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Wen KY, Dayaratna S, Slamon R, Granda-Cameron C, Tagai EK, Kohler RE, Hudson SV, Miller SM. Chatbot-interfaced and cognitive-affective barrier-driven messages to improve colposcopy adherence after abnormal Pap test results in underserved urban women: A feasibility pilot study. Transl Behav Med 2024; 14:1-12. [PMID: 38014626 PMCID: PMC10782901 DOI: 10.1093/tbm/ibad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Challenges in ensuring adherence to colposcopy and follow-up recommendations, particularly within underserved communities, hinder the delivery of appropriate care. Informed by our established evidence-based program, we sought to assess the feasibility and acceptability of a novel cognitive-affective intervention delivered through a Chatbot interface, aimed to enhance colposcopy adherence within an urban inner-city population. We developed the evidence-based intervention, CervixChat, to address comprehension of colposcopy's purpose, human papillomavirus (HPV) understanding, cancer-related fatalistic beliefs, procedural concerns, and disease progression, offered in both English and Spanish. Females aged 21-65, with colposcopy appointments at an urban OBGYN clinic, were invited to participate. Enrolled patients experienced real-time counseling messages tailored via a Chatbot-driven barriers assessment, dispatched via text one week before their scheduled colposcopy. Cognitive-affective measures were assessed at baseline and through a 1-month follow-up. Participants also engaged in a brief post-intervention satisfaction survey and interview to capture their acceptance and feedback on the intervention. The primary endpoints encompassed study adherence (CervixChat response rate and follow-up survey rate) and self-evaluated intervention acceptability, with predefined feasibility benchmarks of at least 70% adherence and 80% satisfaction. Among 48 eligible women scheduled for colposcopies, 27 (56.3%) agreed, consented, and completed baseline assessments. Participants had an average age of 34 years, with 14 (52%) identifying as non-Hispanic White. Of these, 21 (77.8%) engaged with the CervixChat intervention via mobile phones. Impressively, 26 participants (96.3%) attended their diagnostic colposcopy within the specified timeframe. Moreover, 22 (81.5%) completed the follow-up survey and a brief interview. Barriers assessment revealed notable encodings in the Affect and Values/Goals domains, highlighting concerns and understanding around HPV, as well as its impact on body image and sexual matters. Persistent and relatively high intrusive thoughts and lowered risk perceptions regarding cervical cancer were reported over time, unaffected by the intervention. Post-intervention evaluations documented high satisfaction and perceived usefulness, with recommendations for incorporating additional practical and educational content. Our findings underscore the robust satisfaction and practicality of the CervixChat intervention among a diverse underserved population. Moving forward, our next step involves evaluating the intervention's efficacy through a Sequential Multiple Assignment Randomized Trial (SMART) design. Enhanced by personalized health coaching, we aim to further bolster women's risk perception, address intrusive thoughts, and streamline resources to effectively improve colposcopy screening attendance.
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Affiliation(s)
- Kuang-Yi Wen
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Sandra Dayaratna
- Department of Obstetrics, Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, 833 Chestnut Street, Philadelphia, PA 19107, USA
| | - Rachel Slamon
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Clara Granda-Cameron
- Department of Graduate Program, College of Nursing, Thomas Jefferson University, 901 Walnut Street, Suite 703, Philadelphia, PA 19107, USA
| | - Erin K Tagai
- Department of Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Racquel E Kohler
- Cancer Health Equity Center, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Suzanne M Miller
- Department of Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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Swiecki-Sikora AL, Lauder A, Harris A, Tagai EK, Deng M, Jeronis SL, Houck KL, Miller SM, Hernandez E. Attitudes About the Human Papillomavirus Vaccine Among Patients With and Without Cervical Dysplasia. J Low Genit Tract Dis 2024; 28:18-25. [PMID: 37922471 PMCID: PMC10840739 DOI: 10.1097/lgt.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2023]
Abstract
OBJECTIVES The aims of the study are to examine the perception of the human papillomavirus (HPV) vaccine among those with and without a history of cervical dysplasia and to examine perceptions of the vaccine for their children. MATERIALS AND METHODS Patients were recruited to complete a survey about the HPV vaccine for both themselves and their children. Patients in a colposcopy clinic with a history of abnormal cervical cytology and patients in a benign gynecology clinic without a history of abnormal cervical cytology were recruited. Participants' medical records were reviewed. Demographics and survey answers were described, and Fisher exact test was used to compare the groups. RESULTS One hundred eighty-three patients participated: 73 in colposcopy clinic and 110 in benign clinic. The majority self-identified as Black (74% colposcopy, 71% benign, p = .588) and reported an income less than $39,000 a year (77% colposcopy, 65% benign, p = .089). Fifty-six percent in benign clinic agreed the HPV vaccine is a good way to protect oneself from disease compared with 48% in colposcopy clinic ( p = .022). When examining results based on cytology, fewer patients in the highest-grade cytology group agreed the vaccine was effective (30% high-grade, 48% normal, 57% low-grade, p = .027) or a good way to protect themselves from disease (29% high-grade, 53% normal, 62% low-grade, p = .002). There was otherwise no statistically significant difference between the groups on questions regarding self or child vaccination. CONCLUSIONS In a majority Black, low-income population, patients without a history of abnormal cervical cytology have more favorable perceptions of the HPV vaccine's effectiveness in preventing disease. Those with the highest-grade cytology had more negative perceptions of the vaccine's effectiveness and protectability.
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Affiliation(s)
- Allison L Swiecki-Sikora
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA
| | - Abigail Lauder
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Adina Harris
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Erin K Tagai
- Fox Chase Cancer Center-Institute of Cancer Research, Philadelphia, PA
| | - Mengying Deng
- Fox Chase Cancer Center-Institute of Cancer Research, Philadelphia, PA
| | - Stacey L Jeronis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA
| | - Karen L Houck
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA
| | - Suzanne M Miller
- Fox Chase Cancer Center-Institute of Cancer Research, Philadelphia, PA
| | - Enrique Hernandez
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple University Hospital, Philadelphia, PA
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Tagai EK, Mantia‐Smaldone GM, Belfiglio A, Chu CS, Lapitan E, Santos H, Hernandez E, Sarwer DB, Miller SM. Perceived importance of weight loss and exercise among endometrial cancer survivors with overweight or obesity: Implications for lifestyle modification interventions. Obes Sci Pract 2023; 9:661-669. [PMID: 38090692 PMCID: PMC10712408 DOI: 10.1002/osp4.701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/23/2023] [Accepted: 07/17/2023] [Indexed: 02/01/2024] Open
Abstract
Objective Type 1 endometrial cancer (EC) survivors who are overweight or obese are at increased risk of comorbidities and reduced quality of life. Lifestyle modification interventions (e.g., healthy eating, exercise) may help these women reduce excess weight and improve their quality of life. However, existing interventions have shown limited success. Guided by Self-Determination Theory, the proposed study sought to identify factors associated with perceived importance of weight loss and exercise as well as interest in lifestyle modification interventions (components of extrinsic and intrinsic motivation) among EC survivors with overweight or obesity to inform future intervention development. Methods One hundred type 1 EC survivors [body mass index (BMI) ≥ 25 kg/m2] completed a cross-sectional survey assessing sociodemographics, medical factors, exercise, risk perceptions and provider communication, quality of life, barriers to dieting and exercise, perceived importance of healthy lifestyles, and desired intervention content. Results EC survivors who were aware obesity is a risk factor for EC were significantly more likely to perceive weight loss as important and were interested in weight loss programs and receiving information about exercise (ps < 0.05). Additionally, EC survivors who reported their provider discussed the importance of a healthy weight after their diagnosis were significantly more likely to perceive exercise as important and were interested in receiving dieting information. Conclusions EC survivors expressed interest in lifestyle modification interventions. Increasing awareness about the risk of obesity and provider discussions about healthy weight during routine appointments may motivate EC survivors to engage in lifestyle modification interventions.
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Affiliation(s)
- Erin K. Tagai
- Cancer Prevention and ControlFox Chase Cancer Center/Temple University Health SystemPhiladelphiaPennsylvaniaUSA
| | - Gina M. Mantia‐Smaldone
- Division of Gynecologic OncologyFox Chase Cancer Center/Temple University Health SystemPhiladelphiaPennsylvaniaUSA
| | - Andrew Belfiglio
- Cancer Prevention and ControlFox Chase Cancer Center/Temple University Health SystemPhiladelphiaPennsylvaniaUSA
| | - Christina S. Chu
- Division of Gynecologic OncologyFox Chase Cancer Center/Temple University Health SystemPhiladelphiaPennsylvaniaUSA
| | - Emmanuel Lapitan
- Cancer Prevention and ControlFox Chase Cancer Center/Temple University Health SystemPhiladelphiaPennsylvaniaUSA
| | - Heather Santos
- Cancer Prevention and ControlFox Chase Cancer Center/Temple University Health SystemPhiladelphiaPennsylvaniaUSA
- Department of Epidemiology and BiostatisticsDornsife School of Public HealthDrexel UniversityPhiladelphiaPennsylvaniaUSA
| | - Enrique Hernandez
- Obstetrics, Gynecology, and Reproductive SciencesLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - David B. Sarwer
- College of Public HealthCenter for Obesity Research and EducationTemple UniversityPhiladelphiaPAUSA
| | - Suzanne M. Miller
- Cancer Prevention and ControlFox Chase Cancer Center/Temple University Health SystemPhiladelphiaPennsylvaniaUSA
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Diefenbach MA, Marziliano A, Tagai EK, Pfister H, Lapitan E, Hall SJ, Vira M, Ibrahim S, Aibel K, Kutikov A, Horwitz EM, Miyamoto C, Reese AC, Miller SM. Preference Elicitation and Treatment Decision-Making Among Men Diagnosed With Prostate Cancer: Randomized Controlled Trial Results of Healium. J Med Internet Res 2023; 25:e46552. [PMID: 37862103 PMCID: PMC10625066 DOI: 10.2196/46552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/30/2023] [Accepted: 07/31/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Elicitation of patients' preferences is an integral part of shared decision-making, the recommended approach for prostate cancer decision-making. Existing decision aids for this population often do not specifically focus on patients' preferences. Healium is a brief interactive web-based decision aid that aims to elicit patients' treatment preferences and is designed for a low health literate population. OBJECTIVE This study used a randomized controlled trial to evaluate whether Healium, designed to target preference elicitation, is as efficacious as Healing Choices, a comprehensive education and decision tool, in improving outcomes for decision-making and emotional quality of life. METHODS Patients diagnosed with localized prostate cancer who had not yet made a treatment decision were randomly assigned to the brief Healium intervention or Healing Choices, a decision aid previously developed by our group that serves as a virtual information center on prostate cancer diagnosis and treatment. Assessments were completed at baseline, 6 weeks, and 3 months post baseline, and included decisional outcomes (decisional conflict, satisfaction with decision, and preparation for decision-making), and emotional quality of life (anxiety/tension and depression), along with demographics, comorbidities, and health literacy. RESULTS A total of 327 individuals consented to participate in the study (171 were randomized to the Healium intervention arm and 156 were randomized to Healing Choices). The majority of the sample was non-Hispanic (272/282, 96%), White (239/314, 76%), married (251/320, 78.4%), and was on average 62.4 (SD 6.9) years old. Within both arms, there was a significant decrease in decisional conflict from baseline to 6 weeks postbaseline (Healium, P≤.001; Healing Choices, P≤.001), and a significant increase in satisfaction with one's decision from 6 weeks to 3 months (Healium, P=.04; Healing Choices, P=.01). Within both arms, anxiety/tension (Healium, P=.23; Healing Choices, P=.27) and depression (Healium, P=.001; Healing Choices, P≤.001) decreased from baseline to 6 weeks, but only in the case of depression was the decrease statistically significant. CONCLUSIONS Healium, our brief decision aid focusing on treatment preference elicitation, is as successful in reducing decisional conflict as our previously tested comprehensive decision aid, Healing Choices, and has the added benefit of brevity, making it the ideal tool for integration into the physician consultation and electronic medical record. TRIAL REGISTRATION ClinicalTrials.gov NCT05800483; https://clinicaltrials.gov/study/NCT05800483.
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Affiliation(s)
- Michael A Diefenbach
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Allison Marziliano
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Erin K Tagai
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
| | - Halie Pfister
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Emmanuel Lapitan
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
| | - Simon J Hall
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Smith Institute for Urology, Northwell Cancer Institute, Northwell Health, Manhasset, NY, United States
| | - Manish Vira
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Smith Institute for Urology, Northwell Cancer Institute, Northwell Health, Manhasset, NY, United States
| | - Said Ibrahim
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Kelli Aibel
- Institute of Health System Science, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Alexander Kutikov
- Department of Urology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Curtis Miyamoto
- Department of Radiation Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Adam C Reese
- Department of Urology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Suzanne M Miller
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
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George LS, Saraiya B, Trevino KM, Pflueger K, Voelbel S, Tagai EK, Miller SM, Epstein AS, Duberstein P. Feasibility and Acceptability of an Online Oncologist Training to Optimize Oncologist-Patient Communication and Value-Concordant Care in Advanced Cancer. J Palliat Med 2023; 26:1386-1390. [PMID: 37459165 PMCID: PMC10541926 DOI: 10.1089/jpm.2022.0563] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction: This pilot study tested the feasibility and acceptability of a low-resource-intensive scalable online communication training designed to improve oncologists' skills in prognostic and value-concordant care discussions with advanced cancer patients. Methods: The training consisted of on-demand videos on how to convey prognostic information, manage patient emotions, and elicit patient values and incorporate these values into treatment decision making. Post-intervention, oncologists reported on their perceptions of the training. Results: Fifteen oncologists were enrolled, of whom, 13 completed the training, and 14 completed post-intervention interviews. Most oncologists reported the intervention was acceptable: 92.9% indicated the intervention was "moderately" to "very helpful"; 78.6% rated it as "somewhat" to "very much" impactful on their communication with patients. Conclusions: The present self-paced online communication training was acceptable to oncologists, supporting additional research, including evaluating intervention efficacy for improving oncologists' communication skills and value-concordant care in advanced cancer.
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Affiliation(s)
- Login S. George
- Division of Nursing Science and Institute for Health, Healthcare Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - Biren Saraiya
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kelly M. Trevino
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kiersten Pflueger
- Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, New Brunswick, New Jersey, USA
| | - Sydney Voelbel
- Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, New Brunswick, New Jersey, USA
| | - Erin K. Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, Philadelphia, Pennsylvania, USA
| | - Suzanne M. Miller
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, Philadelphia, Pennsylvania, USA
| | - Andrew S. Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Paul Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, New Brunswick, New Jersey, USA
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Kohler RE, Hemler J, Wagner RB, Sullivan B, Macenat M, Tagai EK, Miller SM, Wen KY, Ayers C, Einstein MH, Hudson SV. Confusion and anxiety in between abnormal cervical cancer screening results and colposcopy: "The land of the unknown". Patient Educ Couns 2023; 114:107810. [PMID: 37244133 PMCID: PMC10527466 DOI: 10.1016/j.pec.2023.107810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Attendance to colposcopy after abnormal cervical cancer screening is essential to cervical cancer prevention. This qualitative study explored patients' understanding of screening results, their experiences of the time leading up to the colposcopy appointment, and colposcopy. METHODS We recruited women referred for colposcopy from two urban practices in an academic health system. Individual interviews (N = 15) with participants were conducted after colposcopy appointments about their cervical cancer screening histories, current results, and colposcopy experiences. A team analyzed and summarized interviews and coded transcripts in Atlas.ti. RESULTS We found that most women were confused about their screening results, did not know what a colposcopy was before being referred for one, and experienced anxiety in the interval between receiving their results and having their colposcopy. Most women searched for information online, but found "misinformation," "worst-case scenarios" and generic information that did not resolve their confusion. CONCLUSION Women had little understanding of their cervical cancer risk and experienced anxiety looking for information and waiting for the colposcopy. Educating patients about cervical precancer and colposcopy, providing tailored information about their abnormal screening test results and potential next steps, and helping women manage distress may alleviate uncertainty while waiting for follow-up appointments. PRACTICE IMPLICATIONS Interventions to manage uncertainty and distress in the interval between receiving an abnormal screening test result and attending colposcopy are needed, even among highly adherent patients.
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Affiliation(s)
- Racquel E Kohler
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA.
| | - Jennifer Hemler
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Rachel B Wagner
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Brittany Sullivan
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Myneka Macenat
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Erin K Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Suzanne M Miller
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Kuang-Yi Wen
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Charletta Ayers
- Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ 08901, USA
| | - Mark H Einstein
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, 185 South Orange Avenue, Newark, NJ 07103, USA
| | - Shawna V Hudson
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA; Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
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Fu J, Fu C, Wang RS, Geynisman DM, Ghatalia P, Lynch SM, Harrison SR, Tagai EK, Ragin C. Current Status and Future Direction to Address Disparities in Diversity, Equity, and Inclusion in Prostate Cancer Care. Curr Oncol Rep 2023; 25:699-708. [PMID: 37010786 PMCID: PMC10068208 DOI: 10.1007/s11912-023-01399-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE OF REVIEW Disparities in prostate cancer care and outcomes have been well recognized for decades. The purpose of this review is to methodically highlight known racial disparities in the care of prostate cancer patients, and in doing so, recognize potential strategies for overcoming these disparities moving forward. RECENT FINDINGS Over the past few years, there has been a growing recognition and push towards addressing disparities in cancer care. This has led to improvements in care delivery trends and a narrowing of racial outcome disparities, but as we highlight in the following review, there is more to be addressed before we can fully close the gap in prostate cancer care delivery. While disparities in prostate cancer care are well recognized in the literature, they are not insurmountable, and progress has been made in identifying areas for improvement and potential strategies for closing the care gap.
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Affiliation(s)
- Jerry Fu
- Duke University, Durham, NC, USA
| | - Chen Fu
- Fox Chase Cancer Center, Philadelphia, PA, USA
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Diefenbach MA, Marziliano A, Siembida EJ, Mistretta T, Pfister H, Yacoub A, Aibel K, Patel P, Lapitan E, Tagai EK, Smaldone M, Miller SM. Cancer Resource and Information Support (CRIS) for Bladder Cancer Survivors and Their Caregivers: Development and Usability Testing Study. JMIR Form Res 2023; 7:e41876. [PMID: 37347533 DOI: 10.2196/41876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 03/14/2023] [Accepted: 04/03/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Bladder cancer survivors and their caregivers face profound practical (eg, use of stoma appliances and care for urinary diversion methods) and psychosocial (eg, depression and anxiety) challenges after surgical treatment with cystectomy. OBJECTIVE To improve the health-related quality of life and postsurgical outcomes of both bladder cancer survivors and their caregivers, the team, in collaboration with Sourcetop, Inc (software design) and Dappersmith (graphic design), developed the Cancer Resource and Information Support (CRIS) software. The purpose of this manuscript is to report on the development and usability testing of the CRIS software. METHODS The development of the CRIS software was guided by the Obesity-Related Behavioral Intervention Trials (ORBIT) model for developing behavioral treatments for chronic diseases. The ORBIT model is unique in that it proposes a flexible and progressive process with prespecific clinically significant milestones for forward movement and returns to earlier stages for refinement, and it facilitates communication among diverse groups by using terminology from the drug development model. This paper focuses on 2 phases of the ORBIT model: phase IA: define and IB: refine. During phase IA, the study team developed solutions for the stated clinical problem-adjustment to life post cystectomy-by reviewing the literature and collecting feedback from clinicians, professional organizations, bladder cancer survivors, and their caregivers. During Phase IB, the study team focused on tailoring content in the CRIS software to the user as well as usability testing with 7 participants. RESULTS The finished product is CRIS, a web-based software for survivors of bladder cancer and their caregivers to serve as a health management and lifestyle resource after surgery. Overarching themes from phase IA (participant feedback) included how to use new medical equipment, tips and tricks for easier living with new medical equipment, questions about health maintenance, and questions about lifestyle modifications. To accommodate our target population, we also incorporated recommendations from the Americans with Disabilities Act for website design, such as large text size, large paragraph spacing, highly contrasting text and background colors, use of headings and labels to describe the purpose of the content, portrait orientation without the need for horizontal scrolling, multiple ways to access a web page within a set of pages, ability to navigate web pages in sequential order, and in-text links that are descriptive. Usability participants evaluated CRIS very positively, indicating that it was easy to use, the functions were well-integrated, and if available, they would use CRIS frequently. CONCLUSIONS CRIS, developed over the course of 18 months by integrating feedback from experts, literature reviews, and usability testing, is the first web-based software developed for bladder cancer survivors and their caregivers to help them adjust to life following cystectomy. The efficacy of CRIS in improving patients' and caregivers' quality of life is currently being evaluated in a randomized controlled trial.
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Affiliation(s)
- Michael A Diefenbach
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Allison Marziliano
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Elizabeth J Siembida
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Thomas Mistretta
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Halie Pfister
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Andrea Yacoub
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Kelli Aibel
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Priya Patel
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Emmanuel Lapitan
- Cancer Prevention and Control, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
| | - Erin K Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
| | - Marc Smaldone
- Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
| | - Suzanne M Miller
- Cancer Prevention and Control, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, United States
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Marziliano A, Diefenbach MA, Hudson SV, Tagai EK, Handorf EA, Bator A, Miller SM. Demographic and Psychosocial Characteristics Associated With Use of a Prostate Cancer Survivorship Website: Implications From a Multisite Randomized Controlled Trial. J Med Internet Res 2022; 24:e27890. [PMID: 35311678 PMCID: PMC8981019 DOI: 10.2196/27890] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 09/13/2021] [Accepted: 10/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background Many prostate cancer (PC) survivors experience disease and treatment-related symptomatology in both the physical and psychosocial domains. Although the benefits and barriers to using web-based resources for cancer patients are well-documented, less research has focused on the personal characteristics important for efficient tailoring and targeting of information that are associated with usage. Objective We used the Cognitive-Social Health Information Processing (C-SHIP) framework to guide our exploration of personal characteristics associated with use of PROGRESS, an informational PC survivorship website that addresses physical, emotional, interpersonal, and practical concerns relevant for PC survivors. Methods PC survivors (N=217) were randomized to the intervention arm (PROGRESS) of a randomized controlled trial. Of those randomized to the intervention arm, 84 used PROGRESS, and 133 did not use PROGRESS. Multivariable analyses evaluated demographic and psychosocial characteristics (eg, style of coping, health literacy, self-efficacy, affective states of depression, anxiety, and fatigue) associated with website use. Results A larger proportion of non-Hispanic White (68/160, 42.5%), compared with non-Hispanic Black (9/40, 23%), participants used PROGRESS (P<.001). Further, PROGRESS users were older in age (P<.001), had a monitoring style of coping (P=.01), and were less depressed (P=.004), anxious (P=.02), and fatigued (P<.001) than nonusers. Education, income, health literacy, blunting style of coping, self-efficacy, and treatment type (radiation therapy or surgery) were not significantly related to use. On multivariable analyses, race (OR 0.28, P<.001), age (OR 1.05, P<.001), monitoring style of coping (OR 1.27, P=.02), and overall mood (OR 0.98, P<.001) remained significant. Conclusions A combination of monitoring and low levels of negative affect were associated with website use. Additionally, users were older, non-Hispanic White survivors. To ensure that important survivorship-relevant information reaches users, future efforts need to focus on enhancing patient engagement. Trial Registration ClinicalTrials.gov NCT02224482; https://clinicaltrials.gov/ct2/show/NCT02224482
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Affiliation(s)
- Allison Marziliano
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Michael A Diefenbach
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Shawna V Hudson
- Rutgers Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Erin K Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, United States
| | - Elizabeth A Handorf
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, United States
| | - Alicja Bator
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, United States
| | - Suzanne M Miller
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, Philadelphia, PA, United States
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10
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Tagai EK, Miller SM, Hudson SV, Diefenbach MA, Handorf E, Bator A, Marziliano A, Kutikov A, Hall SJ, Vira M, Schwartz M, Kim IY, Kim S. Improved cancer coping from a web-based intervention for prostate cancer survivors: A randomized controlled trial. Psychooncology 2021; 30:1466-1475. [PMID: 33855796 DOI: 10.1002/pon.5701] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Prostate cancer (PCa) survivors report poor physical functioning alongside negative psychological outcomes as they cope with treatment side effects and practical concerns after treatment completion. This study evaluated PROGRESS, a web-based intervention designed to improve adaptive coping among PCa survivors. METHODS Localized PCa patients (N = 431) within one year of treatment completion were randomized to receive educational booklets or PROGRESS + educational booklets. Surveys completed at baseline, 1-, 3-, and 6-months assessed patient characteristics; functional quality of life and coping (primary outcomes); and psychosocial outcomes (e.g., self-efficacy, marital communication; secondary outcomes). Intent-to-treat and as-treated analyses were completed to assess change in outcomes from baseline to 6 months using linear mixed effects regression models. RESULTS In the intent-to-treat analyses, participants randomized to the intervention group had improved diversion coping (i.e., healthy redirection of worrying thoughts about their cancer), but more difficulties in marital communication (ps < 0.05). However, PROGRESS usage was low among those randomized to the intervention group (38.7%). The as-treated analyses found PROGRESS users reported fewer practical concerns but had worse positive coping compared to PROGRESS non-users (ps < 0.05). CONCLUSIONS The findings suggest PROGRESS may improve certain aspects of adaptive coping among PCa survivors that use the website, but does not adequately address the remaining coping and psychosocial domains. Additional research is needed to better understand the gaps in intervention delivery contributing to low engagement and poor improvement across all domains of functional quality of life and adaptive coping.
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Affiliation(s)
- Erin K Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Suzanne M Miller
- Cancer Prevention and Control, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Michael A Diefenbach
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Elizabeth Handorf
- Department of Biostatistics and Bioinformatics, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Alicja Bator
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Allison Marziliano
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Alexander Kutikov
- Division of Urology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Simon J Hall
- The Arthur Smith Institute for Urology, Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Manish Vira
- The Arthur Smith Institute for Urology, Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Michael Schwartz
- The Arthur Smith Institute for Urology, Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Issac Yi Kim
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Sung Kim
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
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11
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Tagai EK, Miller SM, Belfiglio A, Xu J, Wen KY, Hernandez E. Persistent Barriers to Smoking Cessation Among Urban, Underserved Women: A Feasibility Study of Tailored Barriers Text Messages. Matern Child Health J 2020; 24:1308-1317. [PMID: 32557133 DOI: 10.1007/s10995-020-02963-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Despite health risks for themselves and their children, urban underserved women smoke at high rates postpartum. The postpartum period is a stressful transition time that presents unique barriers to sustained cessation. There is limited extant evidence of efficacious psychosocial programs to maintain postpartum smoking cessation. METHODS Guided by the Cognitive-Social Health Information Processing model, we explored the feasibility of TxT2Commit, a text-messaging intervention designed to prevent postpartum smoking relapse. Participants (n = 43) received supportive cessation-focused text messages for one month postpartum. Using a convergent mixed method design, surveys and interviews assessed changes in psychosocial factors and smoking status through a three month follow-up. RESULTS Participants reported satisfaction with TxT2Commit, rating text messages as helpful, understandable, supportive, and not bothersome. However, a majority of women (n = 28, 65.1%) relapsed by three months. Participants who stayed smoke free (i.e., non-relapsers) reported significantly less temptation to smoke at one and three months postpartum compared to relapsers (ps < .01). While relapsers had significantly less temptation at one month compared to baseline, temptation increased by three months (p < .01). Consistent with the quantitative results, qualitative interviews identified informational and coping needs, with continued temptation throughout the three months. Non-relapsers were able to manage temptation and reported greater support. CONCLUSIONS FOR PRACTICE TxT2Commit demonstrates preliminary feasibility and acceptability among urban, underserved postpartum women. However, most participants relapsed by three months postpartum. Additional research is needed to identify targeted messaging to best help women avoid temptation and bolster support to stay smoke free in this uniquely stressful period.
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Affiliation(s)
- E K Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - S M Miller
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA.
| | - A Belfiglio
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - J Xu
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - K Y Wen
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Suite 314, Philadelphia, PA, 19107, USA
| | - E Hernandez
- Obstetrics, Gynecology, and Reproductive Sciences, Lewis Katz School of Medicine, Temple University, 3500 N. Broad Street, Philadelphia, PA, 19410, USA
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12
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Holt CL, Tagai EK, Santos SLZ, Scheirer MA, Bowie J, Haider M, Slade J. Web-based versus in-person methods for training lay community health advisors to implement health promotion workshops: participant outcomes from a cluster-randomized trial. Transl Behav Med 2020; 9:573-582. [PMID: 29955889 DOI: 10.1093/tbm/iby065] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Project HEAL (Health through Early Awareness and Learning) is an implementation trial that compared two methods of training lay peer community health advisors (CHAs)-in-person ("Traditional") versus web-based ("Technology")-to conduct a series of three evidence-based cancer educational workshops in African American churches. This analysis reports on participant outcomes from Project HEAL. Fifteen churches were randomized to the two CHA training methods and the intervention impact was examined over 24 months. This study was conducted in Prince George's County, MD, and enrolled 375 church members age 40-75. Participants reported on knowledge and screening behaviors for breast, prostate, and colorectal cancer. Overall, cancer knowledge in all areas increased during the study period (p < .001). There were significant increases in digital rectal exam (p < .05), fecal occult blood test (p < .001), and colonoscopy (p < .01) at 24 months; however, this did not differ by study group. Mammography maintenance (56% overall) was evidenced by women reporting multiple mammograms within the study period. Participants attending all three workshops were more likely to report a fecal occult blood test or colonoscopy at 24 months (p < .05) than those who attended only one. These findings suggest that lay individuals can receive web-based training to successfully implement an evidence-based health promotion intervention that results in participant-level outcomes comparable with (a) people trained using the traditional classroom method and (b) previous efficacy trials. Findings have implications for resources and use of technology to increase widespread dissemination of evidence-based health promotion interventions through training lay persons in community settings.
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Affiliation(s)
- Cheryl L Holt
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, MD, USA
| | - Erin K Tagai
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, MD, USA
| | - Sherie Lou Zara Santos
- Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, MD, USA
| | | | - Janice Bowie
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Muhiuddin Haider
- School of Public Health, Institute for Applied Environmental Health, University of Maryland, College Park, MD, USA
| | - Jimmie Slade
- Community Ministry of Prince George's County, Upper Marlboro, MD, USA
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13
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Tagai EK, Hudson SV, Diefenbach MA, Xu J, Bator A, Marziliano A, Miller SM. Social and medical risk factors associated with supportive needs in the first year following localized prostate cancer treatment. J Cancer Surviv 2020; 15:110-118. [PMID: 32681305 PMCID: PMC7872345 DOI: 10.1007/s11764-020-00916-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/10/2020] [Indexed: 01/18/2023]
Abstract
Purpose: Individuals who completed treatment for prostate cancer (PCa) often
report poor coping and practical concerns when adapting to new roles in
their lives—and strong patient-provider communication is critical for
this period. However, there is limited research identifying factors
associated with supportive needs after the completion of PCa treatment. This
study aimed to identify the social and medical risk factors associated with
supportive needs for adapting among individuals who completed treatment for
localized PCa. Methods: Using baseline data from a study evaluating a web-based support
system for patients in the first year following treatment for localized PCa,
self-efficacy for re-entry (e.g., maintaining relationships, symptom
management), medical interactions, and practical concerns (e.g., insurance,
exercise) were assessed. Multivariable regression analyses were completed to
identify risk factors for low readiness. Results: Participants (N=431) with lower health literacy or income, or with
depressive symptoms had lower self-efficacy for re-entry, more negative
interactions with medical providers, and more practical concerns
(ps<.05). Lastly, Non-Hispanic White
participants reported greater readiness compared to all other races
(ps<.05). Conclusions: Multiple social and medical risk factors are associated with greater
supportive needs when adapting to new roles after PCa treatment.
Understanding the risk factors for supportive needs in this period is
critical. Future research is needed to help providers identify and support
individuals at risk for poorer coping and greater practical concerns after
treatment completion. Implications for Cancer Survivors: Identifying individuals with greater supportive needs following
treatment for localized PCa treatment will help ensure successful adaptation
to new roles.
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Affiliation(s)
- Erin K Tagai
- Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA
| | - Shawna V Hudson
- Rutgers Robert Wood Johnson Medical School, The State University of New Jersey, 125 Patterson St, New Brunswick, NJ, 08901, USA.,Division of Population Science, Rutgers Cancer Institute of New Jersey, The State University of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08903, USA
| | - Michael A Diefenbach
- Center for Health Innovation and Outcomes Research, Feinstein Institute for Medical Research, Northwell Health, 300 Community Dr, Manhasset, NY, 11030, USA
| | - Jenny Xu
- Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA
| | - Alicja Bator
- Rutgers Robert Wood Johnson Medical School, The State University of New Jersey, 125 Patterson St, New Brunswick, NJ, 08901, USA
| | - Allison Marziliano
- Center for Health Innovation and Outcomes Research, Feinstein Institute for Medical Research, Northwell Health, 300 Community Dr, Manhasset, NY, 11030, USA
| | - Suzanne M Miller
- Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA.
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14
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Lynch SM, Sorice K, Tagai EK, Handorf EA. Use of empiric methods to inform prostate cancer health disparities: Comparison of neighborhood-wide association study "hits" in black and white men. Cancer 2020; 126:1949-1957. [PMID: 32012234 DOI: 10.1002/cncr.32734] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/30/2019] [Accepted: 01/03/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Black men are more likely to die of prostate cancer (PCa) compared with white men. Factors ranging from genetics to neighborhood environment contribute to these disparities. However, unlike genetics, agnostic investigations that identify candidate variables from large-scale data, and that allow for empiric investigations into differential associations between neighborhood and PCa by race/ethnicity, to the authors' knowledge have not been well explored. Thus, herein, the authors built on their previously developed, empiric neighborhood-wide association study (NWAS) in white men and conducted a NWAS in black men to determine whether findings differed by race. METHODS Pennsylvania Cancer Registry data were linked to US Census data. For the NWAS in non-Hispanic black men, the authors evaluated the association between 14,663 neighborhood census variables and advanced PCa (11 high-stage and/or high-grade cases and 8632 low-stage and/or low-grade cases), adjusting for age, diagnosis year, spatial correlation, and multiple testing. Odds ratios and 95% credible intervals were reported. Replication of NWAS findings across black and white races was assessed using Bayesian mixed effects models. RESULTS Five variables related to housing (3 variables), education (1 variable), and employment and/or transportation (1 variable) were found to be significantly associated with advanced PCa in black men compared with 17 socioeconomic variables (mostly related to poverty and/or income) in white men. The top hit in black men was related to crowding in renter-occupied housing (odds ratio, 1.10; 95% credible interval, 1.001-1.12). Nine of 22 NWAS hits (4 of 5 hits in black men) were replicated across racial/ethnic groups. CONCLUSIONS Different neighborhood variables, or "candidates," were identified across race-specific NWASs. These findings and empiric approaches warrant additional study and may inform PCa racial disparities, particularly future gene-environment studies aimed at identifying patients and/or communities at risk of advanced PCa.
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Affiliation(s)
- Shannon M Lynch
- Cancer Prevention and Control, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Kristen Sorice
- Cancer Prevention and Control, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Erin K Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elizabeth A Handorf
- Population Studies Facility, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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15
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Tagai EK, Miller SM, Kutikov A, Diefenbach MA, Gor RA, Al-Saleem T, Chen DYT, Fleszar S, Roy G. Prostate Cancer Patients' Understanding of the Gleason Scoring System: Implications for Shared Decision-Making. J Cancer Educ 2019; 34:441-445. [PMID: 29333577 PMCID: PMC6557691 DOI: 10.1007/s13187-018-1320-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The Gleason scoring system is a key component of a prostate cancer diagnosis, since it indicates disease aggressiveness. It also serves as a risk communication tool that facilitates shared treatment decision-making. However, the system is highly complex and therefore difficult to communicate: factors which have been shown to undermine well-informed and high-quality shared treatment decision-making. To systematically explore prostate cancer patients' understanding of the Gleason scoring system (GSS), we assessed knowledge and perceived importance among men who had completed treatment (N = 50). Patients were administered a survey that assessed patient knowledge and patients' perceived importance of the GSS, as well as demographics, medical factors (e.g., Gleason score at diagnosis), and health literacy. Bivariate analyses were conducted to identify associations with patient knowledge and perceived importance of the GSS. The sample was generally well-educated (48% with a bachelor's degree or higher) and health literate (M = 12.9, SD = 2.2, range = 3-15). Despite this, patient knowledge of the GSS was low (M = 1.8, SD = 1.4, range = 1-4). Patients' understanding of the importance of the GSS was moderate (M = 2.8, SD = 1.0, range = 0-4) and was positively associated with GSS knowledge (p < .01). Additionally, GSS knowledge was negatively associated with years since biopsy (p < .05). Age and health literacy were positively associated with patients' perceived importance of the GSS (p < .05), but not with GSS knowledge. Patient knowledge is thus less than optimal and would benefit from enhanced communication to maximize shared treatment decision-making. Future studies are needed to explore the potential utility of a simplified Gleason grading system and improved patient-provider communication.
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Affiliation(s)
- Erin K Tagai
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Suzanne M Miller
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA.
| | - Alexander Kutikov
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | | | - Ronak A Gor
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Tahseen Al-Saleem
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - David Y T Chen
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Sara Fleszar
- Northwell Health System, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Gem Roy
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
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16
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Williams RM, Tagai EK, Santos SLZ, Slade JL, Carter RL, Holt CL. The Role of Leadership Support in a Church-Based Cancer Education Implementation Study. J Relig Health 2018; 57:146-156. [PMID: 28597333 PMCID: PMC5723241 DOI: 10.1007/s10943-017-0427-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Leadership plays a role in the success of an organization's initiatives. We examined church leaders' support-as perceived by lay community health advisor (CHA) interventionists-and implementation outcomes in a cancer early detection trial. CHAs perceived that their pastors: helped promote the intervention (M = 3.1/4, SD 1.2) and attended about half (M = 1.6/3, SD 1.3) the workshops. CHAs used marginally more techniques to recruit members when they perceived pastors were engaged in promoting the program (r s = .44, p = .08). Pastor attendance was positively associated with member enrollment (r s = .50, p < .05). Pastor support may be related to receptivity of both CHAs and congregants to engage in church health promotion.
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Affiliation(s)
- Randi M Williams
- Department of Behavioral and Community Health, School of Public Health (255), University of Maryland, 4200 Valley Drive, College Park, MD, 20742, USA.
| | | | - Sherie Lou Zara Santos
- Department of Behavioral and Community Health, School of Public Health (255), University of Maryland, 4200 Valley Drive, College Park, MD, 20742, USA
| | - Jimmie L Slade
- Community Ministry of Prince George's County, Upper Marlboro, MD, USA
| | - Roxanne L Carter
- Community Ministry of Prince George's County, Upper Marlboro, MD, USA
| | - Cheryl L Holt
- Department of Behavioral and Community Health, School of Public Health (255), University of Maryland, 4200 Valley Drive, College Park, MD, 20742, USA
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17
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Miller SM, Tagai EK, Wen KY, Lee M, Hui SKA, Kurtz D, Scarpato J, Hernandez E. Predictors of adherence to follow-up recommendations after an abnormal Pap smear among underserved inner-city women. Patient Educ Couns 2017; 100:1353-1359. [PMID: 28190541 PMCID: PMC5466500 DOI: 10.1016/j.pec.2017.01.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 01/04/2017] [Accepted: 01/30/2017] [Indexed: 05/14/2023]
Abstract
OBJECTIVES This study aimed to identify cognitive-affective predictors of adherence to initial diagnostic colposcopy and 6-month follow-up recommendations among underserved women. METHODS A secondary data analysis was completed of a randomized clinical trial assessing tailored telephone counseling for colposcopy adherence after an abnormal screening Pap smear among 210 underserved inner-city women. RESULTS Adherence to initial diagnostic colposcopy was significantly associated with greater self-efficacy (OR=1.504, 95% CI 1.021-2.216). Women with lower monitoring attentional style had significantly greater adherence to 6-month follow-up recommendations compared to women with higher monitoring scores (OR=0.785, 95% CI 0.659-0.935). CONCLUSION Increasing cervical cancer-related self-efficacy and tailoring cervical cancer risk communication to monitoring attentional style may help improve adherence to follow-up recommendations after an abnormal Pap smear test result. PRACTICE IMPLICATIONS Future research is needed to develop and implement psychosocial approaches to improving adherence to diagnostic colposcopy and follow-up recommendations adherence among underserved women.
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Affiliation(s)
- Suzanne M Miller
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, Temple University School of Medicine, 3500 N. Broad Street, Philadelphia, PA, 19140, USA.
| | - Erin K Tagai
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Kuang-Yi Wen
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Minsun Lee
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Siu-Kuen Azor Hui
- Research & Evaluation Group, Public Health Management Corporation, 1500 Market Street, Suite 1500, Philadelphia, PA, 19102, USA
| | - Deirdre Kurtz
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - John Scarpato
- Department of Patient Empowerment and Decision Making, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Enrique Hernandez
- Department of Obstetrics, Gynecology and Reproductive Sciences, Temple University School of Medicine, 3500 N. Broad Street, Philadelphia, PA, 19140, USA
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18
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Scheirer MA, Santos SLZ, Tagai EK, Bowie J, Slade J, Carter R, Holt CL. Dimensions of sustainability for a health communication intervention in African American churches: a multi-methods study. Implement Sci 2017; 12:43. [PMID: 28351405 PMCID: PMC5371253 DOI: 10.1186/s13012-017-0576-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 03/21/2017] [Indexed: 11/13/2022] Open
Abstract
Background Sustainability of evidence-based health promotion interventions has received increased research attention in recent years. This paper reports sustainability data from Project HEAL (Health through Early Awareness and Learning) a cancer communication implementation trial about early detection, based in African American churches. In this paper, we used a framework by Scheirer and Dearing (Am J Publ Health 101:2059-2067, 2011) to evaluate multiple dimensions of sustainability from Project HEAL. Methods We examined the following dimensions of sustainability: (a) continued benefits for intervention recipients, (b) continuation of intervention activities, c) maintaining community partnerships, (d) changes in organizational policies or structures, (e) sustained attention to the underlying issues, (f) diffusion to additional sites, or even (g) unplanned consequences of the intervention. Project HEAL provided a three-workshop cancer educational series delivered by trained lay peer community health advisors (CHAs) in their churches. Multiple sources of sustainability were collected at 12 and 24 months after the intervention that reflect several levels of analysis: participant surveys; interviews with CHAs; records from the project’s management database; and open-ended comments from CHAs, staff, and community partners. Results Outcomes differ for each dimension of sustainability. For continued benefit, 39 and 37% of the initial 375 church members attended the 12- and 24-month follow-up workshops, respectively. Most participants reported sharing the information from Project HEAL with family or friends (92% at 12 months; 87% at 24 months). For continuation of intervention activities, some CHAs reported that the churches held at least one additional cancer educational workshop (33% at 12 months; 24% at 24 months), but many more CHAs reported subsequent health activities in their churches (71% at 12 months; 52% at 24 months). No church replicated the original series of three workshops. Additional data confirm the maintenance of community partnerships, some changes in church health policies, and continued attention to health issues by churches and CHAs. Conclusions The multiple dimensions of sustainability require different data sources and levels of analysis and show varied sustainability outcomes in this project. The findings reinforce the dynamic nature of evidence-based health interventions in community contexts. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0576-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Sherie Lou Z Santos
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, College Park, MD, USA
| | - Erin K Tagai
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, College Park, MD, USA
| | - Janice Bowie
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jimmie Slade
- Community Ministry of Prince George's County, Seat Pleasant, MD, USA
| | - Roxanne Carter
- Community Ministry of Prince George's County, Seat Pleasant, MD, USA
| | - Cheryl L Holt
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, College Park, MD, USA.
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Santos SLZ, Tagai EK, Scheirer MA, Bowie J, Haider M, Slade J, Wang MQ, Holt CL. Adoption, reach, and implementation of a cancer education intervention in African American churches. Implement Sci 2017; 12:36. [PMID: 28292299 PMCID: PMC5351199 DOI: 10.1186/s13012-017-0566-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 03/02/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Use of technology is increasing in health promotion and has continued growth potential in intervention research. Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, this paper reports on the adoption, reach, and implementation of Project HEAL (Health through Early Awareness and Learning)-a community-based implementation trial of a cancer educational intervention in 14 African American churches. We compare adoption, reach, and implementation at the organizational and participant level for churches in which lay peer community health advisors (CHAs) were trained using traditional classroom didactic methods compared with a new online system. METHODS Fifteen churches were randomized to one of two study groups in which two CHAs per church were trained through either classroom ("Traditional"; n = 16 CHAs in 8 churches) or web-based ("Technology"; n = 14 CHAs in 7 churches) training methods. Once trained and certified, all CHAs conducted a series of three group educational workshops in their churches on cancer early detection (breast, prostate, and colorectal). Adoption, reach, and implementation were assessed using multiple data sources including church-level data, participant engagement in the workshops, and study staff observations of CHA performance. RESULTS The project had a 41% overall adoption rate at the church level. In terms of reach, a total of 375 participants enrolled in Project HEAL-226 participants in the Traditional group (43% reach) and 149 in the Technology group (21% reach; p < .10). Implementation was evaluated in terms of adherence, dosage, and quality. All churches fully completed the three workshops; however, the Traditional churches took somewhat longer (M = 84 days) to complete the workshop series than churches in the Technology group (M = 64 days). Other implementation outcomes were comparable between both the Traditional and Technology groups (p > .05). CONCLUSIONS Overall, the Project HEAL intervention had reasonable adoption, though reach could have been better. Implementation was strong across both study groups, suggesting the promise of using web-based methods to disseminate and implement evidence-based interventions in faith-based settings and other areas where community health educators work to eliminate health disparities.
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Affiliation(s)
- Sherie Lou Zara Santos
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, 4200 Valley Dr., 1101 E SPH Building 255, College Park, MD, 20742, USA.
| | - Erin K Tagai
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, 4200 Valley Dr., 1101 E SPH Building 255, College Park, MD, 20742, USA
| | | | - Janice Bowie
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Muhiuddin Haider
- Institute for Applied Environmental Health, University of Maryland, School of Public Health, College Park, MD, USA
| | - Jimmie Slade
- Community Ministry of Prince George's County, Upper Marlboro, MD, USA
| | - Min Qi Wang
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, 4200 Valley Dr., 1101 E SPH Building 255, College Park, MD, 20742, USA
| | - Cheryl L Holt
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, 4200 Valley Dr., 1101 E SPH Building 255, College Park, MD, 20742, USA
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Roussi P, Miller SM, Giri VN, Obeid E, Wen KY, Tagai EK, Scarpato J, Gross L, Roy G. Effects of a randomized trial comparing standard and enhanced counseling for men at high risk of prostate cancer as a function of race and monitoring style. J Health Psychol 2016; 23:1800-1809. [PMID: 28810355 DOI: 10.1177/1359105316671188] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Despite conflicting guidelines, a significant subset of high-risk men decide to undergo routine prostate cancer screening. Yet, there is a scarcity of available programs, and no studies evaluating interventions to support men in dealing with the psychosocial impact of screening. In this study, one of the first to explore the responses of high-risk men enrolling in a Prostate Cancer Risk Assessment Program ( N = 128), patients underwent a prostate cancer risk counseling visit immediately followed by either a cognitive-affective preparation session designed to help them process the information they received or a general health education session. All men in this self-selected sample chose to participate in prostate cancer screening. Men were assessed 3 weeks and 6 months post-counseling. The impact of the enhanced counseling condition on knowledge, perceived risk, expectancies, and intrusive ideation was a function of racial and coping style group. Implications for tailored interventions to maximize preparedness for risk and screening counseling are discussed.
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Affiliation(s)
| | - Suzanne M Miller
- 2 Fox Chase Cancer Center, USA.,4 Temple University Health System, USA
| | | | | | - Kuang-Yi Wen
- 2 Fox Chase Cancer Center, USA.,4 Temple University Health System, USA
| | - Erin K Tagai
- 2 Fox Chase Cancer Center, USA.,4 Temple University Health System, USA
| | - John Scarpato
- 2 Fox Chase Cancer Center, USA.,4 Temple University Health System, USA
| | | | - Gem Roy
- 2 Fox Chase Cancer Center, USA.,4 Temple University Health System, USA
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Santos SLZ, Tagai EK, Wang MQ, Scheirer MA, Slade JL, Holt CL. Feasibility of a web-based training system for peer community health advisors in cancer early detection among african americans. Am J Public Health 2014; 104:2282-9. [PMID: 25320894 PMCID: PMC4232123 DOI: 10.2105/ajph.2014.302237] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2014] [Indexed: 12/26/2022]
Abstract
We describe the feasibility of a Web-based portal for training peer community health advisors (CHAs). We conducted a community-based implementation trial in African American churches between 2012 and 2014. The Web-based portal allows CHAs to log in and view 13 training videos, preparing them to deliver 3 cancer early detection workshops in their churches. Of 8 churches, 6 completed the training, each certifying 2 CHAs. These CHAs took an average of 26 days to complete the training, requiring little technical assistance. Additional technical assistance was required to implement the workshops. The Web-based system appears to be a feasible method for training lay individuals for the CHA role and has implications for increasing the reach of evidence-based interventions.
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Affiliation(s)
- Sherie Lou Z Santos
- Sherie Lou Z. Santos, Erin K. Tagai, Min Qi Wang, and Cheryl L. Holt are with the Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park. Mary Ann Scheirer is with Scheirer Consulting, Princeton, NJ. Jimmie L. Slade is with Community Ministry of Prince George's County, Upper Marlboro, MD
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Holt CL, Tagai EK, Scheirer MA, Santos SLZ, Bowie J, Haider M, Slade JL, Wang MQ, Whitehead T. Translating evidence-based interventions for implementation: Experiences from Project HEAL in African American churches. Implement Sci 2014; 9:66. [PMID: 24885069 PMCID: PMC4057552 DOI: 10.1186/1748-5908-9-66] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 05/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community-based approaches have been increasing in the effort to raise awareness and early detection for cancer and other chronic disease. However, many times, such interventions are tested in randomized trials, become evidence-based, and then fail to reach further use in the community. Project HEAL (Health through Early Awareness and Learning) is an implementation trial that aims to compare two strategies of implementing evidence-based cancer communication interventions in African American faith-based organizations. METHOD This article describes the community-engaged process of transforming three evidence-based cancer communication interventions into a coherent, branded strategy for training community health advisors with two delivery mechanisms. Peer community health advisors receive training through either a traditional classroom approach (with high technical assistance/support) or a web-based training portal (with low technical assistance/support). RESULTS We describe the process, outline the intervention components, report on the pilot test, and conclude with lessons learned from each of these phases. Though the pilot phase showed feasibility, it resulted in modifications to data collection protocols and team and community member roles and expectations. CONCLUSIONS Project HEAL offers a promising strategy to implement evidence-based interventions in community settings through the use of technology. There could be wider implications for chronic disease prevention and control.
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Affiliation(s)
- Cheryl L Holt
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, 2369 School of Public Health (Building 255), College Park, MD 20742, USA
| | - Erin K Tagai
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, 2369 School of Public Health (Building 255), College Park, MD 20742, USA
| | | | - Sherie Lou Z Santos
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, 2369 School of Public Health (Building 255), College Park, MD 20742, USA
| | - Janice Bowie
- Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Muhiuddin Haider
- Maryland Institute for Applied Environmental Health, University of Maryland, School of Public Health, College Park, USA
| | - Jimmie L Slade
- Community Ministry of Prince George’s County, Upper Marlboro, USA
| | - Min Qi Wang
- Department of Behavioral and Community Health, University of Maryland, School of Public Health, 2369 School of Public Health (Building 255), College Park, MD 20742, USA
| | - Tony Whitehead
- Department of Anthropology, University of Maryland, College Park, USA
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