Barriers and facilitators to implementing a multilevel, multicomponent intervention promoting colorectal cancer screening in health centers: a qualitative study of key informant perspectives.

BACKGROUND: Colorectal cancer (CRC) continues to be a major cause of death in the U.S. despite the availability of effective screening tools. U.S. Latinos have lower rates of CRC screening and higher rates of death due to colorectal disease compared to non-Hispanic whites. Federally Qualified Health Centers (FQHCs) serve medically underserved populations, including many Latino patients. Given the low CRC screening rates, identifying culturally sensitive and cost-effective methods of promoting screening is a priority for many FQHCs. METHODS: We interviewed FQHC leaders and providers using the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to implementation of a multilevel, multicomponent (ML-MC) CRC screening intervention (i.e., promotor navigation and group-based education) in FQHCs. A rapid qualitative analysis approach was used to identify themes organized according to the following CFIR constructs: intervention characteristics, outer and inner settings, and characteristics of the individual. RESULTS: We completed interviews with 13 healthcare professionals in leadership positions at six FQHCs. The participating FQHCs perceived the ML-MC screening CRC program as feasible and expressed interest in implementing the program at their sites. Facilitators included financial incentives for increasing screening rates, the need for patient education programming, and involving promotores to support the work of clinical teams. Barriers included concerns about available resources to implement new programs, lack of federal reimbursement for health education, competing priorities of other health concerns, and the need for more resources for confirmatory screening and treatment following a positive screen. CONCLUSIONS: FQHCs provide essential primary care to millions of underserved patients in the U.S. and have the ability and motivation to provide screenings for colorectal cancer. Partnering with an academic institution to deliver a group-based, promotor-led CRC screening intervention for patients not up to date with screening could help increase screening rates. By identifying the specific barriers and facilitators to implementing CRC intervention, findings suggest that group-based, promotor-led interventions are a promising approach.

Promoting cancer screening among churchgoing Latinas: Fe en Acción/faith in action.

Cancer screening rates among Latinas are generally low, reducing the likelihood of early cancer detection in this population. This article examines the effects of a community intervention (Fe en Acción/Faith in Action) led by community health workers (promotoras) on promoting breast, cervical and colorectal cancer screening among churchgoing Latinas. Sixteen churches were randomly assigned to a cancer screening or a physical activity intervention. We examined cancer knowledge, barriers to screening and self-reported mammography, clinical breast exam, Pap test, fecal occult blood test and sigmoidoscopy or colonoscopy at baseline and 12 months follow-up. Participants were 436 adult Latinas, with 16 promotoras conducting a cancer screening intervention at 8 out of 16 churches. The cancer screening intervention had a significant positive impact on self-reported mammography (OR = 4.64, 95% CI: 2.00-10.75) and breast exams in the last year (OR= 2.82, 95% CI: 1.41-5.57) and corresponding reductions in perceived (87.6%) barriers to breast cancer screening (P < .008). Cervical and colorectal cancer screening did not improve with the intervention. These findings suggest Fe en Acción church-based promotoras had a significant impact on promoting breast cancer screening among Latinas. Colon cancer screening promotion, however, remains a challenge.

Development of a Group-Based Community Health Worker Intervention to Increase Colorectal Cancer Screening Among Latinos.

INTRODUCTION: Latinos are at higher risk of colorectal cancer (CRC) mortality than non-Hispanic Whites due, in part, to disparities in cancer screening. There is a need to evaluate community-based CRC interventions as they may reach underinsured communities and those at highest risk for CRC. This article describes the development of a group-based CRC intervention (Juntos contra el Cancer). METHOD: Purposive sampling was used to recruit Latino men and women aged 50 to 75 years not-up-to-date with CRC screening. The development of the intervention was guided by the socioecologic framework, a community needs assessment, literature reviews, five focus groups (n = 39) from the target community and feedback from a Community Advisory Board. RESULTS: Findings from focus groups suggested that a group-based, promotor or community health worker (CHW) led, cancer prevention education with linkages to care would address barriers to CRC screening. CONCLUSION: Development of community-based CRC screening interventions should be informed by early and sustained community engagement. Interventions led by CHWs with linkages to care are feasible and can reach populations not connected to health care settings.

Socio-demographic Moderators of Associations Between Psychological Factors and Latinas' Breast Cancer Screening Behaviors.

This study tested whether socio-demographic factors moderated associations between psychological factors and Latinas' breast cancer screening behaviors. 222 churchgoing Latinas (40-65 years) in San Diego, CA completed surveys assessing socio-demographics (e.g., income and acculturation), psychological factors (e.g., perceived barriers to screening), and cancer screening behaviors. Multilevel models examined associations of socio-demographic and psychological factors (and their interactions) with adherence to annual mammography or clinical breast exam (CBE) screening. Although no main effects were found, there were moderation effects. Acculturation moderated associations between perceived barriers to screening and both screening outcomes, with inverse associations only among the high-acculturation group. Education moderated the relationship between perceived barriers to screening and CBE screening, with an inverse association only among the low-education group. Marital status moderated the relationship between depressive symptoms and CBE screening, with an inverse association only among single/non-partnered participants. Interventions are needed targeting psychological barriers to breast cancer screening among Latinas.

Measuring disease levels in myeloma using flow cytometry in combination with other laboratory techniques: Lessons from the past 20 years at the Leeds Haematological Malignancy Diagnostic Service.

People with myeloma who obtain a good response to treatment have a better survival if sensitive molecular or flow-cytometric techniques show no detectable minimal residual disease (MRD). The application of MRD techniques to clinical trials is now considered to be increasingly important because treatment approaches are sufficiently effective that using survival outcomes is slowing down the identification of the best new treatments. The articles in this issue consider the laboratory requirements for harmonization of MRD analysis by flow cytometry but there are practical considerations that are also important in implementing a myeloma MRD assay in the cytometry laboratory. In particular, it is important to consider when to request, and how best to utilize, a bone marrow aspirate sample because the procedure is invasive and the cells obtained are valuable for a number of different investigations. This brief article considers some experience obtained over two decades of implementing a service for MRD detection, initially as a scientific bolt-on to clinical trials through to a routine clinical diagnostic assay.

Son preference in Vietnam.

This article assesses the strength of son preference in Vietnam, as reflected in fertility behavior. It formulates and estimates a proportional hazards model applied to birth intervals, and a contraceptive prevalence model, using household survey data from 2,636 ever-married women aged 15-49 with at least one living child who were interviewed for the Vietnam Living Standards Survey 1992-1993. Son preference is found to be strong by world standards, but nevertheless, it has a minor effect on fertility; in its absence, the total fertility rate would fall by roughly 10 percent from the current level of about 3.2 children per woman of reproductive age.

PIP: Vietnam has penalties for having children too soon or for having too many children. The penalties are not as severe as those in China and vary widely within the country. This study examines the impact of son preference on fertility behavior in Vietnam and establishes the existence of gender preferences. Hazard models are used to estimate the risk of having another child after the birth of a son and to determine whether families with a son are more likely to use contraceptives. Data are obtained from the Vietnam Living Standards Survey of 4800 households during 1992-93. The results of the application of four Cox proportional hazard models indicates that son preference is clear and strong for mothers who have 2-4 children. Women with 3 children are at greatest risk of having another child, if the children are all daughters, and at some risk, if the children are all sons. The risk is the least for women with one child of each gender. The desire for gender balance does not appear for women with two children. More maternal education reduces the risk of more births. If women's educational level increased from 6.6 to 8.0 years, the hazard rate would decline by about 9%. Risk of another birth is lowered by increased maternal age, higher expenditure per capita, and urban residence and residence in the Red River Delta. The contraceptive use rate is calculated to be 77% if there is no son preference, according to Arnold's methods. Families with at least one son are about 15% more likely than those with none to be using contraception. The likelihood of contraceptive use declines among breastfeeding women and increases among better educated women and among working women. The same increase in contraceptive use is achieved by 5 years of education and by women's employment. Contraceptive use is highest in the Red River Delta, a densely populated area. Contraceptive use is unaffected by age at first marriage, duration of marriage, gender of household head, expenditure per capita, cost of contraception, urban residence, and the age of the father. Estimates reveal that total fertility would be 10% lower, if son preference declined in importance, but this rate of decline is expected among countries experiencing demographic transition.

Using a mixture model to detect son preference in Vietnam.

Son preference is strong in Vietnam, according to attitudinal surveys and studies of contraceptive prevalence and birth hazards. These techniques assume a single model is valid for all families, but it is more plausible that son preference is found for some, but not all, families. Heterogeneous preferences may be addressed with a mixture model. This paper specifies and estimates a two-Weibull regression model, applied to the interval between the second and third births. The data come from the Vietnam Living Standards Survey of 1992-93. Applying information criteria, graphs, and martingale-based residuals, the two-Weibull model is found to fit better than a one-Weibull model. Roughly half of parents have son preference and, curiously, a propensity for fewer children. The other group has more children, no son preference, and is colourless in the sense that the birth interval is difficult to predict on the basis of the regressors used.

PIP: Attitudinal surveys consistently indicate that parents in Vietnam have a strong desire to bear at least one son before they terminate their childbearing. However, stated preferences for sons are believed to be unreliable as a guide to actual fertility behavior. Contraceptive prevalence models and proportional hazards model have therefore been used to get better insight into the existence or absence of son preference in Vietnam. These latter studies have also found son preference to be strong in Vietnam. A central problem, however, is that these techniques assume a single model is valid for all families. The authors explain that the propensity to have another child may actually depend upon different variables, or depend upon the same variables but in a different way, for different families. One way to address this problem of heterogenous preferences is to fit a mixture model. In the context of son preference, it is plausible that the population is naturally divided into those who prefer sons and those who do not. Such a scenario calls for a two-distribution mixture model. In this paper, a Weibull regression model is applied to the interval between the second and third child, using data from the Vietnam Living Standards Survey of 1992-93. A single Weibull regression model is first estimated, and then a mixture of two Weibull regression models, to explore whether this represents an improvement over the single model. The mixture model estimates that preference for a son is strong for about half of the parents surveyed and absent from the other half.

Improvement-focused information technology for the clinical office practice: a patient registry for disease management.

A patient registry for disease management identifies and tracks key information concerning identified patients enrolled in a care management program. The software tool makes the proactive tracking and outreach of population-based management feasible. It is highly focused on the limited patient demographic and clinical information needed for this purpose. Automated medical records are beyond the reach of most physician practices, and many of those in use lack the features necessary for population-based management. We believe the patient registry will meet both the needs for disease-management focused support and the budget of the typical physician practice.

M/RMS: an EMG method for quantifying upper motoneuron and functional weakness.

A new method for quantifying upper motoneuron (UMN) weakness using standard EMG equipment is presented and compared to the twitch occlusion method. Control subjects and patients with stroke, spinal cord injury (SCI), and peripheral nerve injury (PNI) were evaluated. Force, EMG, and twitch force from nerve electrical stimulation were recorded during isometric contractions of the biceps and triceps. Ratios of the elicited CMAP amplitude (M)/voluntary-root-mean-square EMG activity (RMS) and of the voluntary contraction twitch force (Ti)/the resting twitch force (Tmax) were the two measures of UMN weakness studied. Both ratios are linearly correlated with force for controls, log M/RMS (r = 0.96) and Ti/Tmax (r = 0.86). Log M/RMS ratio was abnormally high (> mean + 2 SD; i.e., > 1.09) for weak muscles affected by stroke and incomplete SCI, but was normal in muscles weakened by PNI. An elevated M/RMS ratio, may aid in quantification of deficient supraspinal activation from UMN or functional weakness.

Cognitive dysfunction in spinal cord injury patients: sensitivity of the Functional Independence Measure subscales vs neuropsychologic assessment.

The Functional Independence Measure (FIM) has been developed to provide an objective measure of functional gains during acute and chronic rehabilitation of disabled individuals, including those with spinal cord injury (SCI). A unique characteristic of the FIM, as compared with other functional scales, is that it reflects abilities in the areas of communication and social cognition. In order to examine the external validity of these subscales, 41 acute SCI patients were evaluated with the FIM just before discharge from acute rehabilitation. The subscale scores were compared to the results of a comprehensive, predominantly motor-free, neuropsychologic battery administered 74.8 +/- 5.3 days postinjury. Evaluation of scatter plots indicated that there were no relationships between any neuropsychologic test results and the discharge FIM social cognition or communication subscale scores. This was attributed to a ceiling effect in the FIM ratings. The results of this study suggest that the FIM cannot be a substitute for comprehensive neuropsychologic assessment in SCI patients.

Clinical photon correlation spectroscopy evaluation of human diabetic lenses.

Clinical research on cataract prevention requires an in vivo assessment of the lens of the eye that is non-invasive, quantitative and detects lens changes that precede lens opacification or cataract formation. The method of photon correlation spectroscopy or quasi-elastic light scattering spectroscopy provides such a non-invasive probe. The measurement, based on fluctuations in scattered light intensity caused by translational Brownian motion of the lens proteins, allows a determination of a protein diffusion coefficient and hence information on quaternary conformational changes of these protein scatterers. These protein changes have been observed in association with the presence of lens opacification. The occurrence of these changes prior to opacification, however, has still to be established. The analyses performed in this study were aimed at testing the hypothesis of an association between subclinical molecular changes in the lens as measured by quasi-elastic light scattering and the presence of selected risk factors for cataract. Measurements were made from 393 diabetics attending the Joslin Diabetes Center Eye Unit and 38 non-diabetic volunteers. Measurements at two different instrument sample times, 1.5 microseconds and 150 microseconds, allowed characterization of two different protein size distributions contributing to the quasi-elastically light scattered signal. Measurements performed at the 1.5 microseconds sample time demonstrated significantly decreased lens protein diffusivity in association with older age, higher grade of nuclear sclerosis and presence of diabetes. Statistically significant associations were also observed between lens protein diffusivity and diabetes related factors such as glycosylated hemoglobin level (diabetes control), duration of diabetes, age at onset of diabetes and type of diabetic therapy. The pattern of association exhibited between decreased protein diffusion coefficient and risk factor status is consistent with the patterns of increased risk previously demonstrated in cataract formation. Measurements performed at the 150 microseconds sample time demonstrated significantly decreased lens protein diffusivity in association with increasing age, female sex and glycosylated hemoglobin level. These associations differed significantly from those observed at the 1.5 microsecond sample time, thereby suggesting that these two sample times assess different species of lens proteins. The results of this analysis demonstrate the clinical utility of quasi-elastic light scattering as a rapid, non-invasive method to quantitate lens changes and assess methods of cataract prevention and treatment.