams are applicable and adaptable to other health behaviors requiring continuous, daily action.