Predictors of guideline treatment nonadherence and the impact on survival in patients with colorectal cancer.

BACKGROUND: This study investigated the effect of comorbidity, age, health insurance payer status, and race on the risk of patient nonadherence to NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Colon and Rectal Cancers. In addition, the prognostic impact of NCCN treatment nonadherence on overall survival was assessed. PATIENTS AND METHODS: Patients with CRC who received primary treatment at Memorial University Medical Center from 2003 to 2010 were eligible for this study. Modified Poisson regression was used to obtain risk ratios for the outcome of nonadherence with NCCN Guidelines. Hazard ratios (HRs) for the relative risk of death from all causes were obtained through Cox regression. RESULTS: Guideline-adherent treatment was received by 82.7% of patients. Moderate/severe comorbidity, being uninsured, having rectal cancer, older age, and increasing tumor stage were associated with increased risks of receiving nonadherent treatment. Treatment nonadherence was associated with 3.6 times the risk of death (HR, 3.55; 95% CI, 2.16-5.85) in the first year after diagnosis and an 80% increased risk of death (HR, 1.80; 95% CI, 1.14-2.83) in years 2 to 5. The detrimental effect of nonadherence declined with increasing comorbidity and varied according to age. CONCLUSIONS: Although medically justifiable reasons exist for deviating from NCCN Guidelines when treating patients with colorectal cancer (CRC), those who received nonadherent treatment had much higher risks of death, especially in the first year after diagnosis. This study's results highlight the importance of cancer health services research to drive quality improvement efforts in cancer care for patients with CRC.

Predictors of regular mammography use among American Indian women in Oklahoma: a cross-sectional study.

BACKGROUND: There are significant disparities in breast cancer screening and survivorship between American Indian (AI) and non-Hispanic white women. This study aimed to identify the salient beliefs AI women from Oklahoma have on regular mammography screening, and to determine which beliefs and health- related practices are associated with past mammography screening behavior. METHODS: This study used an integrated model of the Theory of Planned Behavior as the guiding theoretical framework. Data were collected from 255 (mean age = 51 years, SD 7.64 years) AI women randomly selected from a rural Oklahoma medical clinic (response rate: 79%). Multivariate logistic regression was used to identify factors associated with self-reported past mammography within the last two years while controlling for demographic variables. Associations were summarized using odds ratios (OR), the ratio of the odds of past mammography per a 1-unit increase in continuous independent factor scales (subjective physician norm, cultural affiliation, fatalism, knowledge of mammography screening guidelines, and perceived behavior control barriers) or between groups defined by categorical variables, and 95% confidence intervals (CI). RESULTS: Of the participants, 65% (n = 167) reported a screening mammogram within the last two years. After adjustment for age and educational status, women with a higher total subjective-norm physician score (OR = 1.15, 95% CI: 1.06-1.24), a higher knowledge of mammography screening guidelines (OR = 1.52, 95% CI: 1.00-2.31), a family history of breast cancer (OR = 9.97, 95% CI: 3.05-32.62), or reporting an annual versus none or a single physician breast examination (OR = 5.57, 95% CI: 1.79-17.37) had a higher odds of past mammography. On the other hand, women who were more culturally affiliated (OR = 0.42, 95% CI: 0.24-0.74), perceived more barriers (OR = 0.86, 0.78-0.94), or had higher fatalistic attitudes toward breast cancer (OR = 0.90, 95% CI: 0.82-0.99) had lower odds of past mammography. CONCLUSION: In the development of culturally-appropriate interventions promoting mammography among AI communities, emphasis could be put on the following: a) promoting clinic-related practices (e.g. physician recommendation, physician breast examination); b) promoting community-related practices (e.g. knowledge about mammography while eliminating fatalistic attitudes); and c) reducing environmental barriers.

Adherence to cancer screening guidelines and predictors of improvement among participants in the Kansas State Employee Wellness Program.

INTRODUCTION: Employee wellness programs (EWPs) have been used to implement worksite-based cancer prevention and control interventions. However, little is known about whether these programs result in improved adherence to cancer screening guidelines or how participants' characteristics affect subsequent screening. This study was conducted to describe cancer screening behaviors among participants in a state EWP and identify factors associated with screening adherence among those who were initially nonadherent. METHODS: We identified employees and their dependents who completed health risk assessments (HRAs) as part of the Kansas state EWP in both 2008 and 2009. We examined baseline rates of adherence to cancer screening guidelines in 2008 and factors associated with adherence in 2009 among participants who were initially nonadherent. RESULTS: Of 53,095 eligible participants, 13,222 (25%) participated in the EWP in 2008 and 6,205 (12%) participated in both years. Among the multiyear participants, adherence was high at baseline to screening for breast (92.5%), cervical (91.8%), and colorectal cancer (72.7%). Of participants who were initially nonadherent in 2008, 52.4%, 41.3%, and 33.5%, respectively, became adherent in the following year to breast, cervical, and colorectal cancer screening. Suburban/urban residence and more frequent doctor visits predicted adherence to breast and colorectal cancer screening guidelines. CONCLUSION: The effectiveness of EWPs for increasing cancer screening is limited by low HRA participation rates, high rates of adherence to screening at baseline, and failure of nonadherent participants to get screening. Improving overall adherence to cancer screening guidelines among employees will require efforts to increase HRA participation, stronger interventions for nonadherent participants, and better access to screening for rural employees.

Engaging diverse underserved communities to bridge the mammography divide.

BACKGROUND: Breast cancer screening continues to be underutilized by the population in general, but is particularly underutilized by traditionally underserved minority populations. Two of the most at risk female minority groups are American Indians/Alaska Natives (AI/AN) and Latinas. American Indian women have the poorest recorded 5-year cancer survival rates of any ethnic group while breast cancer is the number one cause of cancer mortality among Latina women. Breast cancer screening rates for both minority groups are near or at the lowest among all racial/ethnic groups. As with other health screening behaviors, women may intend to get a mammogram but their intentions may not result in initiation or follow through of the examination process. An accumulating body of research, however, demonstrates the efficacy of developing 'implementation intentions' that define when, where, and how a specific behavior will be performed. The formulation of intended steps in addition to addressing potential barriers to test completion can increase a person's self-efficacy, operationalize and strengthen their intention to act, and close gaps between behavioral intention and completion. To date, an evaluation of the formulation of implementation intentions for breast cancer screening has not been conducted with minority populations. METHODS/DESIGN: In the proposed program, community health workers will meet with rural-dwelling Latina and American Indian women one-on-one to educate them about breast cancer and screening and guide them through a computerized and culturally tailored "implementation intentions" program, called Healthy Living Kansas-Breast Health, to promote breast cancer screening utilization. We will target Latina and AI/AN women from two distinct rural Kansas communities. Women attending community events will be invited by CHWs to participate and be randomized to either a mammography "implementation intentions" (MI2) intervention or a comparison general breast cancer prevention informational intervention (C). CHWs will be armed with notebook computers loaded with our Healthy Living Kansas-Breast Health program and guide their peers through the program. Women in the MI2 condition will receive assistance with operationalizing their screening intentions and identifying and addressing their stated screening barriers with the goal of guiding them toward accessing screening services near their community. Outcomes will be evaluated at 120-days post randomization via self-report and will include mammography utilization status, barriers, and movement along a behavioral stages of readiness to screen model. DISCUSSION: This highly innovative project will be guided and initiated by AI/AN and Latina community members and will test the practical application of emerging behavioral theory among minority persons living in rural communities.

Understanding the role of violence in incarcerated women's cervical cancer screening and history.

In this exploratory study the authors investigated characteristics, including reported experiences of violence, related to incarcerated women's self-report of cervical cancer screening and cancer history and treatment. During a four month period in 2010, 204 women in Kansas City jails were surveyed. Multiple logistic regression models were used to examine the relations of socio-demographic and community characteristics and history of violence among the women to their cervical cancer screening, diagnosis, and treatment histories. Forty percent of the women in the current sample reported abnormal Pap histories, though only 6% of all Pap smears done in the U.S. are abnormal. Women who reported abuse histories in this study were found to be more likely to report having ever had an abnormal Pap smear (for physical abuse Odds Ratio [OR] = 6.05; CI 2.36, 15.54 and for past year intimate partner violence OR = 2.41; CI 1.09, 5.31). Participants who did not fear neighborhood violence were less likely to report an abnormal Pap history (OR = 0.57; CI 0.34, 0.96) and more likely to visit a family doctor for their Pap screenings (OR = 1.91; CI 1.01, 3.60). Women who perceived greater neighborhood violence had increased odds of reporting that they received Pap screenings in a hospital setting (OR = 1.47; CI 1.08, 2.00). Frequency of Pap screening did not differ in women who did and did not have fear of neighborhood violence. This study highlights the heightened cervical cancer risk experienced by women with criminal justice histories and suggests that violence at several levels has implications for cervical cancer prevention for these women.

An assessment of American Indian women's mammography experiences.

BACKGROUND: Mortality from breast cancer has increased among American Indian/Alaskan Native (AI/AN) women. Despite this alarming reality, AI/AN women have some of the lowest breast cancer screening rates. Only 37% of eligible AI/AN women report a mammogram within the last year and 52% report a mammogram within the last two years compared to 57% and 72% for White women. The experiences and satisfaction surrounding mammography for AI/AN women likely are different from that of women of other racial/ethnic groups, due to cultural differences and limited access to Indian Health Service sponsored mammography units. The overall goals of this study are to identify and understand the mammography experiences and experiential elements that relate to satisfaction or dissatisfaction with mammography services in an AI/AN population and to develop a culturally-tailored AI/AN mammography satisfaction survey. METHODS AND DESIGN: The three project aims that will be used to guide this work are: 1) To compare the mammography experiences and satisfaction with mammography services of Native American/Alaska Native women with that of Non-Hispanic White, Hispanic, and Black women, 2) To develop and validate the psychometric properties of an American Indian Mammography Survey, and 3) To assess variation among AI/AN women's assessments of their mammography experiences and mammography service satisfaction. Evaluations of racial/ethnic differences in mammography patient satisfaction have received little study, particularly among AI/AN women. As such, qualitative study is uniquely suited for an initial examination of their experiences because it will allow for a rich and in-depth identification and exploration of satisfaction elements. DISCUSSION: This formative research is an essential step in the development of a validated and culturally tailored AI/AN mammography satisfaction assessment. Results from this project will provide a springboard from which a maximally effective breast cancer screening program to benefit AI/AN population will be developed and tested in an effort to alter the current breast cancer-related morbidity and mortality trajectory among AI/AN women.

Health status among black African-born women in Kansas City: a preliminary assessment.

BACKGROUND: Health information and statistics for Black foreign-born women in the United States are under-reported or not available. Black foreign-born women typically are classified under the general category of African American, ignoring the heterogeneity that exists in the United States Black population. It is important to identify health issues and behaviors of African-born women to effectively address health disparities. METHODS: Black African-born women (N = 29), 20 years or older completed a survey about general and women's health, health history, acculturation, lifestyle, social and health challenges, beliefs about breast cancer. Data were analyzed using SPSS 14.0 software. Categorical variables were summarized with frequencies and percentages and continuous variables were summarized with means and standard variation. A Likert scale (strongly agree, agree, disagree, and strongly disagree) was used to assess beliefs about breast cancer. RESULTS: Most (71.4%) participants had a high school education or more, 70% were employed, and 50% had health insurance. Two-thirds received health care from primary care doctors, 20.7% from health departments, and 39.3% got annual checkups. Lack of jobs, healthcare cost, language barrier, discrimination, and child care were the top social issues faced by participants. High blood pressure, obesity, oral health, HIV/AIDS, and diabetes were indicated as the most common health problems. The percent of participants (60%) that had not had a mammogram within the previous 2 years was more than the state average (24%) for women 40 years and older reported by the Kansas Department of Health and Environment. The percent of participants (40%) that had a mammogram within the previous 2 years was lower than the national average (73.2%) for African American women. CONCLUSIONS: Study provides a snapshot of social concerns and health issues in an African population residing in Midwestern United States. Understanding the socio-cultural characteristics of this population is necessary to address health disparities.

Targeting and Tailoring Health Communications in Breast Screening Interventions.

BACKGROUND: Members of underrepresented minority (URM) groups are at higher risk of disproportionately experiencing greater breast cancer-related morbidity and mortality and thus, require effective interventions that both appropriately target and tailor to their unique characteristics. OBJECTIVES: We sought to describe the targeting and tailoring practices used in the development and dissemination of three breast cancer screening interventions among URM groups. METHODS: Three national Community Network Programs (CNPs) funded by the National Cancer Institute have focused on breast cancer screening interventions as their major research intervention. Each targeted different populations and used participatory research methods to design their intervention tailored to the needs of their respective audience. The Alameda County Network Program (ACNP) to Reduce Cancer Disparities partnered with community members to design and conduct 2-hour "Tea Party" education sessions for Afghan women. The Kansas Community Cancer Disparities Network co-developed and deployed with community members a computerized Healthy Living Kansas (HLK) Breast Health program for rural Latina and American Indian women. The Johns Hopkins Center to Reduce Cancer Disparities employed a train-the-trainer COACH approach to educate urban African-American women about breast cancer. CONCLUSIONS: Each CNP program targeted diverse URM women and, using participatory approaches, tailored a range of interventions to promote breast cancer screening. Although all projects shared the same goal outcome, each program tailored their varying interventions to match the target community needs, demonstrating the importance and value of these strategies in reducing breast cancer disparities.

Empowering Promotores de Salud as partners in cancer education and research in rural southwest Kansas.

PURPOSE/OBJECTIVES: To describe community-based participatory processes used to develop promotore training on cancer research, and to assess the feasibility of training promotores from rural communities to disseminate cancer research information. DESIGN: Prospective, cohort design. SETTING: Rural communities in the state of Kansas. SAMPLE: 34 Spanish-speaking promotores attended an information session; 27 enrolled and 22 completed training. METHODS: With input from a community advisory board, the authors developed a leadership and cancer curriculum and trained Spanish-speaking promotores to disseminate information on cancer research. Promotores completed pretraining and post-training surveys in Spanish to assess demographic characteristics and changes in knowledge of cancer, cancer treatment and cancer research studies, and intent to participate in cancer research. MAIN RESEARCH VARIABLES: Cancer knowledge, awareness of cancer clinical trials, interest in participating in cancer clinical research studies. FINDINGS: Compared to pretraining, after training, promotores were more likely to correctly define cancer, identify biopsies, describe cancer stages, and report ever having heard of cancer research studies. CONCLUSIONS: Completion rates of the training and willingness to participate in cancer research were high, supporting the feasibility of training promotores to deliver community-based education to promote cancer research participation. IMPLICATIONS FOR NURSING: Nursing professionals and researchers can collaborate with promotores to disseminate cancer education and research among underserved rural Latino communities in Kansas and elsewhere. Members of these communities appear willing and interested in improving their knowledge of cancer and cancer clinical trials.

Impact of geographic barriers on the utilization of mammograms by older rural women.

OBJECTIVES: To examine whether geographic proximity to mammography facilities influences mammogram utilization. DESIGN: Retrospective cohort analysis. SETTING: Rural state. PARTICIPANTS: Female Kansas Medicare beneficiaries aged 65 to 79 (N=117,901). MEASUREMENTS: Using Medicare claims data, we measured county-level mammography rates for beneficiaries in Kansas. We calculated mammography rate differences for beneficiaries according to age, race, distance from permanent and mobile mammography sites, and county characteristics including county mammography service availability. RESULTS: Of 105 counties, 37% had only permanent mammography facilities, 22% had both permanent and mobile sites, 29% had only mobile facilities, and 11% had neither, representing 44%, 44%, 9%, and 3% of the 117,901 beneficiaries, respectively. Of the beneficiaries, 91% lived less than 20 miles from a permanent facility; of the remaining 9%, 67% lived less than 20 miles from a mobile site. In 30 counties with only mobile sites, 90% of the 10,439 beneficiaries residing in the counties had access to the sites fewer than 2 days per month. County-level mammography rates ranged from 37% to 72%. Mammography utilization was 57% in counties with permanent facilities only, 55% in counties with both permanent and mobile sites, 53% in counties with only mobile sites, and 53% in counties with neither (P=0.12). After adjusting for age, race, and county education level, the odds of receiving a mammogram was slightly lower for persons residing longer distances from a permanent facility (odds ratio=0.97 for each 5-mile increase in distance, 95% confidence interval=0.95-0.99). CONCLUSION: The majority of Kansans live near a mammography facility. Although there is a large variation in county-level mammography rates across Kansas, this disparity is not well explained by proximity to mammography facilities.

Office systems and their influence on mammography use in rural and urban primary care.

CONTEXT: Breast cancer screening rates are lower in rural communities. Although studies have addressed barriers to mammography for rural residents, physician practice barriers have received less attention. PURPOSE: Controlled clinical trials have shown that the use of office reminder systems in primary care practices is related to increased clinical care rates. Therefore, we compared office systems use in primary care practices located in rural and urban communities and assessed the impact of these systems on rural-urban differences in mammography utilization. METHODS: We identified female Kansas Medicare beneficiaries aged 65 to 79 from Medicare claims data (N = 24,030) and determined which beneficiaries received a mammogram between April 1, 1999, and March 31, 2001. We linked beneficiaries to their primary care providers and obtained surveys from 180 primary care practices on their use of office reminder systems. FINDINGS: Mammography rates ranged from 20% to 92% (mean = 65%) among the 180 practices. Flowsheets with a mammography prompt were used by 33% of the practices, 38% utilized nonphysician staff to identify women due for mammograms, and 15% used computerized reminder systems. Urban practices used flowsheets more often than rural practices (44% versus 16%, P < 0.001). A multivariable regression model demonstrated higher mammography rates in urban practices, group practices, and practices using mammography flowsheets. CONCLUSIONS: Despite success in randomized controlled trials, reminder systems are not used often by primary care providers and are used even less often in rural compared to urban practices. Consistent implementation may be a major barrier to the successful adaptation of flowsheets by primary care offices.

Finding a practical method to increase engagement of residents on a dementia care unit.

Previous research has shown that it is possible to increase the engagement of residents with dementia in daily activities by making changes in institutional care practices. However, these changes often require expensive and cumbersome staff training programs that long-term care facilities may be unlikely to adopt and maintain. This study evaluates a simple, inexpensive recording and feedback procedure to increase resident engagement in a way that may be more amenable to adoption by long-term care facilities. Nursing assistants working in a locked dementia care unit were asked to complete a daily activity record on which they recorded the amount and quality of resident engagement. The facility's activity director was asked to read these activity records each day and give immediate, positive feedback to the nursing assistants. This procedure was evaluated by using a control series design. Results revealed baseline engagement observations with a mean of 11 percent, which increased to a mean of 44 percent during observations under treatment conditions. This study suggests that simple, inexpensive changes in institutional practices can make meaningful improvements in the level of engagement of residents with dementia.

Restoring dressing independence in persons with Alzheimer's disease: a pilot study.

PURPOSE: Well meaning nursing facility staff may compromise the independence of older adults with dementia by performing activities of daily living for residents. We assessed the impact of teaching certified nursing assistants (CNAs) to use a graduated prompting procedure to increase dressing independence of persons with dementia. DESIGN AND METHODS: This study was conducted in a seven-bed dementia care unit. Three residents and two CNAs participated in the study. We used a repeated-measures experimental design to evaluate the effect of a training workshop for CNAs on a strategy for increasing resident engagement in self-care activities. RESULTS: During a series of baseline observations, we found that CNAs typically dressed residents with minimal resident involvement. Results showed that, following the training workshop for CNAs, resident independence in dressing increased and range of motion improved. IMPLICATIONS: CNAs can provide restorative care that increases dressing independence and range of motion of older adults with dementia.

Variations in diabetes care and the influence of office systems.

Although a variety of office tools have been shown to improve diabetes care, the use and effectiveness of these tools outside the context of clinical trials is largely unknown. We surveyed primary care practices in Kansas. Using Medicare claims, we identified patients with diabetes, linked them to practices, and assessed the use of glycohemoglobin (GHb) tests, eye examinations, and lipid profiles. Performance rates among practices ranged from 15% to 100% (mean = 84%) for GHb tests, 20% to 100% (mean = 70%) for lipid profiles, and 50% to 100% (mean = 78%) for eye examinations. None of the practices used computerized tracking systems, 29% used diabetes flowsheets, and 33% allocated specific diabetes care responsibilities to nonphysician personnel. Neither use of flowsheets nor use of nonphysician personnel was associated with improvements in diabetes care. Although practices varied widely in their care of patients with diabetes, as currently implemented, office system tools have not led to consistently better performance.

Using family-style meals to increase participation and communication in persons with dementia.

Although researchers stress the importance of encouraging independent behavior in persons with dementia, institutional practices often foster dependence. This study took place in a six-resident locked dementia care unit that followed the common institutional practice of serving meals on prepared plates. The purpose of this study was to examine if changing the mode of meal delivery to "family-style," where residents were presented with serving bowls and empty plates, would increase resident communication and participation in mealtime tasks. An ABAB' reversal design revealed very low rates of appropriate communication (5% of intervals) and mealtime participation (10% of tasks) during baseline, when residents received prepared plates (A). Communication and participation doubled when family-style meal delivery was introduced (B) and dropped back to baseline levels when it was withdrawn (A). Because the levels of communication and participation during family-style meals were still low, the nursing assistant was provided with instruction on prompting and praising appropriate mealtime behaviors (B'). After instruction was provided and family-style meals were reintroduced, resident participation rose to 65% of tasks and appropriate communication increased to 18% of observations. This study suggests family-style meals may result in modest increases in mealtime participation and communication of residents with dementia, but staff training in prompting and praising may be necessary to see large changes in these behaviors.

Brief training to promote the use of less intrusive prompts by nursing assistants in a dementia care unit.

We evaluated the efficacy of a brief staff-training procedure to increase the use of graduated prompting by 2 certified nursing assistants (CNAs) while they helped to dress 3 persons with dementia in a seven-bed dementia care unit. The multiple baseline design across participants showed that CNAs dressed residents with minimal resident involvement during baseline observations. Following brief in-service training, CNAs provided graduated prompts and praise appropriately, suggesting that CNAs can promote active involvement in personal care routines by older adults with dementia.

Effective recruitment strategies and community-based participatory research: community networks program centers' recruitment in cancer prevention studies.

BACKGROUND: Community-based participatory research (CBPR) approaches that involve community and academic partners in activities ranging from protocol design through dissemination of study findings can increase recruitment of medically underserved and underrepresented racial/ethnic minority populations into biomedical research. METHODS: Five cancer screening and prevention trials in three National Cancer Institute (Bethesda, MD)-funded Community Networks Program Centers (CNPC), in Florida, Kansas, and South Carolina, were conducted across diverse populations. Data were collected on total time period of recruitment, ratios of participants enrolled over potential participants approached, selected CBPR strategies, capacity-building development, and systematic procedures for community stakeholder involvement. RESULTS: Community-engaged approaches used included establishing colearning opportunities, participatory procedures for community-academic involvement, and community and clinical capacity building. A relatively large proportion of individuals identified for recruitment was actually approached (between 50% and 100%). The proportion of subjects who were eligible among all those approached ranged from 25% to more than 70% (in the community setting). Recruitment rates were very high (78%-100% of eligible individuals approached) and the proportion who refused or who were not interested among those approached was very low (5%-11%). CONCLUSIONS: Recruitment strategies used by the CNPCs were associated with low refusal and high enrollment ratios of potential subjects. Adherence to CBPR principles in the spectrum of research activities, from strategic planning to project implementation, has significant potential to increase involvement in biomedical research and improve our ability to make appropriate recommendations for cancer prevention and control programming in underrepresented diverse populations. IMPACT: CBPR strategies should be more widely implemented to enhance study recruitment.

Implementation intentions and colorectal screening: a randomized trial in safety-net clinics.

CONTEXT: Low-income and racial/ethnic minority populations experience disproportionate colorectal cancer (CRC) burden and poorer survival. Novel behavioral strategies are needed to improve screening rates in these groups. BACKGROUND: The study aimed to test a theoretically based "implementation intentions" intervention for improving CRC screening among unscreened adults in urban safety-net clinics. DESIGN: Randomized controlled trial. SETTING/PARTICIPANTS: Adults (N=470) aged ≥50 years, due for CRC screening, from urban safety-net clinics were recruited. INTERVENTION: The intervention (conducted in 2009-2011) was delivered via touchscreen computers that tailored informational messages to decisional stage and screening barriers. The computer then randomized participants to generic health information on diet and exercise (Comparison group) or "implementation intentions" questions and planning (Experimental group) specific to the CRC screening test chosen (fecal immunochemical test or colonoscopy). MAIN OUTCOME MEASURES: The primary study outcome was completion of CRC screening at 26 weeks based on test reports (analysis conducted in 2012-2013). RESULTS: The study population had a mean age of 57 years and was 42% non-Hispanic African American, 28% non-Hispanic white, and 27% Hispanic. Those receiving the implementation intentions-based intervention had higher odds (AOR=1.83, 95% CI=1.23, 2.73) of completing CRC screening than the Comparison group. Those with higher self-efficacy for screening (AOR=1.57, 95% CI=1.03, 2.39), history of asthma (AOR=2.20, 95% CI=1.26, 3.84), no history of diabetes (AOR=1.86, 95% CI=1.21, 2.86), and reporting they had never heard that "cutting on cancer" makes it spread (AOR=1.78, 95% CI=1.16, 2.72) were more likely to complete CRC screening. CONCLUSIONS: The results of this study suggest that programs incorporating an implementation intentions approach can contribute to successful completion of CRC screening even among very low-income and diverse primary care populations. Future initiatives to reduce CRC incidence and mortality disparities may be able to employ implementation intentions in large-scale efforts to encourage screening and prevention behaviors.

Assessment of mammography experiences and satisfaction among American Indian/Alaska Native women.

BACKGROUND: American Indian/Alaska Native (AI/AN) women have lower breast cancer (BCA) screening and 5-year survival rates than non-Hispanic Whites. Understanding reasons for low screening rates is important to combatting later stage diagnoses. The purpose of this study was to assess mammography experiences and satisfaction among AI/AN women. METHODS: Nine focus groups were held with rural (N = 15) and urban (N = 38) AI/AN women 40 years and older in Kansas and Kansas City, Missouri, living both near and far from Indian Health Service (IHS) and tribal facilities, to examine experiences and satisfaction with mammography. Transcripts were coded and themes identified using a community-based participatory research approach. FINDINGS: Themes were classified under knowledge, communication, and awareness of BCA; barriers to mammography; mammogram facility size; impressions of mammogram technologist; motivations for getting a mammogram; and how to improve the mammogram experience. Participants had knowledge of prevention, but described cultural reasons for not discussing it and described better experiences in smaller facilities. Participants indicated having a mammogram technologist who was friendly, knowledgeable, respectful, competent, and explained the test was a determining factor in satisfaction. Other factors included family history, physician recommendation, and financial incentives. Barriers included transportation, cost, perceptions of prejudice, and time constraints. Participants on reservations or near IHS facilities preferred IHS over mainstream providers. Suggestions for improvement included caring technologists, better machines with less discomfort, and education. CONCLUSIONS: Interventions to enhance the professionalism, empathy, and cultural awareness of mammogram technologists; reduce barriers; and provide positive expectations and incentives could improve satisfaction and compliance with screening mammography.

The index of tobacco treatment quality: development of a tool to assess evidence-based treatment in a national sample of drug treatment facilities.

BACKGROUND: Quitting smoking improves health and drug use outcomes among people in treatment for substance abuse. The twofold purpose of this study is to describe tobacco treatment provision across a representative sample of U.S. facilities and to use these data to develop the brief Index of Tobacco Treatment Quality (ITTQ). METHODS: We constructed survey items based on current tobacco treatment guidelines, existing surveys, expert input, and qualitative research. We administered the survey to a stratified sample of 405 facility administrators selected from all 3,800 U.S. adult outpatient facilities listed in the SAMHSA Inventory of Substance Abuse Treatment Services. We constructed the ITTQ with a subset of 7 items that have the strongest clinical evidence for smoking cessation. RESULTS: Most facilities (87.7%) reported that a majority of their clients were asked if they smoke cigarettes. Nearly half of facilities (48.6%) reported that a majority of their smoking clients were advised to quit. Fewer (23.3%) reported that a majority of their smoking clients received tobacco treatment counseling and even fewer facilities (18.3%) reported a majority of their smoking clients were advised to use quit smoking medications. The median facility ITTQ score was 2.57 (on a scale of 1-5) and the ITTQ displayed good internal consistency (Cronbach's alpha = .844). Moreover, the ITTQ had substantial test-retest reliability (.856), and ordinal confirmatory factor analysis found that our one-factor model for ITTQ fit the data very well with a CFI of 0.997 and an RMSEA of 0.042. CONCLUSIONS: The ITTQ is a brief and reliable tool for measuring tobacco treatment quality in substance abuse treatment facilities. Given the clear-cut room for improvement in tobacco treatment, the ITTQ could be an important tool for quality improvement by identifying service levels, facilitating goal setting, and measuring change.