Intervention to increase screening mammography among women 65 and older.

This paper reports the results of a practice-based intervention program to increase mammography screening among women 65 and older who receive their health care in the private sector. Forty-three primary-care practices and 2147 women in central and western North Carolina were enrolled in the study, and 1911 women completed all phases of the study. The intervention was a three-stage educational and counseling program designed to become progressively more intensive at each stage. The interventions included provider education in the form of current information on issues in mammography for older women, simply written educational materials on breast cancer and screening mailed to women, and a brief telephone counseling session for the women. While the analysis revealed no overall effect across all three stages of the intervention program, tests for interaction indicated a significant program effect for women who were 80 or older, had less than 9 years of education, were black, or had no private insurance to supplement Medicare. The results suggested that providing primary-care physicians with information on screening older women and providing the women with useful educational materials can increase participation in screening mammography among subgroups of women currently least likely to receive mammography screening.

The multimedia computer for low-literacy patient education: a pilot project of cancer risk perceptions.

OBJECTIVE: Inadequate reading literacy is a major barrier to better educating patients. Despite its high prevalence, practical solutions for detecting and overcoming low literacy in a busy clinical setting remain elusive. In exploring the potential role for the multimedia computer in improving office-based patient education, we compared the accuracy of information captured from audio-computer interviewing of patients with that obtained from subsequent verbal questioning. SETTING: Adult medicine clinic, urban community health center PATIENTS: Convenience sample of patients awaiting clinic appointments (n = 59). Exclusion criteria included obvious psychoneurologic impairment or primary language other than English. INTERVENTION: A multimedia computer presentation that used audio-computer interviewing with localized imagery and voices to elicit responses to 4 questions on prior computer use and cancer risk perceptions. MEASUREMENTS AND MAIN RESULTS: Three patients refused or were unable to interact with the computer at all, and 3 patients required restarting the presentation from the beginning but ultimately completed the computerized survey. Of the 51 evaluable patients (72.5% African-American, 66.7% female, mean age 47.5 [+/- 18.1]), the mean time in the computer presentation was significantly longer with older age and with no prior computer use but did not differ by gender or race. Despite a high proportion of no prior computer use (60.8%), there was a high rate of agreement (88.7% overall) between audio-computer interviewing and subsequent verbal questioning. CONCLUSIONS: Audio-computer interviewing is feasible in this urban community health center. The computer offers a partial solution for overcoming literacy barriers inherent in written patient education materials and provides an efficient means of data collection that can be used to better target patients' educational needs.

Risk assessment of first-degree relatives of women with breast cancer: a feasibility study.

PURPOSE/OBJECTIVES: To measure psychological distress and test the feasibility of a psychological intervention to reduce distress in patients undergoing risk assessment. DESIGN: Descriptive. SETTING: A comprehensive cancer center located in the southeastern United States. SAMPLE: 20 first-degree relatives of women diagnosed with breast cancer (X age = 42; range = 21-70) completed the risk assessment process. Three were lost to follow-up at three months, leaving a total of 17 evaluable patients. METHODS: Data collection was by means of family/medical history forms and questionnaires administered at baseline and one and three months. Participants were randomized to either a control group consisting of standard education about risk for breast cancer or to an intervention group consisting of standard education plus a psychological intervention designed to teach stress-management skills. MAIN RESEARCH VARIABLES: Psychological distress, depressive symptoms, intrusive thoughts about breast cancer, and perceived risk for developing breast cancer. FINDINGS: Delivery of a psychological intervention proved feasible. Although no statistically significant differences existed between the intervention and control groups on distress and depressive symptoms, the intervention group reported fewer intrusive thoughts about breast cancer at follow-up. Risk did not predict anxiety levels. A large majority (73%) of the women overestimated the risk of breast cancer at baseline. CONCLUSIONS: This study demonstrated the feasibility of a multidisciplinary team approach to breast cancer risk assessment and counseling and management of psychological distress in first-degree relatives of women with breast cancer. The data suggest that a psychological intervention may reduce cancer-specific psychological distress in women at increased risk for breast cancer. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses can play an important role in the delivery of interventions to educate and reduce distress in women undergoing breast cancer risk assessment.

Dual Tobacco use among Native American adults in southeastern North Carolina.

OBJECTIVE: While patterns of smokeless tobacco (ST) use and cigarette smoking are well documented, the epidemiology of simultaneous use of both tobacco products is less well studied, particularly among Native American populations. This study examines correlates of dual tobacco use among Lumbee Indian adults in southeastern North Carolina. METHODS: A telephone survey among 400 adult Lumbee Indians in Pembroke, North Carolina, collected information on demographics, current tobacco use, amounts of tobacco used, and tobacco related attitudes. RESULTS: Total of 241 (60.3%) individuals did not currently use tobacco, 104 (26%) currently smoked, 74 (18.5%) currently used ST, and 19 (4.8%) used both products. Thus, 19 of 104 (18.3%) current smokers and 19 of 74 (25.7%) current ST users reported dual tobacco use. Compared to exclusive users of either tobacco product, dual tobacco users were intermediate in age and frequency of church attendance, had lower levels of education, and were the highest proportion of subjects reporting no friends and few close relatives. There was no difference by gender or marital status by tobacco use categories. While exclusive cigarette smokers reported smoking more cigarettes per day than dual tobacco users, overall, dual tobacco users had higher estimated daily nicotine exposure levels. Logistic regression analysis showed that younger age and infrequent church attendance predicted exclusive cigarette smoking, while older age and less education predicted exclusive ST use. Dual tobacco use was predicted only by less education. CONCLUSIONS: Simultaneous use of ST and cigarettes is comparatively more common among Lumbee Indian adults than the general population and has an epidemiology distinct from either exclusive cigarette smoking or ST use. These data are the first to explore social support as well as tobacco-related attitudes among dual tobacco users in a Native American population. Recognition of these patterns of dual tobacco use would be important in any future tobacco intervention among Lumbee Indian adults.

Association between smokeless tobacco use and breast cancer among Native-American women in North Carolina.

BACKGROUND: Cigarette smoking and smokeless tobacco use have been associated with the development of a variety of cancers. While cigarette smoking may be associated with breast cancer, smokeless tobacco use has never been evaluated as a breast cancer risk factor. This study explores such an association. METHODS: A complete census was carried out among Eastern Band Cherokee women aged 18 years and older, residing on tribal lands in western North Carolina. Self-reported alcohol, cigarette and smokeless tobacco use, demographic information, and personal history of breast cancer (stratified by age of onset < 55 years or > or = 55 years) were obtained by questionnaire. RESULTS: 1,070 out of 1,408 (76%) eligible women were interviewed. Current and former smokeless tobacco use was common (6% and 21%, respectively). Five cases of breast cancer were identified in women under the age of 55 years and 3 cases were found in women at > or = 55 years. Only the odds ratio (OR) for younger-onset breast cancer among ever-users of smokeless tobacco was significantly elevated (OR = 7.79, 95% CI = 1.05-66.0). While the ORs for younger onset breast cancer were elevated among ever-smokers or women reporting at least monthly alcohol use, these were not significant (OR 8.49, 95% CI = 0.09-200; and OR = 1.72, 95% CI = 0.19-15.2, respectively). No ORs were significantly elevated for breast cancer among older women. CONCLUSIONS: These preliminary data are the first to document an apparent relationship between smokeless tobacco use and breast cancer risk, but should be confirmed in other studies due to the small number of cases. The nearly 8-fold increase in risk suggests that smokeless tobacco is not a safe alternative to cigarette smoking.

Use of an interrupted time-series design to evaluate a cancer screening program.

An alternative approach to intervention-control designs to evaluate community health education studies is to use a quasi-experimental design in which the outcomes of interest are examined over time in the intervention unit. The Forsyth County Cancer Screening Project (FoCaS) was a comprehensive clinic- and community-based education program to increase screening for cervical cancer and breast cancer among low-income women. This paper reports the use of piecewise regression accounting for potential effects of auto-correlation in the data to evaluate the effectiveness of the project in increasing mammography screening. Data for the evaluation of trends in screening consisted of all mammograms performed during the period of May 1992 through June 1995 at the Reynolds Health Center in Forsyth County, North Carolina. The results suggested that the FoCaS project was effective in increasing mammography screening among women age 40 or older in the study population. Analysis of the trends by age indicated that the program had differential effects on women age 40-49 and 50 or older. The results demonstrate that analyses of the type presented here can either complement or serve as an alternative to more traditional intervention-control analyses.

Psychosocial factors associated with the use of breast cancer screening by women age 60 years or over.

This study examined psychosocial factors related to breast cancer screening among older women. Data for the study were obtained from interviews with 719 women age 60 years or over attending rural and urban primary care clinics in North Carolina. The results indicated that 50% of the women had mammograms in the past year, 65% reported clinical breast examinations in the past year, and 31% said they practiced breast self-examinations once a month. Several psychosocial factors were significant predictors of a lower likelihood of being screened. Multivariate analysis confirmed the importance of psychosocial factors as predictors of breast cancer screening. Educational intervention to increase screening for breast cancer in this population is needed, and the results provide specific suggestions regarding the content of effective educational materials and approaches for older women.

Cancer control research and literacy.

Low literacy may be an important predictor of increased cancer risk and poor participation in cancer control programs. Results of the National Adult Literacy Survey indicate that about 90 million individuals, slightly less than half of the U.S. adult population, demonstrate low or limited literacy skills. In contrast, the average health education brochure, pamphlet, or instruction sheet requires a 10th-grade or higher level of reading ability to be understood. Guidelines exist for the development of more readable printed materials; studies have also found that nonprint approaches such as video education are viable alternatives to printed materials. Research on patient populations indicates that educational approaches targeted to low-literacy groups can be effective in reaching individuals with cancer control information. This review identifies the most important areas of needed research and makes recommendations for the development of a research agenda on cancer control and literacy.

Community-based interventions to improve breast and cervical cancer screening: results of the Forsyth County Cancer Screening (FoCaS) Project.

The FoCaS (Forsyth County Cancer Screening) Project was one of six projects funded by the National Cancer Institute "Public Health Approaches to Breast and Cervical Cancer" initiative. The goal of this project was to improve the use of breast and cervical cancer screening among low-income, predominately African-American, women age 40 and older. Strategies implemented in the intervention city included public health clinic in-reach strategies (chart reminders, exam room prompts, in-service meetings, and patient-directed literature) and community outreach strategies (educational sessions, literature distribution, community events, media, and church programs). Baseline and follow-up data from independent cross-sectional samples in both the intervention and comparison cities were used to evaluate the effects of the intervention program. A total of 248 women were surveyed at baseline, and 302 women were surveyed 3 years later at follow-up. The proportion of women reporting regular use of mammography increased (31 to 56%; P < 0.001) in the intervention city. In the comparison city, a nonsignificant (ns) increase in mammography utilization was observed (33 to 40%; P = ns). Pap smear screening rates also improved in the intervention city (73 to 87%; P = 0.003) but declined in the comparison city (67 to 60%; P = ns). These relationships hold in multivariate models. The results suggest that a multifaceted intervention can improve screening rates in low-income populations. These results have important implications for community-based research and efforts in underserved populations.

Epidemiology of tobacco use among Lumbee Indians in North Carolina.

BACKGROUND: Little is known regarding tobacco use among the Lumbee Indians in southeastern North Carolina, despite high prevalence of use and ties to tobacco-related agriculture. This report describes current and early childhood tobacco use in this population. METHODS: A cross-sectional telephone survey of 400 adult Lumbee Indians was done in Pembroke, Robeson County, NC. Information was collected on demographics, tobacco use, knowledge and practices related to tobacco agriculture, and ceremonial tobacco use. RESULTS: 17.8% and 18.2% of the sample reported current and former smokeless tobacco (ST) use, and 26% and 19.5% reported current and former cigarette (CG) use, respectively. 17.3% reported ever use of both CG and ST. Current ST use was associated with older age, childhood involvement in tobacco-related agriculture, and less education. Current CG use was associated with younger age, male sex, less education, having never been married, infrequent church attendance, and fewer close friends or relatives. Early initiation of ST and CG use was more common among women, while early initiation of CG use was more common among persons who were younger and had lower levels of education. CONCLUSIONS: Current ST use is unusually common among Lumbee adults, while CG use reflects rates found in other populations. These data show different patterns of CG use and ST use, and suggest that strategies for tobacco use cessation must target each specific product.

Troglitazone or metformin in combination with sulfonylureas for patients with type 2 diabetes?

BACKGROUND: Combination oral therapy is often used to control the hyperglycemia of patients with type 2 diabetes. We compared the effectiveness of metformin and troglitazone when added to sulfonylurea therapy for patients with type 2 diabetes who had suboptimal blood glucose control. METHODS: We used a randomized 2-group design to compare the efficacy, safety, and tolerability of troglitazone and metformin for patients with type 2 diabetes mellitus that was inadequately controlled with diet and oral sulfonylureas. Thirty-two subjects were randomized to receive either troglitazone or metformin for 14 weeks, including a 2-week drug-titration period. The primary outcome variable was mean change in the level of glycosylated hemoglobin (Hb A1c) from baseline. Secondary outcomes included mean changes from baseline in fasting plasma glucose and C-peptide levels, renal or metabolic side effects, and symptomatic tolerability. RESULTS: The addition of either troglitazone or metformin to oral sulfonylurea therapy significantly decreased Hb A1c levels. Both treatment regimens also significantly reduced fasting plasma glucose and C-peptide levels. We found no significant differences between the treatment arms in efficacy, metabolic side effects, or tolerability. CONCLUSIONS: Our results demonstrate that troglitazone and metformin each significantly improved Hb A1c, fasting plasma glucose, and C-peptide levels when added to oral sulfonylurea therapy for patients with type 2 diabetes who had inadequate glucose control.

Practical assessment of adult literacy in health care.

Low literacy is a pervasive and underrecognized problem in health care Approximately 21% of American adults are functionally illiterate, and another 27% have marginal literacy skills. Such patients may have difficulty reading and understanding discharge instructions, medication labels, patient education materials, consent forms, or health surveys. Properly assessing the literacy level of individual patients or groups may avoid problems in clinical care and research. This article reviews the use of literacy assessments, discusses their application in a variety of health care settings, and cites issues providers need to consider before testing. The authors describe informal and formal methods of screening for reading and comprehension in English and Spanish including the Rapid Estimate of Adult Literacy in Medicine, the Wide Range Achievement Test-3, the Cloze procedure, the Test of Functional Health Literacy in Adults, and others. Practical implications and recommendations for specific use are made.

The prevalence of domestic violence among women seeking abortion.

OBJECTIVE: To determine the prevalence of self-reported abuse in a population of women aged 18 years or older seeking elective pregnancy termination, and to compare abused and nonabused women with respect to the primary reasons for pregnancy termination. METHODS: A self-administered questionnaire was returned by 486 women seeking outpatient abortion. The survey included demographic information, abuse screening, and items regarding partner involvement/awareness of the pregnancy, and abuse as a determinant of the abortion decision. One open-ended item asking the primary reason for pregnancy termination was included. RESULTS: The prevalence of self-reported abuse in this population was 39.5%. White women were significantly more likely to report any history of abuse than nonwhite women. Relationship issues were the only reason for pregnancy termination given more often by women with an abuse history than by nonabused women. Women with abuse histories were significantly less likely than nonabused women to inform the partner of the pregnancy or to have partner support for or involvement in the abortion decision. CONCLUSION: The prevalence of abuse reported by women in this population suggests that many women seeking abortion services may have abuse histories. Abused women may have different reasons for pregnancy termination than nonabused women and may be more likely to make the abortion decision without partner involvement. When routine screening for abuse is included in abortion counseling, health providers have the opportunity for developing a safety plan and initiating appropriate referral.

Church-related correlates of tobacco use among Lumbee Indians in North Carolina.

BACKGROUND: Although minority populations suffer a disproportionately higher burden of tobacco-attributable morbidity and mortality, the church appears to be a promising avenue through which to pursue tobacco-cessation interventions in these communities. This report describes church-related correlates of tobacco use among the Lumbee Indians in North Carolina, a population with a high prevalence of tobacco use, strong ties to tobacco-related agriculture, and high levels of church participation. METHODS: A cross-sectional telephone survey of 400 adult Lumbee Indians was carried out in Pembroke, a town in Robeson County, NC. The questionnaire elicited information on tobacco use, demographic and social support information, knowledge and practices related to tobacco agriculture and traditional Native American tobacco use and church participation. RESULTS: Sixty-three percent of participants were church members and 82% said the church is "very important" to the Lumbee community. In bivariate analysis, church attendance over the past year correlated with age, education, gender, number of close friends and relatives, marital status and current smoking status. Church attendance was not related to current smokeless tobacco use or participation in tobacco-related agriculture. Current smokers who had not attended church in the past year smoked significantly more cigarettes per day than current smokers attending church more often. In logistic regression, participants attending church weekly or more often were 73% less likely to be current smokers (adjusted odds ratio [AOR] = 0.27, 95% confidence interval [CI] = 0.11-0.68). Among ever-smokers, participants having attended church infrequently in the past year were 79% less likely to have quit (AOR = 0.21, 95% CI = 0.07-0.65). Having participated in tobacco agriculture as a child predicted current Christian views on tobacco use. DISCUSSION: Tobacco use, common among Lumbee adults, correlates with a variety of demographic and social support variables. In addition, these data are the first to uncover a dose-response relationship between church attendance and number of cigarettes smoked per day by current smokers, and the relationship between childhood participation in tobacco agriculture and Christian views on tobacco use. Our results should be useful in designing a church-based tobacco-cessation intervention among Lumbee Indians.

Health education to increase screening for cervical cancer among Lumbee Indian women in North Carolina.

Although age-adjusted mortality rates from cancer among Native-Americans are generally lower than for the US population as a whole, cervical cancer mortality rates are higher. This report presents results from a National Cancer Institute-funded health education program conducted among the Lumbee tribe in North Carolina that was designed to increase the proportion of women, age 18 and older, who receive Pap smears to screen for cervical cancer. The Solomon Four Group research design was used for this project. Participants were selected at random from the enrollment records of the Lumbee tribe and data collection was carried out during face-to-face interviews. The health education program was provided one-on-one in women's homes by a trained lay health educator and included verbal, print and videotape information. A total of 979 women were enrolled in the study, and 125 were lost to follow-up between the pre-test and post-test. Women who received the education program were found to be more likely to have knowledge of the Pap smear and to report a Pap smear in the past year at the post-test than those in the control group, regardless of whether they received the pre-test interview, P < 0.05. Women most likely to respond to the education program were also likely to have reported that they receive an annual physical examination. Women with better knowledge of the Pap smear tended to have more education, higher income and greater identification with Native-American culture than those with less knowledge. We conclude that the health education program was associated with greater knowledge about cervical cancer prevention and higher proportions of Lumbee women obtaining Pap smears in the past year.

Factors associated with term low birthweight in Cardiff, Wales.

This project was undertaken to examine the associations of a number of risk factors with impaired fetal growth, exemplified by delivery of a low-birthweight infant at term (TLBW). Utilising a large database of largely homogeneous (white) births in Wales, the Cardiff Births Survey, multivariable analysis by logistic regression examined the relative importance of these risk variables. Significant independent associations with TLBW were found (in decreasing order of magnitude) for low maternal weight, pre-eclampsia, smoking, short maternal height, late pregnancy bleeding, early pregnancy bleeding, history of a previous stillbirth, primiparity and older maternal age. In this population, risk of TBLW was associated with a number of demographic, medical and social factors. Of these, only smoking is likely to be modified by intervention.

Prevalence and predictors of tobacco use among Lumbee Indian women in Robeson County, North Carolina.

Tobacco use among some Native American tribes is high compared to the overall US population. Little is known, however, about tobacco use among Native Americans in North Carolina, a state with strong economic ties to tobacco. To assess the epidemiology of tobacco use in this population, data from the North Carolina Native American Cervical Cancer Project was reviewed. Nine hundred eighty-two Lumbee Indian women in Robeson County provided general demographic information as well as information on cancer risk knowledge, attitudes and behaviors during the 5-year study. Women were selected from the community using a random sample of 5200 persons from the tribal roll of approximately 40,000 persons. 20.6% of women were current smokeless tobacco users, while 23.7% were current smokers. Demographic and social support predictors were unique for the different types of tobacco use. Cigarette smoking was associated with younger age, higher education, excellent or good self-reported health, having a recent physical exam, separated or divorced marital status, low church participation, and alcohol consumption. Conversely, use of smokeless tobacco was associated with older age, lower education level, fair or poor self-reported health, widowed marital status, and having a high number of friends. These data show a high prevalence of smokeless tobacco use among women in this population, and a contrast in the predictors of tobacco use by source. Intervention programs for tobacco use cessation should be sensitive to these differences.

Correlates of tobacco use among Native American women in western North Carolina.

OBJECTIVES: This study examined correlates of tobacco use among Cherokee women. METHODS: Prevalence rates were analyzed for 614 randomly selected Eastern Band Cherokee women. RESULTS: The prevalence rates for current smokeless tobacco use and smoking were 8% and 39%, respectively. Smokeless tobacco use correlates included lower education and having consulted an Indian healer. Smoking correlates included younger age, alcohol use, no yearly physical exam, separated or divorced marital status, and lack of friends or church participation. CONCLUSIONS: Smoking rates among these women were slightly above national rates. The association of smokeless tobacco use with having consulted an Indian healer may help in understanding Cherokee women's smokeless tobacco use.

Skin cancer prevention and early detection practices in a sample of rural women.

BACKGROUND: The incidence of skin cancer in the United States is rapidly increasing, and current estimates suggest that about one in five persons will be diagnosed with skin cancer in their lifetime. However, comparatively little is still known about the prevention and early detection behaviors of healthy individuals. This study presents information on prevention and early detection practices for a sample of non-Hispanic rural white women. METHOD: Interviews were conducted with 1,295 women age 20 or older who were patients in six public health departments and one primary-care clinic serving a low-income population, all located in rural western North Carolina. RESULTS: Both prevention and early detection behaviors were found to be infrequent in this population. Low knowledge of skin cancer, younger and older ages, and low education characterized women least likely to practice prevention. Low knowledge, younger age, and low education characterized women least likely to practice early detection. Perceived barriers to cancer screening including cost, lack of symptoms, and denial also were predictive of a low likelihood of both prevention and early detection behavior. Fatalism and fear of the stigma associated with cancer also were predictive of lower participation in selected early detection behaviors. A summary general barriers score was significantly associated with all prevention and early detection behaviors examined in the study. CONCLUSIONS: The results indicate a need for skin cancer education among this population.