The impact of tailored interventions on a community health center population.

We conducted a 4-year randomized study in a community health center that serves primarily low income Blacks in Durham, North Carolina. Patients (1318 at baseline) were assigned randomly to one of three study groups: provider prompting intervention alone, provider prompting and tailored print materials or the previous group and tailored telephone counseling. The purpose of the study was to determine whether increasingly intensive, tailored print and telephone interventions also were increasingly effective in promoting adherence to mammograms, Pap tests and overall cancer screening compliance. Thus, the combination of tailored print interventions (print and telephone) should have been more effective than the provider prompting intervention alone, or the print intervention and prompting combination. This is one of the few studies to examine a measure of overall cancer screening compliance and to assess the benefit of combinations of tailored interventions in promoting adherence to cancer screening. Patients gave extremely high ratings to the interventions. At the bivariate level, we found a significant effect of the most intensive group (provider prompting intervention, tailored print communications and tailored telephone counseling) on Pap test compliance (P = 0.05) and borderline significance at the multivariate level (P = 0.06) as well on overall screening compliance (P = 0.06). There was not a significant effect on mammography, probably because a majority of the patients were receiving regular mammograms. We also found some important subgroup differences. For example, a larger proportion of women reported Pap tests in the tailored print and counseling group when they believed the materials were 'meant for me.' These results show that a combination of tailored interventions may have potential for reaching the women who have too often been labeled the 'hard to reach.'

Computerized prompts for cancer screening in a community health center.

BACKGROUND: We describe the implementation and subsequent use of a computerized health maintenance tracking system in a large, urban, North Carolina community health center (Lincoln Community Health Center) as part of a larger study designed to increase rates of mammography, Papanicolaou tests, and smoking cessation in low-income African-Americans. METHODS: Clinicians from the Lincoln Community Health Center were involved in the design and implementation of the computer system. At each office visit, clinicians received a computerized encounter form indicating needed screening tests, counseling, and immunizations for each randomly selected study patient (n = 1318). RESULTS: Initial clinician compliance rates with filling out the form were 95 percent (mammography), 82 percent (Papanicolaou test), 77 percent (clinician breast examination), and 55 percent (smoking cessation). Cumulative compliance leveled off at 21 months to 65 percent, 57 percent, 53 percent, and 38 percent, respectively, despite multiple reminder strategies. When surveyed, most clinicians thought it was a good reminder system but said they did not always complete the form because of time demands. Costs of adapting and implementing the system were $23,332.08 ($17.70 per study). Per-patient costs would have been reduced further if more patients had been included in the project. CONCLUSIONS: State-of-the-art computer prompting systems can be useful in a community health center; however, even with prompting, clinicians still only addressed health maintenance with their patients about 50 percent of the time. Additional interventions will be needed, particularly in low-income populations, to meet the Healthy People 2000 goals in health promotion.

Readiness to change smoking behavior in a community health center population.

This study examines predictors of readiness to change smoking behavior in a sample of smokers who receive care at a community health center that serves a predominantly low income African American population. Prior to initiating interventions we conducted a telephone survey with a random sample of 1318 adult users who had visited the center in the last 18 months; 379 (28.8%) were current smokers (40.3% of males, 23.9% of females, 42.7% of Whites, and 25.3%, of African Americans). Multiple logistic regression analysis showed nine factors significantly associated with readiness to change smoking behavior: male gender; a previous quit attempt; a perception of risk of lung cancer from smoking; greater desire to quit smoking; a perception that smoking bothers others; doctor advice to stop smoking at last health visit; records kept for scheduling doctor appointments; thinking that losing a pleasure would not be a problem if quit smoking; and poorer self-reported health status. These findings provide direction for developing interventions for similar low income, high risk populations. The results indicate that it may be useful to heighten awareness of the risks of smoking and to assure that smokers receive clear quit smoking messages from their providers. Women need special attention since they are less ready to quit than men.

Cancer screening practices among women in a community health center population.

BACKGROUND: Cancer takes a disproportionate toll on disadvantaged Americans. Poverty and low education are risk factors for underuse of cancer screening. METHODS: In this report, we discuss predictors of adherence to cancer screening (mammography, clinical breast exam [CBE], and Pap tests) among 926 women who receive care at a community health center that serves a predominantly low-income and minority population. We examine predictors for each of the tests and for a composite measure of overall cancer screening test compliance. In studying multiple screening behaviors we not only investigate factors associated with each individual behavior, but we also identify consistently effective factors across several behaviors. RESULTS: The analysis indicates consistent effects of age, education, and insurance status on cancer screening. In addition, decisional balance, a measure of a person's beliefs about the pros and cons of complying with the screening test, is associated strongly with adherence. We have extended earlier findings about the positive relationship between decisional balance and mammography to include decisional balance and Pap tests, as well. This finding suggests that behavioral interventions that target decisional balance can effectively promote adherence to cancer screening tests.