Design of a randomized controlled trial to assess the comparative effectiveness of a multifaceted intervention to improve three-year adherence to colorectal cancer screening among patients cared for in rural community health centers.

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality, yet significant disparities persist among those living in rural areas, from minority backgrounds, and those having low income. The purpose of this two-arm randomized controlled trial is to test the effectiveness and fidelity of a stepped care (increasing intensity as needed) approach to promoting 3-year adherence to CRC screening via fecal immunochemical testing (FIT) or colonoscopy in rural community clinics serving high rates of low-income and minority patients. We hypothesize that, compared to enhanced usual care (EUC), patients receiving the multifaceted CRC screening intervention will demonstrate higher rates of CRC screening completion over 3 years. Participants from six federally qualified health centers (FQHCs; N = 1200 patients) serving predominately low-income populations in rural Louisiana will be randomized to the intervention or EUC arm. All participants will receive health literacy-directed CRC counseling, simplified materials about both the FIT and colonoscopy procedures, and motivational interviewing to aid in the determination of test preference. Participants in the intervention arm will also receive motivational reminder messages from their primary care provider (via audio recording or tailored text) for either a scheduled colonoscopy or return of a completed FIT. Participants in the EUC arm will receive the standard follow-up provided by their clinic or colonoscopy facility. The primary outcome will be completion of either colonoscopy or annual FIT over 3 years. Results will provide evidence on the effectiveness of the intervention to decrease disparities in CRC screening completion related to health literacy, race, and gender. Trial registration:Clinicaltrials.gov Identifier NCT04313114.

Assessment of Oral Chemotherapy Nonadherence in Chronic Myeloid Leukemia Patients Using Brief Measures in Community Cancer Clinics: A Pilot Study.

The purpose of this pilot study was to assess Chronic Myeloid Leukemia (CML) patients' adherence to, beliefs about, and barriers to oral anticancer agents (OAC) using brief self-report measures in community-based cancer clinics. Patients completed a structured interview including a health literacy assessment, a Brief Medication Questionnaire, two single-item self-report adherence questions, and the Medications Adherence Reasons Scale. Of the 86 participants, 88.4% were white; 55.8% male; mean age, 58.7 years; and 22.1% had limited health literacy. Nonadherence (missing at least one dose in the last week) was reported by 18.6% of participants and associated (p < 0.003) with less-than-excellent perceived ability to take CML medications (16.3%). Black participants reported more difficulty taking CML medications than white participants (28.6% vs. 8.3%, p = 0.053). Among all participants, 43.0% reported their CML medicine was ineffective and 24.4% that taking CML pills was somewhat to very hard. The most common reasons for missing a dose were simply missed it (24.4%) and side effects (18.6%). Most patients perceived their ability to take CML medication was good to excellent, yet nearly one in five reported missing at least one dose in the last week. Brief, no-cost self-report assessments to screen CML patients' OAC adherence, barriers, and beliefs could facilitate counseling in busy community cancer clinics.

Health Literacy Research in Rural Areas.

This report discusses successful approaches to conducting health literacy-directed studies with community clinics and agencies in rural areas of Louisiana. Some lessons learned from two studies in isolated rural areas with a history of health, educational, and economic disparities are presented. The first is a qualitative study eliciting patients', providers' and community members' understanding, access and acceptance of clincial trials. The second is an overview of health literacy interventions that build on each other to improve annual colorectal cancer screening in rural commuity clinics. The results suggest rural providers and patients are interested in participating in clinical trials. To increase participation in clinical trials in rural areas, academic researchers need to develop ongoing "bi-directional" working relationships with rural clinics and agencies. The support of primary care providers trusted by patients is essential. Plain language and culturally appropriate patient education material developed with the input of patients and providers and on-going telephone outreach are effective in increasing initial colon cancer screening among low-income rural patients. More intensive strategies are needed to sustain annual screening. Implementation of health literacy research strategies may help address barriers to understanding and access to appropriate studies and preventive health services.

Repeat Annual Colorectal Cancer Screening in Rural Community Clinics: A Randomized Clinical Trial to Evaluate Outreach Strategies to Sustain Screening.

PURPOSE: The majority of colorectal cancer (CRC) research using the fecal immunochemical test (FIT) has studied short-term screening results in predominantly urban areas. The purpose of this study was to evaluate the effectiveness of 2 outreach strategies embedded in a health literacy intervention on repeat CRC screening in rural community clinics. METHODS: A 2-arm randomized controlled trial was conducted in 4 rural clinics in Louisiana. During a regularly scheduled clinic visit, participants ages 50-75 received a FIT kit and brief educational intervention. Participants were randomized to receive an automated call or a personal call by a prevention counselor after 4 weeks and 8 weeks if FIT kits were not returned. In year 2, materials were mailed, and follow-up calls were conducted as in year 1. The primary outcome was repeat FIT-the return of the FIT kit in both years. PARTICIPANTS: Of 568 eligible participants, 55% were female, 67% were African American, and 39% had low health literacy. FINDINGS: Repeat FIT rates were 36.5% for those receiving the automated call and 33.6% for those receiving a personal call (P = .30). No annual FITs were returned in 30% of participants, while only 1 FIT was returned by 35% of participants (31% only year 1 and 4% only year 2). CONCLUSION: Sustaining CRC screening with FIT is challenging in rural clinics. A lower cost automated call was just as effective as the personal call in promoting repeat annual screening. However, more intensive strategies are needed to improve long-term FIT screening among rural participants.

Follow-up approaches to a health literacy intervention to increase colorectal cancer screening in rural community clinics: A randomized controlled trial.

BACKGROUND: Significant disparities exist in colorectal cancer (CRC) screening rates among those of low socioeconomic status, with fewer years of education, lacking health insurance, or living in rural areas. METHODS: A randomized controlled trial was conducted to compare the effectiveness of 2 follow-up approaches to a health literacy intervention to improve CRC screening: automated telephone call or personal call. Patients aged 50 to 75 years residing in 4 rural community clinics in Louisiana were given a structured interview that assessed demographic, health literacy and CRC screening barriers, knowledge, and attitudes. All were given health literacy-informed CRC education, a patient-friendly CRC screening pamphlet, simplified fecal immunochemical test (FIT) instructions, and a FIT kit, and a "teach-back" method was used to confirm understanding. Patients were randomized to 1 of 2 telephone follow-up arms. If they did not mail their FIT kit within 4 weeks, they received a reminder call and were called again at 8 weeks if the test still was not received. RESULTS: A total of 620 patients were enrolled. Approximately 55% were female, 66% were African American, and 40% had limited literacy. The overall FIT completion rate was 68%: 69.2% in the automated telephone call arm and 67% in the personal call arm. Greater than one-half of the patients (range, 58%-60%) returned the FIT kit without receiving a telephone call. There was no difference noted with regard to the effectiveness of the follow-up calls; each increased the return rate by 9%. CONCLUSIONS: Providing FIT kits and literacy-appropriate education at regularly scheduled clinic visits with a follow-up telephone call when needed was found to increase CRC screening among low-income, rural patients. The lower cost automated call was just as effective as the personal call.

A Qualitative Study Exploring Barriers and Facilitators of Enrolling Underrepresented Populations in Clinical Trials and Biobanking.

Disparities exist in enrollment in clinical trials and biorepositories among adults with low socioeconomic status, racial and ethnic minority groups and individuals who live in rural areas. Diverse participation is necessary to identify the most effective treatments in different groups. The purpose of this study was to use qualitative methods to identify factors that may affect the likelihood that members of underrepresented groups choose to participate in clinical trials and/or biobanking. We conducted 14 focus groups and seven telephone interviews in urban and rural areas of Louisiana to: (1) identify barriers and facilitators to participation; and (2) elicit input in crafting clear, culturally appropriate language and recruitment strategies. Of 103 participants, 25 were safety-net healthcare providers, 18 were primary care or oncology clinic patients, and 60 were members of social and faith-based groups. Patients and community participants were English-speaking, 79% were African American, 81% were female and 24% lived in rural areas. Barriers to participation identified were lack of knowledge about clinical trials and biobanks; limited specific information and access to participation, trust and privacy concerns about clinical trials and biobanking Facilitators included: altruism, high interest in medical research particularly studies that might benefit them or their families; plain language, culturally appropriate information; convenient access to studies; and input of a trusted provider. In addition, all primary care providers were interested in having clinical trial options available for their patients but did not have time to search for available trials. Results of this study can inform the development of education materials and strategies to increase participation of underrepresented groups in clinical trial and biobanking.

Impact of Health Literacy-directed Colonoscopy Bowel Preparation Instruction Sheet.

OBJECTIVES: To improve patient colonoscopy bowel preparation with a newly developed simplified instruction sheet in a safety-net hospital system. METHODS: Bowel preparation quality was compared in a retrospective chart review of 543 patients, 287 of whom received standard instructions (9th grade reading level) between November 2015 and February 2016, and 256 of whom received simplified instructions (6th grade level) between March and May 2016. Instructions were mailed to all patients. The primary outcome was bowel preparation quality recorded by the endoscopist as optimal or suboptimal preparation. RESULTS: 543 medical records were reviewed and results indicated a significant association between the instructions used and preparation quality with patients receiving simplified instructions being significantly more prepared (69.1% vs 65.5%) and having a lower cancellation rate (4.7% vs 10.5%), p = .042. CONCLUSIONS: A no-cost simplified colonoscopy instruction sheet improved bowel preparation among patients in an academic safety-net health system.

Changes in Colorectal Cancer Screening Knowledge, Behavior, Beliefs, Self-Efficacy, and Barriers among Community Health Clinic Patients after a Health Literacy Intervention.

OBJECTIVE: The objective in this pre- and post-survey assessment was to compare the effectiveness of a health literacy-directed intervention designed to increase knowledge, beliefs, barriers, self-efficacy and behavior associated with CRC screening with FOBT among patients cared for in predominantly rural community clinics and the change in these characteristics over the first 15 months after enrolling in a study designed to assess screening strategies. METHODS: Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Patients were orally administered a 15-minute survey at enrollment by a clinic research assistant (RA) and at 15 months by phone by a central RA. Participants included 428 community clinic patients aged 50-85 (mean 58.5); the majority (79%) were female, 69% were African American, and 54% had limited health literacy. RESULTS: There was significant improvement across all groups with the number of patients reporting they had been given information /education on CRC testing (p<.0001), been given an FOBT kit (p<.0001), and completed an FOBT (p<.0001) with significant improvement in having a doctor recommendation in all groups except usual care. Confidence in an FOBT's potential to decrease chances of dying from CRC improved across all groups as well (p<0.002). In addition, patients 'belief that they would get CRC in their lifetime' decreased across all groups post-intervention (p<0.03) as did their worry that they may find out they have CRC (p<0.04). CONCLUSION: Overall these low income FQHC patients who were not up-to-date with screening had heard of CRC screening, had positive attitudes toward screening and wanted to know if they had cancer. Results demonstrate the value of giving patients a recommendation and a kit; patients in all groups reported significant increases at 15 months in completing CRC screening (>83%) as confirmed by study records.

Barriers and Facilitators to Colorectal Cancer Screening Among Rural Women in Community Clinics by Heath Literacy.

BACKGROUND: Rural women lag rural men and urban women in colon cancer (CRC) screening completion. OBJECTIVE: To identify rural female patients' knowledge, beliefs barriers, self-efficacy, prior recommendation and completion of CRC screening using an FOBT and to compare these factors by health literacy (HL) level. METHODS: This descriptive study was conducted between 2015 and 2016 in 4 rural community clinics in south Louisiana. Patients overdue for screening were given a structured interview by a research assistant. RESULTS: 339 women were enrolled, mean age 58.5, 32% had limited HL, 66% were African American. Most (91.7%) had heard of CRC, yet only 71% knew of any CRC screening tests. Women with adequate HL had greater knowledge of specific tests than those with limited HL (78.4% vs 56.6%, p<0.001). Only 25.7% had been given information on CRC testing; those with adequate HL were more likely to have received information (30.1% vs 16.8%; p=0.017). Most women (93.2%) indicated they would want to know if they had CRC, while 72.2% reported a provider had recommended CRC screening. Only 24.9% said a healthcare provider had ever given them an FOBT or that they had ever completed an FOBT (22.7%). There were no differences in women's report of recommendation or completion by HL level.Self-efficacy for completing an FOBT was high; over 90% indicated they could get an FOBT, complete it and mail results to the lab. Level of confidence did not vary by literacy. Three of the four barrier items varied by HL with women with low HL being more likely to fear doing an FOBT because they thought FOBT instructions would be confusing (p=0.002), doing the test would be embarrassing (p=0.025) or messy (p=0.057). CONCLUSIONS: Rural women are receptive to CRC screening and view FOBTs as effective. Rural community clinics need to provide low cost FOBTs with literacy, gender and culturally appropriate information.

Third Annual Fecal Occult Blood Testing in Community Health Clinics.

OBJECTIVES: Our objective was to determine the effectiveness of 3 approaches to encourage completion of fecal occult blood testing (FOBT) in the third year of the intervention. METHODS: Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Clinics were randomly assigned to enhanced care (screening recommendation and FOBT kit mailed annually), education (patients additionally received a health literacy appropriate pamphlet and simplified FOBT instructions), or nurse support (same as education but with nurse follow-up). Participants included 206 patients with negative FOBTs in years 1 and 2; ages 50-85, 80% female, 70% African American, and 52% had limited health literacy. The main outcome measure was completion of a third annual FOBT. RESULTS: Third-year FOBT rates were 48% overall, 34.2% enhanced care, 59.6% education, and 47.4% nurse support (p = .21), even after adjustment for sex, marital status, and health literacy. CONCLUSION: All mailed interventions were similarly effective in sustaining rates of FOBT screening. Post hoc analyses of the results analyzed by health literacy skills found that patients with both limited and adequate health literacy skills were more likely to complete FOBTs when mailed simplified instructions.

Final Results of a 3-Year Literacy-Informed Intervention to Promote Annual Fecal Occult Blood Test Screening.

This three arm study was designed to make CRC screening with FOBTs more accessible, understandable and actionable for patients cared for in predominantly rural Federally Qualified Health Centers. Patients in an enhanced version of usual care received an annual CRC recommendation and FOBT kit; those in the education arm additionally received brief literacy and culturally appropriate education and those in the nurse arm received the education by a nurse manager who followed up by telephone. Baseline FOBT rates in this population were 3 %. We evaluated if FOBT rates could be sustained over 3 years. A three-arm, quasi-experimental evaluation was conducted among eight clinics in Louisiana. Screening efforts included: (1) enhanced usual care, (2) literacy-informed education of patients, and (3) education plus nurse support. Overall, 961 average-risk patients, ages 50-85, eligible for routine CRC screenings were recruited. The primary outcome was completing three annual FOBT tests. Of 961 patients enrolled, 381 (39.6 %) participants did not complete a single FOBT, 60.4 % completed at least one FOBT of which 318 (33.1 %) completed only one, 162 (16.9 %) completed two and 100 (10.4 %) completed three FOBTs over the 3-year period (the primary study outcome). The primary outcome, return of three FOBT kits over the 3-year period, was achieved by 4.7 % in enhanced care, 11.4 % in education and 13.6 % in the nurse arm (p = 0.005). Overall 3-year FOBT screening rates were not sustained with any of the three interventions, despite reports of promising interim results at years 1 and 2. New strategies for sustaining FOBT screening over several years must be developed.

Sustaining mammography screening among the medically underserved: a follow-up evaluation.

BACKGROUND: Our previous three-arm comparative effectiveness intervention in community clinic patients who were not up-to-date with screening resulted in mammography rates over 50% in all arms. OBJECTIVE: Our aim was to evaluate the effectiveness and cost-effectiveness of the three interventions on improving biennial screening rates among eligible patients. METHODS: A three-arm quasi-experimental evaluation was conducted in eight community clinics from 2008 to 2011. Screening efforts included (1) enhanced care: Participants received an in-person recommendation from a research assistant (RA) in year 1, and clinics followed usual clinic protocol for scheduling screening mammograms; (2) education intervention: Participants received education and in-person recommendation from an RA in year 1, and clinics followed usual clinic protocol for scheduling mammograms; or (3) nurse support: A nurse manager provided in-person education and recommendation, scheduled mammograms, and followed up with phone support. In all arms, mammography was offered at no cost to uninsured patients. RESULTS: Of 624 eligible women, biennial mammography within 24-30 months of their previous test was performed for 11.0% of women in the enhanced-care arm, 7.1% in the education- intervention arm, and 48.0% in the nurse-support arm (p<0.0001). The incremental cost was $1,232 per additional woman undergoing screening with nurse support vs. enhanced care and $1,092 with nurse support vs. education. CONCLUSIONS: Biennial mammography screening rates were improved by providing nurse support but not with enhanced care or education. However, this approach was not cost-effective.

Joint breast and colorectal cancer screenings in medically underserved women.

BACKGROUND: Breast and colon cancer screening in rural community clinics is underused. OBJECTIVE: To evaluate the effectiveness and cost-effectiveness of alternative interventions designed to promote simultaneous screening for breast and colon cancer in community clinics. METHODS: A 3-arm, quasi-experimental evaluation was conducted during May 2008-August 2011 in 8 federally qualified health clinics in predominately rural Louisiana. Baseline screening rates reported by the clinics was <10% for breast cancer (using mammography) and 1%-2% for colon cancer (using the fecal occult blood test [FOBT]). 744 women aged 50 years or older who were eligible for routine mammography and an FOBT were recruited. The combined screening efforts included: enhanced care; health literacy-informed education (education alone), or health literacy-informed education with nurse support (nurse support). RESULTS: Postintervention screening rates for completing both tests were 28.1% with enhanced care, 23.7% with education alone, and 38.7% with nurse support. After adjusting for age, race, and literacy, patients who received nurse support were 2.21 times more likely to complete both screenings than were those who received the education alone (95% confidence interval [CI], 1.12-4.38; P = .023). The incremental cost per additional woman completing both screenings was $3,987 for education with nurse support over education alone, and $5,987 over enhanced care. LIMITATIONS: There were differences between the 3 arms in sociodemographic characteristics, literacy, and previous screening history. Not all variables that were significantly different between arms were adjusted for, therefore adjustments for key variables (age, race, literacy) were made in statistical analyses. Other limitations related generalizability of results. CONCLUSIONS: Although joint breast and colon cancer screening rates were increased substantially over existing baseline rates in all 3 arms, the completion rate for both tests was modest. Nurse support and telephone follow-up were most effective. However, it is not likely to be cost effective or affordable in clinics with limited resources.

Strategies to improve repeat fecal occult blood testing cancer screening.

BACKGROUND: A comparative effectiveness intervention by this team improved initial fecal occult blood testing (FOBT) rates from 3% to 53% among community clinic patients. The purpose of this study was to evaluate the effectiveness and costs associated with a literacy-informed intervention on repeat FOBT testing. METHODS: Between 2008 and 2011, a three-arm quasi-experiential comparative effectiveness evaluation was conducted in eight community clinics in Louisiana. Clinics were randomly assigned to receive: enhanced care, a screening recommendation, and FOBT kit annually; a brief educational intervention where patients additionally received a literacy appropriate pamphlet and simplified FOBT instructions; or nurse support where a nurse manager provided the education and followed up with phone support. In year 2, all materials were mailed. The study consisted of 461 patients, ages 50 to 85 years, with a negative initial FOBT. RESULTS: Repeat FOBT rates were 38% enhanced care, 33% education, and 59% with nurse support (P = 0.017). After adjusting for age, race, gender, and literacy, patients receiving nurse support were 1.46 times more likely to complete repeat FOBT screening than those receiving education [95% confidence interval (CI), 1.14-1.06; P = 0.002] and 1.45 times more likely than those in enhanced care but this was not significant (95% CI, 0.93-2.26; P = 0.10). The incremental cost per additional person screened was $2,450 for nurse over enhanced care. CONCLUSION: A mailed pamphlet and FOBT with simplified instructions did not improve annual screening. IMPACT: Telephone outreach by a nurse manager was effective in improving rates of repeat FOBT, yet this may be too costly for community clinics.

Improving mammography screening among the medically underserved.

BACKGROUND: We evaluated the effectiveness and cost-effectiveness of alternative interventions designed to promote mammography in safety-net settings. METHODS: A three-arm, quasi-experimental evaluation was conducted among eight federally qualified health clinics in predominately rural Louisiana. Mammography screening efforts included: 1) enhanced care, 2) health literacy-informed education of patients, and 3) education plus nurse support. Outcomes included mammography screening completion within 6 months and incremental cost-effectiveness. RESULTS: Overall, 1,181 female patients ages 40 and over who were eligible for routine mammography were recruited. Baseline screening rates were < 10%. Post intervention screening rates were 55.7% with enhanced care, 51.8% with health literacy-informed education and 65.8% with education and nurse support. After adjusting for race, marital status, self-efficacy and literacy, patients receiving health-literacy informed education were not more likely to complete mammographic screening than those receiving enhanced care; those additionally receiving nurse support were 1.37-fold more likely to complete mammographic screening than those receiving the brief education (95% Confidence Interval 1.08-1.74, p = 0.01). The incremental cost per additional women screened was $2,457 for literacy-informed education with nurse support over literacy-informed education alone. CONCLUSIONS: Mammography rates were increased substantially over existing baseline rates in all three arms with the educational initiative, with nurse support and follow-up being the most effective option. However, it is not likely to be cost-effective or affordable in resource-limited clinics.

Contrasts in rural and urban barriers to colorectal cancer screening.

OBJECTIVES: To contrast barriers to colon cancer (CRC) screening and Fecal Occult Blood Test (FOBT) completion between rural and urban safety-net patients. METHODS: Interviews were administered to 972 patients who were not up-to-date with screening. RESULTS: Rural patients were more likely to believe it was helpful to find CRC early (89.7% vs 66.1%, p < .0001), yet were less likely to have received a screening recommendation (36.4% vs. 45.8%, p = .03) or FOBT information (14.5% vs 32.3%, p < .0001) or to have completed an FOBT (22.0% vs 45.8%, p < .0001). CONCLUSIONS: Interventions are needed to increase screening recommendation, education and completion, particularly in rural areas.

Literacy barriers to colorectal cancer screening in community clinics.

This article examines the relationship between literacy and colorectal cancer (CRC) screening knowledge, beliefs, and experiences, with a focus on fecal occult blood tests (FOBTs). Participants were 975 patients in 8 Louisiana federally qualified health centers. Participants were 50 years of age or older and not up to date with CRC screening; approximately half (52%) had low literacy (less than a 9th-grade level). Participants with low literacy were less likely than were those with adequate literacy to be aware of advertisements promoting CRC screening (58.7% vs. 76.3%, p < .0001) or to believe it was very helpful to find CRC early (74.5% vs. 91.9%, p < .0001). The majority of participants had positive beliefs about the benefits of CRC screening using FOBTs. Participants with low literacy had more perceived barriers to FOBT completion and were more likely to strongly agree or agree that FOBTs would be confusing, embarrassing, or a lot of trouble; however, none of these remained significant in multivariate analyses controlling for relevant covariates. Confidence in being able to obtain an FOBT kit was high among those with low and adequate literacy (89.8% vs. 93.1%, respectively, p = .20); yet multivariate analyses revealed a significant difference in regard to literacy (p = .04) with low-literacy participants indicating less confidence. There was no significant difference by literacy in ever receiving a physician recommendation for CRC screening (38.4% low vs. 39.0% adequate, p = .79); however, multivariate analyses revealed significant differences in FOBT completion by literacy (p = .036). Overall, findings suggest that literacy is a factor in patients' CRC knowledge, beliefs, and confidence in obtaining a FOBT.

FOBT completion in FQHCs: impact of physician recommendation, FOBT information, or receipt of the FOBT kit.

PURPOSE: To determine the effect of common components of primary care-based colorectal cancer (CRC) screening interventions on fecal occult blood test (FOBT) completion within rural and urban community clinics, including: (1) physician's spoken recommendation, (2) providing information or education about FOBTs, and (3) physician providing the FOBT kit; to determine the relative effect of these interventions; and to compare the effect of each intervention between rural and urban clinics. METHODS: We conducted structured interviews with patients aged 50 years and over receiving care at community clinics that were noncompliant with CRC screening. Self-report of ever receiving a physician's recommendation for screening, FOBT information or education, physician providing an FOBT kit, and FOBT completion were collected. FINDINGS: Participants included 849 screening-eligible adults; 77% were female and 68% were African American. The median age was 57; 33% lacked a high school diploma and 51% had low literacy. In multivariable analysis, all services were predictive of rural participants completing screening (physician recommendation: P = .002; FOBT education: P = .001; physician giving FOBT kit: P < .0001). In urban clinics, only physician giving the kit predicted FOBT completion (P < .0001). Compared to urban patients, rural patients showed a stronger relationship between FOBT completion and receiving a physician recommendation (risk ratio [RR]: 5.3 vs. 2.1; P = .0001), receiving information or education on FOBTs (RR: 3.8 vs 1.9; P = .0002), or receiving an FOBT kit from their physician (RR: 22.3 vs. 10.1; P = .035). CONCLUSIONS: Participants who receive an FOBT kit from their physician are more likely to complete screening.

Differences in barriers to mammography between rural and urban women.

BACKGROUND: Few studies have examined differences between rural and urban women in mammography barriers, knowledge, and experiences. Exploring differences can help inform tailored interventions. METHODS: Women, aged ≥40, who had not been screened in the past 2 years were recruited from eight federally qualified health centers across Louisiana. They were given a structured interview assessing mammography knowledge, beliefs, barriers, experiences, and literacy. RESULTS: Of the 1189 patients who participated, 65.0% were African American, 61.6% were rural, and 44.0% had low literacy. Contrary to guidelines, most believed mammography should be done annually (74.3%) before age 40 (70.5%). Compared to urban women, rural participants were more likely to believe mammography will find small breast lumps early (34.4% vs. 6.5%, p<0.0001) and strongly disagree that mammography is embarrassing (14.6% vs. 8.4%, p=0.0002) or that they are afraid of finding something wrong (21.2% vs.12.3%, p=0.007). Rural women were more likely to report a physician recommendation for mammography (84.3% vs. 76.5%, p=0.006), but they were less likely to have received education (57.2% vs. 63.6%, p=0.06) or to have ever had a mammogram (74.8% vs. 78.1%, p=0.007). In multivariate analyses controlling for race, literacy, and age, all rural/urban differences remained significant, except for receipt of a mammogram. CONCLUSIONS: Most participants were unclear about when they should begin mammography. Rural participants reported stronger positive beliefs, higher self-efficacy, fewer barriers, and having a physician recommendation for mammography but were less likely to receive education or screening.

Vaccine risk/benefit communication: effect of an educational package for public health nurses.

The purpose of this study was to determine whether an in-service for public health nurses (PHNs) and accompanying educational materials could improve vaccine risk/benefit communication. The content and timing of vaccine communication were recorded during 246 pre-and 217 postintervention visits in two public health immunization clinics. Pre-/postintervention comparisons showed PHN communication of severe side effects (13% vs. 44%, p < .0001) and their management (29% vs. 60%, p < .0001) increased. There was no significant change in discussion of vaccine benefits (48% vs. 51%) or common side effects (91% vs. 92%),screening for contraindications (71% vs. 77%), or distribution of written information (89% vs. 92%). More parents initiated vaccine questions postintervention (27% vs. 39%,p < .01) and were more satisfied with vaccine-risk communication (8.1 vs. 8.9 on a 10-point scale, p < .01). Average vaccine communication time increased from 16 to 22 seconds (p < .01).