Persons Who Failed to Obtain Colorectal Cancer Screening Despite Participation in an Evidence-Based Intervention.

In a previous report, we demonstrated the efficacy of an educational intervention focused on increasing colorectal cancer screening rates among African Americans. Despite participating in the intervention, however, nearly two-thirds of participants did not seek and receive screening. Participants were African-Americans over age 49 (N = 257) who had not been screened for colorectal cancer according to guidelines. At baseline, participants completed tests measuring fatalism, perceived stress, self-esteem, attitudes/benefits/barriers, social support, and social network diversity. Those who completed the educational intervention were followed up by telephone to learn if they had been screened. We compared the scores on the psychometric tests of the participants who had been screened against the scores of those who had not. Only the mean scores on the attitudes, benefits, and barriers scale distinguished participants who had been screened from those who had not (p = 0.0816 on bivariate testing and p = 0.0276 in the logistic regression model). Social interaction among participants or social cognitive learning may have played a role in determining which participants were screened, but we were not able to demonstrate this. The major factor distinguishing participants who were not screened was their attitude toward screening at baseline. There is a subset of African Americans who are persistently resistant to screening, and their perspective in this regard must be addressed if colorectal cancer disparities are to be reduced.

Prostate Cancer Screening and Mortality in Blacks and Whites: A Hospital-based Case-Control Study.

BACKGROUND: Prostate cancer incidence and mortality are substantially higher in Black than in white men. Prostate cancer screening remains controversial. This study was conducted to assess the impact of, and racial differences in, prostate cancer screening on prostate cancer mortality. METHODS: This was a case-control study of Black and White men in eight hospitals. Cases were deaths related to prostate cancer; controls were hospital-based subjects that were frequency-matched to cases based on age and race. Multivariable logistic regression was used to test the association between screening and prostate cancer mortality. RESULTS: Cases had fewer PSA (prostate-specific antigen) tests than controls (1.73 vs. 3.98, p<0.001). White controls had higher rates of PSA tests than other sub-groups. There was no difference in PSA testing between Black cases and controls. Mean co-morbidity was 10.3 in cases and 2.63 in controls. Prostate cancer mortality was 55 to 57% lower among the screened persons. Individuals who died of prostate cancer related causes were less likely to have received PSA testing (OR=0.65; 95% Cl 0.56-0.75). CONCLUSIONS: The odds of dying from prostate cancer were lower among white men receiving screening tests. Having less co-morbidity was associated with lower odds of mortality in both races. This study raises the possibility that screening for prostate cancer with the PSA test may be more effective in white than in Black men.

An academic-public health department partnership for education, research, practice, and governance.

Public health departments and medical schools are often disconnected, yet each has much to offer the other. There are 4 areas in which the 2 entities can partner; in Atlanta, Georgia, the Morehouse School of Medicine (particularly its Prevention Research Center or PRC) and the Fulton County Department of Health and Wellness have demonstrated partnership in each area. With respect to teaching, the 2 have collaborated on clerkships for medical students and rotations for preventive medicine residents. In research, Morehouse faculty and health department staff have worked together on projects. In service, the 2 entities have been able to put into practice interventions developed through their joint research efforts. In governance, the health department has a representative on the PRC board, while the PRC principal investigator serves on the Fulton County Board of Health. Benefits have accrued to both entities and to the communities that they serve.

Operationalization of community-based participatory research principles: assessment of the national cancer institute's community network programs.

OBJECTIVES: We examined how National Cancer Institute-funded Community Network Programs (CNPs) operationalized principles of community-based participatory research (CBPR). METHODS: We reviewed the literature and extant CBPR measurement tools. On the basis of that review, we developed a 27-item questionnaire for CNPs to self-assess their operationalization of 9 CBPR principles. Our team comprised representatives of 9 of the National Cancer Institute's 25 CNPs. RESULTS: Of the 25 CNPs, 22 (88%) completed the questionnaire. Most scored well on CBPR principles of recognizing community as a unit of identity, building on community strengths, facilitating colearning, embracing iterative processes in developing community capacity, and achieving a balance between data generation and intervention. CNPs varied in the extent to which they employed CBPR principles of addressing determinants of health, sharing power among partners, engaging the community in research dissemination, and striving for sustainability. CONCLUSIONS: Although the development of assessment tools in this field is in its infancy, our findings suggest that fidelity to CBPR processes can be assessed in a variety of settings.

Training physicians to do office-based smoking cessation increases adherence to PHS guidelines.

UNLABELLED: Cigarette smoking is the leading cause of preventable mortality and morbidity in the United States. Healthcare providers can contribute significantly to the war against tobacco use; patients advised to quit smoking by their physicians are 1.6 times more likely to quit than patients not receiving physician advice. However, most smokers do not receive this advice when visiting their physicians. The Morehouse School of Medicine Tobacco Control Research Program was undertaken to develop best practices for implementing the "2000 Public Health Services Clinical Practice Guidelines on Treating Tobacco Use and Dependence" and the "Pathways to Freedom" tobacco cessation program among African American physicians in private practice and healthcare providers at community health centers. Ten focus groups were conducted; 82 healthcare professionals participated. Six major themes were identified as barriers to the provision of smoking cessation services. An intervention was developed based on these results and tested among Georgia community-based physicians. A total of 308 charts were abstracted both pre- and post-intervention. Charts were scored using a system awarding one point for each of the five "A's" recommended by the PHS guidelines (Ask, Advise, Assess, Assist, Arrange) employed during the patient visit. The mean pre-intervention five "A's" score was 1.29 compared to 1.90 post-intervention (P < 0.001). All charts had evidence of the first "A" ("asked") both pre- and post-intervention, and the other four "A's" all had statistically significant increases pre-to post-intervention. CONCLUSIONS: The results demonstrate that, with training of physicians, compliance with the PHS tobacco guidelines can be greatly improved.

Triangulating on success: innovation, public health, medical care, and cause-specific US mortality rates over a half century (1950-2000).

To identify successes in improving America's health, we identified disease categories that appeared on vital statistics lists of leading causes of death in the US adult population in either 1950 or 2000, and that experienced at least a 50% reduction in age-adjusted death rates from their peak level to their lowest point between 1950 and 2000. Of the 9 cause-of-death categories that achieved this 50% reduction, literature review suggests that 7 clearly required diffusion of new innovations through both public health and medical care channels. Our nation's health success stories are consistent with a triangulation model of innovation plus public health plus medical care, even when the 3 sectors have worked more in parallel than in partnership.

Abnormal mammogram follow-up: do community lay health advocates make a difference?

This pilot study evaluates a community lay health advocate (CLHA) intervention in promoting follow-up for abnormal mammograms among African American women. A controlled trial was implemented at an urban hospital in Atlanta, with 48 women in a CLHA intervention group and 35 in a usual care group. Participants were 25 or older and had an abnormal mammogram between March 25, 2002, and May 2, 2003. Intervention group women received CLHA support including encouragement of timely abnormal mammogram follow-up, reminders of follow-up appointments, identification and removal of barriers to follow-up, and accompaniment to follow-up appointments. Women in the intervention group were significantly more likely to keep their first abnormal mammogram follow-up appointment, all of their scheduled follow-up appointments, and their biopsy or fine needle aspiration appointment. CLHAs are effective in promoting abnormal mammogram followup among African American women and may be an important resource in reducing racial disparities in breast cancer mortality.

A Pipeline Program to Address the South African Crisis in Human Resources for Health.

BACKGROUND: The WHO Africa Region faces a shortage of health workers due to inadequate production of health workers and emigration of physicians and nurses to wealthier countries. South Africa and the United States share a history of discriminatory policies and practices resulting in groups that are under-represented amongst health professionals. One US response is the Area Health Education Centers Program (AHEC), a pipeline program to recruit members of under-represented groups into the health professions. OBJECTIVES: (1) Compare and contrast the United States' AHEC model with that developed in South Africa by Stellenbosch University Faculty of Medicine and Health Sciences SA AHEC in partnership with Morehouse School of Medicine in the United States. (2) Describe a formative evaluation of the Stellenbosch AHEC Program. Methods: Four hundred students (grades 7-12) and 150 teachers participated in SA AHEC with the goal of preparing the students to better compete for university admission. Students received after-school tutoring, holiday schools, and counselling on study skills, health careers, and university entry. Educators received continuing professional education, classroom observation, and feedback. The program was evaluated through a series of interviews and focus groups involving AHEC staff, educators, and parents and caregivers. RESULTS: Program strengths included educator training, collaboration, and increased student maturity, motivation, and academic success. Challenges included limited time with students, the location of some sites, and the educators' need for more engagement with AHEC staff and schools. Quarterly workshops were conducted to address challenges. Over 50% of program alumni are currently enrolled in institutions of higher education. Students will be tracked to determine whether they are able to complete their health professions studies and return to the communities where they grew up, or to similar communities. CONCLUSIONS: With appropriate adaptation and attention to context, it might be possible to implement similar programmes in other African countries. The comparison of the United States and South African models suggested that more parent and teacher participation in an advisory capacity might help to avoid some challenges.

Racial and ethnic disparities in smoking prevalence in Israel and the United States: progress to date and prospects for the future.

An article in this journal in 2016 demonstrated that smoking prevalence among Arab men in Israel is greater than among their Jewish counterparts born in Israel, while the reverse is true among Arab and Jewish Israeli women. This is reflected in lung cancer mortality rates. In the U.S., smoking prevalence in the mid-1960s was 20% higher in African American men than in white men, but has since decreased in both groups, and smoking prevalence in the two groups is now nearly identical. The black-white disparity in lung cancer mortality rates has been reduced by more than half as compared to its zenith in the early 1990s. The strategies employed to achieve these gains will continue to be important going forward, and successful strategies employed in Israel in addressing smoking in the male Arab population will be of increasing interest in the U.S. as its Arab population increases.

Social networks as predictors of colorectal cancer screening in African Americans.

BACKGROUND: Early detection can reduce colorectal cancer (CRC) mortality by 15%-33%, and screening is widely recommended for average-risk adults beginning at age 50 years. Colorectal cancer mortality rates are higher in African Americans than in whites, while screening rates are somewhat lower. Individual social networks can reduce emotional and/or logistical barriers to health-promoting but distasteful procedures such as CRC screening. The aim of this study was to examine social network interactions, and their impact on CRC screening among African Americans. We hypothesized a positive association between social network index (SNI) scores and CRC screening. METHODS: In a community intervention trial with four arms, we previously demonstrated the efficacy of a small group educational intervention to promote CRC screening among African Americans. This intervention outperformed a one-on-one educational intervention, a reduced out-of-pocket expense intervention, and a control condition. In the present analysis, we compared the SNI scores for participants in the small group intervention cohort with a comparison group comprised of the other three cohorts. Social networks were assessed using the Social Network Index developed by Cohen. RESULTS: Small group participants had a significantly higher network diversity score (Mean difference 0.71; 95% CI, 0.12-1.31; p=0.0017) than the comparison group. In the second component of the SNI score - the number of people talked to over a two week period - the small group intervention cohort also scored significantly higher than the comparison group. (Mean difference, 9.29; 95% CI, 3.963-14.6266; p=0.0004). CONCLUSIONS: The findings suggest that social interaction and support was at least partially responsible for the relatively high post-intervention screening rate in the small group intervention participants. Education in small groups could foster strong social networks. Strong and positive network diversity and a large number of people in social networks may enhance CRC screening rates among African Americans.

A community coalition board creates a set of values for community-based research.

BACKGROUND: Researchers generally agree that communities should participate in the community-based research process, but neither a universally accepted approach to community participation nor a set of guiding principles exists. CONTEXT: The Morehouse School of Medicine Prevention Research Center was established in 1999 with the support of a grant from the Centers for Disease Control and Prevention. Its partners include a low-income, predominantly African American community, six public agencies, and two other academic institutions. A Community Coalition Board was established to represent the partners. The majority of the board is community members; it serves in a governance rather than an advisory capacity, with the community acting as the senior partner in interactions with the medical school, the agencies, and other academic institutions. METHODS: The Community Coalition Board developed a set of research priorities and a set of 10 community values, or principles, to guide research. A board committee reviews each protocol to ensure they uphold the values. CONSEQUENCES: The Community Coalition Board has been using the values since 1999, and in this article we describe its experience. After an initial period that included some disagreements between researchers and community members on the board, relationships have been good, and protocols have been approved with only minor changes. INTERPRETATION: Although the established community values reflect universally acknowledged principles of research ethics, they also address local concerns. An equal partnership between community members and researchers is most beneficial if the partners can agree on a set of values to govern research.

A web-based smoking cessation and prevention curriculum for medical students: why, how, what, and what next.

This paper summarises some major developments in medical education relating to the health risks of tobacco and to training in tobacco cessation and prevention strategies, and discusses some of the barriers to training. We also describe a project whose purpose was to design, implement and evaluate a web-based self-study tobacco curriculum for medical students to teach medical students to assist smokers to quit and to counsel non-smoking adolescents not to start smoking. This curriculum addresses some of the barriers, namely lack of curriculum time, lack of access to materials and experts, and relevance of the materials. The project was designed and evaluated at two medical schools in Georgia: Morehouse School of Medicine and Mercer University School of Medicine. A curriculum on tobacco control strategies and techniques designed for use in clinical settings was made available to first-year medical students as interactive computer-based tutorials. The curriculum, based on the US Public Health Service Clinical Guideline for Treating Tobacco Use and Dependence, was divided into two parts: the tutorial and practicum sections. Pre- and post-exposure measures were collected for the evaluation. The mean differences for correctly answered knowledge items in the two schools were similar: mean for Morehouse was +2.07 and for Mercer +1.67, indicating improvements in knowledge for both schools. There were statistically significant improvements in all categories of self-rated ability to perform six counselling skills, except for Mercer students for the 'Ask' skill category (p=0.069). The amount of exposure (measured only at Morehouse) was not related to overall change in scores but was associated with self-reported improvement in skill in assisting patients to quit smoking, confidence in counselling patients not interested in quitting, and confidence in counselling teens. The web-based curriculum successfully improved the students' self-rated counselling skills. Given the need and desire on the part of practitioners for training, the curriculum may be found useful by practising physicians and other health-care professionals who wish to improve their skills in smoking prevention and cessation.

Toward the Elimination of Colorectal Cancer Disparities Among African Americans.

BACKGROUND: In the USA, race and socioeconomic status are well-known factors associated with colorectal cancer incidence and mortality rates. These are higher among blacks than whites and other racial/ethnic groups. METHODS: In this article, we review opportunities to address disparities in colorectal cancer incidence, mortality, and survivorship among African Americans. RESULTS: First, we summarize the primary prevention of colorectal cancer and recent advances in the early detection of the disease and disparities in screening. Then, we consider black-white disparities in colorectal cancer treatment and survival including factors that may contribute to such disparities and the important roles played by cultural competency, patient trust in one's physician, and health literacy in addressing colorectal cancer disparities, including the need for studies involving the use of colorectal cancer patient navigators who are culturally competent. CONCLUSION: To reduce these disparities, intervention efforts should focus on providing high-quality screening and treatment for colorectal cancer and on educating African Americans about the value of diet, weight control, screening, and treatment. Organized approaches for delivering colorectal cancer screening should be accompanied by programs and policies that provide access to diagnostic follow-up and treatment for underserved populations.

Lessons Learned from Three Models that Use Small Grants for Building Academic-Community Partnerships for Research.

Despite the direct contribution of community-engaged research towards effective translation, establishing strong and sustained community academic research partnerships remains a challenge. The Atlanta Clinical and Translational Science Institute's Community Engagement Research Program (CERP) has developed and implemented three models for using small grants to seed new community academic partnerships for research: 1) community-initiated health projects with faculty partners, 2) dissemination of discoveries to community partners, and 3) building collaborative research capacity. In this paper, we describe each model in terms of its purpose, funding level, funding period, proposal requirements, selection criteria and faculty involvement. Resulting partnerships are described, along with benefits and challenges from faculty and community perspectives, and lessons learned in using these mechanisms to promote community-engaged research. These models may aid others attempting to promote community-engaged research for the purpose of narrowing the gap between research, practice and ultimately, impact on community health.

Reducing Disparities by way of a Cancer Disparities Research Training Program.

BACKGROUND: For minority populations, there is a continuing disparity in the burden of death and illness from cancer. Research to address this disparity should be conducted by investigators who can best understand and address the needs of culturally diverse communities. However, minorities are under-represented in health-related research. The goal of this project was to develop and evaluate an approach to motivating and preparing master's degree students for careers dedicated to cancer disparities research. METHOD: A Cancer Disparities Research Training Program (CDRTP) was initiated in 2010. The program consists of coursework, practicum experiences, and research opportunities. Assessment of the curriculum is based on monitoring achievement of evaluation indicators and included a mixed-method approach with included both quantitative and qualitative approach. RESULTS: In its first three years, the program graduated 20 trainees, all of whom were minorities (18 African Americans and two Asians). When asked about career goals, two-thirds of the trainees indicated interest in pursuing careers in research in cancer prevention and control. The trainees expressed high satisfaction with the courses, instructor, materials, and curriculum. Although trainees had suggestions about course details, evaluations overall were positive. Across focus groups, three recurrent themes emerged regarding activities to enhance the trainee experience: having a wider variety of topics, more guest speakers, and field trips. CONCLUSION: The CDRTP was intended to recruit students - primarily African Americans - into research on prevention and control of cancer disparities. Although final evaluation of the program's overall outcome will not be available for several years, this preliminary evaluation indicates early program success.

Exploration of barriers and facilitators to publishing local public health findings: A mixed methods protocol.

BACKGROUND: Worldwide, the US accounts for a large proportion of journals related to public health. Although the American Public Health Association (APHA) includes 54 affiliated regional and state associations, little is known about their capacity to support public health scholarship. The aim of this study is to assess barriers and facilitators to operation of state journals for the dissemination of local public health research and practices. METHODS: A mixed methods approach will be used to complete the 12-month study. Affiliate websites will be accessed through the APHA membership portal to evaluate organizational infrastructure and ascertain the presence/absence of a journal. The leader of each affiliate will be contacted via email containing a link to a 12-question on-line survey to collect his/her perceptions of scholarly journals and the publication of local health data. To determine barriers and facilitators to publication of local public health findings, 30-minute semi-structured telephone interviews will focus on the infrastructure of the association, perceptions of the leader about the journal (if in place), and its operation. ANTICIPATED RESULTS: We anticipate that 54 affiliate websites will be reviewed to complete the extraction checklist, that 74% of affiliate leaders will respond to the survey, and that 11 semi-structured interviews will be conducted. A limited number of state/regional public health associations will operate journals and a small percentage of those without journals may express an interest in implementing them. Barriers to operation of journals may include lack of resources (i.e., personnel, funding), and low prioritization of publication of state and local public health findings. Facilitators may include strong affiliate-academic relationships, affiliate leadership with experience in publications, and affiliate relationships with state and local departments of health. CONCLUSIONS: The research proposed in this protocol may stimulate other state public health associations and other academic public health programs to follow suit; it would not be the first time that an observational research study served as an intervention.

Impact of a two-city community cancer prevention intervention on African Americans.

We report the first multisite, multicomponent community intervention trial to focus on cancer prevention in African Americans. The project explored the potential of historically black medical schools to deliver health information to their local communities and used a community-based participatory research approach. The intervention consisted of culturally sensitive messages at appropriate educational levels delivered over an 18-month period and tested in predominantly black census tracts in Nashville, TN and Atlanta, GA. Chattanooga, TN and Decatur, GA served as comparison cities. Results were evaluated by pre- and postintervention random-digit dial telephone surveys. The intervention cities showed an increase in reported contact with or knowledge of the project. There was little or no effect on knowledge or attitudes in the intervention cities. Compared to Chattanooga, Nashville showed an increase in percentage of women receiving Pap smears. Compared to Decatur, Atlanta showed an increase in percentage of age-appropriate populations receiving digital rectal exams, colorectal cancer screenings and mammograms. The results of this community intervention trial demonstrated modest success and are encouraging for future efforts of longer duration.

Community-based participatory research principles for the African American community.

BACKGROUND: Numerous sets of principles have been developed to guide the conduct of community-based participatory research (CBPR). However, they tend to be written in language that is most appropriate for academics and other research professionals; they may not help lay people from the community understand CBPR. METHODS: Many community members of the National Black Leadership Initiative on Cancer assisting with the Educational Program to Increase Colorectal Cancer Screening (EPICS) had little understanding of CBPR. We engaged community members in developing culturally-specific principles for conducting academic-community collaborative research. RESULTS: We developed a set of CBPR principles intended to resonate with African-American community members. CONCLUSIONS: Applying NBLIC-developed CBPR principles contributed to developing and implementing an intervention to increase colorectal cancer screening among African Americans.

The Second Annual Primary Care Conference--Programming to eliminate health disparities among ethnic minority populations: an introduction to proceedings.

From October 31, 2002 through November 2, 2002, the Second Annual Primary Care Conference was held, sponsored by the Morehouse School of Medicine's National Center for Primary Care and its Prevention Research Center. The conference was designed as a collaborative activity with the Atlanta Regional Health Forum; The Carter Center; Emory University's School of Medicine, Nell Hodgson Woodruff School of Nursing, and Rollins School of Public Health; Georgia Chapter of the American College of Physicians/American Society of Internal Medicine; Georgia Nurses Foundation; Southeastern Primary Care Consortium, Inc./Atlanta Area Health Education Center; St. Joseph's Mercy Care Services; United States Department of Health and Human Services: Agency for Healthcare Research and Quality; Centers for Disease Control and Prevention; Health and Human Services (Region IV); Health Resources and Services Administration; Office of Minority Health (Region IV); and Office on Women's Health (Region IV). The 2 and a half-day conference featured 5 plenary sessions and 3 tracks of medical education for primary care physicians and other healthcare providers. The tracks were categorized as: Track A: Adult Health; Track B: Public Health and Prevention; and Track C: Maternal/Child/Youth Health. Within each track, 6 working sessions were presented on topic areas including diabetes, obesity, cardiovascular disease, cancer, mental health, infectious disease, behavioral and social health, women's health, stroke, and asthma. A total of 18 working sessions took place and each working session included 3 presentations. Continuing medical education credits or continuing education units were granted to participants. In all, 485 individuals participated in the conference, with the majority of the participants from the southeastern United States. Of the attendees, 35% were physicians (MD); 13% were nurses (RN); 12% held master-level degrees; and 12% held other doctorate-level degrees.

Building an academic-community partnership for increasing representation of minorities in the health professions.

We evaluated collaboration among academic and community partners in a program to recruit African American youth into the health professions. Six institutions of higher education, an urban school system, two community organizations, and two private enterprises became partners to create a health career pipeline for this population. The pipeline consisted of 14 subprograms designed to enrich academic science curricula, stimulate the interest of students in health careers, and facilitate entry into professional schools and other graduate-level educational programs. Subprogram directors completed questionnaires regarding a sense of common mission/vision and coordination/collaboration three times during the 3-year project. The partners strongly shared a common mission and vision throughout the duration of the program, although there was some weakening in the last phase. Subprogram directors initially viewed coordination/collaboration as weak, but by midway through the project period viewed it as stronger. Feared loss of autonomy was foremost among several factors that threatened collaboration among the partners. Collaboration was improved largely through a process of building trust among the partners.