Roshan Bastani

Effectiveness of Interventions to Increase Screening for Breast, Cervical, and Colorectal Cancers Nine Updated Systematic Reviews for the Guide to Community Preventive Services

CONTEXT Screening reduces mortality from breast, cervical, and colorectal cancers. The Guide to Community Preventive Services previously conducted systematic reviews on the effectiveness of 11 interventions to increase screening for these cancers. This article presents results of updated systematic reviews for nine of these interventions. EVIDENCE ACQUISITION Five databases were searched for studies published during January 2004-October 2008. Studies had to (1) be a primary investigation of one or more intervention category; (2) be conducted in a country with a high-income economy; (3) provide information on at least one cancer screening outcome of interest; and (4) include screening use prior to intervention implementation or a concurrent group unexposed to the intervention category of interest. Forty-five studies were included in the reviews. EVIDENCE SYNTHESIS Recommendations were added for one-on-one education to increase screening with fecal occult blood testing (FOBT) and group education to increase mammography screening. Strength of evidence for client reminder interventions to increase FOBT screening was upgraded from sufficient to strong. Previous findings and recommendations for reducing out-of-pocket costs (breast cancer screening); provider assessment and feedback (breast, cervical, and FOBT screening); one-on-one education and client reminders (breast and cervical cancer screening); and reducing structural barriers (breast cancer and FOBT screening) were reaffirmed or unchanged. Evidence remains insufficient to determine effectiveness for the remaining screening tests and intervention categories. CONCLUSIONS Findings indicate new and reaffirmed interventions effective in promoting recommended cancer screening, including colorectal cancer screening. Findings can be used in community and healthcare settings to promote recommended care. Important research gaps also are described.

Demographic predictors of cancer screening among Filipino and Korean immigrants in the United States.

BACKGROUND Little is known about cancer-screening practices of various Asian subgroups, and even less is known about factors that may predict screening in these populations. DESIGN Two independent surveys were conducted with 218 Filipino and 229 Korean female immigrants, aged 50 years and older, residing in Los Angeles. RESULTS In these convenience samples, 48% of Filipino and 41% of Korean women reported receipt of a Pap smear within the past 2 years; 41% of Filipino and 25% of Korean women reported receipt of a mammogram and a clinical breast exam within the past 2 years; and 25% of Filipino and 38% of Korean women reported colorectal cancer screening (blood stool test within the past 12 months or sigmoidoscopy/colonoscopy within the past 5 years). Only 14% of Filipino and 10% of Korean women were adherent to cancer-screening guidelines for all three sites. These differences in screening rates were statistically significant in multivariate analyses of the combined sample, controlling for all demographic characteristics, including age, percent of lifetime in the United States, education, marital status, health insurance, employment, and ethnicity. The two variables that were most consistently independently associated with adherence to cancer screening in both samples were higher percentage of lifetime spent in the United States and ever having had a checkup when no symptoms were present. CONCLUSIONS These two variables-percent of lifetime in the United States and ever having had a checkup when no symptoms were present-can alert a physician that cancer-screening tests may be overdue among Korean and Filipino immigrants in the United States. Future research should identify predictors of cancer screening among other Asian immigrant groups and U.S.-born Asian women to assist in targeting intervention efforts.

Screening mammography rates and barriers to use: A Los Angeles county survey

The use of screening mammography among women 40 years of age and older in Los Angeles County was assessed through a random digit dial telephone interview. The sample of 802 women represents a large urban population with substantial proportions of blacks, Hispanics, and Asians. The survey obtained information regarding adherence to the ACS/NCI screening mammography guidelines, perceived benefits of early detection and mammography, perceived threat of developing breast cancer, and barriers to utilization. The results showed that 71% of the women had had at least one mammogram, with 49% having received a screening mammogram according to the guidelines for their age. Less than half the respondents knew the screening guidelines for their age, with women ages 40-49 years being less knowledgeable than women greater than or equal to 50 years old (29 vs 58% answering correctly). A logistic regression analysis predicting the likelihood of having obtained a screening mammogram according to the guidelines found the following to be predictive: concern over radiation (negative association), age (negative association), family history, knowledge of guidelines, and cost of a mammogram (negative association). Other demographic factors and beliefs were not significantly related to this dependent variable.

Sociodemographic predictors of non-attendance at invitational mammography screening: a population-based register study (Sweden)

Objective: To investigate the role of sociodemographic factors in predicting mammography uptake in an outreach screening program. Methods: Linkage of data from a regional population-based mammography program with four Swedish nationwide registers: the Population and Housing Census of 1990, the Fertility Register, the Cancer Register, and the Cause of Death Register. We computed odds ratios (OR) and 95% confidence intervals (CI) for non-attendance by sociodemographic factors. Non-attendance was defined as failure to attend in response to the two most recent invitations. Results: Multivariate analyses among 4198 non-attenders and 38,972 attenders revealed that both childless and high-parity women were more likely to be non-attenders (OR = 1.8, 95% CI: 1.6–2.0 and OR = 2.2, 95% CI: 1.8–2.7, respectively). Women living without a partner were less likely to attend (OR = 1.7, 95% CI: 1.5–1.9), as were non-employed women (OR = 2.1, 95% CI: 1.9–2.3). Those renting an apartment were more likely to be non-attenders compared with home-owners (OR = 1.8, 95% CI: 1.6–2.0), and immigrants from non-Nordic countries were more than twice as likely to be non-attenders compared with Swedish-born women (OR = 2.4, 95% CI: 2.0–2.8). Conclusions: There are identifiable subgroups in which mammography utilization can be increased. Special attention should be paid to women who have never attended, childless women, and non-Nordic immigrants.

Promoting Culturally Appropriate Colorectal Cancer Screening Through a Health Educator A Randomized Controlled Trial

Colorectal cancer (CRC) is a leading cause of cancer mortality in the US. Surveys reveal low CRC screening levels among Asians in the US, including Chinese Americans.

Risk Factors for Chronic Liver Disease in Blacks, Mexican Americans, and Whites in the United States: Results From NHANES IV, 1999–2004

OBJECTIVES:Morbidity and mortality due to liver disease and cirrhosis vary significantly by race/ethnicity in the United States. We examined the prevalence of liver disease risk factors among blacks, Mexican Americans, and whites, including elevated aspartate aminotransferase and alanine aminotransferase activity, infection with viral hepatitis B or hepatitis C, alcohol intake, obesity, diabetes, and metabolic syndrome.METHODS:Data were obtained from the Fourth National Health and Nutrition Examination Survey (NHANES IV). A logistic regression was used to examine the association of race/ethnicity to liver disease risk factors, controlling for the demographic and socioeconomic variables.RESULTS:Mexican-American men and women are the most likely to have elevated aminotransferase activity. Among men, Mexican Americans are more likely than whites to be heavy/binge drinkers, and blacks are more likely to have hepatitis B or hepatitis C. Among women, Mexican Americans are more likely than whites to be obese and diabetic, and less likely to be heavy/binge drinkers; blacks are more likely than whites to have hepatitis B or hepatitis C, be obese or diabetic, and less likely to be heavy/binge drinkers.CONCLUSIONS:In this national sample, the prevalence of risk factors for liver disease varies by race/ethnicity. Mexican Americans and blacks have a greater risk of developing liver disease than their white counterparts. These findings are consistent with the observed racial/ethnic disparities in morbidity and mortality due to chronic liver disease and contribute to the efforts to identify the causes of these disparities. This information can be used by health professionals to tailor screening and intervention programs.

Interventions to Improve Follow-Up of Abnormal Findings in Cancer Screening

The potential reduction in morbidity and mortality through cancer screening cannot be realized without receipt of appropriate follow‐up care for abnormalities identified via screening. In this paper, the authors critically examine the existing literature on correlates of receipt of appropriate follow‐up care for screen‐detected abnormalities, as well as the literature on interventions designed to increase rates of receipt of follow‐up care. Lessons learned describe what is known and not known about factors that are related to or predict receipt of follow‐up care. Similarly, effective interventions to increase follow‐up are described and gaps identified. A conceptual model is developed that categorizes the health care system in the United States as comprising four levels: policy, practice, provider, and patient. Some patient‐level factors that influence follow‐up receipt are identified, but the lack of data severely limit the understanding of provider, practice, and policy‐level correlates. The majority of intervention studies to increase follow‐up receipt have focused on patient‐level factors and have targeted follow‐up of abnormal Papanicolaou smears. Insufficient information is available regarding the effectiveness of provider, practice, or policy‐level interventions. Standard definitions of what constitutes appropriate follow‐up are lacking, which severely limit comparability of findings across studies. The validity of various methods of obtaining outcome data has not been clearly established. More research is needed on interventions targeting provider, system, and policy‐level factors, particularly interventions focusing on follow‐up of colorectal and breast abnormalities. Standardization of definitions and measures is needed to facilitate comparisons across studies. Cancer 2004. Published 2004 by the American Cancer Society.

Understanding Suboptimal Human Papillomavirus Vaccine Uptake Among Ethnic Minority Girls

Background: The introduction of human papillomavirus (HPV) vaccines represents a breakthrough in the primary prevention of cervical cancer. However, little is known about vaccination uptake and correlates among low-income, ethnic minority, and immigrant populations in the U.S. who may benefit most from the vaccine. Methods: Telephone interviews (N = 490) were conducted in six languages between January and November 2009 among mothers of vaccine-eligible girls (ages 9–18) using the Los Angeles County Department of Public Health, Office of Womens Health service referral hotline. HPV and vaccine awareness, knowledge, beliefs, barriers, and daughters vaccine receipt were assessed. Results: The sample consisted of low-income, uninsured, ethnic minority, and immigrant women. Only 29% of daughters initiated the vaccine and 11% received all three doses. No ethnic differences were observed in initiation or completion rates. Ethnic differences were observed in HPV awareness, perceived risk, and other vaccine-related beliefs. The strongest predictor of initiation was vaccine awareness (OR = 12.00). Daughters age and reporting a younger acceptable age for vaccination were positively associated with initiation. Mothers of unvaccinated girls reported lacking information about the vaccine to make a decision (66%) and not knowing where they could obtain the vaccine (74%). Conclusion: Vaccination rates in this sample were lower than state and national estimates, and were associated with low levels of vaccine awareness. Interventions, including culturally targeted messaging, may be helpful for enhancing HPV–vaccine knowledge, modifying vaccine-related beliefs and increasing uptake. Impact: Our findings provide valuable guidance for developing interventions to address suboptimal HPV vaccination in high-risk groups. Cancer Epidemiol Biomarkers Prev; 20(7); 1463–72. ©2011 AACR.

Effect of Mental Health Care and Shared Decision Making on Patient Satisfaction in a Community Sample of Patients with Depression

This study sought to understand if shared decision making and/or receipt of mental health care was associated with patient satisfaction for patients with depression and to determine whether gender modified this relationship. The data are from the Quality Improvement for Depression study, a national collaborative study of 1,481 patients diagnosed with major depression in managed care settings. The cross-sectional analyses were performed using multiple logistic regression on a sample of 1,317 patients who answered both the baseline and month six questionnaires. Shared decision making and receipt of mental health care were both positively associated with patient satisfaction. Gender was not a moderator of this relationship. Health plans may be able to improve patient satisfaction levels by teaching physicians the importance of shared decision making. Contrary to expectations, patient gender made no difference in the effects of quality of care on patient satisfaction.

Primary care provider perceptions of barriers to and facilitators of colorectal cancer screening in a managed care setting

Colorectal cancer (CRC) screening tests (e.g., fecal occult blood testing [FOBT], flexible sigmoidoscopy [FS], etc.) are underused. Primary care providers (PCPs) play a critical role in screening, but barriers to and facilitators of screening as perceived by PCPs in managed care settings are poorly understood. The objectives of the current study were to describe current CRC screening practices and to explore determinants of test use by PCPs in a managed care setting.