Improving colon cancer screening in community clinics.

BACKGROUND: The authors evaluated the effectiveness and cost effectiveness of 2 interventions designed to promote colorectal cancer (CRC) screening in safety-net settings. METHODS: A 3-arm, quasi-experimental evaluation was conducted among 8 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 to 85 years were eligible for routine CRC screening and were recruited. Outcomes included CRC screening completion and incremental cost effectiveness using literacy-informed education of patients and education plus nurse support versus enhanced usual care. RESULTS: The baseline screening rate was <3%. After the interventions, the screening rate was 38.6% with enhanced usual care, 57.1% with education, and 60.6% with education that included additional nurse support. After adjusting for age, race, sex, and literacy, patients who received education alone were not more likely to complete screening than those who received enhanced usual care; and those who received additional nurse support were 1.60-fold more likely to complete screening than those who received enhanced usual care (95% confidence interval, 1.06-2.42; P = .024). The incremental cost per additional individual screened was $1337 for education plus nurse support over enhanced usual care. CONCLUSIONS: Fecal occult blood test rates were increased beyond enhanced usual care by providing brief education and nurse support but not by providing education alone. More cost-effective alternatives to nurse support need to be investigated.

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.

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.

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.

Diabetes Implementation of a Self-management Program in Resource Poor and Rural Community Clinics.

PURPOSE: To evaluate the implementation of a brief diabetes self-management support intervention designed for resource-poor community clinics. METHODS: The authors conducted a pilot study among patients with type 2 diabetes in 3 community clinics. The intervention consisted of research assistants introducing and reviewing a diabetes self-management guide, helping patients set an achievable behavioral action plan, and following up with 2 telephone sessions. The primary outcome was patients' success setting and achieving behavioral goals. RESULTS: All participants set an action plan (N = 247); most focused on physical activity or diet (97%). The initial session took an average of 15 minutes. At 2 to 4 weeks, 200 participants were contacted; 68% recalled their action plan; and 84% of these achieved it. At 6 to 9 weeks, approximately half of those who completed the first call were reached for the second call. Of those who remained in the intervention, 79% recalled their action plan, and 80% of these achieved it. At the end of the study, 62% of those initially enrolled reported behavior change. Most participants who did not complete the intervention could not be reached for telephone follow-up. CONCLUSIONS: Although only about a third of patients remained engaged through the 2 follow-up calls, most of those who did reported they had achieved their action plan. This pilot study provides insight into initiating brief diabetes self-management strategies in resource-poor community clinics. Although telephone follow-up was challenging, using the self-management guide and action plan framework, particularly during the initial clinic visit, helped focus patients on behavior change.

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.

Use of a visual aid to improve counseling at the threshold of viability.

OBJECTIVES: To pilot-test a visual aid developed to help counsel pregnant women. METHODS: After agreeing to participate, pregnant women at >28 weeks of gestation were assigned randomly to counseling with or without a visual aid. The visual aid contained pictures, graphics, and short messages about delivery room resuscitation, chances of survival, anticipated neonatal course, and long-term neurodevelopmental disabilities. A neonatal fellow performed counseling with a standardized script for an anticipated delivery at 23 weeks of gestation. In precounseling and postcounseling sessions, women were given a structured interview to assess their knowledge of chances of survival and disability and attitudes toward resuscitation. RESULTS: Of the 89 women who participated, 76% were black and 59% read below a 9th-grade level. Compared with the no-visual aid group, women in the visual aid group recalled more disabilities and predicted longer neonatal stays (P = .01). For both groups, mothers' perceptions of the chances of survival were lower after counseling; the decrease was greater in the visual aid group (P = .03). The majority of women in each group opted for resuscitation, which was not affected by counseling. In multivariate analyses, use of the visual aid was a significant independent factor in explaining before/after differences in survival chances and recall of a long NICU stay and number of disabilities; higher literacy levels also were significant for recalling the number of disabilities. CONCLUSIONS: Use of a visual aid improved mothers' knowledge and showed promise as a decision aid for counseling at the threshold of viability.