John B. Lowe

A randomised trial of population screening for melanoma

Objectives: Melanoma is a significant cause of morbidity and mortality worldwide and incidence is increasing. Survival after treatment is inversely related to the thickness of the tumour at diagnosis. Population screening has the potential to reduce mortality but there is no conclusive evidence of benefit. Such evidence can come best from a randomised trial. Here we describe the design of a community based randomised trial of a population screening programme for melanoma in Queensland, Australia and early results of the first phase of the trial. Methods: A total of 44 communities (aggregate population 560 000 adults aged 30 years or more) will be randomised to receive either a community based screening programme for 3 years or normal practice. The screening programme promotes thorough skin self examination and whole body skin examination by a doctor and provides open access skin cancer screening clinics. In its first phase, the trial is underway in nine intervention and nine control communities. The primary outcome measure is mortality from melanoma during 15 years of follow up. Results: The first phase of the trial has shown the feasibility of implementing a population skin screening programme including regular skin cancer screening clinics, and has shown the strong support of communities and doctors for the programme. There has been a significant 2.5-fold increase in participation in screening in the intervention communities in this first phase after the first 12 months of the trial and no significant increase in participation in screening in control communities during this period. Conclusions: The design of a community based randomised trial of screening for melanoma has been successfully peer reviewed and the intervention has been shown to be feasible in practice. This randomised trial may be one of the last opportunities to develop the evidence required for public health recommendations for population screening for melanoma.

Tobacco Outlet Density and Demographics at the Tract Level of Analysis in Iowa: Implications for Environmentally Based Prevention Initiatives

This study assessed the geographic association between tobacco outlet density and three demographic correlates—income, race, and ethnicity—at the tract level of analysis for one county in the Midwestern United States. Data for residential census tracts in a Midwestern U.S. county were derived from year 2003 licenses for 474 tobacco outlets. Demographic variables were based on 2000 census data. Census tracts with lower median household income, higher percent of African American residents, and higher percent of Latinos residents had greater density of tobacco selling retail outlets. Areas characterized by lower income and disproportionately more African Americans and Latinos have greater physical access to tobacco products. Physical access to tobacco is a critical public-health issue because, given that smokers have been shown to be price sensitive, lowering access costs (e.g., reduced travel time) is likely to increase consumption. Findings also suggest the need for structural or environmental interventions, i.e., tobacco outlet zoning laws, to mitigate the health consequences associated with tobacco use in certain populations and geographic regions.

Tobacco Outlet Density, Cigarette Smoking Prevalence, and Demographics at the County Level of Analysis

The geographic associations between tobacco outlet density, cigarette smoking prevalence, and demographic variables at the county unit of analysis were examined. End of year 2002 data were derived from licenses of 4745 tobacco selling retail outlets in all 99 Iowa counties. The 2000 census and the 2002 Iowa Behavioral Risk Factor Surveillance System (IBRFSS) were used to gather data for demographic variables and smoking prevalence rates. The IBRFSS telephone interviews were conducted from January through December in 2002 with a random sample of 3662 Iowa residents. As expected, results showed that counties with higher density of tobacco outlets and smoking prevalence also tended to have a higher percentage of minority residents. Contrary to previous studies, however, counties with higher tobacco outlet density and smoking prevalence also tended to have higher median household income. Findings are discussed in light of the states low income inequality. Implications of the study and directions for future research are discussed.

Prevalence of whole-body skin self-examination in a population at high risk for skin cancer (Australia).

AbstractObjective: Whole-body skin self-examination (SSE) with presentation of suspicious lesions to a physician may improve early detection of melanoma. The aim of this study was to establish the prevalence and determinants of SSE in a high-risk population in preparation for a community-based randomised controlled trial of screening for melanoma. Methods: A telephone survey reached 3110 residents older than 30 years (overall response rate of 66.9%) randomly selected from 18 regional communities in Queensland, Australia. Results: Overall, 804 (25.9%) participants reported whole-body SSE within the past 12 months and 1055 (33.9%) within the past three years. Whole-body SSE was associated in multivariate logistic regression analysis with younger age ( <50 years); higher education; having received either a whole-body skin examination, recommendation or instruction on SSE by a primary care physician; giving skin checks a high priority; concern about skin cancer and a personal history of skin cancer. Conclusion: Overall, the prevalence of SSE in the present study is among the highest yet observed in Australia, with about one-third of the adult population reporting whole-body SSE in the past threeyears. People over 50 years, who are at relatively higher risk for skin cancer, currently perform SSE less frequently than younger people.

Smoking-Cessation Services in Iowa Community Pharmacies

Study Objective. To examine community pharmacy practice with regard to providing smoking‐cessation counseling.

Cutaneous Melanoma and Obesity in the Agricultural Health Study

PURPOSE To describe the risk of cutaneous melanoma in the Agricultural Health Study (AHS), a cohort of pesticide applicators and their spouses, according to baseline characteristics related to obesity along with sun exposure and sun sensitivity. METHODS The AHS cohort was enrolled in Iowa and North Carolina during 1993-1997 and followed up through 2003 for cancer incidence. We identified 315 cases of cutaneous melanoma, which reduced to 168 incident cases among subjects reporting height, weight, sun sensitivity, and sun exposure information (on the spouse questionnaire or take-home applicator questionnaire; N = 44,086). Unconditional multiple logistic regression models were used to obtain adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS The results were consistent with those of prior studies of melanoma that indicate an association with measures of sun sensitivity. The highest category of body surface area (BSA; OR = 2.6; 95% CI, 1.5-4.4) and body mass index (BMI; OR = 2.5; 95% CI, 1.5-4.3) at age 20 were significantly associated with melanoma. There was some evidence for an association with BSA, but not BMI, at enrollment. CONCLUSIONS Obesity was associated with an increased risk of melanoma, indicating strategies to control obesity may result in risk reduction for melanoma.

Empowerment and Sense of Community: Clarifying Their Relationship in Community Organizations

The research reported here tested the factor structure of a measure for sense of community in community organizations, and it evaluated sense of communitys potential as an empowering organizational characteristic within an organizational empowerment framework. Randomly selected community organization participants (N = 561) were surveyed as part of a study of a substance abuse prevention initiative located in the northeastern United States. Confirmatory factor analysis verified the putative structure of the sense of community measure tailored to community organizations. Hierarchical regression analyses indicated that community organization sense of community significantly predicted intrapersonal empowerment after controlling for demographics, participation, alienation, and other empowering organizational characteristic. Findings imply that organizational sense of community should be considered as an empowering organizational characteristic in community-based health education.

Paths to Leisure Physical Activity Among Adults With Intellectual Disabilities: Self-Efficacy and Social Support

Purpose. This study tested a path model that included perceptions of social support and self-efficacy for leisure physical activity and leisure physical activity participation among adults with intellectual disabilities. Design. A cross-sectional design was used. Data was collected via oral interview. Setting. Community-based group, supported-living settings in one Midwestern state. Sample. A total of 152 adults with mild to moderate intellectual disabilities, which provided a 39% response rate. Measures. Self-efficacy and social support (from family, residential staff, and peers with disabilities) for leisure physical activity were assessed using self-reported scales. Leisure physical activity participation was measured with a self-reported checklist of the frequency of leisure physical activity participation. Analysis. Path analysis was conducted for the entire sample and was repeated for younger and older age groups. Results. The hypothesized model fit the data from each group. Social support and self-efficacy predicted physical activity participation, and self-efficacy served as a mediator between social support and physical activity. Significant sources of social support differed between groups; among younger participants, social support from family predicted physical activity, whereas, for the older group, social support from staff and peers predicted physical activity. Conclusion. Self-efficacy and social support for leisure physical activity are related to leisure physical activity participation among adults with intellectual disabilities who are receiving supported-living services. The results provide information to guide health promotion programs for this group.

Increase in Skin Cancer Screening During a Community-Based Randomized Intervention Trial

Survival from cutaneous melanoma is mainly dependent on the thickness of the lesion at diagnosis. Skin screening may increase detection of thin lesions and hence improve survival. Within a community‐based randomized controlled trial of a population screening program for melanoma in Queensland, Australia, 9 communities were randomly assigned to the 3‐year intervention and 9 communities to the control group. Skin screening prevalence was monitored by cross‐sectional surveys at baseline, 1, 2 and 3 years into the intervention and 2 years later. At baseline, prevalence of whole‐body clinical skin examination was similar in intervention and control communities. In intervention communities, the prevalence of whole‐body skin examinations increased to 29.2%, an absolute difference of 18% from baseline, with a peak of 34.8% 2 years after baseline, and began to decline again at the end of the intervention period. The largest increases were seen in men and women ≥50 years. Uptake of screening did not differ according to melanoma risk factors; however, the decline in screening was less in participants who reported a number of melanoma risk factors. The prevalence of skin self‐examination remained stable during the intervention program. No changes were observed in the control communities. These results indicate that the intervention program significantly increased the prevalence of whole‐body clinical skin examinations in intervention communities. Once the intervention program ceased, and particularly after skin clinics ceased, levels of skin screening began to decline. The provision of specialized skin screening clinics may be needed to achieve sufficient screening rates should population based screening for skin cancer be considered.

Online information exchanges for parents of children with a rare health condition: key findings from an online support community.

Background The Internet provides new opportunities for parents of children with difficult illnesses and disabilities to find information and support. The Internet is particularly important for caregivers of children with special needs due to numerous health-related decisions they face. For at-risk populations, online support communities can become key settings and channels for health promotion and communication. Objective This study is an initial exploration of the information-seeking and information-provision processes present in an online support community, which is an area of opportunity and interest for Internet-based medical research and practice. The aim of this study was to explore and describe information-related processes of uncertainty management in relationship to clubfoot. Specifically, the study explored interpersonal communication (information seeking and provision) in an online support community serving the needs of parents of children with clubfoot. Methods The study population consisted of messages posted to an online community by caregivers (parents) of children with clubfoot. The theoretical framework informing the study was the Uncertainty Management Theory (UMT). The study used content analysis to explore and categorize the content of 775 messages. Results Women authored 664 of 775 messages (86%) and men authored 47 messages (6%). Caregivers managed uncertainty through information seeking and provision behaviors that were dynamic and multilayered. The ratio of information-seeking messages to information-provision responses was 1 to 4. All five types of information-seeking behaviors proposed by Brashers’ schema were identified, most of them being correlated. Information seeking using direct questions was found to be positively correlated to self-disclosure (r=.538), offering of a candidate answer (r=.318), and passive information seeking (r=.253). Self-disclosure was found to be positively correlated to provision of a candidate answer (r=.324), second-guessing (r=.149), and passive information seeking (r=.366). Provision of a candidate answer was found to be positively correlated with second-guessing (r=.193) and passive information seeking (r=.223). Second-guessing was found to be positively correlated to passive information seeking (r=.311). All correlations reported above were statistically significant (P<0.01). Of the 775 messages analyzed, 255 (33%) identified a medical professional or institution by name. Detailed medical information was provided in 101 (13%) messages, with the main source of information identified being personal experience rather than medical sources. Conclusion Online communities can be an effective channel for caregivers, especially women, to seek and offer information required for managing clubfoot-related uncertainty. To enhance communication with parents, health care institutions may need to invest additional resources in user-friendly online information sources and online interactions with caregivers of children with special illnesses such as clubfoot. Furthermore, explorations of information-seeking and information-provision behaviors in online communities can provide valuable data for interdisciplinary health research and practice.