Promoting informed prostate cancer screening decision-making for African American men in a community-based setting.

PURPOSE: Current screening guidelines for prostate cancer (PCa) encourage men to make individual screening decisions after consulting with their primary care provider to weigh the risks and benefits of undergoing prostate specific antigen (PSA) testing, but many men at high risk of PCa diagnosis (notably African American men) are more likely to be uninsured and lack a primary care provider. An academic-community partnership redesigned its community-based screening program to ensure access to services for African American men, incorporating a session with a trained clinical educator in community settings, designed to increase knowledge and promote informed decision-making regarding PSA testing. This study evaluated effects of the intervention on decision-making outcomes. METHODS: To evaluate program efficacy, 88 men completed pre- and post-test surveys assessing outcomes of interest. RESULTS: Participants' knowledge, beliefs, attitudes, anxiety levels, and self-efficacy all improved from pre- to post-test at a statistically significant level. Most notably participants' awareness that PCa is often not life-threatening, and watchful waiting is a reasonable treatment option increased after the encounter. More than half of the study sample felt they had received enough knowledge to make an informed decision about whether the PSA test was right for them. CONCLUSION: Our findings show the program had positive effects on men's ability to make informed decisions about PCa screening and demonstrate that educational outreach programs with an emphasis on informed decision-making can effectively balance screening guidelines with the needs of underserved populations in community settings to improve outcomes.

Enhancing organizational health literacy in a rural Missouri clinic: a qualitative case study.

PURPOSE: The purpose of this paper is to evaluate a collaborative effort between a health care organization and academic institution to strengthen organizational health literacy. DESIGN/METHODOLOGY/APPROACH: The intervention took place at a rural, federally qualified health clinic in Missouri between May 2009 and April 2011. Qualitative interviews of key informants were conducted before (n=35) and after (n=23) the intervention to examine program implementation and success in effecting organizational change. FINDINGS: Intervention activities helped establish a comprehensive understanding of health literacy. The project achieved moderate, fundamental and sustainable organizational change. The program successfully integrated health literacy practices into clinic systems and garnered leadership and organizational commitment, helped the workforce improve interpersonal communication and embedded practices making health education materials more accessible. ORIGINALITY/VALUE: The study points to programmatic, conceptual and methodological challenges that must be addressed for organizations to improve health literacy practices, and suggests change management strategies to advance organizational health literacy.

An Unexpected, Yet Welcomed Outcome of the St. Louis Healthy Start Program.

Introduction Racial disparities in birth outcomes are a significant problem in the U.S. The St. Louis Healthy Start (SLHS) program, funded for 14 years, had a goal of reducing disparate rates of poor birth outcomes in three disadvantaged communities in the St. Louis area. The Making Change Happen Leadership Academy (MCHLA) was an unanticipated community-driven effort that grew out of SLHS and continues today. The primary goal of the MCHLA is to empower women to gain mastery over their lives and use their power to improve birth outcomes in their communities. Methods Qualitative interviews were conducted with MCHLA participants to determine the impact of participation in the MCHLA on their leadership skills and attitudes. Results Participants reported positive attitudes about themselves including increased confidence and improved parenting skills. Through active participation in project work, they noted increased professional and advocacy skills and recognition of the importance of their voice. As leaders, they recognized the importance of giving and receiving emotional, tangible, and information social support. The small sample prevents us from confidently reporting that findings directly relate to the MCHLA. Discussion Leaders exist in all communities. Public health practitioners may help enhance and develop leaders with tangible support. We need to encourage more MCHLA type programs while systematically evaluating their impact on empowerment in underserved women.

Translating an Evidence-Based Injury Prevention Program for Implementation in a Home Visitation Setting.

Safe N' Sound (SNS), a computer-based childhood injury prevention program, provides individually tailored information to parents about their child's injury risks with specific behavioral recommendations. We translated SNS for implementation in a home visitation organization in order to increase its capacity to effectively address injury prevention and decrease the burden of injury experienced by high-need families. The aim of this study was to identify behavioral and organizational barriers and facilitators to translating and implementing SNS in a home visitation setting. Nurse home visitors (NHVs) participated in semistructured interviews that examined perceptions of program implementation, intervention characteristics, individual characteristics of NHVs, and recommendations for improving implementation. The utility of the program for promoting injury prevention systematically and its alignment with the organization's mission were facilitators of successful implementation. Barriers included NHVs' concerns about overburdening clients and missed educational opportunities related to injury risks not addressed by the program and delayed delivery of educational reports. Findings illustrate the dynamic interactions of intervention characteristics with organizational and individual factors and suggest that customizing implementation to organizational capacity and specific needs may better support successful program implementation in home visitation settings.

Prostate cancer survivors as community health educators: implications for informed decision making and cancer communication.

Recent evidence questioning the effectiveness of prostate-specific antigen testing leave community-based prostate cancer (CaP) outreach programs with a dilemma between promoting screening and highlighting screening risks. CaP survivors are uniquely positioned to address this problem by drawing upon real-life experiences to share nuanced information and perspectives. While CaP survivors have historically been incorporated into outreach programs, little is known about their impact on psychosocial outcomes and their effectiveness compared to professional health educators. This study addressed these gaps through a quasi-experimental design where African American men attended a CaP screening session conducted by a health educator (HE) or survivor educator (SV). The presentation included prostate cancer statistics, CaP information, and descriptions of CaP screening tests. SV were encouraged to bolster their presentations with personal stories whereas HE maintained fidelity to the curriculum content. All participants completed pre- and post-test questionnaires. Our sample comprised a total of 63 participants (HE group = 32; SV group = 31) with an age range of 40-70 years. Decision self-efficacy increased significantly in the SV group (p = 0.01) whereas perceived screening risks reduced significantly in the HE group (p < 0.001). No significant changes were found in knowledge, subjective norms, outcome expectancies, and screening benefits. Survivor educators were found to have significantly greater appeal (p = 0.03), identification with audience (p = 0.01), and liking (p = 0.03). Training CaP survivors as health educators might be a viable strategy for community-based cancer communication efforts confronted by the CaP screening controversy. We discuss conceptual and programmatic implications of our findings and present directions for future research.

Young adults' perceptions about established and emerging tobacco products: results from eight focus groups.

INTRODUCTION: In order to sustain their market, tobacco producers target young adults through novel product design and marketing strategies. Public health professionals need to understand young adults' risks perceptions about and use of new tobacco products to best inform tobacco control interventions. METHODS: In 2009, researchers conducted 8 focus groups with 67 young adults stratified by self-reported tobacco use and nonuse, residence in rural and urban areas, and living in a state with or without a statewide smoking restriction policy. Participants provided feedback about their knowledge and risk perceptions about and use of tobacco products and marketing. RESULTS: Participants reported a high level of familiarity with a wide range of novel tobacco products. A great deal of confusion and disagreement appeared with regard to absolute and relative risk of different tobacco products. Participants readily discussed using smokeless tobacco products as alternatives to smoking when smoking is prohibited. Fewer differences in tobacco-related knowledge risk perceptions and use were found between urban and rural participants and those in smoke-free policy and nonpolicy states than between user and nonuser groups. Both users and nonusers were familiar with and skeptical about tobacco marketing and prevention efforts. CONCLUSIONS: Young adults are familiar with many tobacco products, but they convey little understanding of relative risks of new or trendy tobacco products, such as snus or hookah. Mindful of industry innovation, tobacco control advocates must continuously update prevention efforts, seeking new strategies to limit promotion, marketing, and use of new and conventional products.

Advancing organizational health literacy in health care organizations serving high-needs populations: a case study.

Health care organizations, well positioned to address health literacy, are beginning to shift their systems and policies to support health literacy efforts. Organizations can identify barriers, emphasize and leverage their strengths, and initiate activities that promote health literacy-related practices. The current project employed an open-ended approach to conduct a needs assessment of rural federally qualified health center clinics. Using customized assessment tools, the collaborators were then able to determine priorities for changing organizational structures and policies in order to support continued health literacy efforts. Six domains of organizational health literacy were measured with three methods: environmental assessments, patient interviews, and key informant interviews with staff and providers. Subsequent strategic planning was conducted by collaborators from the academic and clinic teams and resulted in a focused, context-appropriate action plan. The needs assessment revealed several gaps in organizational health literacy practices, such as low awareness of health literacy within the organization and variation in perceived values of protocols, interstaff communication, and patient communication. Facilitators included high employee morale and patient satisfaction. The resulting targeted action plan considered the organization's culture as revealed in the interviews, informing a collaborative process well suited to improving organizational structures and systems to support health literacy best practices. The customized needs assessment contributed to an ongoing collaborative process to implement organizational changes that aided in addressing health literacy needs.

Changing the conversation about prostate cancer among African Americans: results of formative research.

OBJECTIVES: To understand obstacles to and opportunities for improving prostate cancer communication to and within African American communities. DESIGN: Researchers conducted interviews with 19 community leaders and five focus groups with healthy men and survivors. The team also conducted process evaluations of two outreach projects in which survivors spoke to African American men about prostate cancer and screening. RESULTS: Three levels of obstacles to prostate cancer screening and treatment were identified. Individual-level obstacles included limited knowledge about the condition, about prevention and treatment, and fear of cancer. Socio-cultural barriers included distrust of the medical system, lack of a provider for routine and preventive care, reluctance to talk about cancer, and aversion to aspects of screening. Institutional deficits included the scarcity of educational efforts targeting prostate cancer. Outreach project evaluations suggested that survivors can be effective in building prostate cancer knowledge, promoting positive attitudes toward screening, and fostering conversations about prostate cancer. Educational efforts included little information about screening risks and decision-making however. CONCLUSIONS: The findings suggest that most potent interventions may combine survivor-led education with mass media and institution-based outreach. Such comprehensive programs could shift social norms that inhibit conversation and foster fear, leading in turn to more informed decisions and better treatment outcomes.

Disparities by race and ethnicity in cancer survivor stories available on the web.

BACKGROUND: The rapid growth of eHealth could have the unintended effect of deepening health disparities between population subgroups. Most concerns to date have focused on population differences in access to technology, but differences may also exist in the appropriateness of online health content for diverse populations. OBJECTIVE: This paper reports findings from the first descriptive study of online cancer survivor stories by race and ethnicity of the survivor. METHODS: Using the five highest-rated Internet search engines and a set of search terms that a layperson would use to find cancer survivor stories online, we identified 3738 distinct sites. Of these, 106 met study criteria and contained 7995 total stories, including 1670 with an accompanying photo or video image of the survivor. Characteristics of both websites and survivor stories were coded. RESULTS: All racial minority groups combined accounted for 9.8% of online cancer survivor stories, despite making up at least 16.3% of prevalent cancer cases. Also notably underrepresented were stories from people of Hispanic ethnicity (4.1%), men (35.7%), survivors of colon cancer (3.5%), and older adults. CONCLUSIONS: Because racial/ethnic minority cancer survivors are underrepresented in survivor stories available online, it is unlikely that this eHealth resource in its current form will help eliminate the disproportionate burden of cancer experienced by these groups.

Organizational factors related to the adoption of an injury prevention program by U.S. children's hospitals.

Most childhood injuries can be prevented with the correct use of safety devices and appropriate supervision. Children's hospitals are well positioned to promote these behaviors with evidence-based programming; however, barriers exist to adopting such programs. The purpose of this study was to describe organizational and administrative factors related to the adoption of an efficacious injury prevention (IP) program by children's hospitals in the USA. IP specialists at 232 U.S. children's hospitals were invited to complete a baseline survey, and then offered Safe N' Sound (SNS), an efficacious computer IP program targeting parents of young children. Following this promotion period, specialists were surveyed again to assess their level of SNS adoption. Organizational and administrative factors associated with SNS adoption were identified using conditional random forest models (n = 93). Random forests identified a set of six predictors with potential utility for classifying hospitals as having SNS adoption activity or not; the final pruned classification tree indicated that four of these were best able to differentiate hospitals with and without adoption activity-having a medical director, having other hospital units that provided IP programming, the number of requests the IP unit received within the past year, and the belief of administrative leaders in their responsibility to develop programming all influence decisions. Hospitals without a medical director were most likely to demonstrate adoption activity. Medical directors, or other organizational leaders, can facilitate the adoption process for evidence-based intervention, but may need to be engaged intentionally when disseminating new products, tools, or approaches.

Communicating with the public about emerging health threats: lessons from the Pre-Event Message Development Project.

OBJECTIVES: We sought to better understand the challenges of communicating with the public about emerging health threats, particularly threats involving toxic chemicals, biological agents, and radioactive materials. METHODS: At the request of the Centers for Disease Control and Prevention, we formed an interdisciplinary consortium of investigative teams from 4 schools of public health. Over 2 years, the investigative teams conducted 79 focus group interviews with 884 participants and individual cognitive response interviews with 129 respondents, for a total sample of 1013 individuals. The investigative teams systematically compared their results with other published research in public health, risk communication, and emergency preparedness. RESULTS: We found limited public understanding of emerging biological, chemical, and radioactive materials threats and of the differences between them; demand for concrete, accurate, and consistent information about actions needed for protection of self and family; active information seeking from media, local authorities, and selected national sources; and areas in which current emergency messaging can be improved. CONCLUSIONS: The public will respond to a threat situation by seeking protective information and taking self-protective action, underlining the critical role of effective communication in public health emergencies.

Applying projective techniques to formative research in health communication development.

This article describes a new approach to formative research in which projective techniques commonly used in psychological assessment were adapted for use in focus groups to help design colorectal-cancer screening materials for African American men and women. Participants (N = 20) were divided into six "design teams." Each team was given a selection of design supplies and asked to create and discuss a visual layout for screening materials. Participants chose design elements that reflected visual preferences that they felt would connect meaningfully with other African Americans. The dynamics within the design teams were different than in traditional focus groups, with participants having more control over the group's direction. Using projective techniques helped draw out unique information from participants by allowing them to "project" their opinions onto objects. This approach may be a valuable tool for health-promotion and health-communication practitioners seeking insight on the implicit values of a priority population.

Becoming a health literate organization: Formative research results from healthcare organizations providing care for undeserved communities.

Background Integrating health literacy into primary care institutional policy and practice is critical to effective, patient centered health care. While attributes of health literate organizations have been proposed, approaches for strengthening them in healthcare systems with limited resources have not been fully detailed. Methods We conducted key informant interviews with individuals from 11 low resourced health care organizations serving uninsured, underinsured, and government-insured patients across Missouri. The qualitative inquiry explored concepts of impetus to transform, leadership commitment, engaging staff, alignment to organization wide goals, and integration of health literacy with current practices. Findings Several health care organizations reported carrying out health literacy related activities including implementing patient portals, selecting easy to read patient materials, offering community education and outreach programs, and improving discharge and medication distribution processes. The need for change presented itself through data or anecdotal staff experience. For any change to be undertaken, administrators and medical directors had to be supportive; most often a champion facilitated these changes in the organization. Staff and providers were often resistant to change and worried they would be saddled with additional work. Lack of time and funding were the most common barriers reported for integration and sustainability. To overcome these barriers, managers supported changes by working one on one with staff, seeking external funding, utilizing existing resources, planning for stepwise implementation, including members from all staff levels and clear communication. Conclusion Even though barriers exist, resource scarce clinical settings can successfully plan, implement, and sustain organizational changes to support health literacy.

Comparing State Legislative Aides' Perspectives on Tobacco Policymaking in States With Strong and Weak Policies: A Qualitative Study.

PURPOSE: The study compared perceptions of state legislative aides about tobacco policymaking in states with strong and weak tobacco control policies. APPROACH: Qualitative in-depth interviews carried out in 2009. SETTING: The US states were ranked on a combination of tobacco prevention funding, taxes, and presence of smoke-free policies. States at the top and bottom of the rankings were chosen. PARTICIPANTS: Interviews were conducted with 10 legislative aides in 5 states with strong tobacco control policies and 10 aides in 7 states with weak policies. METHOD: Twenty semistructured interviews were conducted, coded, and analyzed using a consensus coding process. RESULTS: Tobacco control was a lower priority in states with weak policies, and respondents from these states listed more barriers to tobacco control policymaking than those from states with strong policies. Successful arguments for tobacco control emphasized operational applications, for example, enhanced revenue from tobacco taxes or safety of children and employees. CONCLUSION: Our findings support propositions posited in the Advocacy Coalition Framework. They point to the preeminence of contextual factors, notably political leanings and economic climate on success of policy change efforts. Lessons learned from participants from states with strong policy nonetheless show promise for success in states with weak policy.

A community-wide media campaign to promote walking in a Missouri town.

INTRODUCTION: Engaging in moderate physical activity for 30 minutes five or more times per week substantially reduces the risk of coronary heart disease, stroke, colon cancer, diabetes, high blood pressure, and obesity, and walking is an easy and accessible way to achieve this goal. A theory-based mass media campaign promoted walking and local community-sponsored wellness initiatives through four types of media (billboard, newspaper, radio, and poster advertisements) in St Joseph, Mo, over 5 months during the summer of 2003. METHODS: The Walk Missouri campaign was conducted in four phases: 1) formative research, 2) program design and pretesting, 3) implementation, and 4) impact assessment. Using a postcampaign-only, cross-sectional design, a telephone survey (N = 297) was conducted in St Joseph to assess campaign impact. Study outcomes were pro-walking beliefs and behaviors. RESULTS: One in three survey respondents reported seeing or hearing campaign messages on one or more types of media. Reported exposure to the campaign was significantly associated with two of four pro-walking belief scales (social and pleasure benefits) and with one of three community-sponsored activities (participation in a community-sponsored walk) controlling for demographic, health status, and environmental factors. Exposure was also significantly associated with one of three general walking behaviors (number of days per week walking) when controlling for age and health status but not when beliefs were introduced into the model, consistent with an a priori theoretical mechanism: the mediating effect of pro-walking beliefs on the exposure-walking association. CONCLUSION: These results suggest that a media campaign can enhance the success of community-based efforts to promote pro-walking beliefs and behaviors.

What does the public want to know in the event of a terrorist attack using plague?

We used formative research to assess the information needs and information-seeking strategies with general public audience segments in response to a hypothetical attack using plague, and we pretested informational materials about plague. Twelve focus groups were conducted across the country, with 129 individuals being purposively sampled by ethnicity and place of residence. Across groups, participants wanted to understand: the nature of the threat of plague, how to protect themselves from transmission, how to detect exposure and symptoms, how to treat infection, and progress in apprehending perpetrators. Participants reported that they would seek information from both the news media and local authorities. Based on the findings and the challenges posed by a terrorist attack using plague, the authors recommend that message materials answer key questions, provide clear action steps, be clear and easily understood, include sources for credibility, and reflect full government disclosure. A dissemination plan is required to ensure that critical information will be available when people need it and where they look.

Challenges and Opportunities with Empowering Baby Boomers for Personal Health Information Management Using Consumer Health Information Technologies: an Ecological Perspective.

"Baby Boomers" (adults born between the years of 1946 and 1964) make up the largest segment of the population in many countries, including the United States (about 78 million Americans) [1]. As Baby Boomers reach retirement age and beyond, many will have increasing medical needs and thus demand more health care resources that will challenge the healthcare system. Baby Boomers will likely accelerate the movement toward patient self-management and prevention efforts. Consumer Health Information Technologies (CHIT) hold promise for empowering health consumers to take an active role in health maintenance and disease management, and thus, have the potential to address Baby Boomers' health needs. Such innovations require changes in health care practice and processes that take into account Baby Boomers' personal health needs, preferences, health culture, and abilities to use these technologies. Without foundational knowledge of barriers and opportunities, Baby Boomers may not realize the potential of these innovations for improving self-management of health and health outcomes. However, research to date has not adequately explored the degree to which Baby Boomers are ready to embrace consumer health information technology and how their unique subcultures affect adoption and diffusion. This position paper describes an ecological conceptual framework for understanding and studying CHIT aimed at satisfying the personal health needs of Baby Boomers. We explore existing literature to provide a detailed depiction of our proposed conceptual framework, which focuses characteristics influencing Baby Boomers and their Personal Health Information Management (PHIM) and potential information problems. Using our ecological framework as a backdrop, we provide insight and implications for future research based on literature and underlying theories represented in our model.

Assessing Community-Based Injury Prevention Services in U.S. Children's Hospitals.

OBJECTIVE: Not-for-profit hospitals are required to meet federal reporting requirements detailing their community benefit activities, which support their tax-exempt status. Children's hospitals have long provided community injury prevention (IP) programming and thus can inform public health outreach work in other areas. This work describes IP programming as a community service offered by children's hospitals in the U.S. METHODS: The IP specialist at 232 US-based member institutions of the Children's Hospital Association were invited to complete an assessment of their hospital's IP outreach programming. RESULTS: 47.7 percent of hospitals request financial data from IP programming for tax reporting purposes. Almost all offer injury prevention (IP) services; the majority are in the community (60.3%) and 34.5% are hospital-based. Most IP units are independent (60.3%) and 71.8% are responsible for their own budgets. CONCLUSIONS: By integrating dissemination and implementation sciences and community health needs assessments, these findings can help advance community services provided by hospitals to impact public health.

Individual and community influences on adherence to directives in the event of a plague attack: survey results.

OBJECTIVES:   During a public health emergency, public health officials issue directives with actions people need to take to protect themselves. Past research has shown that adherence to these directives depends on individual beliefs and circumstances. This report presents new research about the effects of community factors on adherence. METHODS:   A random digit-dial survey of 936 residents in the St Louis, Missouri, area was conducted in 2008 to assess barriers to and facilitators of adherence to directives issued in response to a hypothetical scenario involving the intentional release of the bacterium that causes plague. Community factors were assessed using characteristics of census tracts for individual respondents. Multilevel modeling was used to understand how individual and community factors contributed to the likelihood of adherence. RESULTS:   The majority of participants indicated that they would adhere to 3 distinct directives. Community poverty and ethnic homogeneity as well as individual-level barriers were negatively associated with adherence to a 6-day quarantine. Having children younger than 18 years and being away from home when the directive was called were negatively associated with adherence to a 10-hour quarantine. Logistical concerns were negatively associated with visiting a point of dispensing for prophylactic antibiotics. CONCLUSIONS:   Our findings establish an empirical basis for the influence of community factors on adherence to public health directives. The influence of community and individual factors on adherence varies across directives. Consequently, communication strategies to disseminate directives and organizational strategies to support them must vary according to the nature of the directives.

Addressing the challenge of informed decision making in prostate cancer community outreach to African American men.

African American men are disproportionately affected by prostate cancer. This project adopted a community-based participatory approach to design and pilot test an educational outreach strategy that promotes informed decision making about screening among African American men in community settings in St. Louis, Missouri. Interviews with local subject matter experts informed the design of the strategy. The revised curriculum was pilot tested in 2009 with 63 men who completed pre- and posttest surveys that measured knowledge, norms, beliefs, decision self-efficacy, and screening intention. The intervention resulted in statistically significant improvement in prostate cancer knowledge, decreased perceived risks and barriers, and increased screening decision self-efficacy. The educational outreach strategy offered in community settings was effective in improving knowledge, beliefs, and decision self-efficacy related to prostate cancer screening. This project sought to devise a screening outreach strategy that struck a balance between the imperatives of informed decision-making goals and the pragmatics of community settings. The findings suggest the need for further research to assess the effectiveness of community-based outreach efforts in enhancing engagement of men in decision making related to screening, diagnostics, and treatment.