Social Media as a Tool to Promote Health Awareness: Results from an Online Cervical Cancer Prevention Study.

Online social media platforms represent a promising opportunity for public health promotion. Research is limited, however, on the effectiveness of social media at improving knowledge and awareness of health topics and motivating healthy behavior change. Therefore, we investigated whether participation in an online social media platform and receipt of brief, tailored messages is effective at increasing knowledge, awareness, and prevention behaviors related to human papillomavirus (HPV) and cervical cancer. We conducted an online study in which 782 recruited participants were consecutively assigned to nine-person groups on a social media platform. Participants were shown a unique random set of 20 tailored messages per day over five days. Participants completed a baseline and post survey to assess their knowledge, awareness, and prevention behaviors related to HPV and cervical cancer. There were no statistically significant changes in knowledge and prevention behaviors from the baseline to the post survey among study participants. There was a modest, statistically significant change in response to whether participants had ever heard of HPV, increasing from 90 to 94% (p = 0.003). Our findings suggest that most study participants had substantial knowledge, awareness, and engagement in positive behaviors related to cervical cancer prevention at the start of the study. Nevertheless, we found that HPV awareness can be increased through brief participation in an online social media platform and receipt of tailored health messages. Further investigation that explores how social media can be used to improve knowledge and adoption of healthy behaviors related to cervical cancer is warranted.

Effective communication in the era of precision medicine: A pilot intervention with low health literacy patients to improve genetic counseling communication.

Effective communication, where all parties share a common understanding, is necessary to realize the promise of Genomic Medicine. It is especially salient given the imperative to increase the participation of diverse populations in genomics research and to expand the reach of clinical genomics. We have previously shown that cancer genetic counseling is suboptimal for patients with limited health literacy. To address this finding, we implemented a pilot study to improve verbal communication between genetic counselors and their patients of limited health literacy that consisted of: i) curriculum development and delivery of a Genetic Counselors (GC) communication workshop; ii) two-month post-workshop interviews with GC participants (n = 9); iii) observations/audio recordings of counseling sessions involving 24 patients and two GC workshop participants; iv) post-counseling interviews with patients (n = 9). The 4.5-h workshop presented evidenced-based principles and strategies for effective communication with limited health literacy patients (e.g. use of plain language and teach-back), and offered specific techniques and exercises to practice adoption of such practices in the genetic counseling context. GCs expressed appreciation for the opportunity to refine their skills; however, they reported that some strategies were challenging given their professional training and communication habits. For example, GCs were concerned that use of plain language could undermine efforts to obtain informed consent and provide scientifically accurate information. Observations and patient interviews after the workshop revealed that GCs were able to employ the communication strategies with positive effects, with patients indicating sufficient understanding of the genetic test and its implications as well as satisfaction with the counselors' communication. While derived from research on communication with those of limited health literacy, the communication approaches taught in the GC workshop could benefit most patients, given the high rates of low health literacy in many countries, and the many factors beyond health literacy that can contribute to reduced comprehension in health care environments.

The San Francisco Cancer Initiative: A Community Effort To Reduce The Population Burden Of Cancer.

The great potential for reducing the cancer burden and cancer disparities through prevention and early detection is unrealized at the population level. A new community-based coalition, the San Francisco Cancer Initiative (SF CAN), focuses on the city and county of San Francisco, where cancer is the leading cause of death. SF CAN is an integrated, cross-sector collaboration launched in November 2016. It brings together the San Francisco Department of Public Health; the University of California, San Francisco; major health systems; and community coalitions to exert collective impact. Its goals are to reduce the burden of five common cancers-breast, lung and other tobacco-related, prostate, colorectal, and liver-for which there are proven methods of prevention and detection, while reducing known disparities. We describe the infrastructure, coalition building, and early progress of this initiative, which may serve as a model for other municipalities.

Educational Interventions to Promote Healthy Nutrition and Physical Activity Among Older Chinese Americans: A Cluster-Randomized Trial.

OBJECTIVES: To evaluate the efficacy of an in-language intervention of 2 lectures plus printed materials versus printed materials alone on knowledge and adherence to nutrition and physical activity guidelines among older Chinese Americans in San Francisco, California. METHODS: From August 2010 to September 2013, we randomized 756 Chinese Americans aged 50 to 75 years to either lectures plus print (n = 361) or print (n = 357). Clusters were the participants recruited by each lay health worker. Intervention outcomes were changes in knowledge of recommended vegetable intake, fruit intake, and physical activity level and adherence to those recommendations from pre- to 6 months postintervention. RESULTS: The retention rate was 99%. At baseline, knowledge and adherence to recommendations were low. Print yielded increases in knowledge of recommended vegetable intake and physical activity level and adherence to fruit intake and physical activity recommendations. Lectures plus print had significant increases in all 6 outcomes. In multivariable models, lectures plus print was superior to print for knowledge of vegetable (adjusted odds ratio [AOR] = 12.61; 95% confidence interval [CI] = 6.50, 24.45) and fruit (AOR = 16.16; 95% CI = 5.61, 46.51) intake recommendations and adherence to vegetable intake recommendations (AOR = 5.53; 95% CI = 1.96, 15.58). CONCLUSIONS: In-language print materials, alone and combined with lectures, increased nutrition and physical activity knowledge and behaviors among older Chinese Americans.

The Minority Training Program in Cancer Control Research: impact and outcome over 12 years.

The Minority Training Program in Cancer Control Research (MTPCCR) encourages underrepresented master's level students and professionals in the social, behavioral, and public health sciences to pursue doctoral training and careers in cancer disparities research. This paper reports new data on the program outcome after 12 years. A web-based survey was sent to all 462 program alumni. The questions addressed current academic status and plans, job status and plans, research focus, and influence of the MTPCCR. The survey response rate was 79 %. Overall, 30 % of alumni are enrolled in or have completed doctoral programs; 88 % of whom report involvement in research related to cancer. Scaled and open-ended responses indicate a strong influence of the program on doctoral program enrollment and cancer focus. The MTPCCR model is successful because it targets underrepresented minorities who are capable of doctoral studies but have not yet chosen that path.

Theorizing social context: rethinking behavioral theory.

Major behavioral theories focus on proximal influences on behavior that are considered to be predominantly cognitive characteristics of the individual largely uninfluenced by social context. Social ecological models integrate multiple levels of influence on health behavior and are noted for emphasizing the interdependence of environmental settings and life domains. This theory-based article explains how social context is conceptualized in the social sciences and how the social science conceptualization differs from and can broaden the analytic approach to health behavior. The authors use qualitative data from the Behavioral Constructs and Culture in Cancer Screening study to illustrate our conceptualization of social context. We conclude that the incorporation into health behavior theory of a multidimensional socioculturally oriented, theoretical approach to social context is critical to understand and redress health disparities in multicultural societies like the United States.

Behavioral constructs and mammography in five ethnic groups.

Intention, self-efficacy, perceived susceptibility, perceived benefits, and subjective norms are key constructs of health behavior theories; their predictive validity for cancer screening has not been ascertained in multiethnic populations. Participants were 1,463 African American, Chinese, Filipina, Latina, and White women aged 40 to 74 interviewed by telephone in their preferred languages. The relationship between baseline constructs and mammography 2 years later was assessed using multivariable logistic regression. Intention predicted mammography overall and among Whites (odds ratio [OR] = 5.0, 95% confidence interval [CI] = 2.4, 10), with racial/ethnic differences in association (p = .020). Self-efficacy predicted mammography overall and among Whites (OR = 3.5, 95% CI = 1.1, 11), with no racial/ethnic interaction. Perceived benefits and subjective norms were associated with screening overall and in some racial/ethnic groups. These results generally support cross-cultural applicability of four of the five constructs to screening with mixed predictive value of measures across racial/ethnic groups. Additional in-depth inquiry is required to refine assessment of constructs.

Social and cultural meanings of self-efficacy.

This article describes the influences of social context on women's health behavior through illustration of the powerful influences of social capital (the benefits and challenges that accrue from participation in social networks and groups) on experiences and perceptions of self-efficacy. The authors conducted inductive interviews with Latino and Filipino academics and social service providers and with U.S.-born and immigrant Latinas and Filipinas to explore direct and indirect influences of social context on health behaviors such as mammography screening. Iterative thematic analysis identified themes (meanings of efficacy, spheres of efficacy, constraints on efficacy, sources of social capital, and differential access to and quality of social capital) that link the domain of social capital with the behavioral construct perceived self-efficacy. The authors conclude that social capital addresses aspects of social context absent in the current self-efficacy construct and that these aspects have important implications for scholars' and practitioners' understandings of health behavior and intervention development.

Healthy Colon, Healthy Life (Ruot Lành, Song Khoe): patient and physician factors associated with colorectal cancer screening among Vietnamese Americans in a county medical care system.

OBJECTIVE: To examine factors associated with colorectal cancer (CRC) screening among Vietnamese Americans. METHODS: Telephone survey of Vietnamese aged 50-79 receiving primary care at participating clinics. RESULTS: Among 808 participants, 53% were up to date (UTD) with fecal occult blood test (FOBT), 19% were UTD with sigmoidoscopy, 28% were UTD with colonoscopy. Females were more likely to be UTD with FOBT (OR 1.4, 95% CI 1.02, 1.93). Individuals in the U.S. for less than 15 years were less likely than others to be UTD with any CRC screening (OR 0.65, 95% CI 0.44, 0.96). Patients of female physicians were more likely to be UTD with sigmoidoscopy or colonoscopy (OR 1.72, 95% CI 1.15, 2.57). Ethnicity and language concordance were not associated with screening. CONCLUSIONS: Many Vietnamese people are not receiving CRC screening. Women and patients of female physicians receive more screening.

A critical review of theory in breast cancer screening promotion across cultures.

This article reviews the contribution and potential of widely used health behavior theories in research designed to understand and redress the disproportionate burden of breast cancer borne by diverse race/ethnic, immigrant, and low-income groups associated with unequal use of mammography. We review the strengths and limitations of widely used theories and the extent to which theory contributes to the understanding of screening disparities and informs effective intervention. The dominant focus of most theories on individual cognition is critically assessed as the abstraction of behavior from its social context. Proposed alternatives emphasize multilevel ecological approaches and the use of anthropologic theory and methods for more culturally grounded understandings of screening behavior. Common and alternative treatments of fatalism exemplify this approach, and descriptive and intervention research exemplars further highlight the integration of screening behavior and sociocultural context.

Recruiting low-income healthy women to research: an exploratory study.

OBJECTIVE: The study goals were (1) to assess the feasibility of using an existing telephone health information and referral service for low-income, ethnically diverse women to recruit women for research participation; (2) to assess the feasibility of recruiting low-income, African American and Latino men into health research through the women callers to the telephone service; and (3) to describe the challenges women face and the strategies they use when talking to men about the men's health and research participation. DESIGN: We recruited women for individual semi-structured qualitative interviews via the Every Woman Counts (EWC) telephone information and referral service, a California Department of Health Services Cancer Detection Program. This paper describes our eligibility and recruitment assessment, and our qualitative data from 23 interviews with low-income African American and Latino women who called EWC. RESULTS: We found that it was feasible to recruit women, but not to recruit men through women who call this telephone service. Almost 50% (113) of women demographically eligible for recruitment, completed our screening questionnaire, despite calling EWC for a different purpose. Some 48% (54) of those women were eligible for an interview. Of interview-eligible women, 58% (10) of African Americans and 35% (13) of Latinos completed an interview. Only 17% (4) of women referred a man for participation in an interview for our study. Several themes emerged from our analysis of interview data: (1) women's role in men's health can be significant but is often uneasy; (2) challenges when talking to men about their health include health access, gender dynamics, and men's fear of health care; (3) women's understanding of research may be limited; (4) women use a range of strategies to address and overcome men's resistance to taking care of their health and participating in research. CONCLUSIONS: The challenges women face when talking with men about their health affect their ability to effectively speak to men about research participation. However, EWC and similar telephone health services may be an effective means for recruiting low-income women to chemoprevention and other studies requiring healthy participants.

Ethnic differences in decisional balance and stages of mammography adoption.

Behavioral theories developed through research with mainstream, English-speaking populations have been applied to ethnically diverse and underserved communities in the effort to eliminate disparities in early breast cancer detection. This study tests the validity of the transtheoretical model (TTM) decisional balance measure and the application of the TTM stages of change in a multiethnic, multilingual sample. A random sample of 1,463 Filipino, Latino, African American, Chinese, and White women aged 40 to 74 completed a phone survey of mammography beliefs and practices. Consistent with the TTM and independent of ethnicity, decisional balance was associated with mammography stage in all five ethnic groups when controlling for socioeconomic and other factors. In addition, having private insurance and a regular physician and being a long-time resident in the United States were positively associated with mammography maintenance. The application of the TTM for mammography is supported in a multiethnic and multilingual sample.

The costs of an outreach intervention for low-income women with abnormal Pap smears.

INTRODUCTION: Follow-up among women who have had an abnormal Papanicolaou (Pap) smear is often poor in public hospitals that serve women at increased risk for cervical cancer. This randomized controlled trial evaluated and compared the total cost and cost per follow-up of a tailored outreach intervention plus usual care with the total cost and cost per follow-up of usual care alone. METHODS: Women with an abnormal Pap smear (n = 348) receiving care at Alameda County Medical Center (Alameda County, California) were randomized to intervention or usual care. The intervention used trained community health advisors to complement the clinic's protocol for usual care. We assessed the costs of the intervention and the cost per follow-up within 6 months of the abnormal Pap smear test result. RESULTS: The intervention increased the rate of 6-month follow-up by 29 percentage points, and the incremental cost per follow-up was 959 dollars (2005 dollars). The cost per follow-up varied by the severity of the abnormality. The cost per follow-up for the most severe abnormality (high-grade squamous intraepithelial lesion) was 681 dollars, while the cost per follow-up for less severe abnormalities was higher. CONCLUSION: In a health care system in which many women fail to get follow-up care for an abnormal Pap smear, outreach workers were more effective than usual care (mail or telephone reminders) at increasing follow-up rates. The results suggest that outreach workers should manage their effort based on the degree of abnormality; most effort should be placed on women with the most severe abnormality (high-grade squamous intraepithelial lesion).

Progress in the pipeline: replication of the minority training program in cancer control research.

BACKGROUND: This paper evaluates the replicability of an NCI-funded didactic/experiential program to increase the diversity of doctorally-prepared cancer disparities investigators. METHODS: The program was developed and operated successfully for three years in Northern California when a replication was established at UCLA. Feasibility, process, impact, and outcome measures on UCSF and UCLA summer-institute participants were compared. RESULTS: Average participant rankings of the influence of the program on intention to apply for a doctorate were 9.1/10 (UCSF) and 8.6/10 (UCLA). A total of 22.5% of UCSF and 10% of UCLA participants have enrolled in, been accepted by, or completed doctoral programs. Among these alumni, 68% (21/31) of UCSF and 60% (3/5) of UCLA participants plan to conduct their doctoral research in cancer control. CONCLUSIONS: This program has been successfully replicated and has met its objective to increase the pipeline of ethnically diverse doctoral-level public health researchers. Expansion of the program to other regions of the US is feasible and indicated.

The effect of access and satisfaction on regular mammogram and Papanicolaou test screening in a multiethnic population.

BACKGROUND: Access and satisfaction are determinants of preventive service use, but few studies have evaluated their role in breast and cervical cancer screening in multiethnic populations. OBJECTIVES: We sought to investigate the relationship between race/ethnicity, access, satisfaction, and regular mammogram and Papanicolaou test receipt in 5 racial/ethnic groups. RESEARCH DESIGN: We conducted a telephone survey in 4 languages. SUBJECTS: Our subjects were black, Chinese, Filipino, Latino, or white women aged 40 to 74 residing in Alameda County, California. OUTCOME: regular mammograms (last test within 15 months and another within 2 years prior) and Papanicolaou tests (36 months and 3 years, respectively). Independent: race/ethnicity, sociodemographic variables, access (health insurance, usual site of care, regular doctor, check-up within 12 months, knowing where to go, copayment for tests), and satisfaction (overall satisfaction scale, waiting times, test-related pain and embarrassment, test satisfaction). RESULTS: Among women who had ever had a mammogram or Papanicolaou test, 54% and 77%, respectively, received regular screening. In multivariate analyses, regular mammography was positively associated with increased age (odds ratio [OR] 1.05 per year), private insurance (OR 1.7), check-up in the past year (OR 2.3), knowing where to go for mammography (OR 3.0), and greater satisfaction with processes of care (OR 1.04 per unit), and negatively with not knowing copayment amount (OR 0.4), too many forms to fill out (OR 0.5), embarrassment at the last mammogram (OR 0.6), and Filipino race/ethnicity. Similar results were found for regular Papanicolaou tests. CONCLUSIONS: Access and satisfaction are important predictors of screening but do little to explain racial/ethnic variation. Tailored interventions to improve regular mammography and Papanicolaou test screening in multiethnic populations are needed.

Comparison of methods for identifying a population-based sample of Filipina women for a health survey.

This paper describes and compares 2 random-digit dialing (RDD) methods that have been used to select minority subjects for population-based research. These methods encompass the census-based method, which draws its primary sampling units from census tracts with a high proportion of minority persons, and the registry-based method, which derives its primary sampling units from a population-based cancer registry. Our study targeted Filipinos living in 10 Northern California counties, where they constitute 4% of the total population. Eligible participants (Filipina women, at least aged 20, who spoke 1 of 4 interview languages) were asked to complete a short telephone interview. Both the census and registry methods located Filipino households with comparable efficiency and with a higher yield than would be expected in a non-targeted population survey, such as the Mitofsky-Waksberg RDD method. No systematic pattern of responses was evident that would indicate that either method sampled women who were systematically less acculturated or less likely to use cancer screening tests. Although both methods offer substantial gains in efficiency, their utility is limited by generating samples that tend to over-represent high-density areas. The degree to which these methods are considered viable depends on further refinement to limit, or eliminate, their inherent selection biases without sacrificing their increased efficiency to locate minority populations.

Increasing ethnic diversity in cancer control research: description and impact of a model training program.

BACKGROUND: There is little ethnic diversity at the doctoral level among researchers in cancer control. The Minority Training Program in Cancer Control Research is designed to encourage underrepresented master's level health science students to pursue doctoral training and careers in research. METHODS: Program components include an annual 5-day summer institute, internships, and doctoral incentive awards. Intention to pursue doctoral training is measured before and after participation. Doctoral applications and enrollment are tracked through annual surveys. RESULTS: Seventy students participated during the first three years, 1999-2001. Intention to apply increased significantly for each class (year one, p %lt; 0.001; year two, p = 0.042; year three, p = 0.006). Thirty-one percent of participants have either enrolled in doctoral programs (n= 10) or report plans to apply in the next one to two years (n = 9). Over half of these students indicated that the MTPCCR had a positive influence on their plans. CONCLUSIONS: A targeted training program encourages under-represented students to pursue doctoral degrees and thus has the potential to increase ethnic diversity in public health research.