Yelena N. Tarasenko

A community-based randomized trial of a faith-placed intervention to reduce cervical cancer burden in Appalachia.

OBJECTIVE Faith Moves Mountains assessed the effectiveness of a faith-placed lay health advisor (LHA) intervention to increase Papanicolaou (Pap) test use among middle-aged and older women in a region disproportionately affected by cervical cancer and low screening rates (regionally, only 68% screened in prior 3 years). METHOD This community-based RCT was conducted in four Appalachian Kentucky counties (December 2005-June 2008). Women aged 40-64 and overdue for screening were recruited from churches and individually randomized to treatment (n=176) or wait-list control (n=169). The intervention provided LHA home visits and newsletters addressing barriers to screening. Self-reported Pap test receipt was the primary outcome. RESULTS Intention-to-treat analyses revealed that treatment group participants (17.6% screened) had over twice the odds of wait-list controls (11.2% screened) of reporting Pap test receipt post-intervention, OR=2.56, 95% CI: 1.03-6.38, p=0.04. Independent of group, recently screened participants (last Pap >1 but <5 years ago) had significantly higher odds of obtaining screening during the study than rarely or never screened participants (last Pap ≥5 years ago), OR=2.50, 95% CI: 1.48-4.25, p=0.001. CONCLUSIONS The intervention was associated with increased cervical cancer screening. The faith-placed LHA addressing barriers comprises a novel approach to reducing cervical cancer disparities among Appalachian women.

The Role of Social Support in Multiple Morbidity: Self-Management among Rural Residents

Social support generally is considered a valuable asset that may compensate for health service deficiencies among rural populations. Employing a mixed methods approach, we explored how vulnerable rural residents described social support in the context of self-management for multiple chronic conditions. Participants generally felt support was available, though emotional/informational support was perceived as less available than other types of support. Participants did not rely heavily on informal support to help them manage their multiple morbidities, preferring to call on their doctor and their own resources. We discuss implications of these findings for meeting this vulnerable populations self-management needs.

Prevalence of Colorectal Cancer Screening among a Multimorbid Rural Appalachian Population

Objectives The purpose of this study was to determine the relation among multiple morbidities and the prevalence of colorectal cancer (CRC) screening among older adult Appalachian residents of Kentucky. This is the first known study to address multiple morbidities exclusively with a health-disparities population. Methods This was a cross-sectional study of 1153 subjects, aged 50 to 76 years, from Appalachian Kentucky. Results White race, post–high school education, and perception of having more than enough income on which to survive were associated with higher rates of any guideline concordant CRC screening. Statistically significant trends in the outcome of adjusted odds ratios for colonoscopy with greater number of morbidities (P < 0.05) were noted; the higher number of morbidities, the higher rates of screening. Conclusions Contrary to much existing research, within a health-disparities population, we found a dose-response relation between comorbidities and greater likelihood of CRC screening. Future research in this area should focus on explanations for this seldom-described finding. In addition, this finding has meaningful clinical and behavioral implications, including ensuring provider screening recommendation during routine office visits and outreach, perhaps through community clinics and public health departments, to extremely vulnerable populations lacking access to preventive care.

Rural Residents' Perspectives on Multiple Morbidity Management and Disease Prevention.

Middle-aged and older adults often experience several simultaneously occurring chronic conditions or “multiple morbidity” (MM). The task of both managing MM and preventing chronic conditions can be overwhelming, particularly in populations with high disease burdens, low socioeconomic status, and health care provider shortages. This article sought to understand Appalachian residents’ perspectives on MM management and prevention. Forty-one rural Appalachian residents aged 50 and above with MM were interviewed about disease management and colorectal cancer (CRC) prevention. Transcripts were examined for overall analytic categories and coded using techniques to enhance transferability and rigor. Participants indicate facing various challenges to prevention due, in part, to conditions within their rural environment. Patients and providers spend significant time and energy on MM management, often precluding prevention activities. This article discusses implications of MM management for CRC prevention and strategies to increase disease prevention among this rural, vulnerable population burdened by MM.

Using Decision Tree Models to Depict Primary Care Physicians CRC Screening Decision Heuristics

ObjectiveThe purpose of this study was to identify decision heuristics utilized by primary care physicians in formulating colorectal cancer screening recommendations.DesignQualitative research using in-depth semi-structured interviews.ParticipantsWe interviewed 66 primary care internists and family physicians evenly drawn from academic and community practices. A majority of physicians were male, and almost all were white, non-Hispanic.ApproachThree researchers independently reviewed each transcript to determine the physician’s decision criteria and developed decision trees. Final trees were developed by consensus. The constant comparative methodology was used to define the categories.ResultsPhysicians were found to use 1 of 4 heuristics (“age 50,” “age 50, if family history, then earlier,” “age 50, if family history, then screen at age 40,” or “age 50, if family history, then adjust relative to reference case”) for the timing recommendation and 5 heuristics [“fecal occult blood test” (FOBT), “colonoscopy,” “if not colonoscopy, then...,” “FOBT and another test,” and “a choice between options”) for the type decision. No connection was found between timing and screening type heuristics.ConclusionsWe found evidence of heuristic use. Further research is needed to determine the potential impact on quality of care.

The Emergency Department as a Potential Intervention Recruitment Venue Among Vulnerable Rural Residents

Meeting the health care needs of rural residents is complicated by their substantial medical burdens that frequently outstrip patient and community resources. Nowhere is this more evident than in central Appalachia. Preventive procedures are often sacrificed as patients and providers attend to more pressing medical issues. We report the results of a pilot study designed to explore the need for and appropriateness of a potential intervention placed in an emergency department (ED), with the eventual goal of using the ED to link traditionally underserved patients to preventive services. We used a convenience sample of 49 ED patients to explore their characteristics and health needs and compare them with a sample of 120 case management clients participating in the Kentucky Homeplace Program (KHP), and a general sample of 3,165 Appalachian Kentuckians. The recruited ED patients had low socio-economic status, numerous health conditions, and several unmet health needs, including need for colorectal, cervical, and breast cancer screening. Compared to their KHP counterparts, more ED patients were uninsured. Participants in the ED and KHP groups had particularly low income, were less educated, and had less insurance coverage than an average Appalachian resident. Although case management services, including the KHP have been successful in increasing access to health care by those in need, certain segments of the population remain underserved and continue to be missed by such programs. Our study suggests the need for and appropriateness of reaching out to such underserved populations in the ED and involving them into potential interventions designed to enhance preventive health services.

Self-perceived Income Sufficiency and Self-reported Income Level among a Health Inequity Population

This study presents a dynamic approach to collecting income information. We conducted a cross-sectional survey of 2,022 residents of historically underserved Appalachian Kentucky, an ideal location due to pervasive low income and our ability to control for potential confounders such as race/ethnicity and residential heterogeneity. In unadjusted analyses, nearly half of the sample indicated they struggled to meet their needs; 43% said they made just enough to get by; and 10% indicated they had more than they needed to live well. Adjusting for socio-demographic characteristics, proportionately more of those with lower self-rated health and a higher number of morbidities reported struggling to make ends meet. Less than 1% refused to respond to the question on self-perceived income sufficiency, compared with 20% who refused to report income levels. We conclude that self-perceived income sufficiency is a useful question to assess resources, both theoretically and practically, in an underserved population.