Joyce Q. Sheats

TRANSLATION TO PRACTICE OF AN INTERVENTION TO PROMOTE COLORECTAL CANCER SCREENING AMONG AFRICAN AMERICANS

In a previous report, we demonstrated the efficacy of an intervention to promote colorectal cancer screening among African Americans in a controlled community intervention trial. Participants in the intervention, named EPICS (Educational Program to Increase Colorectal Cancer Screening), were twice as likely to be screened after six months as those in the control group. In the current project, we put the intervention into practice through an academic‐health department partnership, and the intervention performed as well as it had in the controlled trial. This success may be due to the community‐based participatory methods used in designing and testing the intervention. Clin Trans Sci 2012; Volume 5: 412–415

Enhancing cancer control programmatic and research opportunities for African-Americans through technical assistance training.

African‐Americans remain severely underrepresented in cancer control program delivery and research. Community‐based organizational leaders and minority junior investigators have received little attention as representatives of target populations, or as agents to deliver and evaluate efforts to eliminate cancer health disparities. This paper describes activities of the National Black Leadership Initiative on Cancer II: Network Project, which has sought to address these issues. Community leaders and junior investigators received technical assistance (TA) and mentoring to develop applications for cancer education and community‐based participatory research (CBPR) projects. TA was provided to 35 community leaders and 32 junior investigators. Twenty‐nine community leaders won funding through the Community Partners for Cancer Education Program. Three pilot research applications were funded. Technical assistance may improve minority recruitment/retention in CBPR cancer control research and enhance understanding and elimination of cancer health disparities among African‐Americans. Cancer 2006.

Formative research to develop a lifestyle application (app) for African American breast cancer survivors.

Background There is a proliferation of lifestyle-oriented mobile technologies; however, few have targeted users. Through intervention mapping, investigators and community partners completed Steps 1–3 (needs assessment, formulation of change objectives, and selection of theory-based methods) of a process to develop a mobile cancer prevention application (app) for cancer prevention. The aim of this qualitative study was to complete Step 4 (intervention development) by eliciting input from African American (AA) breast cancer survivors (BCSs) to guide app development. Methods Four focus group discussions (n=60) and three individual semi-structured interviews (n=36) were conducted with AA BCSs (40–72 years of age) to assess barriers and strategies for lifestyle change. All focus groups and interviews were recorded and transcribed verbatim. Data were analyzed with NVivo qualitative data analysis software version 10, allowing categories, themes, and patterns to emerge. Results Three categories and related themes emerged from the analysis: 1) perceptions about modifiable risk factors; 2) strategies related to adherence to cancer prevention guidelines; and 3) app components to address barriers to adherence. Participant perceptions, strategies, and recommended components guided development of the app. Conclusions For development of a mobile cancer prevention app, these findings will assist investigators in targeting features that are usable, acceptable, and accessible for AA BCSs.

A Community-Engaged Approach to Developing a Mobile Cancer Prevention App: The mCPA Study Protocol

Background Rapid growth of mobile technologies has resulted in a proliferation of lifestyle-oriented mobile phone apps. However, most do not have a theoretical framework and few have been developed using a community-based participatory research approach. A community academic team will develop a theory-based, culturally tailored, mobile-enabled, Web-based app—the Mobile Cancer Prevention App (mCPA)—to promote adherence to dietary and physical activity guidelines. Objective The aim of this study is to develop mCPA content with input from breast cancer survivors. Methods Members of SISTAAH (Survivors Involving Supporters to Take Action in Advancing Health) Talk (N=12), treated for Stages I-IIIc breast cancer for less than 1 year, 75 years of age or younger, and English-speaking and writing, will be recruited to participate in the study. To develop the app content, breast cancer survivors will engage with researchers in videotaped and audiotaped sessions, including (1) didactic instructions with goals for, benefits of, and strategies to enhance dietary intake and physical activity, (2) guided discussions for setting individualized goals, monitoring progress, and providing or receiving feedback, (3) experiential nutrition education through cooking demonstrations, and (4) interactive physical activity focused on walking, yoga, and strength training. Qualitative (focus group discussions and key informant interviews) and quantitative (sensory evaluation) methods will be used to evaluate the participatory process and outcomes. Results Investigators and participants anticipate development of an acceptable (frequency and duration of usage) feasible (structure, ease of use, features), and accessible mobile app available for intervention testing in early 2017. Conclusions Depending on the availability of research funding, mCPA testing, which will be initiated in Miami, will be extended to Chicago, Houston, Philadelphia, and Los Angeles.

Engaging African Americans in developing an intervention to reduce breast cancer recurrence: A brief report.

Background To develop a culturally appropriate lifestyle intervention, involvement of its intended users is needed. Methods Members of an African American (AA) breast cancer support group participated in two 4-hour guided discussions, which were audiotaped, transcribed, and analyzed to guide the content. Results The support group collaborated with researchers to develop 24 experiential nutrition education sessions using a social cognitive framework and incorporating self-regulation skills (goal-setting, self-monitoring, problem-solving, stimulus control) and social support to enhance self-efficacy for changes in dietary intake. Conclusions Community engagement fostered autonomy, built collaboration, and enhanced the capacity of AA breast cancer survivors to participate in developing a lifestyle intervention.

Assessing similarities and differences in health-related quality of life among African-American women with and without breast cancer

Background: While current incidence rates are 4% lower for African American compared to white women (118 v. 123 per 100,000); African-American women are more likely to be diagnosed with breast cancer at younger ages with more aggressive and advanced tumors. Consequently, death rates are 41% higher for African-American women as compared to whites. This disparity may also extend to nonclinical outcomes, including health-related quality of life (HR-QoL). When compared to their white counterparts, consistent patterns in HR-QoL deficits have been noted among African-American women with and without breast cancer. It is important to examine the impact of physical, social and psychological factors on health outcomes in greater detail. The present study compares HR-QoL among African-American women without breast cancer, to those with breast cancer and other cancers from a national representative sample to a community cohort. The primary purpose was to assess similarities and differences in HR-QoL among African-American women with and without a history of breast cancer. We hypothesized that African American women with breast cancer would report poorer HR-QoL than those without breast cancer. Methods: Three cohorts of African-American women from the 2010 National Health Interview Survey (NHIS): without cancer (n=1,348); with breast cancer (n=50) and with other cancers (n=82) were compared to participants from Survivors Involving Supporters to Take Action in Advancing Health (SISTAAH Talk) breast cancer support group (n=70) to assess HR-QoL characterized by recent physical and mental health using the Patient Reported Outcomes Measurement Information System (PROMIS) v. 1.0 Global Health Scale. Descriptive statistics were completed to characterize study participants demographics. Multivariate regression analyses estimated differences in respondents9 HR-QoL. Results: Demographic differences were noted among study cohorts. Proportionately, more African-American women with any cancer were 50 years or older compared to respondents without cancer. Significantly more SISTAAH Talk respondents were: 1) married when compared to NHIS respondents with breast cancer (p=0.0148) and with other cancers (p = 0.0042) and 2) better educated than NHIS respondents without cancer (p Conclusions/Discussion: Based on similar studies, we hypothesized that African American breast cancer survivors would have poorer HR-QoL than their cancer-free counterparts. Our results, however, suggested the opposite, for the following reasons: 1) noted differences in HR-QoL between SISTAAH Talk respondents and African-American women in the NHIS cohorts may be related to support group participation; 2) SISTAAH Talk respondents were more likely married, have more education with higher incomes, all of which are associated with better health resulting in 3) higher overall mental and physical health scores (higher than the national norm of 50). Additional research is needed to determine reasons for differences in HR-QoL among African- American women with and without breast cancer. Funding Source: This research is supported by: National Cancer Institute (Grant #: 1R01CA166785-02 and U54 CA118638-08) and National Institute of Minority Health & Health Disparities (Grant #: 1P20 MD006881-01). Citation Format: Selina A. Smith, Mechelle D. Claridy, Mary S. Whitehead, Joyce Q. Sheats, Ernest Alema-Mensah. Assessing similarities and differences in health-related quality of life among African American women with and without breast cancer. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C45. doi:10.1158/1538-7755.DISP13-C45

Abstract C10: Attrition in a cluster randomized controlled trial: Lessons learned from the Educational Program to Increase Colorectal Cancer Screening (EPICS) pilot study

Background: High attrition rates in community intervention trials limit study generalizability, threaten internal validity and decrease statistical power. Attrition can introduce selection bias in randomized controlled trials (RCT); however, cluster randomization minimizes this effect because cohorts formed at baseline are balanced on known covariates. Nonetheless, attrition is a challenge for research with traditionally difficult-to-follow populations, including African Americans. The purpose of this paper is to determine attrition rates for the Educational Program to Increase Colorectal Cancer Screening (EPICS) cluster RCT, describe challenges encountered during a study pilot period and provide solutions to overcome threats to full-scale trial implementation. Methods: We intend to enroll 7,200 individuals in this study, with 1,800 in four dissemination arms (in-person with technical assistance, in-person without technical assistance, web-access with technical assistance and web-access without technical assistance). Based on data from a previously published study, we calculated an intracluster correlation coefficient to equal 0.0911 (9.1%). The effective sample size was 5,645, which still has high power (>99%) 320 with design effect of 1.2754. Quantitative and qualitative measures were used to obtain data from community coalitions targeting African Americans ages 50-74 years with no personal or family history and not current on colorectal cancer (CRC) screening for EPICS implementation. Community coalition participation, facilitator-training outcomes and participant enrollment were analyzed to determine attrition rates. Key informant interviews were conducted to identify challenges to trial implementation. Results: Thirty-three community coalitions were approached for participation; 13 did not meet inclusion criteria, eight were not available when the trial was offered and two declined participation. At baseline (Time 1), 20 community coalitions were randomized to passive or active study arms. At Time 2 (facilitator training), one community coalition was lost from each study arm (attrition rate=10%). Two hundred and fifty individuals were approached to complete facilitator training; 204 were trained and certified as EPICS facilitators (attrition rate=18%). At pilot testing (Time 3) 665 participants were enrolled; 436 completed all three EPICS sessions at Time 4 (attrition rate=34%). Conclusions: We previously reported a participant attrition rate for the Colorectal Cancer Screening Intervention Trial (CCSIT). We attribute the 9% difference in participant attrition between CCSIT (25%) and EPICS cRCT (34%) to research conducted in an academic versus real world settings. Difficulty recruiting and engaging participants may be overcome by offering additional locations and more convenient days/times for EPICS sessions. For community coalitions, results suggest that enhancing capacity to conduct research would limit attrition in trials such as EPICS. Interviewing potential facilitators, describing the cRCT and describing roles and responsibilities in greater detail may result in greater training participation. Citation Format: Selina A. Smith, Ernestine Delmoor, Joyce Q. Sheats, Mechelle D. Claridy, Francesca Damus, Ernest Alemah-Mensah, Daniel S. Blumenthal. Attrition in a cluster randomized controlled trial: Lessons learned from the Educational Program to Increase Colorectal Cancer Screening (EPICS) pilot study. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr C10.

Abstract C11: Factors impacting implementation of a community coalition-driven evidence-based intervention: Results from a cluster randomized controlled trial

Background: For the past two decades there has been increased emphasis on implementing community coalition-driven, evidence-based interventions. However, little information is available to determine which elements of coalition infrastructure and partnerships are most supportive of successful intervention implementation. The Educational Program to Increase Colorectal Cancer Screening (EPICS) is a cluster randomized controlled trial (cRCT) currently underway in 20 communities located in 12 US states. The objective of this paper is to describe the role of three elements important in EPICS implementation by community coalitions: organizational infrastructure, facilitator selection and partnership formation. We hypothesized that more experienced community coalitions with larger, formal structures will train more facilitators and establish more partnerships when compared to smaller, less formal coalitions. Methods: National Black Leadership Initiative on Cancer (NBLIC) community coalitions were charged with recruiting facilitators and community partners for EPICS delivery. The role of the facilitators was to deliver the educational intervention to small groups of participants. Facilitators selected were either community health educators (CHEs) – persons with a health professions degree - or community health workers (CHWs). Partnerships were formed with churches, clinics and other community sites to serve as settings and to assist in participant recruitment. Data were collected using a mixed method approach: two self-administered surveys (Organizational Assessment and Facilitator Baseline, Knowledge, Attitudes and Confidence Survey) and telephone key informant interviews. Descriptive analyses of the three groups of study participants (e.g., community coalitions, facilitators and partners) and correlational analysis was also performed within each community coalition to test for differences in facilitator and partnership type. Results: A total of 20 community coalitions, 204 facilitators and 61 community institutions formed partnerships for EPICS implementation. Organizational Structure: All but one community coalition targets primarily African American populations (95.24%). Facilitator Selection: CHEs and CHWs were demographically similar (e.g., gender, race, age, language of preference, marital status, religious preference, and insurance coverage). While the association between community coalition size and the number of CHEs was not significant, there was a significant difference between community coalition size and the number of CHWs. Smaller and medium-sized coalitions engaged more CHWs as facilitators (p=0.0071). Partnership Formation: Community coalition size did not correlate with partnership type or number. Community coalitions indicating partnerships with clinics were more likely to select CHEs than CHWs (p=0.0338). Conclusions: We examined multiple organizational characteristics to determine their relationship to facilitators and partners implementing EPICS. Although demographically similar, CHWs were selected more often by smaller and medium-sized community coalitions to train as EPICS facilitators. This finding suggests that smaller community coalitions, with a less formal structure were more likely to engage individuals with limited health backgrounds to facilitate the intervention. As a community-driven intervention, EPICS facilitation does not require a health professional for delivery. Interestingly, for community coalitions planning to implement EPICS in clinical settings, CHEs were selected over CHWs as facilitators. Citation Format: Selina A. Smith, Sandra J. Hamilton, Rene D. Jackson, Mechelle D. Claridy, Ernest Alemah-Mensah, Joyce Q. Sheats, Joyce Q. Sheats. Factors impacting implementation of a community coalition-driven evidence-based intervention: Results from a cluster randomized controlled trial. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr C11.