Implementation studio: implementation support program to build the capacity of rural community health educators serving immigrant communities to implement evidence-based cancer prevention and control interventions.

PURPOSE: Rural community-based organizations (CBOs) serving immigrant communities are critical settings for implementing evidence-based interventions (EBIs). The Implementation Studio is a training and consultation program focused on facilitating the selection, adaptation, and implementation of cancer prevention and control EBIs. This paper describes implementation and evaluation of the Implementation Studio on CBO's capacity to implement EBIs and their clients' knowledge of colorectal cancer (CRC) screening and intention to screen. METHODS: Thirteen community health educators (CHEs) from two CBOs participated in the Implementation Studio. Both CBOs selected CRC EBIs during the Studio. The evaluation included two steps. The first step assessed the CHEs' capacity to select, adapt, and implement an EBI. The second step assessed the effect of the CHEs-delivered EBIs on clients' knowledge of CRC and intention to screen (n = 44). RESULTS: All CHEs were Hispanic and women. Pre/post-evaluation of the Studio showed an increase on CHEs knowledge about EBIs (pre: 23% to post: 75%; p < 0.001). CHEs' ability to select, adapt, and implement EBIs also increased, respectively: select EBI (pre: 21% to post: 92%; p < 0.001), adapt EBI (pre: 21% to post: 92%; p < 0.001), and implement EBI (pre: 29% to post: 75%; p = 0.003). Pre/post-evaluation of the CHE-delivered EBI showed an increase on CRC screening knowledge (p < 0.5) and intention to screen for CRC by their clients. CONCLUSION: Implementation Studio can address unique needs of low resource rural CBOs. An implementation support program with training and consultation has potential to build the capacity of rural CBOs serving immigrant communities to implementation of cancer prevention and control EBIs. CLINICAL TRIALS REGISTRATION NUMBER: NCT04208724 registered.

Understanding Complex Roles of Family for Latina Health: Evaluating Family Obligation Stress.

We developed a measure of family obligation stress and compared its relationship to health and unmet health care needs relative to social support among a sample of US-based Latinas. Data come from a randomized controlled trial within 4 clinics to increase mammography among Latinas (n = 539). The 1-factor measure had acceptable reliability and construct validity. Family obligation stress was associated with worse health and greater unmet health care needs. Family obligation stress varied by years in the United States and country of origin. Our measure of family obligation stress contributes new venues to family research among Latino populations.

Psychosocial Factors of Diet and Physical Activity among Rural, Hispanic Children: Findings from a Multilevel Health Intervention Study.

OBJECTIVE: To examine the relationship of psychosocial factors, such as self-efficacy, family role modeling, and perceptions of the environment, on diet, physical activity, and sedentary behavior in Hispanic children living in rural Washington State. METHODS: Gender, heights, and weights were obtained from Hispanic 8-12 year olds (n = 553) from two rural communities in Lower Yakima, Washington. A subsample of 179 children provided psychosocial measures, diet, and screen time via questionnaire and physical activity via accelerometer. Body mass index percentiles were used to calculate the prevalence of obesity. The association of demographic and psychosocial measures on the mean difference (95% confidence interval (CI)) of fruit, vegetable, and sugar consumption and minutes spent active was estimated using linear regression models. RESULTS: Prevalence of obesity was 35%. Children with obesity consumed one-fifth (- 0.3, - 0.02) fewer cups of fruits, 2.2 (0.1, 4.2) more teaspoons of total added sugars, and spent 16.1 (- 22.0, - 10.2) fewer minutes in moderate-to-vigorous physical activity per day compared with children with healthy weights. Males consumed more added sugars and reported more screen time than females, but spent more daily minutes in moderate-to-vigorous physical activity. Higher fruit and vegetable self-efficacy scores were associated with more consumption of fruits and vegetables, more engagement in light physical activity, and less time spent sedentary per day. CONCLUSION: Male gender and some psychosocial measures were associated with obesogenic behaviors. Insight about factors associated with obesity-related behaviors in rural, Hispanic children may help the development of successful and effective behavioral health interventions for this understudied population.

Estimating the costs and cost-effectiveness of promoting mammography screening among US-based Latinas.

PURPOSE: We characterize the costs and cost-effectiveness of a community health worker (CHW)-based intervention to promote screening mammography among US-based non-adherent Latinas. METHODS: The parent study was a randomized controlled trial for 536 Latinas aged 42-74 years old who had sought care within a safety net health center in Western Washington. Participants were block-randomized within clinic to the control arm (usual care) or intervention arm (CHW-led motivational interviewing intervention). We used the perspective of the organization implementing promotional activities to characterize costs and cost-effectiveness. Cost data were categorized as program set-up and maintenance (initial training, booster/annual training) program implementation (administrative activities, intervention delivery); and, overhead/miscellaneous expenses. Cost-effectiveness was calculated as the incremental cost of screening for each additional woman screened between the intervention and control arms. RESULTS: The respective costs per participant for standard care and the intervention arm were $69.96 and $300.99. There were no study arm differences in 1-year QALYs were small among women who completed a 12-month follow-up survey (intervention= 0.8827, standard care = 0.8841). Most costs pertained to program implementation and administrative activities specifically. The incremental cost per additional woman screened was $2,595.32. CONCLUSIONS: Our findings are within the ranges of costs and cost-effectiveness for other CHW programs to promote screening mammography among underserved populations. Our strong study design and focus on non-adherent women provides important strengths to this body of work, especially give implementation and dissemination science efforts regarding CHW-based health promotion for health disparity populations.

Neighborhood Predictors of Mammography Barriers Among US-Based Latinas.

BACKGROUND: Little is known about how neighborhood factors are associated with Latinas' barriers to cancer screening, including mammography. To address this gap, we examined barriers to mammography by neighborhood racial/ethnic composition and socioeconomic status among a federally qualified health center (FQHC)-based sample of non-adherent Latinas in Western Washington State. METHODS: Baseline data were drawn from a larger intervention study (n = 536 Latinas). Women indicated why they had not obtained a mammogram in the past 2 years (no reason, knowledge, psychocultural, economic). American Community Survey (2007-2011) data were used to calculate four neighborhood measures that were categorized in tertiles (T): socioeconomic-based concentration, socioeconomic-based segregation, Latino-based concentration, and Latino-based segregation. RESULTS: The proportion of women reporting knowledge-, psychocultural-, and economic-based reasons for not obtaining mammograms in the past 2 years was, respectively, 0.35, 0.19, and 0.31. Approximately 14 % indicated no particular reason. Relative to women residing in areas with greater Latino-based segregation, women in areas with less Latino-based segregation were less likely to report knowledge-based and economic-based reasons for not obtaining a mammogram (p ≤ 0.05). Relative to women residing in areas with greater concentration of Latinos, women in areas with the lowest concentrations were less likely to report knowledge-based reasons for not obtaining a mammogram (p ≤ 0.05). CONCLUSIONS: Our findings provide important information about the role of neighborhood characteristics and mammography use among Latinas obtaining care from FQHCs. Future research might examine the mediating role of neighborhood characteristics in the efficacy of mammography screening interventions.

Healthcare Factors for Obtaining a Mammogram in Latinas With a Variable Mammography History.

PURPOSE/OBJECTIVES: To understand the relationship between mammography history and current thoughts about obtaining a mammogram among Latinas and examine the mediation effects of several healthcare factors.
. DESIGN: Cross-sectional survey.
. SETTING: Federally qualified health centers (Sea Mar Community Health Centers) in western Washington.
. SAMPLE: 641 Latinas nonadherent and adherent with screening mammography.
. METHODS: Baseline survey data from Latinas with a mammography history of never, not recent (more than two years), or recent (less than two years) were analyzed. Preacher and Hayes methods were used to estimate the mediation effect of healthcare factors.
. MAIN RESEARCH VARIABLES: The survey assessed mammography history, sociodemographic and healthcare factors, and current thoughts about obtaining a mammogram.
. FINDINGS: Latinas' thoughts about obtaining a mammogram were associated with mammography history. Having had a clinical breast examination mediated 70% of differences between Latinas with a never and recent mammography history. Receipt of a provider recommendation mediated 54% of differences between Latinas with and without a recent mammography history.
. CONCLUSIONS: These findings emphasize the importance of the patient-provider relationship during a clinic visit and help inform how nurses may be incorporated into subsequent screening mammography interventions tailored to Latinas.
. IMPLICATIONS FOR NURSING: As providers, health educators, and researchers, nurses have critical roles in encouraging adherence to screening mammography guidelines among Latinas.

Multilevel Intervention Raises Latina Participation in Mammography Screening: Findings from ¡Fortaleza Latina!

BACKGROUND: Breast cancer is the most commonly diagnosed cancer in women in the United States, and Latinas have relatively low rates of screening participation. The Multilevel Intervention to Increase Latina Participation in Mammography Screening study (¡Fortaleza Latina!) sought to assess the efficacy of a clinic- and patient-level program to increase breast cancer screening among Latinas in Western Washington who seek care at a safety net health center. METHODS: The study enrolled 536 Latinas ages 42 to 74 who had a primary care clinic visit in the previous 5 years and had not obtained a mammogram in the previous 2 years. Participants were block-randomized within clinic to either (i) a control arm (usual care) or (ii) a promotora-led, motivational interviewing intervention that included a home visit and telephone follow-up. At the clinic level, two of four participating clinics were provided additional mammography services delivered by a mobile mammography unit. RESULTS: Rates of screening mammography 1 year post-randomization were 19.6% in the intervention group and 11.0% in the usual care group (P < 0.01), based on medical record data. No significant differences in participants' mammography screening were observed in clinics randomized to additional mammography services versus usual care (15.8% vs. 14.4%; P = 0.68). CONCLUSION: This multilevel intervention of promotora-delivered motivational interviewing and free mammography services modestly raised rates of participation in breast cancer screening among Latinas. IMPACT: Our findings can inform future efforts to boost mammography participation in safety net practices. Cancer Epidemiol Biomarkers Prev; 25(4); 584-92. ©2016 AACR SEE ALL ARTICLES IN THIS CEBP FOCUS SECTION, "MULTILEVEL APPROACHES TO ADDRESSING CANCER HEALTH DISPARITIES".

Family/friend recommendations and mammography intentions: the roles of perceived mammography norms and support.

Identifying factors that increase mammography use among Latinas is an important public health priority. Latinas are more likely to report mammography intentions and use, if a family member or friend recommends that they get a mammogram. Little is known about the mechanisms underlying the relationship between social interactions and mammography intentions. Theory suggests that family/friend recommendations increase perceived mammography norms (others believe a woman should obtain a mammogram) and support (others will help her obtain a mammogram), which in turn increase mammography intentions and use. We tested these hypotheses with data from the ¡Fortaleza Latina! study, a randomized controlled trial including 539 Latinas in Washington State. Women whose family/friend recommended they get a mammogram within the last year were more likely to report mammography intentions, norms and support. Perceived mammography norms mediated the relationship between family/friend recommendations and intentions, Mediated Effect = 0.38, 95%CI [0.20, 0.61], but not support, Mediated Effect = 0.002, 95%CI [-0.07, 0.07]. Our findings suggest perceived mammography norms are a potential mechanism underlying the effect of family/friend recommendations on mammography use among Latinas. Our findings make an important contribution to theory about the associations of social interactions, perceptions and health behaviors.

Promoting changes in obesogenic behaviors: does coworker social support play a role?

PURPOSE: To examine the association between worksite social support and changes in diet, physical activity, and body mass index (BMI). DESIGN: Cohort analysis of an underlying randomized, controlled weight gain prevention worksite trial: Promoting Activity and Changes in Eating. SETTING: The trial occurred in the greater Seattle area. SUBJECTS: Baseline and follow-up data were obtained on a nested cohort of employees (n = 958-1078) from 33 small- to medium-sized worksites. MEASURES: Worksite social support, diet, physical activity, and BMI measures were assessed using a self-reported questionnaire. ANALYSIS: To adjust for multilevel data and multiple time points, we used generalized estimating equations and logistic mixed models. RESULTS: Higher baseline worksite social support was associated with greater changes in fruit and vegetable intake (p = .001; summary food-frequency questions). CONCLUSION: This study does not support a conclusive relationship between worksite social support and health behavior change.

Multi-level Intervention to increase participation in mammography screening: ¡Fortaleza Latina! study design.

BACKGROUND: Breast cancer is the most common cancer and the leading cause of death among Latinas in the United States. The Multi-level Intervention to Increase Participation in Mammography Screening study (¡Fortaleza Latina!) is a partnership among research institutions, a Latino-serving community-based primary care clinic organization, and a cancer treatment center. The study will assess the efficacy of a clinic- and patient-level program to increase breast cancer screening among Latinas in Western Washington. METHODS/DESIGN: The intervention is a multi-level breast cancer screening program in four participating primary care clinics. The study is a parallel randomized controlled trial of 600 Latino women aged 42-74 who are non-compliant with breast cancer screening guidelines. Participants will be randomized within clinic using block randomization to: (1) a control arm (usual care); and (2) a theory-based counseling program consisting of a 'promotora' or community health worker-led home-based intervention to encourage breast cancer screening. At the clinic-level, two clinics will offer additional mammography services provided by a mobile mammography unit operated by the Seattle Cancer Care Alliance. The primary endpoint is the rate of mammography uptake over the 1-year follow-up period. DISCUSSION: This multi-level intervention aims to raise rates of participation in breast cancer screening among Latino women. If effective, the program may improve rates of early detection of breast cancer in Latino women. Clinicaltrials.gov REGISTRATION NUMBER: NCT02010008.

The association between worksite social support, diet, physical activity and body mass index.

OBJECTIVE: Social support may be associated with improved diet and physical activity-determinants of overweight and obesity. Wellness programs increasingly target worksites. The aim was to evaluate the relationship between worksite social support and dietary behaviors, physical activity, and body mass index (BMI). METHOD: Baseline data were obtained on 2878 employees from 2005 to 2007 from 34 worksites through Promoting Activity and Changes in Eating, a group-randomized weight reduction intervention in Greater Seattle. Worksite social support, diet, physical activity, and BMI were assessed via self-reported questionnaire. Principal component analysis was applied to workgroup questions. To adjust for design effects, random effects models were employed. RESULTS: No associations were found with worksite social support and BMI, or with many obesogenic behaviors. However, individuals with higher worksite social support had 14.3% higher (95% CI: 5.6%-23.7%) mean physical activity score and 4% higher (95% CI: 1%-7%) mean fruit and vegetable intake compared to individuals with one-unit lower support. CONCLUSION: Our findings do not support a conclusive relationship between higher worksite social support and obesogenic behaviors, with the exception of physical activity and fruit and vegetable intake. Future studies are needed to confirm these relationships and evaluate how worksite social support impacts trial outcomes.

Long-term fruit and vegetable change in worksites: Seattle 5 a Day follow-up.

OBJECTIVE: To evaluate long-term change in fruit and vegetable intake following a group randomized trial of worksites. METHODS: Medium-sized blue-collar businesses in the Seattle metropolitan area were recruited. Intake was assessed using serial cross-sectional samples of current workforce at 3 time points. The multilevel 18-month intervention involved partnership with the companies. Long-term follow-up was at 4.4 years postbaseline. Statistical analysis used general linear models, adjusting for worksite random effects. RESULTS: Initially, 45 worksites were randomized, with 29 agreeing to participate in a new study. Fruits and vegetable intake increased, with larger sustained changes in the intervention worksites, resulting in a long-term differential change of 0.25 servings per day, 95% confidence interval (0.09 to 0.40). CONCLUSIONS: Intervention sustained small effects at 4 years, including 2 years with no contact. Although effects were not large, this low-intensity intervention approach could provide an important public health model.

Environmental assessment at worksites after a multilevel intervention to promote activity and changes in eating: the PACE project.

OBJECTIVE: To evaluate changes in the worksite environment in response to a multilevel intervention over a 2-year period. METHODS: Worksites were recruited in the greater Seattle area, and 34 were randomized to intervention or comparison condition. The intervention was based on the ecological model, with a framework of defined phases of intervention that included worksite-wide events implemented in partnership with employee-based advisory boards. The assessment of the worksite environment used a modification of the Checklist of Health Promotion Environments at Worksites. Subscales were developed using baseline data only. The intervention effect on different aspects of the worksite environment was estimated using logistic regression with robust estimating procedures. RESULTS: Only changes in the physical activity and nutrition information environments were significantly associated with the intervention. CONCLUSIONS: This article provides one of the first attempts at using environmental assessment in the evaluation of worksite interventions.

Heavy smokers: a qualitative analysis of attitudes and beliefs concerning cessation and continued smoking.

In this qualitative analysis, we conducted intensive interviews of a group of heavy smokers to better understand psychosocial characteristics related to smoking and quitting. A total of 51 heavy smokers were recruited to participate in this study. In-depth interviews lasting 60-90 min explored factors related to smoking and attitudes toward cessation. N'Vivo was used to analyze the data. We modeled a number of factors related to heavy smoking in this population. A comprehensive model appeared to fit the data well. Key factors related to heavy smoking included those that promote smoking, those that influence quitting, perceptions of quitting, and explanations of failure. Along each of these dimensions, clusters of variables, such as the social environment, emotional identity, addiction, and physical health, emerged as being important in understanding the perceptions of heavy smokers when it comes to smoking and quitting. The models add important information to our understanding of heavy smokers. This work indicates that this sample of heavy smokers had many issues around smoking and quitting, including the perceived difficulty of quitting, physical and psychological addictions to smoke, reinforcement for smoking, and a tendency to procrastinate in quitting.