Implementation of evidence-based primary cancer prevention interventions in MA community health centers: an explanatory sequential mixed methods study

BACKGROUND

More than half of cancers could be prevented by employing evidence-based interventions (EBIs), including prevention interventions targeting nutrition, physical activity, and tobacco. Federally qualified health centers (FQHCs) are the primary source of patient care for over 30 million Americans - making them an optimal setting for ensuring evidence-based prevention that advances health equity. The aims of this study are to (1) determine the degree to which primary cancer prevention EBIs are being implemented within Massachusetts FQHCs and (2) describe how these EBIs are implemented internally and via community partnerships.

METHODS

We used an explanatory sequential mixed methods design to assess the implementation of cancer prevention EBIs. First, we collected 34 quantitative surveys from staff at 16 FQHCs across Massachusetts to determine the frequency of EBI implementation. We followed up with 12 qualitative one-on-one interviews among a sample of staff to understand how the EBIs selected on the survey were implemented. Exploration of contextual influences on implementation and use of partnerships was guided by the Consolidated Framework for Implementation Research (CFIR). Quantitative data were summarized descriptively, and qualitative analyses used reflexive, thematic approaches, beginning deductively with codes from CFIR, then inductively coding additional categories.

RESULTS

All FQHCs indicated they offered clinic-based tobacco interventions, such as clinician-delivered screening practices and prescription of tobacco cessation medications. Quitline interventions and some diet/physical activity EBIs were available at all FQHCs, but staff perceptions of penetration were low. Only 38% of FQHCs offered group tobacco cessation counseling and 63% referred patients to mobile phone-based cessation interventions. We found multilevel factors influenced implementation across intervention types - including the complexity of intervention trainings, available time and staffing, motivation of clinicians, funding, and external policies and incentives. While partnerships were described as valuable, only one FQHC reported using clinical-community linkages for primary cancer prevention EBIs.

CONCLUSIONS

Adoption of primary prevention EBIs in Massachusetts FQHCs is relatively high, but stable staffing and funding are required to successfully reach all eligible patients. FQHC staff are enthusiastic about the potential of community partnerships to foster improved implementation-providing training and support to build these relationships will be key to fulfilling that promise.

Implementation of evidence-based primary cancer prevention interventions in MA community health centers: an explanatory sequential mixed methods study

Background More than half of cancers could be prevented by employing evidence-based interventions (EBIs), including prevention interventions targeting nutrition, physical activity, and tobacco. Federally qualified health centers (FQHCs) are the primary source of patient care for over 30 million Americans - making them an optimal setting for ensuring evidence-based prevention that advances health equity. The aims of this study are to: 1) determine the degree to which primary cancer prevention EBIs are being implemented within Massachusetts FQHCs and 2) describe how these EBIs are implemented internally and via community partnerships. Methods We used an explanatory sequential mixed methods design to assess the implementation of cancer prevention EBIs. First, we used quantitative surveys of FQHC staff to determine the frequency of EBI implementation. We followed up with qualitative one-on-one interviews among a sample of staff to understand how the EBIs selected on the survey were implemented. Exploration of contextual influences on implementation and use of partnerships was guided by the Consolidated Framework for Implementation Research (CFIR). Quantitative data were summarized descriptively, and qualitative analyses used reflexive, thematic approaches, beginning deductively with codes from CFIR, then inductively coding additional categories. Results All FQHCs indicated they offered clinic-based tobacco interventions, such as clinician-delivered screening practices and prescription of tobacco cessation medications. Quitline interventions and some diet/physical activity EBIs were available at all FQHCs, but staff perceptions of penetration were low. Only 38% of FQHCs offered group tobacco cessation counseling and 63% referred patients to mobile phone-based cessation interventions. We found multilevel factors influenced implementation across intervention types - including the complexity of intervention trainings, available time and staffing, motivation of clinicians, funding, and external policies and incentives. While partnerships were described as valuable, only one FQHC reported using clinical-community linkages for primary cancer prevention EBIs. Conclusions Adoption of primary prevention EBIs in Massachusetts FQHCs is relatively high, but stable staffing and funding are required to successfully reach all eligible patients. FQHC staff are enthusiastic about the potential of community partnerships to foster improved implementation - providing training and support to build these relationships will be key to fulfilling that promise.

Is there still a problem with lead in drinking water in the European Union?

The presence of lead in drinking water poses a range of risks to human health, including the retardation of some aspects of child development, the inducement of abortion, and other clinical disorders. The extent of these risks has not been quantified at the European Union (EU) scale. A number of sampling methods are in use across the EU, some of which are inadequate for determining the concentrations of lead in drinking water at consumers' taps. In consequence, non-compliance with the EU standards for lead in drinking water has been under-estimated. Emerging data indicates significant non-compliance with these standards in some countries, particularly with the 10 microg(-1) standard that will become a legal requirement in 2013; the current interim standard of 25 microg l(-1) is also exceeded in some locations. An initial estimate is that 25% of domestic dwellings in the EU have a lead pipe, either as a connection to the water main, or as part of the internal plumbing, or both, potentially putting 120 million people at risk from lead in drinking water within the EU. These issues are relevant to the implementation of the Protocol on Water and Health and to drinking water safety planning.

Experience in Wales (UK) of the optimisation of ortho-phosphate dosing for controlling lead in drinking water

Dwr Cymru Welsh Water supplies over three million people with drinking water throughout most of Wales (UK). Ortho-phosphate has increasingly been dosed at around 1 mg/L (P) to further reduce the corrosivity of supplies to the lead pipes which connect approximately 30% of houses to water mains in the company's area, additional to long-establish pH adjustment measures. The installation of new ortho-phosphate dosing schemes and the optimisation of these and existing dosing schemes, 29 schemes in total, were subject to a regulatory programme of work, agreed with the Drinking Water Inspectorate (DWI). Optimisation comprised (i) selection of appropriate ortho-phosphate doses by a procedure involving laboratory based plumbosolvency testing linked to zonal lead emission (compliance) modelling, (ii) tight dose control and (iii) extensive monitoring of lead in supply by random daytime (RDT) sampling and by the use of lead pipe test rigs. The successful outcome was confirmed by 99% of over 5,000 RDT samples complying with the future standard of 10 microg/L for lead in drinking water.

Nitrate and water supplies in the United Kingdom

Nitrate concentrations in UK waters are rising, with the highest levels occurring in the south and east of England, particularly Lincolnshire, Cambridgeshire and East Anglia. The source of the nitrate is arable agriculture where intensification in the last few decades has increased nitrate leaching from soils into both surface and underground waters. Concentrations in underground waters are expected to reach 150 to 200 mg litre(-1) nitrate (i.e. NO(3)) in the future, if agricultural losses remain stable. No widespread environmental deterioration due to nitrate has been observed in rivers or lakes. Excessive concentrations of nitrate in drinking waters can cause methaemoglobinaemia (blue-baby syndrome) in bottle-fed infants and the government Chief Medical Officer has recommended that a maximum concentration of 100 mg litre(-1) is appropriate for public water supplies in the UK. This level has not been exceeded in public water supplies in the UK, but maintaining it has cost approximately 15m pounds in borehole replacement and arrangements to blend high and low nitrate waters. Future capital costs are estimated as 37m pounds over the next 20 years. The European Economic Community (EEC) Drinking Water Directive (80/778/EEC) sets a maximum admissible concentration of 50 mg litre(-1) nitrate. Adherence to this standard will cost 199m pounds over the same period.

Direct Readout of Sediment Analyses by Settling Tube for Computer Processing

Sediment fall-velocities measured by the Woods Hole Rapid Sediment Analyzer can now be obtained directly on punched paper tape in a form suitable for processing by a computer. This technique saves much time because it eliminates manual card punching, a step in which an operator transfers values from sediment analyses to punch cards in order to make the data acceptable tocomputers.