Mary Altpeter

Increasing Use of Mammography Among Older, Rural African American Women: Results From a Community Trial

OBJECTIVES A community trial was undertaken to evaluate the effectiveness of the North Carolina Breast Cancer Screening Program, a lay health advisor network intervention intended to increase screening among rural African American women 50 years and older. METHODS A stratified random sample of 801 African American women completed baseline (1993-1994) and follow-up (1996-1997) surveys. The primary outcome was self-reported mammography use in the previous 2 years. RESULTS The intervention was associated with an overall 6 percentage point increase (95% confidence interval [CI] = -1, 14) in community-wide mammography use. Low-income women in intervention counties showed an 11 percentage point increase (95% CI = 2, 21) in use above that exhibited by low-income women in comparison counties. Adjustment for potentially confounding characteristics did not change the results. CONCLUSIONS A lay health advisor intervention appears to be an effective public health approach to increasing use of screening mammography among low-income, rural populations.

Lay Health Advisors: A Strategy for Getting the Word out about Breast Cancer

Transforming natural helpers into lay health advisors (LHAs) is a complex undertaking. Using the North Carolina Breast Cancer Screening Program (NC-BCSP) as a case study, this article describes the steps involved in developing, implementing, and evaluating an LHA intervention, considering factors that make the LHA approach appropriate for the NC-BCSPs population, setting, and health focus. The authors review five phases of implementation (start-up, training, LHA activities, follow-up, resource mobilization) and discuss the NC-BCSPs evaluation strategies and tools in light of difficulties involved in assessing natural helping processes and impact. Program challenges related to resource needs, identification of natural helpers, and LHA monitoring and support also are considered. The authors describe ways in which one large group of older, rural, African American LHAs are helping establish countywide partnerships between health care providers, agencies, and local communities that support and sustain individual changes in health behavior.

The North Carolina Breast Cancer Screening Program: foundations and design of a model for reaching older, minority, rural women

SummaryBreast cancer screening programs do not reach all women at the same rate. Screening mammography use varies according to sociodemographic characteristics; mammography utilization is highest among women in their fifties but then decreases with age. In North Carolina, breast cancer is a particular burden for Black and lower-income women. Black women are more likely to be diagnosed with late stage disease, and their rate of breast cancer mortality is higher than it is for White women even though the incidence in White women is greater. Older, Black, and low-income women are less likely to obtain screening by mammography and clinical breast examination. The Black-White gap is even more pronounced among rural women, in part because they are more likely to be poor.The North Carolina Breast Cancer Screening Program (NC-BCSP) was established to increase the rate of regular mammography screening by an absolute 20% in 3 years among older Black women ages 50 and older in five rural counties in the eastern part of the state. In this paper, we describe the genesis of this comprehensive community intervention model, highlighting the behavioral science constructs, health education principles, and theories of behavioral and organizational change that form its conceptual foundation. NC-BCSPs theoretical foundations include the social ecological perspective, the PRECEDE model of health promotion, the Health Belief Model of individual change, and the “stages of change” transtheoretical model. We also review the experiences and lessons learned from two previous outreach initiatives in North Carolina that provided valuable “lessons” in the development of the NC-BCSP intervention model. In the second half of the paper, we describe the actual NC-BCSP interventions, activities, and evaluation tools, citing specific examples of how the underlying theories are implemented.NC-BCSPs goal goes beyond individual behavior change to raise low mammography screening rates among Black women in rural North Carolina. Its ultimate objective is to create linkages across agencies, and between agencies and communities, that will endure after the research project ends.Breast cancer screening programs do not reach all women at the same rate. Screening mammography use varies according to sociodemographic characteristics; mammography utilization is highest among women in their fifties but then decreases with age. In North Carolina, breast cancer is a particular burden for Black and lower-income women. Black women are more likely to be diagnosed with late stage disease, and their rate of breast cancer mortality is higher than it is for White women even though the incidence in White women is greater. Older, Black, and low-income women are less likely to obtain screening by mammography and clinical breast examination. The Black-White gap is even more pronounced among rural women, in part because they are more likely to be poor. The North Carolina Breast Cancer Screening Program (NC-BCSP) was established to increase the rate of regular mammography screening by an absolute 20% in 3 years among older Black women ages 50 and older in five rural counties in the eastern part of the state. In this paper, we describe the genesis of this comprehensive community intervention model, highlighting the behavioral science constructs, health education principles, and theories of behavioral and organizational change that form its conceptual foundation. NC-BCSPs theoretical foundations include the social ecological perspective, the PRECEDE model of health promotion, the Health Belief Model of individual change, and the “stages of change” transtheoretical model. We also review the experiences and lessons learned from two previous outreach initiatives in North Carolina that provided valuable “lessons” in the development of the NC-BCSP intervention model. In the second half of the paper, we describe the actual NC-BCSP interventions, activities, and evaluation tools, citing specific examples of how the underlying theories are implemented. NC-BCSPs goal goes beyond individual behavior change to raise low mammography screening rates among Black women in rural North Carolina. Its ultimate objective is to create linkages across agencies, and between agencies and communities, that will endure after the research project ends.

Lay Health Advisor Activity Levels: Definitions from the Field

One type of lay health advisor model assumes that an effective mechanism for reaching the underserved is through informal advice-givers called natural helpers. Despite the growing use of this approach, few programs have defined what an active lay health advisor does within the natural helping process. To explore perceptions and definitions of lay health advisors’ activity, we conducted semistructured, in-person interviews with four field staff who coordinate the advisors’ activities in a breast cancer screening program. These staff viewed lay health advisor activity as fluctuating over the course of a year, occurring along a continuum of participation (inactive, moderately active, active, and superactive), and reflecting varying degrees of proactivity and participation in multiple activities. These results suggest an empirical process for refining the definition of an active lay health advisor, improving advisors’productivity in achieving outreach objectives, and managing and monitoring their ongoing activities.

Evaluation of group and self-directed formats of the Arthritis Foundation's Walk With Ease Program.

To evaluate the effects of a revised 6‐week walking program for adults with arthritis, Walk With Ease (WWE), delivered in 2 formats, instructor‐led group or self‐directed.

Evaluation of Health Promotion Programs for Older Adults: An Introduction

This article provides an overview of the evaluation of evidence-based health promotion programs for older adults and introduces an upcoming series of related articles in the Journal of Applied Gerontology. With an aging population, a growing demand for health promotion and chronic disease self-management programs, and limited resources, evaluators must provide leadership to identify positive outcomes for adult older clients, inform program planning, and provide accountability to funders. The article addresses the following topics: the need for assessing the effectiveness of programs; research-based foundations for evaluation, specifically the RE-AIM model; the role of the evaluator; and guiding principles for evaluation and theoretical models that drive measurement. It concludes with the description of a process for conducting program evaluation based on the Center for Disease Controls framework for program evaluation, which actively engages program and community stakeholders in tailoring evaluation to the unique needs, characteristics, and barriers present in a community.

Feasibility and promise of a 6-week program to encourage physical activity and reduce joint symptoms among elderly breast cancer survivors on aromatase inhibitor therapy.

BACKGROUND National guidelines suggest that women with hormone receptor positive breast cancer be considered for adjuvant endocrine treatment with an aromatase inhibitor (AI). Joint symptoms (arthralgia) are a common AI side-effect. There is a need for effective approaches to arthralgia management that enable survivors to remain on AI therapy while optimizing as pain-free a life as possible. This feasibility study investigates a 6-week self-directed walking program in a sample of elderly female breast cancer survivors on AIs reporting joint pain. METHODS INTERVENTION Walk With Ease (WWE) goal--minimum 30 min of walking 5 days a week (150 min per week). Eligibility: age >65; Stage I-III breast cancer; ≥3 months of AI therapy; self-reported joint pain/stiffness. MEASURES (1) walking--number of days/week and number of minutes/walk, (2) visual analog scales (VAS) for joint pain, fatigue and stiffness, and (3) arthritis self-efficacy (ASE) to manage joint pain and fatigue. STATISTICS t-tests, correlation coefficients and effect sizes. RESULTS Sample target of 20 was achieved--mean age 71 (65-87), 85% Caucasian, mean BMI 29. Proportion walking 150 min/week increased from 21% at baseline to 50% at 6 weeks (p < 0.001). Mean joint pain at baseline (39.7 + 26.9) decreased 10% (p = 0.63), fatigue (37.4+33.3) decreased 19% (p = 0.31), joint stiffness (46.1 + 27.2) decreased 32% (p = 0.07). CONCLUSIONS A self-directed walking program among elderly breast cancer survivors on AI therapy significantly increased total time of walking per week over a 6 week period. Joint pain, stiffness, and fatigue also decreased, although not significantly. Testing within a larger sample is warranted.

Designing a process evaluation for a comprehensive breast cancer screening intervention: Challenges and opportunities

Abstract Process evaluation is increasingly viewed as a vital adjunct to outcome evaluation. In this paper, we discuss the steps taken to develop a process evaluation plan for an ongoing eight-year, community-based breast cancer screening program (NC-BCSP) for African American women in five rural North Carolina counties. NC-BCSP builds on community networks, enhances the delivery of local screening services, and reduces health system barriers in the widely dispersed and resource-poor communities that comprise NC-BCSPs 2500-square mile region. This article includes a discussion of: the process evaluation s aims and scope; how and why we selected various methods and approaches; the challenges involved in launching the data collection process; early lessons learned about the resources needed for developing an effective process evaluation; and some of the advantages of gathering process data.

Personal and delivery site characteristics associated with intervention dosage in an evidence-based fall risk reduction program for older adults

ABSTRACTThe objective of this study is to identify sociodemographics of older adults enrolled in a nationally disseminated evidence-based fall risk reduction program, describe different delivery sites, and examine personal and site characteristics associated with intervention adherence. Data were analyzed from 6,922 older adults enrolled in A Matter of Balance/Volunteer Lay Leader (AMOB/VLL) model between 2006 and 2009. Intervention dosage was measured by workshop attendance. Logistic regression analyses examined factors associated with attendance levels. Intervention dosage differed by sociodemographic and delivery site characteristics. Patterns of intervention dose significantly differed between Hispanic and non-Hispanic White participants. Those with less education and living in rural areas were more likely to receive adequate program doses. Although senior services agencies offered the most programs, intervention adherence was more likely in nonaging service sites. Findings may help program administrators better understand and minimize attrition issues within their AMOB/VLL workshops.

Using the RE-AIM Framework to translate a research-based falls prevention intervention into a community-based program: Lessons Learned

PROBLEM Exercise-based research interventions demonstrate reduced risk and rates of falls for community dwelling older adults; however, little is known about effective mechanisms for the translation, implementation, and maintenance of these interventions in community settings. METHOD The RE-AIM framework was used to assess the translatability of an effective exercise-based research intervention in a community setting. Questions included: Reach - Would the target population attend? Effectiveness - What was the adherence and compliance to the program? Were there individual improvements in falls risk factors? Adoption: Would staff at the center adopt the program and offer it past the funding period? Implementation - What adaptations, including optimal frequency and duration, should be made to meet the community needs, still adhere to core elements and achieve similar outcomes? Maintenance - Would the program be sustained by our community partners? DISCUSSION The process of translating a controlled research intervention targeting older adults at risk of falls into a community setting was challenging. Licensed professionals developed the infrastructure to safely and effectively deliver the program. The end product was highly appealing program to our target audience, resulted in improved outcomes and was successfully adopted and maintained by the community partner. SUMMARY Partnerships between community and healthcare providers are key to successful implementation of falls prevention interventions. Lessons learned from this experience can be applied to the translation of future exercise-based falls prevention interventions.