Roberta E. Goldman

Model for incorporating social context in health behavior interventions: applications for cancer prevention for working-class, multiethnic populations

BACKGROUND This article proposes a conceptual framework for addressing social contextual factors in cancer prevention interventions, and describes work that operationalizes this model in interventions for working class, multiethnic populations. METHODS The Harvard Cancer Prevention Program Project Includes Three Studies: (1) an intervention study in 25 small businesses; (2) an intervention study in 10 health centers; and (3) a computer simulation modeling project that translates risk factor modifications into gains in life expectancy and number of cancers averted. The conceptual framework guiding this work articulates pathways by which social context may influence health behaviors, and is used to frame the interventions and guide evaluation design. RESULTS Social contextual factors cut across multiple levels of influence, and include individual factors (e.g., material circumstances, psychosocial factors), interpersonal factors (e.g., social ties, roles/responsibilities, social norms), organizational factors (e.g., work organization, access to health care), and neighborhood/community factors (e.g., safety, access to grocery stores). Social context is shaped by sociodemographic characteristics (e.g., social class, race/ethnicity, gender, age, language) that impact day-to-day realities. CONCLUSIONS By illuminating the pathways by which social contextual factors influence health behaviors, it will be possible to enhance the effectiveness of interventions aimed at reducing social inequalities in risk behaviors.

Patients’ Perceptions of Cholesterol, Cardiovascular Disease Risk, and Risk Communication Strategies

PURPOSE Despite some recent improvement in knowledge about cholesterol in the United States, patient adherence to cholesterol treatment recommendations remains suboptimal. We undertook a qualitative study that explored patients’ perceptions of cholesterol and cardiovascular disease (CVD) risk and their reactions to 3 strategies for communicating CVD risk. METHODS We conducted 7 focus groups in New England using open-ended questions and visual risk communication prompts. The multidisciplinary study team performed qualitative content analysis through immersion/crystallization processes and analyzing coded reports using NVivo qualitative coding software. RESULTS All participants were aware that “high cholesterol” levels adversely affect health. Many had, however, inadequate knowledge about hypercholesterolemia and CVD risk, and few knew their cholesterol numbers. Many assumed they had been tested and their cholesterol concentrations were healthy, even if their physicians had not mentioned it. Standard visual representations showing statistical probabilities of risk were assessed as confusing and uninspiring. A strategy that provides a cardiovascular risk-adjusted age was evaluated as clear, memorable, relevant, and potentially capable of motivating people to make healthful changes. A few participants in each focus group were concerned that a cardiovascular risk-adjusted age that was greater than chronological age would frighten patients. CONCLUSIONS Complex explanations about cholesterol and CVD risk appear to be insufficient for motivating behavior change. A cardiovascular risk-adjusted age calculator is one strategy that may engage patients in recognizing their CVD risk and, when accompanied by information about risk reduction, may be helpful in communicating risk to patients.

Tools for health: the efficacy of a tailored intervention targeted for construction laborers.

ObjectivesNovel approaches to worksite health promotion are needed for high-risk workers who change job sites frequently, and thus may have limited access to worksite health promotion efforts. The objective of this study was to test a behavioral intervention among construction laborers.MethodsUsing a randomized-controlled design, we tested the efficacy of a tailored telephone-delivered and mailed intervention to promote smoking cessation and increased fruit and vegetable consumption (n = 582).ResultsAt baseline, 40% of control group participants and 45% of intervention group participants reported using any tobacco in the last seven days. At final, 8% of baseline cigarette smokers in the control group had quit, compared to 19% in the intervention group (p = 0.03). In both groups, the mean consumption of fruits and vegetables at baseline was over five servings per day. At final, the intervention group had increased consumption by approximately one and one-half servings, compared to a slight decrease in consumption in the control group (p < 0.001).ConclusionsA tailored intervention can be efficacious in promoting tobacco use cessation and increased fruit and vegetable consumption among construction laborers, a high-risk, mobile workforce.

Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study.

OBJECTIVE To understand factors that women feel facilitate or hinder their receipt of diagnostic services following an abnormal screening mammogram. METHODS This qualitative study used a purposive sampling strategy to identify low-income, ethnically diverse women aged 40 or over who had a recent abnormal mammogram. Working with a community health center, breast evaluation center, and mobile mammography van, 64 women were interviewed to identify salient themes that differentiated women who received timely follow-up from those who did not. RESULTS Prominent themes among women who delayed follow-up included dissatisfaction with communication of results; perceived disrespect on the part of providers and clinic staff; logistical barriers to access of diagnostic services; anxiety and fear about a possible cancer diagnosis; and a lack of information about breast cancer screening and symptoms. Women who received timely care more often reported an appreciation of efforts by providers and clinic staff to support their prompt follow-up; availability of social support that facilitated appointment-keeping; confidence in their ability to advocate for their health; and a high priority placed on self-care. CONCLUSION A comprehensive approach to improving timely diagnostic follow-up among underserved groups must address patient beliefs and attitudes, provider practices and communication, and practices at the health care systems level. PRACTICE IMPLICATIONS Implications and strategies for improving patient education, patient-provider communication, and organizational practices are discussed.

Effect of Language on Colorectal Cancer Screening Among Latinos and Non-Latinos

Background: Language barriers among some Latinos may contribute to the lower rates of colorectal cancer (CRC) screening between Latinos and non-Latino Whites. The purpose of this study was to examine the relationship between language and receipt of CRC screening tests among Latinos and non-Latinos using a geographically diverse, population-based sample of adults. Methods: Cross-sectional analysis of the Behavioral Risk Factor Surveillance System (BRFSS) survey. Analysis included adults age 50 years and older, who completed the 2006 BRFSS in a state that recorded data from English- and Spanish-speaking participants. Results: The primary outcome measure was receipt of colorectal screening tests (fecal occult blood testing within prior 12 months and/or lower endoscopy within 10 years). Of the 99,895 respondents included in the study populations, 33% of Latinos responding-in-Spanish reported having had CRC testing, whereas 51% of Latinos responding-in-English and 62% of English-speaking non-Latinos reported test receipt. In multivariable analysis, compared with non-Latinos, Latinos responding-in-English were 16% less likely to have received CRC testing [odds ratio (OR), 0.84; 95% confidence interval (95% CI), 0.73-0.98], and Latinos responding-in-Spanish were 43% less likely to have received CRC testing (OR, 0.57; 95% CI, 0.44-0.74). Additionally, compared with Latinos responding-in-English, Latinos responding-in-Spanish were 36% less likely to have received CRC testing (OR, 0.64; 95% CI, 0.48-0.84). Conclusion: Latinos responding to the 2006 BRFSS survey in Spanish had a significantly lower likelihood of receiving CRC screening tests compared with non-Latinos and to Latinos responding-in-English. Based on this analysis, Spanish language use is negatively associated with CRC screening and may contribute to disparities in CRC screening. (Cancer Epidemiol Biomarkers Prev 2008;17(8):2169–73)

Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation

PURPOSE Although there is significant interest in implementation of electronic health records (EHRs), limited data have been published in the United States about how physicians, staff, and patients adapt to this implementation process. The purpose of this research was to examine the effects of EHR implementation, especially regarding physician-patient communication and behaviors and patients’ responses. METHODS We undertook a 22-month, triangulation design, mixed methods study of gradual EHR implementation in a residency-based family medicine outpatient center. Data collection included participant observation and time measurements of 170 clinical encounters, patient exit interviews, focus groups with nurses, nurse’s aides, and office staff, and unstructured observations and interviews with nursing staff and physicians. Analysis involved iterative immersion-crystallization discussion and searches for alternate hypotheses. RESULTS Patient trust in the physician and security in the physician-patient relationship appeared to override most patients’ concerns about information technology. Overall, staff concerns about potential deleterious consequences of EHR implementation were dispelled, positive anticipated outcomes were realized, and unexpected benefits were found. Physicians appeared to become comfortable with the “third actor” in the room, and nursing and office staff resistance to EHR implementation was ameliorated with improved work efficiencies. Unexpected advantages included just-in-time improvements and decreased physician time out of the examination room. CONCLUSIONS Strong patient trust in the physician-patient relationship was maintained and work flow improved with EHR implementation. Gradual EHR implementation may help support the development of beneficial physician and staff adaptations, while maintaining positive patient-physician relationships and fostering the sharing of medical information.

The Life History Interview Method: Applications to Intervention Development:

There is an urgent need to develop and test health promotion strategies that both address health disparities and elucidate the full impact of social, cultural, economic, institutional, and political elements on peoples lives. Qualitative research methods, such as life history interviewing, are well suited to exploring these factors. Qualitative methods are also helpful for preparing field staff to implement a social contextual approach to health pro-motion. This article reports results and application of findings of life history interviews conducted as part of intervention planning for the Harvard Cancer Prevention Program Project, “Cancer Prevention in Working-Class, Multi-Ethnic Populations.” The salient themes that emerged from interviews with a multi-ethnic, purposive sample are centered on six construct domains: immigration and social status, social support, stress, food, physical activity, and occupational health. Insights gained from thematic analysis of the interviews were integrated throughout intervention and materials development processes.

An Investigation Into the Social Context of Low-Income, Urban Black and Latina Women Implications for Adherence to Recommended Health Behaviors

Understanding factors that promote or prevent adherence to recommended health behaviors is essential for developing effective health programs, particularly among lower income populations who carry a disproportionate burden of disease. We conducted in-depth qualitative interviews (n = 64) with low-income Black and Latina women who shared the experience of requiring diagnostic follow-up after having a screening mammography with abnormal findings. We found that in addition to holding negative and fatalistic cancer-related beliefs, the social context of these women was largely defined by multiple challenges and major life stressors, factors that may interfere with their ability to attain health. Factors commonly mentioned included competing health issues, economic hardship, demanding caretaking responsibilities and relationships, insurance-related challenges, distrust of health care providers, and inflexible work policies. Black women also reported discrimination and medical mistrust, whereas Latinas experienced difficulties associated with immigration and social isolation. These results suggest that effective health interventions not only address change among individuals but must also change health care systems and social policies in order to reduce health disparities.

Perspectives of Colorectal Cancer Risk and Screening Among Dominicans and Puerto Ricans: Stigma and Misperceptions

Colorectal cancer is the second most common cancer among Latinos, but a lower percentage of Latinos are screened than Whites and Blacks. Along with recognized economic barriers, differences in knowledge and perceptions might impede colorectal screening among Latinos. We conducted 147 individual, qualitative interviews with Dominicans and Puerto Ricans in the northeastern United States to explore their explanatory models for colorectal cancer and screening barriers. Many participants had not previously heard of colorectal cancer. The most commonly mentioned cause of colorectal cancer was anal sex. Also considered risks were “bad food,” digestion leading to constipation, and strained bowel movements. Screening barriers included stigma, misperceptions, embarrassment, and machismo. Progress toward increasing colorectal cancer screening requires normalization of this screening among Latinos. Higher patient familiarity, along with improved physician counseling and referral, might contribute to reducing stigma and other barriers, and to enhancing knowledge and Latino community support of colorectal cancer screening.

Cancer prevention for working class, multiethnic populations through small businesses: the healthy directions study

Objective: We report demographic and social contextual characteristics of multiethnic, blue-collar workers from the baseline survey of a study conducted in 24 small businesses. We discuss ways in which we incorporated these characteristics into the design of the intervention. Methods: We used a randomized controled design, with 12 small businesses assigned to a social contextual intervention and 12 to a minimum intervention control condition. The response rates to the survey were 84% at baseline (n = 1717). Primary outcomes included reduction in red meat consumption and increase in physical activity and daily multivitamin intake. Secondary outcomes targeted reduction in smoking and occupational exposures. Results: The majority of the respondents were male (67.6%). This was an ethnically diverse sample with 24.7% representing racial/ethnic groups other than white and 43.6% of participants or their parents born outside of the US. To meet study recommendations, workers needed improvement in all behaviors measured. Participants reported a smoking rate of 25.8, 86.2% ate fewer than 5 servings of fruits and vegetables a day 69.5% ate more than three servings of red meat a week, 46.8% engaged in less than 2.5h a week and 72.4% reported that they did not consume a daily multivitamin. Conclusions: Interventions that address the contextual environment in which health behaviors occur, may provide a method that researchers and practitioners can use to reduce health disparities.