Long-Term Evaluation of a Course on Evidence-Based Public Health in the U.S. and Europe.

The evidence-based public health course equips public health professionals with skills and tools for applying evidence-based frameworks and processes in public health practice. To date, training has included participants from all the 50 U.S. states, 2 U.S. territories, and multiple other countries besides the U.S. This study pooled follow-up efforts (5 surveys, with 723 course participants, 2005-2019) to explore the benefits, application, and barriers to applying the evidence-based public health course content. All analyses were completed in 2020. The most common benefits (reported by >80% of all participants) were identifying ways to apply knowledge in their work, acquiring new knowledge, and becoming a better leader who promotes evidence-based approaches. Participants most frequently applied course content to searching the scientific literature (72.9%) and least frequently to writing grants (42.7%). Lack of funds for continued training (35.3%), not having enough time to implement evidence-based public health approaches (33.8%), and not having coworkers trained in evidence-based public health (33.1%) were common barriers to applying the content from the course. Mean scores were calculated for benefits, application, and barriers to explore subgroup differences. European participants generally reported higher benefits from the course (mean difference=0.12, 95% CI=0.00, 0.23) and higher frequency of application of the course content to their job (mean difference=0.17, 95% CI=0.06, 0.28) than U.S. participants. Participants from later cohorts (2012-2019) reported more overall barriers to applying course content in their work (mean difference=0.15, 95% CI=0.05, 0.24). The evidence-based public health course represents an important strategy for increasing the capacity (individual skills) for evidence-based processes within public health practice. Organization-level methods are also needed to scale up and sustain capacity-building efforts.

Evaluating a train-the-trainer approach for improving capacity for evidence-based decision making in public health.

BACKGROUND: Evidence-based public health gives public health practitioners the tools they need to make choices based on the best and most current evidence. An evidence-based public health training course developed in 1997 by the Prevention Research Center in St. Louis has been taught by a transdisciplinary team multiple times with positive results. In order to scale up evidence-based practices, a train-the-trainer initiative was launched in 2010. METHODS: This study examines the outcomes achieved among participants of courses led by trained state-level faculty. Participants from trainee-led courses in four states (Indiana, Colorado, Nebraska, and Kansas) over three years were asked to complete an online survey. Attempts were made to contact 317 past participants. One-hundred forty-four (50.9 %) reachable participants were included in analysis. Outcomes measured include frequency of use of materials, resources, and other skills or tools from the course; reasons for not using the materials and resources; and benefits from attending the course. Survey responses were tabulated and compared using Chi-square tests. RESULTS: Among the most commonly reported benefits, 88 % of respondents agreed that they acquired knowledge about a new subject, 85 % saw applications for the knowledge to their work, and 78 % agreed the course also improved abilities to make scientifically informed decisions at work. The most commonly reported reasons for not using course content as much as intended included not having enough time to implement evidence-based approaches (42 %); other staff/peers lack training (34 %); and not enough funding for continued training (34 %). The study findings suggest that utilization of course materials and teachings remains relatively high across practitioner groups, whether they were taught by the original trainers or by state-based trainers. CONCLUSIONS: The findings of this study suggest that train-the-trainer is an effective method for broadly disseminating evidence-based public health principles. Train-the-trainer is less costly than the traditional method and allows for courses to be tailored to local issues, thus making it a viable approach to dissemination and scale up of new public health practices.

Development of a claims-based algorithm to identify colorectal cancer recurrence.

PURPOSE: To examine the validity of claims data to identify colorectal cancer (CRC) recurrence and determine the extent to which misclassification of recurrence status affects estimates of its association with overall survival in a population-based administrative database. METHODS: We calculated the accuracy of claims data relative to medical records from one large tertiary hospital to identify CRC recurrence. We estimated the effect of misclassifying recurrence on survival by applying these findings to the linked Surveillance, Epidemiology, and End Results-Medicare data. RESULTS: Of 174 eligible CRC patients identified through medical records, 32 (18.4%) had a recurrence. A claims-based algorithm of secondary malignancy codes yielded a sensitivity of 81% and specificity of 99% for identifying recurrence. Agreement between data sources was almost perfect (kappa: 0.86). In a model unadjusted for misclassification, CRC patients with recurrence were 3.04 times (95% confidence interval: 2.92-3.17) more likely to die of any cause than those without recurrence. In the corrected model, CRC patients with recurrence were 3.47 times (95% confidence interval: 3.06-4.14) more likely to die than those without recurrence. CONCLUSIONS: Identifying recurrence in CRC patients using claims data is feasible with moderate sensitivity and high specificity. Future studies can use this algorithm with Surveillance, Epidemiology, and End Results-Medicare data to study treatment patterns and outcomes of CRC patients with recurrence.

Serratia odorifera mediated enhancement in susceptibility of Aedes aegypti for chikungunya virus.

BACKGROUND & OBJECTIVES: The susceptibility of the mosquito to the invading pathogen is predominantly dictated by the complex interactions between the mosquito midgut and the surface proteins of the invading pathogen. It is well documented that the midgut microbiota plays an important role in determining the susceptibility of the mosquito to the pathogen. In the present study, we investigated the influence of Serratia odorifera, an endogenous cultivable midgut inhabitant of Aedes aegypti on the chikungunya virus (CHIKV) susceptibility to this mosquito. METHODS: Ae. aegypti females free of gutflora were co-fed with CHIKV and either of the two midgut inhabitants namely, S. odorifeara and Microbacterium oxydans. CHIKV dissemination was checked on 10 th day post feeding (DPF) using indirect immunoflurescence assay and plaque assay. CHIKV interacting proteins of the mosquito midgut were identified using virus overlay protein binding assay and MALDI TOF/TOF analysis. RESULTS: The observations revealed that co-feeding of S. odorifera with CHIKV significantly enhanced the CHIKV susceptibility in adult Ae. aegypti, as compared to the mosquitoes fed with CHIKV alone and CHIKV co-fed with another midgut inhabitant, M. oxydans. Virus overlay protein binding assay (VOPBA) results revealed that porin and heat shock protein (HSP60) of Ae. aegypti midgut brush border membrane fraction interacted with CHIKV. INTERPRETATION & CONCLUSIONS: The results of this study indicated that the enhancement in the CHIKV susceptibility of Ae. aegypti females was due to the suppression of immune response of Ae. aegypti as a result of the interaction between S. odorifera P40 protein and porin on the gut membrane.

Hospital and geographic variability in thirty-day all-cause mortality following colorectal cancer surgery.

OBJECTIVE: To assess hospital and geographic variability in 30-day mortality after surgery for CRC and examine the extent to which sociodemographic, area-level, clinical, tumor, treatment, and hospital characteristics were associated with increased likelihood of 30-day mortality in a population-based sample of older CRC patients. DATA SOURCES/STUDY SETTING: Linked Surveillance Epidemiology End Results (SEER) and Medicare data from 47,459 CRC patients aged 66 years or older who underwent surgical resection between 2000 and 2005, resided in 13,182 census tracts, and were treated in 1,447 hospitals. STUDY DESIGN: An observational study using multilevel logistic regression to identify hospital- and patient-level predictors of and variability in 30-day mortality. DATA COLLECTION/EXTRACTION METHODS: We extracted sociodemographic, clinical, tumor, treatment, hospital, and geographic characteristics from Medicare claims, SEER, and census data. PRINCIPAL FINDINGS: Of 47,459 CRC patients, 6.6 percent died within 30 days following surgery. Adjusted variability in 30-day mortality existed across residential census tracts (predicted mortality range: 2.7-12.3 percent) and hospitals (predicted mortality range: 2.5-10.5 percent). Higher risk of death within 30 days was observed for CRC patients age 85+ (12.7 percent), census-tract poverty rate >20 percent (8.0 percent), two or more comorbid conditions (8.8 percent), stage IV at diagnosis (15.1 percent), undifferentiated tumors (11.6 percent), and emergency surgery (12.8 percent). CONCLUSIONS: Substantial, but similar variability was observed across census tracts and hospitals in 30-day mortality following surgery for CRC in patients 66 years and older. Risk of 30-day mortality is driven not only by patient and hospital characteristics but also by larger social and economic factors that characterize geographic areas.

Alcohol outlet availability and excessive alcohol consumption in breast cancer survivors.

BACKGROUND: Breast cancer survivors who consume alcohol excessively are at increased risk of recurrence and have worse prognosis. Because the environments in which people live shape many health behaviors, there has been increased attention to how neighborhood environments (eg, alcohol outlet availability) may influence alcohol consumption. The authors hypothesized that proximity to alcohol outlets increases the likelihood of excessive consumption (ie, more than 1 drink/day) among breast cancer survivors independent of their personal or neighborhood characteristics. METHODS: With the Missouri Cancer Registry, the authors conducted a cross-sectional study of 1047 female breast cancer survivors (aged 27-96 years) 1 year after diagnosis. Using telephone interviews, the authors obtained data regarding survivors' alcohol consumption during the past 30 days and several covariates of alcohol use. They also obtained street addresses of all licensed alcohol outlets in Missouri and calculated the road network distance between a participant's address of residence and the nearest alcohol outlet, using a geographic information system. Logistic regression was used to determine if distance was independently associated with excessive alcohol consumption. RESULTS: Eighteen percent of participants reported consuming more than 1 drink on average per day. Women who lived within 3 miles of the nearest outlet were more likely to report excessive alcohol consumption (odds ratio: 2.09; 95% confidence interval: 1.08, 4.05) than women who lived at least 3 miles from the nearest outlet in adjusted analysis. DISCUSSION: Opportunities exist to reduce excessive alcohol use among breast cancer survivors through policy (eg, restricting number of alcohol outlets) and behavioral (eg, counseling) interventions.

Inflammatory monocyte mobilization decreases patient survival in pancreatic cancer: a role for targeting the CCL2/CCR2 axis.

PURPOSE: To determine the role of the CCL2/CCR2 axis and inflammatory monocytes (CCR2(+)/CD14(+)) as immunotherapeutic targets in the treatment of pancreatic cancer. EXPERIMENTAL DESIGN: Survival analysis was conducted to determine if the prevalence of preoperative blood monocytes correlates with survival in patients with pancreatic cancer following tumor resection. Inflammatory monocyte prevalence in the blood and bone marrow of patients with pancreatic cancer and controls was compared. The immunosuppressive properties of inflammatory monocytes and macrophages in the blood and tumors, respectively, of patients with pancreatic cancer were assessed. CCL2 expression by human pancreatic cancer tumors was compared with normal pancreas. A novel CCR2 inhibitor (PF-04136309) was tested in an orthotopic model of murine pancreatic cancer. RESULTS: Monocyte prevalence in the peripheral blood correlates inversely with survival, and low monocyte prevalence is an independent predictor of increased survival in patients with pancreatic cancer with resected tumors. Inflammatory monocytes are increased in the blood and decreased in the bone marrow of patients with pancreatic cancer compared with controls. An increased ratio of inflammatory monocytes in the blood versus the bone marrow is a novel predictor of decreased patient survival following tumor resection. Human pancreatic cancer produces CCL2, and immunosuppressive CCR2(+) macrophages infiltrate these tumors. Patients with tumors that exhibit high CCL2 expression/low CD8 T-cell infiltrate have significantly decreased survival. In mice, CCR2 blockade depletes inflammatory monocytes and macrophages from the primary tumor and premetastatic liver resulting in enhanced antitumor immunity, decreased tumor growth, and reduced metastasis. CONCLUSIONS: Inflammatory monocyte recruitment is critical to pancreatic cancer progression, and targeting CCR2 may be an effective immunotherapeutic strategy in this disease.

Microscopic margins and patterns of treatment failure in resected pancreatic adenocarcinoma.

OBJECTIVE: To correlate microscopic margin status with survival and local control in a large cohort of patients from a high-volume pancreatic cancer center. DESIGN: Retrospective database review. A uniform procedure for margin analysis was used with 4-color inking (neck, portal vein groove, uncinate, and posterior pancreatic margin) by the surgeon in the operating room. SETTING: A tertiary care hospital. PATIENTS: We reviewed patients who underwent pancreaticoduodenectomy between September 1, 1997, and December 31, 2008, from a prospective, institutional database. MAIN OUTCOME MEASURES: Using Cox regression models, we identified pathologic characteristics associated with local recurrence (LR) after controlling for potential confounding variables. Overall and LR-free survival curves were generated by the Kaplan-Meier method. RESULTS: Of 285 patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma, 97 (34.0%) had 1 or more positive microscopic margins (uncinate, 16.5%; portal vein groove, 8.8%; neck, 7.7%; and posterior, 10.5%). A total of 198 patients (69.5%) recurred, with the first site of failure being LR only in 47 (23.7%), local plus distant recurrence in 42 (21.2%), and distant recurrence only in 109 (55.1%). Patients with LR only were significantly more likely to have lymph node involvement (adjusted hazard ratio, 2.66; 95% CI, 1.25-5.63) or a positive posterior margin (adjusted hazard ratio, 4.27; 95% CI, 2.07-8.81). Patients with a positive posterior margin had significantly poorer LR-free survival with (P < .001) or without (P = .01) lymph node involvement. CONCLUSIONS: When systematically assessed, the incidence of positive microscopic margins is high. Positive posterior margins and lymph node involvement were each independently and significantly associated with LR.

Mediators of the effect of neighborhood poverty on physical functioning among breast cancer survivors: a longitudinal study.

PURPOSE: Female breast cancer survivors, a large and growing population, experience impaired physical functioning after treatment. Survivors living in impoverished neighborhoods may suffer even greater impairment, but the mechanisms linking neighborhood poverty and individual outcomes are poorly understood. This study sought to identify mediators of the effect of neighborhood poverty on physical functioning using longitudinal data from a Missouri cancer registry-based sample of 909 female breast cancer survivors. METHODS: Survivors were recruited 1 year after diagnosis (Y1) and completed two telephone interviews, at Y1 and 1 year later (Y2). The association between census-tract-level poverty and physical functioning (RAND SF-36) was tested using a multilevel a priori path model with 19 hypothesized mediators, demographic and socioeconomic confounders, and covariates. Hypothesized mediators included clinical and treatment variables, psychosocial factors (depression, stress, social support), perceived neighborhood characteristics, behavioral risk factors (physical activity, smoking, body mass index, alcohol use), and comorbidity. RESULTS: In unadjusted analysis, women living in neighborhoods with higher poverty were more likely to report lower physical functioning at Y2 (ß = -.19, p < .001). The final mediated model fit the data well (χ(2)(8) = 12.25, p = 0.14; CFI = .996; RMSEA = .024). The effect of neighborhood poverty on physical functioning was fully mediated by physical activity and body mass index. CONCLUSIONS: Breast cancer survivors living in neighborhoods with greater poverty reported lower physical functioning, but this effect was fully explained by physical activity and body mass index. Community-based lifestyle interventions sensitive to the unique challenges faced by cancer survivors and the challenges of living in a high-poverty neighborhood are needed to ameliorate neighborhood socioeconomic disparities in physical functioning.

Influence of primary care physician availability and socioeconomic deprivation on breast cancer from 1988 to 2008: a spatio-temporal analysis.

BACKGROUND: Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States. It is unclear how county-level primary care physician (PCP) availability and socioeconomic deprivation affect the spatial and temporal variation of breast cancer incidence and mortality. METHODS: We used the 1988-2008 public-use county-based data from nine Surveillance, Epidemiology, and End Results (SEER) programs to analyze the temporal and spatial disparity of PCP availability and socioeconomic deprivation on early-stage incidence, advanced-stage incidence and breast cancer mortality. The spatio-temporal analysis was implemented by a novel structural additive modeling approach. RESULTS: Greater PCP availability was significantly associated with higher early-stage incidence, advanced-stage incidence and mortality during the entire study period while socioeconomic deprivation was significantly negatively associated with early-stage incidence, advanced-stage incidence, and mortality up to 1992. However, the observed influence of PCP availability and socioeconomic deprivation varied by county. CONCLUSIONS: We showed important associations of PCP availability and socioeconomic deprivation with the three breast cancer indicators. However, the effect of these associations varied over time and across counties. The association of PCP availability and socioeconomic deprivation was stronger in selected counties.

A survey tool for measuring evidence-based decision making capacity in public health agencies.

BACKGROUND: While increasing attention is placed on using evidence-based decision making (EBDM) to improve public health, there is little research assessing the current EBDM capacity of the public health workforce. Public health agencies serve a wide range of populations with varying levels of resources. Our survey tool allows an individual agency to collect data that reflects its unique workforce. METHODS: Health department leaders and academic researchers collaboratively developed and conducted cross-sectional surveys in Kansas and Mississippi (USA) to assess EBDM capacity. Surveys were delivered to state- and local-level practitioners and community partners working in chronic disease control and prevention. The core component of the surveys was adopted from a previously tested instrument and measured gaps (importance versus availability) in competencies for EBDM in chronic disease. Other survey questions addressed expectations and incentives for using EBDM, self-efficacy in three EBDM skills, and estimates of EBDM within the agency. RESULTS: In both states, participants identified communication with policymakers, use of economic evaluation, and translation of research to practice as top competency gaps. Self-efficacy in developing evidence-based chronic disease control programs was lower than in finding or using data. Public health practitioners estimated that approximately two-thirds of programs in their agency were evidence-based. Mississippi participants indicated that health department leaders' expectations for the use of EBDM was approximately twice that of co-workers' expectations and that the use of EBDM could be increased with training and leadership prioritization. CONCLUSIONS: The assessment of EBDM capacity in Kansas and Mississippi built upon previous nationwide findings to identify top gaps in core competencies for EBDM in chronic disease and to estimate a percentage of programs in U.S. health departments that are evidence-based. The survey can serve as a valuable tool for other health departments and non-governmental organizations to assess EBDM capacity within their own workforce and to assist in the identification of approaches that will enhance the uptake of EBDM processes in public health programming and policymaking. Localized survey findings can provide direction for focusing workforce training programs and can indicate the types of incentives and policies that could affect the culture of EBDM in the workplace.

Estimated effects of potential interventions to prevent decreases in self-rated health among breast cancer survivors.

PURPOSE: To estimate the effect of hypothetical changes in modifiable predictors on the incidence of fair-to-poor self-rated health (SRH) in breast cancer survivors. METHODS: In 2007-2008, we interviewed 832 breast cancer survivors 1 year after diagnosis (baseline) and 1 year later. First, multivariable logistic regression models estimated the association between the predictors (sociodemographic factors, access to medical care, comorbid conditions, psychosocial factors, perceived neighborhood conditions, cancer-related behaviors, clinical factors) and SRH. Second, we estimated the probabilities of fair-to-poor SRH for values of the predictors for each breast cancer survivor. Third, we estimated the population-wide effect of potential changes in modifiable predictors on the incidence of fair-to-poor SRH. RESULTS: A total of 7.6% of participants (92.4% white; mean age, 58.0 years) whose SRH was rated good-to-excellent at baseline reported fair-to-poor SRH 1 year later. The largest potential reduction in incidence of fair-to-poor SRH could be obtained by eliminating surgical side effects (27.8% reduction) and comorbidity (21.8% reduction) and by engaging in any physical activity (19.6% reduction). CONCLUSIONS: A significant portion of the decline in SRH can be avoided by reducing surgical side effects, preventing comorbidity, and improving physical activity with the use of evidence-based strategies.

Different effects of multiple health status indicators on breast and colorectal cancer screening in a nationally representative US sample.

OBJECTIVE: To examine the independent associations between multiple health status indicators and breast and colorectal cancer screening (CRCS) in a national US sample. STUDY DESIGN AND SETTING: Analysis of cross-sectional data from the 2005 National Health Interview Survey (NHIS) involved 5115 men and 7100 women aged 50 years and older. MEASURES: Health status indicators included: self-reported perceived health status, number of chronic conditions, and functional limitation due to a chronic condition. Individuals were considered adherent to CRCS guidelines if they reported having a home-based fecal occult blood test in the past year or endoscopy in the past 10 years. Women were adherent to breast cancer screening guidelines if they reported having a mammogram in the previous 2 years. Statistical analyses were conducted using SUDAAN software to account for the complex sampling of the NHIS survey. Logistic regression was used to examine associations between each of the health status indicators and screening adherence for CRCS and mammography and to calculate estimated screening rates. RESULTS: The three health status indicators were independently and differentially associated with screening adherence. Poor perceived health was associated with lower mammography among women, whereas a greater number of chronic conditions were consistently associated with greater screening. In adjusted analyses, functional limitation was only significantly associated with greater CRCS among women. CONCLUSIONS: Our analyses included three common indicators of health status and provide new evidence of their complex associations with cancer screening. Future studies must examine the mechanisms by which these indicators influence screening recommendations and adherence among older adults over time.

Neighborhood foreclosures and self-rated health among breast cancer survivors.

PURPOSE: We determined the association of neighborhood foreclosure risk on the health status of a statewide sample of breast cancer survivors (n = 1047) and the extent to which covariates accounted for observed associations. METHODS: Measures of self-rated health and several covariates were obtained by telephone interview 1 year after diagnosis. We used the federal Housing and Urban Development agency's estimated census-tract foreclosure-abandonment-risk score and multilevel, logistic regression to determine the association of foreclosure risk (high, moderate versus low) with self-rated health (fair-poor versus good, very good, excellent) and whether covariates could explain the observed association. RESULTS: Women who resided in high-foreclosure-risk (HFR) areas were 2.39 times (95% CI: 1.83-3.13) more likely to report being in fair-poor health than women who lived in low-foreclosure-risk areas. The odds ratio (OR) was reduced for women who lived in high-foreclosure-risk versus low-foreclosure-risk areas after adjusting for income (HFR OR: 1.78; 95% CI: 1.01-3.15), physical activity (HFR OR: 1.74; 95% CI: 0.98-3.08), and perceived neighborhood conditions (HFR OR: 1.76; 95% CI: 1.02-3.05). CONCLUSIONS: Breast cancer survivors who lived in census tracts with high- versus low-foreclosure risk reported poorer health status. This association was explained by differences in household income, physical activity, and perceived neighborhood conditions.

Selected sociocultural correlates of physical activity among African-American adults.

OBJECTIVE: Previous studies have identified several factors to be associated with physical activity (PA) among African-Americans, e.g., demographic and health-related characteristics. Formative studies suggest a link between sociocultural factors and PA among ethnic minorities; yet, it is unclear whether these factors play a role in PA among African-Americans. This paper explores the association of selected sociocultural characteristics with self-reported PA by gender among African-American adults, taking into account demographic and health-related characteristics. DESIGN: Data from the baseline survey of a colorectal cancer communication intervention trial were used. Participants included 446 African-American men and women, aged 45-75 years. Self-report data were collected on demographics, health-related characteristics, selected sociocultural constructs (e.g., ethnic identity, religiosity, collectivism, and medical mistrust), and PA. PA was categorized as meeting or not meeting recommended levels; recommended levels were defined as participating in vigorous PA for 20 minutes/day for at least three days/week or moderate PA for 30 minutes/day for at least five days/week or a minimum of 600 MET-minutes/week in at least five days. Chi-square and multivariate logistic regression models were used to characterize the association between the selected sociocultural constructs and PA among men and women, after adjusting for demographic and health-related characteristics. RESULTS: Most participants reported some PA but only 59% were found to be meeting recommended levels. Univariate analyses revealed that high collectivist attitudes were associated with meeting recommended PA (OR = 1.74), particularly for women (OR = 1.81). In multivariate analyses, high collectivist attitudes were significantly associated with meeting PA recommendations among men (OR = 1.87); while high religiosity and high collectivism were significant among women (OR = 1.87 and 1.85, respectively). CONCLUSIONS: Few of the selected sociocultural characteristics were found to be associated with meeting recommended PA levels. Further study is needed to understand the association of these characteristics with PA among African-Americans.

Temporal trends in geographic disparities in small-area-level colorectal cancer incidence and mortality in the United States.

OBJECTIVE: We examined the extent of changes in absolute and relative geographic disparities in six colorectal cancer (CRC) indicators using data about persons aged 50 and older from 195 counties in the 1988-2006 Surveillance, Epidemiology, and End Results Program database. METHODS: County-level trends in six colorectal cancer indicators (overall CRC incidence, descending colon cancer incidence, proximal colon cancer incidence, late-stage CRC incidence, CRC mortality, and 5-year probability of CRC death) were summarized using the estimated annual percentage change. Observed county rates were smoothed using Bayesian hierarchical spatiotemporal methods to calculate measures of absolute and relative geographic disparity and their changes over time. RESULTS: During the study period, absolute disparity for all six indicators decreased (CRC incidence: 43.2%; proximal colon cancer: 31.9%; descending colon cancer: 52.8%; late-stage CRC: 50.0%; CRC mortality: 57.8%; 5-year CRC-specific probability of death: 12.2%). Relative disparity remained stable for all six indicators over the entire study period. CONCLUSION: Important progress has been made toward achieving the Healthy People 2010 and NCI strategic objectives for reducing geographic disparities, although absolute and relative disparities remain in CRC.

Poorer survival outcomes for male breast cancer compared with female breast cancer may be attributable to in-stage migration.

BACKGROUND: Male breast cancer accounts for less than 1% of all breast cancers, yet males have a worse prognosis than females with breast cancer. METHODS: Using the 1988-2003 Surveillance, Epidemiology, and End Results Program data, we conducted a retrospective, population-based cohort study to investigate stage-specific differences in breast cancer-specific and all-cause mortality between males and females. We calculated adjusted hazard ratios (aHR) and 95% confidence intervals (CI) using Cox regression models to compare breast cancer-specific and all-cause mortality by stage between males and females, controlling for potential confounding variables. RESULTS: There were 246,059 patients with a first, single, primary breast cancer [1,541 (0.6%) male; 244,518 (99.4%) female]. Compared with females, males were more likely to be older, Black, married, diagnosed at more advanced stages, and treated with mastectomy (each P < 0.001). Males also were more likely to have lower grade and estrogen/progesterone receptor-positive tumors (each P < 0.001). After controlling for confounders, males were more likely to die from their breast cancer when compared with females, only if diagnosed with stage I disease (aHR 1.72, CI 1.15-2.61). For all-cause mortality, males were more likely than females to die at each stage of disease except stage IV. CONCLUSIONS: Although all-cause mortality was higher for men than women at all stages of nonmetastatic breast cancer, higher male breast cancer-specific mortality was attributed to poorer survival in stage I disease. However, this statistical difference is unlikely to be clinically relevant and attributable to in-stage migration.

The association between chronic disease burden and quality of life among breast cancer survivors in Missouri.

Greater chronic disease burden may decrease quality of life (QOL) of breast cancer survivors. Our objective was to investigate the association between chronic disease burden and QOL in breast cancer survivors at 1 year post-diagnosis. We analyzed cross-sectional data collected 1 year post-diagnosis from a sample of female breast cancer survivors identified from the Missouri cancer registry. We used eight RAND-36 subscales to assess physical, emotional, and social functioning QOL domains. Using Katz's measure of comorbidity, we computed chronic disease burden (0, 1, and 2+). Multivariable general linear models for each QOL subscale were used to examine associations between chronic disease burden and QOL after controlling for potential covariates: socio-demographic, clinical, psychosocial, behavioral risk factors, and access to medical care. Participants (n = 1089) were 58-year old on average (range 27-96) and mostly White (92%), married (68%), had at least a high school education (95%), and had health insurance (97%). Sixty-six percent of survivors had a chronic disease burden score of 0, 17% had 1, and 17% had 2+. Chronic disease burden was significantly associated with each QOL subscale in crude models (P < 0.001). In fully adjusted models, chronic disease burden was still significantly correlated with six subscales, but not with the emotional well-being and role limitations due to emotional problems subscales. One year post-diagnosis, breast cancer survivors with higher chronic disease burden had lower physical and social functioning than survivors without additional health conditions. These differences were not fully explained by relevant covariates. Identifying modifiable targets for intervention will be critical for improving QOL outcomes among survivors who have other chronic health conditions.

Barriers to evidence-based decision making in public health: a national survey of chronic disease practitioners.

OBJECTIVE: Existing knowledge of evidence-based chronic disease prevention is not systematically disseminated or applied. This study investigated state and territorial chronic disease practitioners' self-reported barriers to evidence-based decision making (EBDM). METHODS: In a nationwide survey, participants indicated the extent to which they agreed with statements reflecting four personal and five organizational barriers to EBDM. Responses were measured on a Likert scale from 0 to 10, with higher scores indicating a larger barrier to EBDM. We analyzed mean levels of barriers and calculated adjusted odds ratios for barriers that were considered modifiable through interventions. RESULTS: Overall, survey participants (n=447) reported higher scores for organizational barriers than for personal barriers. The largest reported barriers to EBDM were lack of incentives/rewards, inadequate funding, a perception of state legislators not supporting evidence-based interventions and policies, and feeling the need to be an expert on many issues. In adjusted models, women were more likely to report a lack of skills in developing evidence-based programs and in communicating with policy makers. Participants with a bachelor's degree as their highest degree were more likely than those with public health master's degrees to report lacking skills in developing evidence-based programs. Men, specialists, and individuals with doctoral degrees were all more likely to feel the need to be an expert on many issues to effectively make evidence-based decisions. CONCLUSIONS: Approaches must be developed to address organizational barriers to EBDM. Focused skills development is needed to address personal barriers, particularly for chronic disease practitioners without graduate-level training.

Individual and setting level predictors of the implementation of a skin cancer prevention program: a multilevel analysis.

BACKGROUND: To achieve widespread cancer control, a better understanding is needed of the factors that contribute to successful implementation of effective skin cancer prevention interventions. This study assessed the relative contributions of individual- and setting-level characteristics to implementation of a widely disseminated skin cancer prevention program. METHODS: A multilevel analysis was conducted using data from the Pool Cool Diffusion Trial from 2004 and replicated with data from 2005. Implementation of Pool Cool by lifeguards was measured using a composite score (implementation variable, range 0 to 10) that assessed whether the lifeguard performed different components of the intervention. Predictors included lifeguard background characteristics, lifeguard sun protection-related attitudes and behaviors, pool characteristics, and enhanced (i.e., more technical assistance, tailored materials, and incentives are provided) versus basic treatment group. RESULTS: The mean value of the implementation variable was 4 in both years (2004 and 2005; SD = 2 in 2004 and SD = 3 in 2005) indicating a moderate implementation for most lifeguards. Several individual-level (lifeguard characteristics) and setting-level (pool characteristics and treatment group) factors were found to be significantly associated with implementation of Pool Cool by lifeguards. All three lifeguard-level domains (lifeguard background characteristics, lifeguard sun protection-related attitudes and behaviors) and six pool-level predictors (number of weekly pool visitors, intervention intensity, geographic latitude, pool location, sun safety and/or skin cancer prevention programs, and sun safety programs and policies) were included in the final model. The most important predictors of implementation were the number of weekly pool visitors (inverse association) and enhanced treatment group (positive association). That is, pools with fewer weekly visitors and pools in the enhanced treatment group had significantly higher program implementation in both 2004 and 2005. CONCLUSIONS: More intense, theory-driven dissemination strategies led to higher levels of implementation of this effective skin cancer prevention program. Issues to be considered by practitioners seeking to implement evidence-based programs in community settings, include taking into account both individual-level and setting-level factors, using active implementation approaches, and assessing local needs to adapt intervention materials.