Resa M. Jones

The Relative Importance of Patient-Reported Barriers to Colorectal Cancer Screening

BACKGROUND Colorectal cancer (CRC) screening rates are suboptimal. The most important barriers identified by patients are poorly understood. A comprehensive assessment of barriers to all recommended modalities is needed. METHODS In 2007, a questionnaire was mailed to 6100 patients, aged 50-75 years, from 12 family medicine practices in the Virginia Ambulatory Care Outcomes Research Network. People aged 65-75 years and African Americans were oversampled. Patients were asked to rate 19-21 barriers to each of four recommended tests. In 2008, responses were coded on a 5-point scale; higher scores reflected stronger barrier endorsement. RESULTS The response rate was 55% (n=3357). Approximately 40% of respondents were aged >/=65 years, 30% were African-American, and 73% were adherent to screening. A clinicians failure to suggest screening and not knowing testing was necessary received the highest mean scores as barriers. Financial concerns and misconceptions were also cited. Barrier scores differed depending on whether respondents were never screened, overdue for screening, or adherent to guidelines. The top five barriers for each modality included test-specific barriers (e.g., handling stool, bowel preparation), which often outranked generic barriers to screening. Not knowing testing was necessary was a top barrier for all tests but colonoscopy. CONCLUSIONS Although physician advice and awareness of the need for screening are important, barriers to screening are not homogenous across tests, and test-specific barriers warrant consideration in designing strategies to improve screening rates. Barrier scores differ by screening status, highlighting the need to address prior screening experience. Evidence that patients are more familiar with colonoscopy than with other modalities suggests an opportunity to improve screening rates by educating patients about alternative tests.

Validity of Four Self-reported Colorectal Cancer Screening Modalities in a General Population: Differences over Time and by Intervention Assignment

Little is known about the validity of self-reported colorectal cancer screening. To date, few published studies have validated all four screening modalities per recommended guidelines or included a general population-based sample, and none has assessed validity over time and by intervention condition. To estimate the validity of self-reported screening, a random sample of 200 adults, ages ≥50 years, was selected from those completing annual surveys on screening behavior as part of an intervention study. Approximately 60% of the validation sample authorized medical record review. Sensitivity, specificity, and positive and negative predictive values were calculated for baseline and year 1 follow-up reports for each test and for overall screening adherence. Sensitivity at baseline ranged from 86.9% (flexible sigmoidoscopy) to 100% (colonoscopy). Sensitivity at follow-up was slightly lower. Adjusting for validity measures, the sample overreported screening prevalence at baseline for each of the four modalities. At follow-up, overreporting was greatest for fecal occult blood test (13.0%). Overreporting across intervention conditions was highest for fecal occult blood test (10.8% for control; 24.8% for the most intense intervention) and overall screening adherence (10.9% for control; 14.3% for the most intense intervention). Sensitivity and specificity of self-reported colorectal cancer screening compared with medical records were high; however, adjusting self-reported screening rates based on relative error rates reduced screening prevalence estimates. Those exposed to more intense interventions to modify screening behavior seemed more likely to overestimate their screening rates compared with those who were not exposed. (Cancer Epidemiol Biomarkers Prev 2008;17(4):777–84)

Is discussion of colorectal cancer screening options associated with heightened patient confusion

Background: Clinical guidelines recommend offering patients options for colorectal cancer (CRC) screening, but the modalities vary by frequency, accuracy, preparations, discomfort, and cost, which may cause confusion and reduce screening rates. We examined whether patients reported confusion about the options and whether confusion was associated with socio-demographic characteristics, number of options discussed, and adherence. Methods: Patients ages 50 to 75 years who had visited a clinician within 2 years were randomly selected for a cross-sectional study (n = 6,100). A questionnaire mailed in 2007 asked the following: whether a clinician had ever discussed CRC screening options; which of four recommended tests (i.e., fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema) were presented; and whether the options were confusing. Analyses were restricted to respondents who reported discussing one or more screening options (n = 1,707). Weighted frequencies were calculated and multivariate logistic regression was done. Results: The sample was 55.5% female, 15.6% African American, and 83.2% adherent to screening recommendations, and 56.0% had discussed two or more screening options. In adjusted analyses, nonadherent patients reported greater confusion than adherent patients (P < 0.01). Adults who discussed two or more options were 1.6 times more likely to be confused than those who discussed one option [95% confidence interval (CI), 1.08-2.26]. Patients who reported being confused were 1.8 times more likely to be nonadherent to screening than those who did not (95% CI, 1.14-2.75). Conclusions: Our study provides the first empirical evidence linking multiple options with confusion and confusion with screening adherence. Impact: Confusion may act as a barrier to screening and should be considered in public health messages and interventions. Cancer Epidemiol Biomarkers Prev; 19(11); 2821–5. ©2010 AACR.

Avertable Deaths Associated With Household Income in Virginia

OBJECTIVES We estimated how many deaths would be averted if the entire population of Virginia experienced the mortality rates of the 5 most affluent counties or cities. METHODS Using census data and vital statistics for the years 1990 through 2006, we applied the mortality rates of the 5 counties/cities with the highest median household income to the populations of all counties and cities in the state. RESULTS If the mortality rates of the reference population had applied to the entire state, 24.3% of deaths in Virginia from 1990 through 2006 (range = 21.8%-28.1%) would not have occurred. An annual mean of 12 954 deaths would have been averted (range = 10 548-14 569), totaling 220 211 deaths from 1990 through 2006. In some of the most disadvantaged areas of the state, nearly half of deaths would have been averted. CONCLUSIONS Favorable conditions that exist in areas with high household incomes exert a major influence on mortality rates. The corollary-that health suffers when society is exposed to economic stresses-is especially timely amid the current recession. Further research must clarify the extent to which individual-level factors (e.g., earnings, education, race, health insurance) and community characteristics can improve health outcomes.

Patient Costs As a Barrier to Intensive Health Behavior Counseling

BACKGROUND Although intensive health behavior counseling has been demonstrated to help patients lose weight and quit smoking, many payers offer limited coverage for such counseling. PURPOSE This mixed-methods case study examined how coverage affected utilization of an electronic linkage system (eLinkS) to help adult patients obtain intensive health behavior counseling, provided through a collaboration of primary care practices and community programs. METHODS Grant support enabled patients to obtain counseling at no cost, but funds were exhausted within 5 weeks as a result of an overwhelming response. To study the influence of cost as a barrier, referrals were resumed for an additional 3 weeks, but patients were required to pay for them. Use of eLinkS, level of clinician counseling and referrals, and patient interest in referrals were measured using electronic medical record data and patient and clinician interviews. RESULTS When counseling was free, approximately one in five patients with an unhealthy behavior and an eLinkS prompt was referred for intensive counseling. However, when patient charges were instituted, referrals decreased by 97% (from 21.8% to 0.7%, p<0.001); clinicians asked fewer patients about health behaviors (37% vs 29%, p<0.001); clinicians offered fewer patients referrals (29% vs 6%, p<0.001); and patients were less interested in accepting referrals (76% vs 14%, p<0.001). In interviews, patients and clinicians cited cost as a major barrier. CONCLUSIONS Coverage for intensive health behavior counseling is important to utilization, particularly for interventions that involve clinician-community partnerships. The potential public health benefits of such collaborations to reduce unhealthy behaviors justify the elimination of financial barriers (e.g., copayments) by payers.

The impact of family history of breast cancer and cancer death on women's mammography practices and beliefs

Purpose: To summarize the impact of a family history of breast cancer on mammography practices and beliefs.Method: Survey data concerning breast health practices and beliefs were utilized for a cross-sectional analysis. Participants were 899 racially diverse nonpregnant women 40 years and older without breast cancer. The impact of various aspects of cancer family history on mammography, perceived barriers to and benefits of screening, and perceived breast cancer risk was assessed.Results: More women with a first-degree relative with breast cancer reported a mammogram within the past year and rated their breast cancer risk higher. Death of a first-degree relative impacted the belief that breast cancer can be cured with early detection. Degree of relatedness of affected relative impacted mammography practice and risk perceptions.Conclusion: Family history of breast cancer impacted mammography adherence, beliefs about outcomes with early detection, and risk perceptions. Breast cancer death in a family may be a better predictor of beliefs about breast cancer detection and cure than family history of cancer alone. These findings have implications for how screening recommendations and risk information are communicated to patients with different familial cancer experiences.

Spiritual coping, family history, and perceived risk for breast cancer--can we make sense of it?

Differences in spiritual beliefs and practices could influence perceptions of the role of genetic risk factors on personal cancer risk. We explored spiritual coping and breast cancer risk perceptions among women with and without a reported family history of breast cancer. Analyses were conducted on data from 899 women in primary care clinics who did not have breast cancer. Structural equation modeling (SEM), linear, and logistic modeling tested an interaction of family history of breast cancer on the relationship between spiritual coping and risk perceptions. Overall analyses demonstrated an inverse relationship between spiritual coping and breast cancer risk perceptions and a modifying effect of family history. More frequent spiritual coping was associated with lower risk perceptions for women with positive family histories, but not for those with negative family histories. Results support further research in this area that could influence communication of risk information to cancer genetic counseling patients.

Decision Making about Cancer Screening: An Assessment of the State of the Science and a Suggested Research Agenda from the ASPO Behavioral Oncology and Cancer Communication Special Interest Group

Broad participation in screening is key to cancer prevention and early detection. Unfortunately, screening rates are low for many modalities. At its core, successful screening involves an individual deciding to take action (e.g., completing self-exams or scheduling appointments). Therefore, the

Fruit and vegetable intake among rural youth following a school-based randomized controlled trial

OBJECTIVE We implemented a theory-based randomized controlled trial (Living Free of Tobacco, Plus (LIFT+) in ten rural middle schools and assessed impact on tobacco use and fruit/vegetable (F/V) intake in 2008-2010. Data on F/V intake at baseline, immediate post intervention, and 1-year follow-up are presented. METHODS Schools were randomized to intervention or control groups. Goal setting, peer leaders, and class workshops with parent involvement, were intervention features; community partners were supportive. Seventh graders filled out surveys on health behaviors, psycho-social variables, and demographic characteristics. Adjusted models comparing intervention and control conditions were analyzed. RESULTS Sample (n=1119) was 48.5% female, 50% White, with a mean age of 12.7 years. Mean F/V servings were significantly higher in intervention schools at immediate post (3.19 servings) and at 1-year (3.02 servings) compared to controls (2.90, 2.69 respectively). Knowledge of 5-a-day recommendation was significantly higher in intervention schools at immediate post test (75.0%) versus controls (53.8%) but not at 1-year follow-up. CONCLUSIONS Intervention schools reported significantly higher mean F/V servings at post intervention and 1-year, and for knowledge of F/V recommendations at immediate post compared to controls. Higher levels of parent and community involvement may further increase F/V intake in future interventions. ClinicalTrials.gov Identifier: NCT01412697.

Nourishing Our Understanding of Role Modeling to Improve Support and Health (NOURISH): Design and methods

Pediatric overweight is associated with numerous physical and psychological health risks, and overweight children are at significant risk for obesity in adulthood. African-American children are at particularly high risk for obesity and related health complications. However, this racial group has traditionally had limited access to obesity treatment and relatively few studies have included sufficient numbers of lower-SES, African American participants. Further, although parental involvement in treatment for pediatric overweight has been found to be beneficial, few studies have examined the efficacy of offering treatment exclusively to parents, a potentially cost-effective approach which could benefit the entire family. This pilot project will evaluate the efficacy of an intensive parenting intervention, (NOURISH; Nourishing Our Understanding of Role modeling to Improve Support and Health), targeting racially diverse parents of overweight children (ages 6-11). NOURISH addresses several urgent research priorities by targeting the underserved and addressing the significant disparity in obesity treatment services. Parents meeting study criteria (having a child between the ages of 6 and 11 with a BMI ≥ the 85th percentile) will be offered participation in the randomized trial comparing NOURISH with a control group. We hypothesize that children whose parents participate in NOURISH will manifest greater decreases in BMI, and greater improvements in dietary intake, and quality of life compared to children whose parents do not participate. This study is designed explicitly to gather preliminary feasibility, acceptability, and effectiveness data to inform a subsequent larger randomized controlled trial.