Receipt, uptake, and satisfaction with tailored DVD and patient navigation interventions to promote cancer screening among rural women

Process evaluation is essential to understanding and interpreting the results of randomized trials testing the effects of behavioral interventions. A process evaluation was conducted as part of a comparative effectiveness trial testing a mailed, tailored interactive digital video disc (DVD) with and without telephone-based patient navigation (PN) to promote breast, cervical and colorectal cancer screening among rural women who were not up-to-date (UTD) for at least one screening test. Data on receipt, uptake, and satisfaction with the interventions were collected via telephone interviews from 542 participants who received the tailored interactive DVD (n = 266) or the DVD plus telephone-based PN (n = 276). All participants reported receiving the DVD and 93.0% viewed it. The most viewed sections of the DVD were about colorectal, followed by breast, then cervical cancer screening. Most participants agreed the DVD was easy to understand, helpful, provided trustworthy information, and gave information needed to make a decision about screening. Most women in the DVD+PN group, 98.2% (n = 268), reported talking with the navigator. The most frequently discussed cancer screenings were colorectal (86.8%) and breast (71.3%); 57.5% discussed cervical cancer screening. The average combined length of PN encounters was 22.2 minutes with 21.7 additional minutes spent on coordinating activities. Barriers were similar across screening tests with the common ones related to the provider/health care system, lack of knowledge, forgetfulness/too much bother, and personal issues. This evaluation provided information about the implementation and delivery of behavioral interventions as well as challenges encountered that may impact trial results.

Factors associated with the accurate self-report of cancer screening behaviors among women living in the rural Midwest region of the United States

This study examines the accuracy of the self-report of up-to-date cancer screening behaviors (Mammography, Papanicolaou (Pap)/Human Papillomavirus (HPV) tests, Fecal Occult Blood Test (FOBT)/Fecal Immunochemical Test (FIT), Colonoscopy) compared to medical record documentation prior to eligibility determination and enrollment in a randomized controlled trial of an intervention to increase cancer screening among women living in rural counties of Indiana and Ohio. Women (n = 1,641) completed surveys and returned a medical record release form from November 2016-June 2019. We compared self-report to medical records for up-to-date cancer screening behaviors to determine the validity of self-report. Logistic regression models identified variables associated with accurate reporting. Women were up-to-date for mammography (75 %), Pap/HPV test (54 %), colonoscopy (53 %), and FOBT/FIT (6 %) by medical record. Although 39.6 % of women reported being up-to-date for all three anatomic sites (breast, cervix, and colon), only 31.8 % were up to date by medical records. Correlates of accurate reporting of up-to-date cancer screening varied by screening test. Approximately-one-third of women in rural counties in the Midwest are up-to-date for all three anatomic sites and correlates of the accurate reporting of screening varied by test. Although most investigators use medical records to verify completion of cancer screening behaviors as the primary outcome of intervention trials, they do not usually use medical records for the routine verification of study eligibility. Study results suggest that future research should use medical record documentation of cancer screening behaviors to determine eligibility for trials evaluating interventions to increase cancer screening.

Increasing breast, cervical, and colorectal cancer screening among rural women: Baseline characteristics of a randomized control trial

BACKGROUND

Rural women suffer disproportionately from breast, cervical, and colorectal cancer mortality compared to those in urban areas. Screening behaviors for these three cancers share many similar beliefs and barriers. Unfortunately, published interventions have not attempted to simultaneously bring women up to date with screening for three cancers (breast, cervical, and colorectal) even though multiple behavior change interventions are effective. The aim of this randomized controlled study was to compare the effectiveness of a mailed interactive and tailored DVD vs. DVD plus telephonic patient navigation (DVD + PN) vs. Usual Care (UC) to increase the percentage of rural women (aged 50-74) up to date for breast, cervical, and colorectal cancer screening.

METHODS

Nine hundred eighty-three participants needing one, two, or three cancer screening tests were consented and randomized to one of three groups. Prior to randomization, women were assessed for baseline characteristics including sociodemographics, health status, and cancer screening test beliefs. Screening status was assessed by medical record review.

RESULTS

At baseline, the average age of participants was 58.6 years. Nineteen percent of the sample was not up to date with screenings for all three cancers. Colorectal cancer had the highest percentage of women (69%) who were not up to date with screening followed by cervical (57%) and then breast cancer (41%). Sixty percent of women reported receiving a reminder for mammography; 30%, for cervical cancer screening; 15% for colonoscopy; and 6% for FOBT/FIT.

DISCUSSION

Increasing adherence to colorectal cancer screening may be the most urgent need among all screening tests. This clinical trial is registered at clinicaltrials.gov with identifier NCT02795104.

Unconventional Spin Relaxation Involving Localized Vibrational Modes in Ho Single-Atom Magnets

We investigate the spin relaxation of Ho single atom magnets on MgO/Ag(100) as a function of temperature and magnetic field. We find that the spin relaxation is thermally activated at low field, while it remains larger than 1000 s up to 30 K and 8 T. This behavior contrasts with that of single molecule magnets and bulk paramagnetic impurities, which relax faster at high field. Combining our results with density functional theory, we rationalize this unconventional behavior by showing that local vibrations activate a two-phonon Raman process with a relaxation rate that peaks near zero field and is suppressed at high field. Our work shows the importance of these excitations in the relaxation of axially coordinated magnetic atoms.

Predictors of Willingness to Participate in Biospecimen Donation and Biobanking among Appalachian Adults

BACKGROUND

Rural residents in the U.S., particularly residents of Appalachia, are underrepresented in biomedical research, limiting the generalizability of research findings.

OBJECTIVE

To examine factors associated with Appalachian adults' willingness to participate in biospecimen donation and banking.

METHODS

A survey assessing willingness to donate blood, saliva, and buccal specimens and to have these biospecimens stored for future use in genetic studies was conducted among 493 Appalachian adults.

RESULTS

Most participants 73% (358/493) were willing to donate one or more biospecimen type; among them, 75% (268/358) were willing to donate blood, saliva, and buccal specimens. Approximately 61% (300/493) were willing to have their biospecimens banked and 97% (290/300) of these were willing to have their samples used for genetic studies. Appalachian self-identity predicted willingness to donate biospecimens, to have them stored, and used in genetic studies (OR1.52, 95% CI 1.03-2.24).

CONCLUSIONS

Appalachian adults were generally willing to participate in biobanking research.

Predictors of Colorectal Cancer Screening in Two Underserved U.S. Populations: A Parallel Analysis

Background

Despite declining colorectal cancer (CRC) incidence and mortality rates in the U.S., significant geographic and racial disparities in CRC death rates remain. Differences in guideline-concordant CRC screening rates may explain some of these disparities. We aim to assess individual and neighborhood-level predictors of guideline-concordant CRC screening within two cohorts of individuals located within CRC mortality geographic hotspot regions in the U.S.

Methods

A total of 36,901 participants from the Southern Community Cohort Study and 4,491 participants from the Ohio Appalachia CRC screening study were included in this study. Self-reported date of last CRC screening was used to determine if the participant was within guidelines for screening. Logistic regression models were utilized to determine the association of individual-level predictors, neighborhood deprivation, and residence in hotspot regions on the odds of being within guidelines for CRC screening.

Results

Lower household income, lack of health insurance, and being a smoker were each associated with lower odds of being within guidelines for CRC screening in both cohorts. Area-level associations were less evident, although up to 15% lower guideline adherence was associated with residence in neighborhoods of greater deprivation and in the Lower Mississippi Delta, one of the identified CRC mortality hotspots.

Conclusion

These results reveal the adverse effects of lower area-level and individual socioeconomic status on adherence to CRC guideline screening.

Abstract PR03: Multi-level research designs for understanding the determinants of cervical cancer disparities

Appalachia, a region that spans 420 counties in 13 states from New York to Mississippi, has a greater proportion of residents with low socioeconomic status (SES), including lower household incomes, higher unemployment, and deficits in education compared to the United States (U.S.) as a whole. These factors contribute to disparities such as access to quality healthcare and an increased cancer burden. Cervical cancer incidence and mortality rates in Appalachia are significantly higher than among other women in the U.S. In order to understand and intervene on cancer health disparities, the Centers for Population Health and Health Disparities (CPHHD) initiative developed and tested a multi-level socio-ecological framework (Warnecke model) which included social, behavioral, environmental and biological variables as contributing and interacting factors. The Ohio State University Comprehensive Cancer Center's CPHHD (P50CA015632) used this framework to better understand why cervical cancer disparities exist and to attempt to reduce the cervical cancer burden within Appalachian Ohio.

Four studies, that spanned the Warnecke model levels of influence, were conducted to address important factors causing cervical cancer: 1) the genetic contributions to invasive cervical cancer; 2) the influence of social networks on smoking behaviors; 3) the biological effects of stress on immunity to the HPV vaccine; 4) and the effects of a multi-level intervention on uptake of the HPV vaccine among adolescent girls. The results of each study were examined on a multi-level basis and then the significant factors from each study were included in an overall multi-level model to explain the disparity of cervical cancer in Appalachian Ohio. In all, a total of 1340 participants were included in these studies.

Results from the multi-level models from each study revealed that 1) the interaction of individual risk factors and genetic mechanisms is related to cervical cancer in non-smokers; 2) in terms of tobacco use, individual factors such as age and depression as well as an individual's social network and social influence and social cohesion are relevant factors; 3) poverty, discrimination, social cohesion, neighborhood disadvantage, social support, age, SES, and depression were associated with the immune response to the HPV vaccine; and 4) the interplay of institutional structures such as healthcare systems and families, social influences, as well as SES were associated with HPV vaccine uptake among adolescent girls. Taken together, these results suggest that upstream (poverty, discrimination, health care systems, families, social cohesion, social networks, social support, social influences, and neighborhood factors) as well as downstream factors (tobacco use, age, SES, education, depression, genetics and immune function) together contribute to cervical cancer disparities in Appalachian Ohio. Interventions must now be developed and implemented across these multiple levels to reduce disparities.

Citation Format: Electra D. Paskett, Ryan Baltic, Cecilia R. DeGraffinreid, Mary Ellen Wewers, Mack T. Ruffin, IV, Christopher M. Weghorst, Thomas J. Knobloch, Mira L. Katz, Cathy M. Tatum, Michael L. Pennell, Bo Lu, Erinn M. Hade, Amy K. Ferketich. Multi-level research designs for understanding the determinants of cervical cancer disparities. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr PR03.

Magnetic remanence in single atoms

A permanent magnet retains a substantial fraction of its saturation magnetization in the absence of an external magnetic field. Realizing magnetic remanence in a single atom allows for storing and processing information in the smallest unit of matter. We show that individual holmium (Ho) atoms adsorbed on ultrathin MgO(100) layers on Ag(100) exhibit magnetic remanence up to a temperature of 30 kelvin and a relaxation time of 1500 seconds at 10 kelvin. This extraordinary stability is achieved by the realization of a symmetry-protected magnetic ground state and by decoupling the Ho spin from the underlying metal by a tunnel barrier.

Abstract A41: Willingness of adults in Appalachia to participate in research involving biospecimens, biobanking and genetics

Introduction: Rural residents in the U.S., specifically residents of Appalachia, continue to be underrepresented in cancer-related research, which limits the generalizability of findings. In this study, we examined factors associated with willingness of Appalachian adults to participate in donation and banking of biospecimens for research.

Methods: As a component of the Appalachian Community Cancer Network (ACCN) II Research Study, between January 2012 and September 2013, we conducted a survey among a faith-based sample of 493 Appalachian adults age 18-92 years (mean = 55.8 years). Five questions aimed at assessing participants' willingness (five-point scale: not willing at all, hesitant but willing, neutral, willing, very willing) to donate blood, saliva, and buccal specimens and to have their specimens banked and used in future genetics studies were included in the survey. Using univariate logistic regression models, where the outcomes were dichotomized (“willing” [very willing or willing] vs. “not willing” [neutral, hesitant but willing, or not willing at all]), we calculated odds ratios (ORs) and 95% confidence intervals (CIs) to describe factors significantly associated with participants' willingness to provide these samples. Future analyses will include multivariable-adjusted models.

Results: Approximately 73% (358/493) indicated willingness to donate ≥1 biospecimen type; among them, 75% (268/358) were willing to donate all 3 types. Years of education (16 yrs vs. ≤12 yrs: OR 1.85, 95% CI 1.15-2.99), being employed (OR 1.63, 95% CI 1.07-2.49), having private insurance (OR 1.75, 95% CI 1.18-2.63), identifying as Appalachian (OR 1.61, 95% CI 1.00-2.58), being religious (OR 1.66, 95% CI 1.03-2.66) and being normotensive (OR 1.64, 95% CI 1.12-2.38) were associated with willingness to donate blood. Years of education (16 yrs vs. ≤12 yrs: OR 2.47, 95% CI 1.48-4.11), being employed (OR 1.64, 95% CI 1.06-2.52) and having private insurance (OR 1.52, 95% CI 1.01-2.27) were associated with willingness to donate a buccal sample. Years of education (16 yrs vs. ≤12 yrs: OR 1.94, 95% CI 1.22-3.10) and being employed (OR 1.52, 95% CI 1.01-2.31) were associated with willingness to donate saliva. Approximately 61% (300/493) of participants indicated willingness to have their biospecimens banked for use in future studies; among them, 97% (290/300) were willing to have their samples used for future genetics studies. Years of education (16 yrs vs. ≤12 yrs: OR 2.04, 95% CI 1.27-3.28), regularly engaging in physical activity (OR 1.60, 95% CI 1.10-2.33) and experiencing fewer depressive symptoms (OR 1.85, 95% CI 1.10-3.13) were associated with willingness to have donated biospecimens stored for future research. Years of education (16 yrs vs. ≤12 yrs: OR 2.29, 95% CI 1.40-3.74) and being employed (OR 1.66, 95% CI 1.08-2.54) were associated with willingness to allow donated biospecimens to be used in genetics studies.

Conclusions: Appalachian adults in this study responded favorably to questions regarding willingness to participate in biospecimen donation and banking for future research, including genetics studies. Respondents with higher socioeconomic status and positive self-reported health status were most likely to endorse biospecimen donation. This study offers insights into the predictors of willingness to participate in donation and banking of biospecimens for research and may contribute to future efforts to increase equitable representation of Appalachian residents in biomedical research.

Citation Format: Adana A.M. Llanos, Gregory S. Young, Eugene J. Lengerich, Ryan Baltic, Betsy B. Aumiller, Mark B. Dignan, Electra D. Paskett. Willingness of adults in Appalachia to participate in research involving biospecimens, biobanking and genetics. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A41.

Abstract A37: A group randomized trial to reduce obesity among Appalachian church members: The Walk by Faith study

Purpose: Appalachia is a rural, socioeconomically disadvantaged region with limited access to preventive health services. The Appalachia Community Cancer Network (ACCN) is an NCI-funded research initiative that collaborates with community-based cancer coalitions and other community groups to increase awareness, provide education, and promote cancer prevention. Using Community Based Participatory Research (CBPR) principles, ACCN tested a program to reduce overweight and obesity, a modifiable risk factor for cancer, by working with churches, an important institution in Appalachia. The primary outcome of this study was change in weight from baseline to twelve months. The goal of this report is to present trial results for weight reduction at 12 months.

Methods: The study was a group randomized trial where county or group of counties in five Appalachian states (Ohio, Pennsylvania, Kentucky, Virginia, and West Virginia) were randomly assigned to receive either an intervention program on diet and physical activity titled “Walk by Faith” (WbF) or an educational program focused on cancer screening titled “Ribbons of Faith” (RoF). Participants attended an information session, provided informed consent, were screened for eligibility, and completed biometric measurements including height, weight, blood pressure, and waist and hip circumference. Biometric measurements were also collected at 12 and 24 months. Participants reported on demographic, tobacco use, cancer and cancer screening history, healthcare access, Appalachian identity, physical activity and diet-related information at baseline and annually for two years. Church members were eligible if they were 18 years of age or older, overweight, willing to use a computer, and medically cleared to participate. Ohio and Pennsylvania sites enrolled participants from January through September in 2012, while the other three states enrolled participants from February to November 2013.

Participants in the WbF program received pedometers, monthly education sessions focused on healthy eating and exercise, healthy eating guide books, physical activity journals, and access to a website (Faithfully Living Well) customized for each church and designed to assist participants to overcome barriers to healthy eating and physical activity, track their weight and activities, and access health-related articles and healthy recipes. RoF participants were invited to attend monthly educational sessions about cancer and cancer screening.

Results: Of 866 interested parishioners at 28 churches, 159 (18%) were ineligible; of the 707 eligible individuals who completed screening, 663 (94%) were enrolled. Participants were predominantly female (71%) with average BMI of 33.2; 42% reported regular exercise, 25% had a high school education or lower, and 26% had household incomes <$40,000. Although the difference in weight loss from baseline to 12 months for WbF compared to RoF was not statistically significant overall (1.1% decrease in weight for WbF vs. RoF, p=0.17), results varied by gender. Among men, those in the WbF arm experienced a 2.5% loss in weight compared to men in the RoF arm (p=0.03). Participants in the WbF group increased fruit and vegetable consumption by 26% at 12-months compared to the RoF group (p=0.03). Among WbF participants, greater participation in monthly educational sessions was associated with greater weight loss; for every two sessions attended, weight at 12-months reduced on average by 0.7% (p=0.002).

Conclusions: Overall, the WbF program facilitated weight loss in mainly male participants, and all participants improved fruit and vegetable intake. If participants were engaged in WbF activities, they lost more weight; thus, ways to improve participation should be explored. These results lend support to church-based intervention programs for underserved rural communities.

Citation Format: Ryan Baltic, Electra D. Paskett, Samuel Lesko, Stephenie Kennedy, Gene Lengerich, Karen A. Roberto, Nancy Schoenberg, Gregory Young, Mark Dignan. A group randomized trial to reduce obesity among Appalachian church members: The Walk by Faith study. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A37.

Abstract PR01: Development and implementation of a church-based eHealth program to reduce obesity in Appalachian adults

Purpose: Significant disparities in incidence and mortality for cancers related to obesity have been identified in Appalachian adults compared to the entire US. The Appalachia Community Cancer Network (ACCN) partnered with churches in Kentucky, Ohio, Virginia, West Virginia, and Pennsylvania to conduct a community-based participatory research program with a goal of reducing obesity through environmental and individual change. The primary outcome is change in body mass index (BMI) from baseline to twelve months. Secondary outcomes include change in physical activity level, blood pressure and diet. The focus of this paper is on the development and implementation of the intervention program in thirteen churches across five states, maintenance of the program during the sustainability phase, and preliminary feedback on the intervention from participants.

Methods: The intervention program, Walk by Faith (WbF) was developed with input from focus groups and community advisory boards. The main component is the Faithfully Living Well (FLW) website that allows participants to upload steps from pedometers, track progress in walking and weight, health-related articles, recipes, forums, albums, and a rewards page – all tailored to each county. Comments from participants are recorded both on FLW and via email or paper. Comments were separated by phase and classified as either positive, neutral, requests for additional support, or reporting issues.

Ohio and Pennsylvania acted as a vanguard group, recruiting overweight adults one year prior to the other three states. Participants completed food frequency and physical activity questionnaires, biometric measurements (height, weight, blood pressure, resting heart rate, body image, waist and hip), and survey questions regarding their health behaviors, social support, and cancer history. Enrolled participants received Omron pedometers, string bags, CalorieKing pocket guides and food journals, and access to the FLW website. Monthly education sessions were held, as were church walks, physical activity and cooking classes, and a celebration event at the end of the 12-month intervention. Interventionists were employed to complete quarterly wellness plans with participants and assist with website use. Volunteer church navigators (CNs) within the churches coordinated monthly events with the help of staff. The sustainability phase started at the end of the 12-month period, when study staff distanced themselves from the program and CNs took over staff roles. Activities are suggested to CNs, CNs and participants decide type and frequency of activities, and CNs report on activities, attendance, and reception of events back to study staff.

Results: 429 intervention participants were enrolled from 13 churches. To date, 11 churches with 399 participants have moved to the sustainability phase. Participants have reported positive experiences and health benefits through voluntarily submitted success stories and comments on monthly process evaluations. Participants reported weight loss, increased fruit, vegetable and water intake, reduction in soda intake, and discontinuation of medications. Of the 194 comments received to date, 121 (62%) were positive comments about the program. The most common positive comments were about the quality of presentations (44%), materials and overall program (39%), and improved health status (7%). 15 comments (8%) requested additional support or communication from program leaders.

This abstract was also presented as Poster A14.

Citation Format: Ryan Baltic, Electra D. Paskett, Samuel Lesko, Stephenie Kennedy, Gene Lengerich, Karen Roberto, Nancy Schoenberg, Mark Dignan. Development and implementation of a church-based eHealth program to reduce obesity in Appalachian adults. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr PR01.