Developing and Evaluating a School-Based Tobacco and E-Cigarette Prevention Program for Deaf and Hard-of-Hearing Youth.

School-based programs are an important tobacco prevention tool. Yet, existing programs are not suitable for Deaf and Hard-of-Hearing (DHH) youth. Moreover, little research has examined the use of the full range of tobacco products and related knowledge in this group. To address this gap and inform development of a school-based tobacco prevention program for this population, we conducted a pilot study among DHH middle school (MS) and high school (HS) students attending Schools for the Deaf and mainstream schools in California (n = 114). American Sign Language (ASL) administered surveys, before and after receipt of a draft curriculum delivered by health or physical education teachers, assessed product use and tobacco knowledge. Thirty-five percent of students reported exposure to tobacco products at home, including cigarettes (19%) and e-cigarettes (15%). Tobacco knowledge at baseline was limited; 35% of students knew e-cigarettes contain nicotine, and 56% were aware vaping is prohibited on school grounds. Current product use was reported by 16% of students, most commonly e-cigarettes (12%) and cigarettes (10%); overall, 7% of students reported dual use. Use was greater among HS versus MS students. Changes in student knowledge following program delivery included increased understanding of harmful chemicals in tobacco products, including nicotine in e-cigarettes. Post-program debriefings with teachers yielded specific recommendations for modifications to better meet the educational needs of DHH students. Findings based on student and teacher feedback will guide curriculum development and inform next steps in our program of research aimed to prevent tobacco use in this vulnerable and heretofore understudied population group.

Adapting E-cigarette prevention programming to reach the latinx community.

PURPOSE: E-cigarettes are the most commonly used tobacco product among youth in the United States. Yet evidence-based prevention programming is limited due to the rapid onset of this threat. Community-based efforts to address vaping largely target youth in school settings. Although parents can play an important role in youth tobacco control efforts, messages about the dangers of vaping, use among adolescents, and strategies for intervening have not reached many Spanish-speaking parents in low-income Latinx communities. Our community-academic team developed e-cigarette prevention programming for use by promotor/as de salud to address this unmet need. METHODS: During the 1-year project, the team worked closely with a Project Advisory Committee to: review existing evidence-informed materials; conduct focus groups with parents, youth and promotor/as to guide program development; develop a curriculum to prepare promotor/as to educate low-literacy, Spanish-speaking parents about vaping; craft Spanish language resources for promotor/as to use in community education sessions; train 61 promotor/as to deliver the program; and support program delivery to 657 community members. RESULTS: Focus groups with promotor/as and community members, key-informant interviews, and brief surveys informed program development and assessment. Community member feedback was essential to development of appropriate materials. Promotor/as demonstrated significant pre- to post- training increases in e-cigarette knowledge and confidence in delivering vaping prevention education. Community members demonstrated a mastery of basic e-cigarette concepts and expressed intention to discuss vaping with their children. CONCLUSIONS: Promotor/a-led programming for parents represents a promising approach to vaping prevention and control in the Latinx community.

Effectiveness and feasibility of three types of parent reminders to increase adolescent human papillomavirus (HPV) vaccination.

Parent reminders have produced modest improvements in human papillomavirus (HPV) vaccination among adolescents. However, little prior research has compared the effectiveness and feasibility of different HPV reminder types in resource-limited settings. We conducted a quasi-experimental study (2016-2017) to evaluate the effectiveness of three parent reminder types (mailed letters, robocalls, text messages) on next-dose HPV vaccine receipt among 12-year-olds in a large Federally Qualified Health Center in Los Angeles County. Six clinics were matched into three pairs: randomly assigning one clinic within each pair to intervention and control. Intervention clinics were randomly assigned to deliver one of the three parent reminder types. We calculated rates of next-dose vaccine receipt and assessed intervention effects using logistic regression models. We calculated the proportion of each type of reminder successfully delivered as a feasibility measure. The study sample comprised 877 12-year-olds due for an HPV vaccine dose (47% female, >85% Latino). At 4-month follow-up, 23% of intervention patients received an HPV vaccine dose compared to only 12% of control patients. Overall, receipt of any reminder increased rates of the next-needed HPV vaccine compared to usual care (p = 0.046). Significant improvements were observed for text reminders (p = 0.036) and boys (p = 0.006). Robocalls were the least feasible reminder type. Text message reminders are feasible and effective for promoting HPV vaccination. Future research is needed to assess the effectiveness and feasibility of reminders compared to other vaccine promotion strategies.

Impact of a Multi-Level, Multi-Component, System Intervention on HPV Vaccination in a Federally Qualified Health Center.

BACKGROUND: Human papillomavirus (HPV) vaccines can significantly reduce the burden of HPV-associated cancers, but remain underutilized. We evaluated a multi-component, system-level intervention to improve HPV vaccination in a large Federally Qualified Health Center (FQHC) that serves a primarily low income Latino population. METHODS: From January 2015 through March 2017, we evaluated the effectiveness of a multi-component, system-level intervention to improve HPV vaccination rates in eight clinics randomly assigned to study condition (four intervention, four usual care). The intervention included parent reminders for HPV vaccine series completion, provider training, clinic-level audit and feedback, and workflow modifications to reduce missed opportunities for vaccination. Using a difference-in-differences approach, we compared HPV vaccination rates among patients, ages 11 to 17 during a 12-month preintervention period and a 15-month intervention period. Linear mixed models were used to estimate intervention effects on vaccine initiation and completion. RESULTS: The sample included approximately 15,000 adolescents each quarter (range 14,773-15,571; mean age 14 years; 51% female, 88% Latino). A significantly greater quarterly increase in HPV vaccine initiation was observed for intervention compared with usual care clinics (0.75 percentage point greater increase, P < 0.001), corresponding to 114 additional adolescents vaccinated per quarter. The intervention led to a greater increase in HPV vaccine completion rates among boys (0.65 percentage point greater increase, P < 0.001), but not girls. CONCLUSIONS: Our system-level intervention was associated with modest improvements in HPV vaccine initiation overall and completion among boys. IMPACT: Study findings have implications for reducing HPV-related cancers in safety net populations.

Increasing HPV Vaccination among Low-Income, Ethnic Minority Adolescents: Effects of a Multicomponent System Intervention through a County Health Department Hotline.

BACKGROUND: Introduction of the human papillomavirus (HPV) vaccine in 2006 was a game-changing advance in cancer control. Despite the vaccine's potential cancer prevention benefits, uptake remains low. We utilized a randomized design to evaluate a multicomponent intervention to improve HPV vaccine uptake among low-income, ethnic minority adolescents seeking services through a county health department telephone hotline. METHODS: Hotline callers who were caregivers of never-vaccinated adolescents (11-17 years) were randomized by call-week to intervention or control conditions. The intervention included brief telephone and print education, delivered in multiple languages, and personalized referral to a low-cost/free vaccine provider. Participants completed baseline (n = 238), 3-month (n = 215), and 9-month (n = 204) telephone follow-up surveys. RESULTS: HPV vaccine initiation rates increased substantially by 9-month follow-up overall, although no differences were observed between intervention and control groups (45% vs. 42%, respectively, P > 0.05). We also observed significant improvements in perceived HPV risk, barriers to vaccination, and perceived knowledge in both study conditions (P < 0.05). CONCLUSIONS: A low-intensity county hotline intervention did not produce a greater increase in HPV vaccination rates than routine practice. However, 44% of unvaccinated adolescents in both conditions received at least one dose of the vaccine, which can be viewed as a successful public health outcome. Future studies should evaluate more intensive interventions that address accessing and utilizing services in complex safety net settings. IMPACT: Study results suggest the need for investigators to be aware of the potential priming effects of study participation, which may obscure the effect of low-intensity interventions.

Colorectal cancer screening among Hispanics in the United States: Disparities, modalities, predictors, and regional variation.

Hispanics represent the largest and one of the fastest growing minority populations in the U.S. and have lower survival from colorectal cancer (CRC) than non-Hispanic Whites (NHW). We aimed to examine screening modalities, predictors, and regional disparities among Hispanics and NHW in the U.S. by conducting a cross-sectional analysis of Hispanic participants age 50 to 75 from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) survey. The primary outcome was self-reported CRC screening status. We used the Rao-Scott Chi-square test to compare screening rates and modalities in NHWs and Hispanics. We also used univariable and multivariable logistic regression to determine predictors of screening among Hispanics and calculated Hispanic-NHW screening rate differences for each U.S. state/territory as a measure of regional screening disparities. The screening rate was 53.4% for Hispanics (N = 12,395), compared to 70.4% for NHWs (N = 186,331) (p < 0.001). Among Hispanics, colonoscopy was most common (75.9%). Uninsured status (aOR = 0.51; 95% CI = 0.38-0.70) and limited access to medical care (aOR = 0.38; 95% CI = 0.29-0.49) predicted lack of screening. States/territories with the largest screening disparities were North Carolina (33.9%), Texas (28.3%), California (25.1%), and Nebraska (25.6%). Disparities were smallest in New York (2.6%), Indiana (3.1%), and Delaware (4.0%). In Ohio and Guam, Hispanics had higher screening rates than NHWs. In conclusion, Hispanics have lower CRC screening rates than NHWs across most U.S. states/territories; however, the disparity varies by region. Future efforts must address multi-level barriers to screening among Hispanics and target regions with low rates to improve CRC outcomes in this growing population.

Measuring Constructs of the Consolidated Framework for Implementation Research in the Context of Increasing Colorectal Cancer Screening in Federally Qualified Health Center.

OBJECTIVE: To operationalize constructs from each of the Consolidated Framework for Implementation Research domains and to present psychometric properties within the context of evidence-based approaches for promoting colorectal cancer screening in federally qualified health centers (FQHCs). METHODS: Data were collected from FQHC clinics across seven states. A web-based Staff Survey and a Clinic Characteristics Survey were completed by staff and leaders (n = 277) from 59 FQHCs. RESULTS: Internal reliability of scales was adequate ranging from 0.62 for compatibility to 0.88 for other personal attributes (openness). Intraclass correlations for the scales indicated that 2.4 percent to 20.9 percent of the variance in scale scores occurs within clinics. Discriminant validity was adequate at the clinic level, with all correlations less than 0.75. Convergent validity was more difficult to assess given lack of hypothesized associations between factors expected to predict implementation. CONCLUSIONS: Our results move the field forward by describing initial psychometric properties of constructs across CFIR domains.

Developing measures to assess constructs from the Inner Setting domain of the Consolidated Framework for Implementation Research.

BACKGROUND: Scientists and practitioners alike need reliable, valid measures of contextual factors that influence implementation. Yet, few existing measures demonstrate reliability or validity. To meet this need, we developed and assessed the psychometric properties of measures of several constructs within the Inner Setting domain of the Consolidated Framework for Implementation Research (CFIR). METHODS: We searched the literature for existing measures for the 7 Inner Setting domain constructs (Culture Overall, Culture Stress, Culture Effort, Implementation Climate, Learning Climate, Leadership Engagement, and Available Resources). We adapted items for the healthcare context, pilot-tested the adapted measures in 4 Federally Qualified Health Centers (FQHCs), and implemented the revised measures in 78 FQHCs in the 7 states (N = 327 respondents) with a focus on colorectal cancer (CRC) screening practices. To psychometrically assess our measures, we conducted confirmatory factor analysis models (CFA; structural validity), assessed inter-item consistency (reliability), computed scale correlations (discriminant validity), and calculated inter-rater reliability and agreement (organization-level construct reliability and validity). RESULTS: CFAs for most constructs exhibited good model fit (CFI > 0.90, TLI > 0.90, SRMR < 0.08, RMSEA < 0.08), with almost all factor loadings exceeding 0.40. Scale reliabilities ranged from good (0.7 ≤ α < 0.9) to excellent (α ≥ 0.9). Scale correlations fell below 0.90, indicating discriminant validity. Inter-rater reliability and agreement were sufficiently high to justify measuring constructs at the clinic-level. CONCLUSIONS: Our findings provide psychometric evidence in support of the CFIR Inner Setting measures. Our findings also suggest the Inner Setting measures from individuals can be aggregated to represent the clinic-level. Measurement of the Inner Setting constructs can be useful in better understanding and predicting implementation in FQHCs and can be used to identify targets of strategies to accelerate and enhance implementation efforts in FQHCs.

Developing Theory to Guide Building Practitioners' Capacity to Implement Evidence-Based Interventions.

Public health and other community-based practitioners have access to a growing number of evidence-based interventions (EBIs), and yet EBIs continue to be underused. One reason for this underuse is that practitioners often lack the capacity (knowledge, skills, and motivation) to select, adapt, and implement EBIs. Training, technical assistance, and other capacity-building strategies can be effective at increasing EBI adoption and implementation. However, little is known about how to design capacity-building strategies or tailor them to differences in capacity required across varying EBIs and practice contexts. To address this need, we conducted a scoping study of frameworks and theories detailing variations in EBIs or practice contexts and how to tailor capacity-building to address those variations. Using an iterative process, we consolidated constructs and propositions across 24 frameworks and developed a beginning theory to describe salient variations in EBIs (complexity and uncertainty) and practice contexts (decision-making structure, general capacity to innovate, resource and values fit with EBI, and unity vs. polarization of stakeholder support). The theory also includes propositions for tailoring capacity-building strategies to address salient variations. To have wide-reaching and lasting impact, the dissemination of EBIs needs to be coupled with strategies that build practitioners' capacity to adopt and implement a variety of EBIs across diverse practice contexts.

Healthcare Access and Utilization among Korean Americans: The Mediating Role of English Use and Proficiency.

The literature suggests that Korean Americans underutilize health services. Cultural factors and language barriers appear to influence this pattern of low utilization but studies on the relationships among length of stay in the US, English use and proficiency, and utilization of health services among Korean Americans have yielded inconsistent results. This study examines whether English language use and proficiency plays a mediating role in the relationships between length of stay in the US and health insurance coverage, access to and use of care. Structural equation modeling was used for mediation analysis with multiple dependent variables among Korean Americans (N = 555) using baseline data from a large trial designed to increase Hepatitis B testing. The results show 36% of the total effect of proportion of lifetime in the US on having health insurance was significantly mediated by English use and proficiency (indirect effect = 0.166, SE = 0.07, p<.05; direct effect = 0.296, SE = 0.13, p<.05). Proportion of lifetime in the US was not associated with usual source of care and health service utilization. Instead, health care utilization was primarily driven by having health insurance and a usual source of care, further underscoring the importance of these factors. A focus on increasing English use and proficiency and insurance coverage among older, female, less educated Korean Americans has the potential to mitigate health disparities associated with reduced access to health services in this population.

Cluster-Randomized Trial to Increase Hepatitis B Testing among Koreans in Los Angeles.

BACKGROUND: In the United States, Korean immigrants experience a disproportionately high burden of chronic hepatitis B (HBV) viral infection and associated liver cancer compared with the general population. However, despite clear clinical guidelines, HBV serologic testing among Koreans remains persistently suboptimal. METHODS: We conducted a cluster-randomized trial to evaluate a church-based small group intervention to improve HBV testing among Koreans in Los Angeles. Fifty-two Korean churches, stratified by size (small, medium, large) and location (Koreatown versus other), were randomized to intervention or control conditions. Intervention church participants attended a single-session small-group discussion on liver cancer and HBV testing, and control church participants attended a similar session on physical activity and nutrition. Outcome data consisted of self-reported HBV testing obtained via 6-month telephone follow-up interviews. RESULTS: We recruited 1,123 individuals, 18 to 64 years of age, across the 52 churches. Ninety-two percent of the sample attended the assigned intervention session and 86% completed the 6-month follow-up. Sample characteristics included were as follows: mean age 46 years, 65% female, 97% born in Korea, 69% completed some college, and 43% insured. In an intent-to-treat analysis, the intervention produced a statistically significant effect (OR = 4.9, P < 0.001), with 19% of intervention and 6% of control group participants reporting a HBV test. CONCLUSION: Our intervention was successful in achieving a large and robust effect in a population at high risk of HBV infection and sequelae. IMPACT: The intervention was fairly resource efficient and thus has high potential for replication in other high-risk Asian groups.

What strategies are used to build practitioners' capacity to implement community-based interventions and are they effective?: a systematic review.

BACKGROUND: Numerous agencies are providing training, technical assistance, and other support to build community-based practitioners' capacity to adopt and implement evidence-based prevention interventions. Yet, little is known about how best to design capacity-building interventions to optimize their effectiveness. Wandersman et al. (Am J Community Psychol.50:445-59, 2102) proposed the Evidence-Based System of Innovation Support (EBSIS) as a framework to guide research and thereby strengthen the evidence base for building practitioners' capacity. The purpose of this review was to contribute to further development of the EBSIS by systematically reviewing empirical studies of capacity-building interventions to identify (1) the range of strategies used, (2) variations in the way they were structured, and (3) evidence for their effectiveness at increasing practitioners' capacity to use evidence-based prevention interventions. METHODS: PubMed, EMBASE, and CINAHL were searched for English-language articles reporting findings of empirical studies of capacity-building interventions that were published between January 2000 and January 2014 and were intended to increase use of evidence-based prevention interventions in non-clinical settings. To maximize review data, studies were not excluded a priori based on design or methodological quality. Using the EBSIS as a guide, two researchers independently extracted data from included studies. Vote counting and meta-summary methods were used to summarize findings. RESULTS: The review included 42 publications reporting findings from 29 studies. In addition to confirming the strategies and structures described in the EBSIS, the review identified two new strategies and two variations in structure. Capacity-building interventions were found to be effective at increasing practitioners' adoption (n = 10 of 12 studies) and implementation (n = 9 of 10 studies) of evidence-based interventions. Findings were mixed for interventions' effects on practitioners' capacity or intervention planning behaviors. Both the type and structure of capacity-building strategies may have influenced effectiveness. The review also identified contextual factors that may require variations in the ways capacity-building interventions are designed. CONCLUSIONS: Based on review findings, refinements are suggested to the EBSIS. The refined framework moves the field towards a more comprehensive and standardized approach to conceptualizing the types and structures of capacity-building strategies. This standardization will assist with synthesizing findings across studies and guide capacity-building practice and research.

Costs associated with women's physical activity musculoskeletal injuries: the women's injury study.

BACKGROUND: Despite benefits of physical activity (PA), exercise is also associated with risks. Musculoskeletal injury (MSI) risk increases with exercise frequency/intensity. MSI is associated with costs including medical care and time lost from work. PURPOSE: To evaluate the economic costs associated with PA-related MSIs in community-dwelling women. METHOD: Participants included 909 women in the Women's Injury Study reporting PA behaviors and MSI incidence weekly via the Internet for up to 3 years (mean follow-up 1.89 years). Participants provided consent to obtain health records. Costs were estimated by medical records and self-reports of medical care. Components included physician visits, medical facility contacts, medication costs, and missed work. RESULTS: Of 909 participants, 243 reported 323 episodes of expenditure or contact with the health care system associated with PA. Total costs of episodes ranged from $0-$18,934. Modal cost was $0 (mean = $433 ± $1670). Costs were positively skewed with nearly all participants reporting no or very low costs. CONCLUSIONS: About 1 in 4 community-dwelling women who are physically active experienced a PA-related MSI. The majority of injuries were minor, and large expenses associated with MSI were rare. The long-term health benefits and costs savings resulting from PA likely outweigh the minor costs associated with MSI from a physically-active lifestyle.

Training Mixtec promotores to assess health concerns in their community: a CBPR pilot study.

An academic institution and a community organization partnered for one of the first studies assessing health needs of Mixtecs, indigenous immigrants from Southern Mexico, residing in Ventura County, California. Ten bilingual Spanish- and Mixteco-speaking promotores received a 1-day focus group training, participated in a focus group themselves and conducted 5 focus groups with 42 Mixtec community members. The focus group training is described. Health concerns discussed in the focus groups include outdoor exercise among women viewed as flirtatious; reluctance to ask for governmental assistance due to fear that children will have to pay back later; soda consumption perceived as a symbol of socio-economic status; and unwillingness to obtain mammograms or pap smears because private body parts are to be touched by husbands only. Training promotores to conduct focus groups can increase organizational capacity to identify pressing health needs in under-represented and hard-to-reach population groups.

Prostate cancer screening among ethnically diverse first-degree relatives of prostate cancer cases.

OBJECTIVE: This study examined potential ethnic differences in prostate cancer screening behavior and correlates of screening in an ethnically diverse sample of first-degree relatives of prostate cancer cases. METHODS: The California Cancer Registry was used to identify a sample of prostate cancer cases who were contacted and invited to refer male first-degree relatives to the study. Telephone surveys with 1,029 first-degree relatives (354 non-Latino Whites, 228 Latinos, 272 African Americans, 175 Asians) assessed prostate cancer screening behavior and correlates of screening. RESULTS: Less than half of the participants had received a prostate specific antigen (PSA) test in the past year, with lowest rates observed among Latinos. Factors independently associated with an increased likelihood of the PSA test receipt in the total sample included: prior PSA testing, having a physician recommendation to be screened, and reporting fewer barriers to screening. Being the brother versus the son of the case predicted a higher likelihood of screening for all ethnic groups except for African Americans. In addition, the negative influence of barriers on screening was significantly greater for Latinos compared with Asians. CONCLUSIONS: Although ethnicity was not an independent predictor of screening, ethnic variations were observed in the relationship between some predictors and screening and in the modifiable correlates of screening. Findings may inform future intervention research that aims to enhance informed decision-making regarding prostate cancer screening and ultimately reduce prostate cancer health disparities.

Changes in risk perceptions in relation to self-reported colorectal cancer screening among first-degree relatives of colorectal cancer cases enrolled in a randomized trial.

OBJECTIVE: This secondary data analysis was conducted to evaluate the applicability of the Risk Reappraisal Hypothesis, which has been proposed to explain the influence of performing a health behavior on perceived risk. Data were collected in the context of a randomized trial, which found that an individually tailored, multicomponent intervention was successful in increasing colorectal cancer (CRC) screening among first-degree relatives of CRC cases. METHOD: The ethnically diverse study sample (N = 841; 29% Latino, 21% African American, 20% Asian) consisted of adult siblings and children (40-80 years) of CRC cases, identified through the California Cancer Registry. Data were collected at baseline and at 6- and 12-month follow-up. Changes in self-reported risk perception (perceived likelihood of developing CRC) were examined over the study period in relation to study condition and screening status. RESULTS: Greater increases in perceived risk were observed among intervention versus control-group participants over the study period, but increases were limited to intervention participants who had not been screened. We also examined trajectories of perceived risk in relation to timing of screening receipt (e.g., before 6 months, 6-12 months, never). Continued upward shifts in risk were observed during the study period among intervention participants not screened during the study. In contrast, participants screened by 6 months displayed a reduction or leveling off in perceived risk between 6- and 12-month follow-up. CONCLUSION: Results provide support for the applicability of the Risk Reappraisal Hypothesis within a high-risk sample enrolled in a CRC screening promotion trial. Future research is needed to explore the impact of short-term risk reductions on future CRC screening behavior.