Outcomes of the Learn, Share & Live breast cancer education program for older urban women

Group Versus Individual Culturally Tailored and Theory-Based Education to Promote Cervical Cancer Screening Among the Underserved Hispanics: A Cluster Randomized Trial

Purpose:

To determine whether group education is as effective as individual education in improving cervical cancer screening uptake along the US–Mexico border.

Design:

Cluster randomized controlled study.

Setting:

El Paso and Hudspeth Counties, Texas.

Participants:

Three hundred women aged 21 to 65 years, uninsured, due for a Pap test, no prior history of cervical cancer or hysterectomy.

Intervention:

Theory-based, culturally appropriate program comprised of outreach, educational session, navigation services, and no-cost cervical cancer testing.

Measures:

Baseline, immediate postintervention, and 4-month follow-up surveys measured knowledge and theoretical constructs from the Health Belief Model, Theory of Reasoned Action, and the Social Cognitive Theory.

Analysis:

Relative risk regression analyses to assess the effects of educational delivery mode on the uptake of screening. Mixed effect models to analyze changes in psychosocial variables.

Results:

One hundred and fifty women assigned to each educational group; 99% Hispanic. Of all, 85.7% completed the follow-up survey. Differences in screening rate at follow-up were analyzed by education type. Overall screening rate at follow-up was 73.2%, no significant difference by education type (individual: 77.6%, group: 68.9% P = .124). Significant increases among group education at follow-up for knowledge, perceived susceptibility, perceived seriousness, and subjective norms and significant decrease for perceived benefits.

Conclusion:

This study provides evidence to support the effectiveness of group education to promote cervical cancer screening among vulnerable Hispanic women and offers an additional method to address cervical cancer disparities.

Peer support of complex health behaviors in prevention and disease management with special reference to diabetes: systematic reviews

OBJECTIVES

Examine Peer Support (PS) for complex, sustained health behaviors in prevention or disease management with emphasis on diabetes prevention and management.

DATA SOURCES AND ELIGIBILITY

PS was defined as emotional, motivational and practical assistance provided by nonprofessionals for complex health behaviors. Initial review examined 65 studies drawn from 1442 abstracts identified through PubMed, published 1/1/2000-7/15/2011. From this search, 24 reviews were also identified. Extension of the search in diabetes identified 30 studies published 1/1/2000-12/31/2015.

RESULTS

In initial review, 54 of all 65 studies (83.1%) reported significant impacts of PS, 40 (61.5%) reporting between-group differences and another 14 (21.5%) reporting significant within-group changes. Across 19 of 24 reviews providing quantifiable findings, a median of 64.5% of studies reviewed reported significant effects of PS. In extended review of diabetes, 26 of all 30 studies (86.7%) reported significant impacts of PS, 17 (56.7%) reporting between-group differences and another nine (30.0%) reporting significant within-group changes. Among 19 of these 30 reporting HbA1c data, average reduction was 0.76 points. Studies that did not find effects of PS included other sources of support, implementation or methodological problems, lack of acceptance of interventions, poor fit to recipient needs, and possible harm of unmoderated PS.

CONCLUSIONS

Across diverse settings, including under-resourced countries and health care systems, PS is effective in improving complex health behaviors in disease prevention and management including in diabetes.

Assessing Lay Health Advisor Activity in an Intervention to Prevent Lead Poisoning in Native American Children

The purpose of this study is to assess patterns of lay health advisor (LHA) activity in an intervention to reduce lead exposure in Native American children exposed to mine waste. A total of 39 LHAs were recruited and trained to become LHAs from eight tribes in northeastern Oklahoma. LHAs completed activity tracking forms over a 2-year intervention period to document contacts made with community groups and individuals in their social networks. They engaged in an average of 5.4 activities per month, reaching an average of 39 persons. Close members of their social networks were reached in 40.4% of the contacts; persons outside of their networks were reached in 24% of the contacts. This study suggests that 1 to 3 contacts per week may be a reasonable expectation for LHA activity. Findings also suggest that LHA interventions are a promising approach for engaging Native American communities in addressing an environmental health problem.

The German SCREEN project--design and evaluation of the communication strategy

BACKGROUND

Skin cancer is the most common cancer in light-skinned populations worldwide. Primary and secondary preventive activities such as skin cancer screening are intended to reduce skin cancer burden. In 2003, a population-based skin cancer screening project [SCREEN (Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany)] was conducted in Northern Germany with more than 360,000 people screened. SCREEN was supported by a communication intervention that was aimed at informing the population about skin cancer, its risk factors and the screening intervention as well as preparing the health professionals for the project. Within SCREEN both physicians and practice nurses were educated in counselling. The aim of the present article is to describe and evaluate the communication strategy accompanying SCREEN.

METHODS

Two computer-assisted telephone interview surveys were performed in April/May 2003 and May 2004. Participants had to be members of the statutory health insurance and be aged 20 years. They were asked about knowledge of skin cancer, perception of physicians' performance and skin cancer screening in general. Data are mainly presented in a descriptive manner. For statistical analyses, Mann-Whitney U test and Pearson's chi-square test were used.

RESULTS

Knowledge about sunburn in childhood and high ultraviolet exposure as skin cancer risk factors increased during SCREEN. Simultaneously, the awareness for early detection of skin cancer increased significantly from 41.3 to 74.0% (P < 0.001). A total of 21.5% of the interviewees participated in the skin cancer screening project, similar to the population-based participation rate reached.

CONCLUSION

A comprehensive communication strategy accompanying a screening intervention improves the knowledge of potential screenees and may additionally increase the participation rate.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

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.

Community-based participatory approach to reduce breast cancer disparities in south Dallas

BACKGROUND

South Dallas experiences significant disparities in breast cancer mortality, with a high proportion of stage III and IV diagnoses. To address these rates, the Dallas Cancer Disparities Community Research Coalition created an educational intervention to promote breast health and early detection efforts.

OBJECTIVES

The goals of the intervention were to increase (a) knowledge regarding the chief contributing factors for breast cancer, (b) awareness of the importance of screening for early detection, and (c) the proportion of women who have engaged in appropriate breast cancer screening practices.

METHODS

Eligibility criteria for this nonrandomized, controlled trial included women age 40 and older, English-speaking, and having no personal history of cancer. Control participants received written breast health educational materials. Intervention participants attended 8 weekly sessions that included interactive educational materials, cooking demonstrations, and discussions emphasizing primary and secondary breast cancer prevention. All study participants completed a 1-hour survey at baseline and 4 months later.

RESULTS

There were 59 women were enrolled in the intervention and 60 in the control group. At follow-up, after controlling for baseline mammography status, women in the intervention group were 10.4 times more likely (95% confidence interval [CI], 2.9-36.4) to have received a screening mammogram in the last year compared with the control group. Intervention participants demonstrated statistically significantly higher rates of breast self-examination (odds ratio [OR], 3.0; 95% CI, 1.0-8.6) and breast cancer knowledge (p=.003).

CONCLUSION

Lessons learned from this community-based participatory research (CBPR) study can be used to create sustainable cancer disparity reduction models that can be replicated in similar communities.

Interventions to promote cancer awareness and early presentation: systematic review

Background:

Low cancer awareness contributes to delay in presentation for cancer symptoms and may lead to delay in cancer diagnosis. The aim of this study was to review the evidence for the effectiveness of interventions to raise cancer awareness and promote early presentation in cancer to inform policy and future research.

Methods:

We searched bibliographic databases and reference lists for randomised controlled trials of interventions delivered to individuals, and controlled or uncontrolled studies of interventions delivered to communities.

Results:

We found some evidence that interventions delivered to individuals modestly increase cancer awareness in the short term and insufficient evidence that they promote early presentation. We found limited evidence that public education campaigns reduce stage at presentation of breast cancer, malignant melanoma and retinoblastoma.

Conclusions:

Interventions delivered to individuals may increase cancer awareness. Interventions delivered to communities may promote cancer awareness and early presentation, although the evidence is limited.

Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

A critical review of theory in breast cancer screening promotion across cultures

This article reviews the contribution and potential of widely used health behavior theories in research designed to understand and redress the disproportionate burden of breast cancer borne by diverse race/ethnic, immigrant, and low-income groups associated with unequal use of mammography. We review the strengths and limitations of widely used theories and the extent to which theory contributes to the understanding of screening disparities and informs effective intervention. The dominant focus of most theories on individual cognition is critically assessed as the abstraction of behavior from its social context. Proposed alternatives emphasize multilevel ecological approaches and the use of anthropologic theory and methods for more culturally grounded understandings of screening behavior. Common and alternative treatments of fatalism exemplify this approach, and descriptive and intervention research exemplars further highlight the integration of screening behavior and sociocultural context.

Breast health education for working women in Appalachia: insights from focus group research

BACKGROUND

This study seeks to understand rural working women, their knowledge of health systems, and how breast health issues fit into their lives. A key aim of this study was to identify regionally and culturally specific factors that influence how these women approach breast health and to identify ways that more positive breast health behaviors can be achieved.

METHODS

Five focus groups (N = 42) were conducted among women at sites where the Breast Health Outreach Program (BHOP) had been conducted. Focus groups were composed of 7 to 10 women who were in about the same age cohort.

RESULTS

Women provided multiple insights about their attitudes and behaviors related to breast heath concerns. Analysis of the data revealed that many of the comments clustered around two types of "systems" in these women's lives: the professional health care system and personal community systems. The BHOP provides a bridge between these two systems and seems to facilitate positive actions. Workplace health professionals also provide a bridge between professional and personal systems.

CONCLUSIONS

Women exhibited the general distrust of the medical system that the literature indicates is often associated with Appalachian culture. However, this study found that distrust can be overcome with education programs that meet women where they live and work. Such programs are most likely to be successful when the materials and methods are sensitive to Appalachian culture and when medical services are brought into the community.

Examining the theory of planned behavior and the construct of self-efficacy to predict mammography intention

This article examines the applicability of the Theory of Planned Behavior (TPB) with the addition of the self efficacy construct in the understanding of the motivation to obtain an initial screening mammogram among Cypriot women. The study sample consisted of 293 women aged 40 to 65 years, asymptomatic of breast cancer, and with no previous mammography experience. The study took place at the General Hospital of Nicosia in Cyprus. The results of the study provided support of the TPB with the addition of self-efficacy in an international setting. Self-efficacy was the strongest predictor of intention. Other predictors of intention included educational level, time of last clinical breast examination, and age. The study also provided some empirical support of the distinction between self-efficacy and perceived behavioral control. Researchers may want to include self-efficacy in addition to the TPB and other demographic characteristics in future applications to more fully explain behavioral outcomes.

The novella approach to inform women living on low income about early breast cancer detection

Economically disadvantaged women have a greater likelihood of later-stage breast cancer diagnosis when compared to women with higher levels of income. Later-stage diagnosis decreases the chances of survival. The purpose of this article is to describe a project whereby breast cancer survivors, living on lower incomes, created novellas (stories) using artistic media to reach their peers with a message about the importance of early breast cancer detection. The recruitment and engagement of breast cancer survivors in a 2-year community development project that used participatory, women-driven approaches are discussed, and the reciprocal learning between health care providers, community partners, and women living on low income is shared. Recommendations for health promotion practice are presented.

Psychosocial factors related to repeat mammography screening over 5 years in African American women

The purpose of this study was to investigate health beliefs associated with repeat mammography screening in African American women 51 years or older over a 5-year period. Long-term repeat mammography screening is inconsistent in African American women; therefore, this study measured demographic, knowledge, and health belief predictors of repeat screening. The theoretical framework for this study was the health belief model. Baseline data from a larger randomized controlled trial were analyzed using descriptive statistics and logistic regression. The sample consisted of 602 African American women with no breast cancer history and at least 1 reported screening mammogram in the past 5 years. They were recruited from 3 primary care health settings. Having been screened 4 to 5 times in the past 5 years was associated with more knowledge about screening guidelines and fewer perceived barriers to screening. Results point to the importance of collaborating with African American communities to promote life-long mammography screening by increasing access to culturally appropriate information on screening guidelines and ameliorating barriers to screening within the context of the African American experience.

Use of Computer Kiosks for Breast Cancer Education in Five Community Settings

Finding ways to bring effective computer-based behavioral interventions to those with limited access to technology is a continuing challenge for health educators. Computer kiosks placed in community settings may help reach such populations. The Reflections of You kiosk generates individually tailored magazines on breast cancer and mammography and was adapted from an evidence-based intervention that increased mammography use in African American women. This usage study tracked patterns of use and characteristics of kiosk users in beauty salons, churches, neighborhood health centers, Laundromats, and social service agencies in St. Louis. Kiosks were used 4,527 times in 470 kiosk days at 40 different host sites. Highly significant differences among community settings were found in rates and patterns of kiosk use as well as user characteristics, breast cancer knowledge, and use of mammography. Findings inform strategic decision making about technology dissemination and community outreach to women needing information about breast cancer and mammography.

A systematic review of mammography educational interventions for low-income women

OBJECTIVE

We conducted a systematic review to examine the effectiveness of educational interventions in increasing mammography screening among low-income women.

DATA SOURCES

Bibliographic databases, including MEDLINE, The Cochrane Central Register of Controlled Trials, The Cochrane Database of Systematic Reviews, and the ISI Web of Science, were searched for relevant articles.

STUDY INCLUSION AND EXCLUSION CRITERIA

Randomized, community-based trials targeting low-income women and published between January 1980 and March 2003 were included.

DATA EXTRACTION

The search yielded 242 studies; 24 met all inclusion criteria.

DATA SYNTHESIS

Three studies used mammography vans, three used low-cost vouchers or provided free mammograms, three used home visits, one used community education alone, one provided referrals, five incorporated multiple intervention strategies, two used phone calls, one used videos and print material, and five used primarily print material.

RESULTS

Of nine studies that reduced barriers to care via mammography vans, cost vouchers, or home visits, eight showed statistically significant increases in mammography screening. Seven of the eight studies that used peer educators had significant increases in screening, as did four of the five studies that used multiple (intervention) components.

CONCLUSIONS

Interventions that used peer educators, incorporated multiple intervention strategies, or provided easy access via vans, cost vouchers, or home visits were effective in increasing screenings. Mailed letter or telephone reminders were not effective in trials involving low-income women, which is contrary to findings from middle/upper-income studies.

Cancer education for home health care workers: a process evaluation

BACKGROUND

In this article, we evaluate adoption of cancer education into the mandatory in-service training of home health attendants (HHA) comprised predominantly of African American and Hispanic women.

METHODS

Three home health care training agencies in Bronx, NY, incorporated cancer prevention and outreach education into HHA training.

RESULTS

Across 3 years, 87% (n = 2513) of HHAs received the intervention and disseminated it to 1600 clients/family/friends. HHAs reported high program satisfaction (98%) and interest (82%) in cancer outreach. Agency staff reported more benefits than costs to implementation.

CONCLUSIONS

The home health care training agency appears an accessible and effective bridge for disseminating cancer education to the underserved.

Lessons learned from community-based cancer screening intervention research

Behaviors associated with cancer screening have been the focus of intensive research over the past 2 decades, primarily in the form of intervention trials to improve screening based in both clinical and community settings. Meta-analyses and literature reviews have synthesized and organized the resulting literature. From the accumulated work, this review distilled lessons learned from cancer screening intervention research in community settings. The authors posed the question, "What do we know about the development of effective community-based interventions (the level of good over harm achieved in real-world conditions)?" Framed around the concept of focal points (the simultaneous combination of target population, behavioral objective, and setting for an intervention), 13 lessons were derived. One lesson was cross-cutting, and the other lessons addressed the three focal-point components and the major intervention categories (access-enhancing strategies, mass media, small media, one-on-one and small-group education, and combinations of these categories). To build more systematically on existing research, recommendations are made for new directions in basic behavioral and intervention research.

Analysis of the cost-effectiveness of mammography promotion by volunteers in rural communities

The Community Trial of Breast Cancer Screening Promotion assessed the effectiveness and cost-effectiveness of mammography promotion by community volunteer groups in rural areas using three different intervention approaches: individual counseling, community activities, and a combined intervention including both. Societal costs of the interventions were calculated and used in conjunction with measures of effectiveness to calculate cost-effectiveness in terms of cost per additional mammogram and cost per year of life saved. Methods of collecting and using cost information to assess the cost-effectiveness of community interventions are described. The Community Activities intervention was found to be the most cost-effective, at approximately $2,000 for each additional regular mammography user in the community. The cost per year of life saved associated with mammography promotion was approximately $56,000 per year of life saved. Exploratory analyses suggest that the most cost-effective method of promoting mammography use may vary with the target population.

Development and validation of brief scales to measure collectivism, religiosity, racial pride, and time orientation in urban African American women

This article describes the development and pilot-testing of brief scales to measure four cultural constructs prevalent in urban African American women. Internal consistency and temporal stability were assessed in two convenience samples (n=47 and n=25) of primarily lower-income African American women. All scales performed well: collectivism alpha=.93, r=.85, p<.001); religiosity (alpha=.88, r=.89, p<.001); racial pride (alpha=.84, r=.52, p<.001); present time orientation (alpha=.73, r=.52, p<.01) and future time orientation (alpha=.72, r=.54, p=.07).