Feasibility of universal screening mammography. Lessons from a community intervention.

It is estimated that 44,500 American women will die of breast cancer in 1991. The breast cancer screening guidelines of the American Cancer Society and the National Cancer Institute calling for annual mammography for all women older than 50 years have been endorsed by numerous professional groups. Third-party reimbursement for screening mammography is becoming more prevalent, and payment for screening mammography is now a Medicare benefit. Our studies, conducted as part of a National Cancer Institute grant to increase the routine use of screening mammography and clinical breast examination in women 50 to 75 years of age, have uncovered a number of significant barriers to the implementation of screening guidelines among women, primary care physicians, and providers of mammography services. These barriers, as well as methods to assure the quality of mammography, need to be addressed before universal screening is feasible.

Predictors of AIDS-preventive behavior among homosexually active men: a longitudinal study.

Predictors of adoption of safer sexual behaviors were examined in a cohort of 278 homosexually active men with stable HIV-antibody status followed over 12 months at a Boston community health center. The behaviors examined included: (1) restriction of partners to one monogamous or steady relationship and (2) among men who maintained multiple or non-steady partners, the avoidance of unprotected receptive and insertive anogenital contact. For each behavior, men who adopted consistently safer behavior were compared with those who remained unsafe, using bivariate analyses and multiple logistic regression modelling. The strongest predictor of all behaviors was the initial level of the unsafe behavior. After controlling for this, weak effects of several health beliefs were found, including perceived susceptibility and medical efficacy. Men who became aware of a positive HIV-antibody test result and who reported greater effort to change their behavior were more likely to adopt safer insertive anogenital contact. In this generally well-educated cohort with high levels of knowledge about AIDS, adoption of safer sexual behaviors is best predicted from previous levels of unsafe behavior.

Maintenance of behavioral change in a cohort of homosexually active men.

OBJECTIVES: To assess associations of perceptions of sexual behavior change with actual risk behaviors and psychosocial variables, and to determine whether perceptions of behavior change predict subsequent behavior. DESIGN: Cohort study of homosexually active men. SETTING: Community health center in Boston, Massachusetts, USA. PATIENTS, PARTICIPANTS: Two hundred and sixty-two cohort members who participated in follow-up in 1989 and who had at least one subsequent visit. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Composite risk behavior variable, based on unprotected anogenital contact and number of partners. RESULTS: Of the 96% who had effected behavior change, 47% perceived that they were able to maintain those changes consistently and 58% wanted to make more changes. Perceptions of consistent maintenance were associated with lower risk behavior, lower perceived riskiness of behaviors and susceptibility to AIDS, and fewer barriers to behavior change. Desire for more change was associated with increased behavioral effort, fewer barriers to condom use, and greater perceived riskiness of current behavior. Among those with lower risk behaviors, perceived inconsistent maintenance predicted relapse to more risky behavior at the following visit. CONCLUSIONS: Perceived maintenance of behavior change is potentially useful in identifying individuals at risk of relapse from safer sex.

PIP: Public health researchers followed a cohort of 322 homosexually active male clients enrolled at a community health center in Boston, Massachusetts between January 1985-April 1987 at 6-month intervals to examine cross-sectional and longitudinal data on perceptions of sexual behavior change among initially asymptomatic and homosexually active men. Only 262 completed the questionnaire addressing perceptions of behavior change. 40% of the 60 students who did not complete the questionnaire tested positive for HIV compared with 22% of those who did complete the questionnaire (p.01). High risk included unprotected anogenital contact with multiple partners. HIV status was not associated with behavior change. Behavior change was associated with alcohol or drug use during sex for men of low or modified high risk at baseline (p=.01). 96% of 262 men achieved sexual behavior change after learning about AIDS. 58% hoped to make additional changes. 47% thought that they could always sustain the changes. Men who were not consistent in practicing behavioral changes were more likely to want to make more changes (p.001). Men who perceived themselves to practice inconsistent behavior did indeed practice high risk behavior (p=.005). Those who perceived themselves to consistently practice lower risk behavior at follow up were 2.07 times more likely to practice safer behavior than those who did not see themselves as practicing consistent behavior. Follow up data showed that men were somewhat more likely to return to risky behavior than change to safe behavior (p=.07). In fact, men who at baseline participated in high risk behavior were 1.57 times likely to continue the high risk behavior. For men who at baseline participated in low risk behavior tended to continue that behavior (odds ratio=8.88). The researchers concluded that perceived maintenance of behavior change could help health professionals determine which people are at a risk of reverting to risky sex behavior.

Use of drugs and alcohol by homosexually active men in relation to sexual practices.

The use of alcohol and recreational drugs in relationship to sexual practices was investigated longitudinally and cross-sectionally in a cohort of homosexually active men at a Boston community health center. Use of marijuana, nitrite inhalants, and cocaine decreased by approximately 25-48% during 42 months of follow-up, whereas use of alcohol showed little change. Men who initially reported both high-risk sexual practices and some use of alcohol or marijuana and who subsequently stopped using marijuana or reduced their frequency of alcohol use were significantly more likely to stop those unsafe sexual practices than were those who continued to use these substances. Men who at their most recent visit reported impaired judgement during sexual activity due to substance use, and particularly due to drug use, had significantly higher levels of perceived susceptibility to AIDS and barriers to behavior change, and lower levels of self-efficacy, which were independent of their unsafe sexual practices.

Impact of a physician intervention program to increase breast cancer screening.

In order to improve compliance with the National Cancer Institute's breast cancer screening guidelines, we developed a multifaceted intervention designed to alter physician screening practice. A pre-post test, two-community design was used. Primary care physicians in one community served as the control. Data were collected by two mailed surveys (1987 and 1990). Response rates were 61% and 64%, respectively. The physician intervention program consisted of a hospital-based continuing medical education program and an outreach component which focused on implementing a reminder system. Outcome measures were self-reported attitudinal, knowledge, and screening practices changes. In spite of an impressive change in comparison community physicians' practice, the difference in change over time in the intervention community physicians' ordering of annual mammography compared to the change in the comparison community physicians' ordering was significant (P = 0.04). The adjusted odds ratio is nearly 8. We conclude that our in-service continuing medical education program was successful in improving breast cancer screening practices among primary care physicians.

Provider education to promote implementation of clinical practice guidelines.

STUDY OBJECTIVES: Although the interest in and promulgation of clinical practice guidelines have significantly increased in the past 2 decades, concern exists about their actual implementation. This article focuses on one strategy to encourage guideline implementation at the clinician level: clinician education. The objectives of the article are to review educational strategies, to consider them within the context of complementary strategies carried out at the organizational and clinic setting levels, and to outline challenges and recommendations for clinicians' continuing education. METHODS: Experience and data from relevant randomized clinical trials within an educational framework are reviewed. OBSERVATIONS: Implementation of clinical practice guidelines requires a variety of skills, including assessment, appropriate delineation of a treatment and monitoring plan, patient tracking, and patient counseling and education skills. Continuing education strategies must reflect the content and teaching methods that best match the learning objectives. The pressures of current-day practices place limits on the resources, particularly clinician time, that are available for continuing education. Organizational resources must be committed to build the complementary supportive systems necessary for improved clinician practice. In addition to physicians, education must be directed at nonphysician clinicians, office staff, and administrators who also are responsible for guideline implementation. CONCLUSIONS: To meet the challenges of developing clinician motivation, balancing competing demands, and treating patients with complex medical conditions, all within time constraints, clinical leaders need to design education activities that have leadership support, reflect compelling evidence, use multiple strategies and teaching techniques, and engage learners in skill building and problem solving.

The risk factors of age and family history and their relationship to screening mammography utilization.

OBJECTIVE: To study the association of two well known risk factors for breast cancer and the association of knowledge of those risk factors with mammography utilization. DESIGN: Cross sectional: two independent random telephone surveys. SETTING: Two Northeastern metropolitan communities surveyed in 1987 and in 1989. PARTICIPANTS: Women without breast cancer who spoke English and who were between 45 and 75 years of age. MAIN OUTCOME MEASURES: The two risk factors measured were a family history of breast cancer and being 65 or older. Participants were surveyed about their knowledge of risk factors, presence of risk factors, selected beliefs, attitudes, reinforcing factors and mammography use. Results were analyzed for women 50-75. RESULTS: There was a substantial increase in mammography use over the 2-year period. Having a positive family history or being older is not associated with increased mammography utilization. Knowledge that family history and/or age are risks is associated with increased utilization. However, knowledge of risk factors is not associated with having those risks. Older women have lower utilization than younger women regardless of their knowledge of age as a risk. Increased physician recommendation is associated with increased utilization. CONCLUSION: Since knowing that a factor is a risk and having a physician recommend mammography are each associated with increased use, we conclude that the primary care physicians' role in increasing mammography utilization is critical.

Breast self-examination by young women: I. Characteristics associated with frequency.

We surveyed a stratified random sample of college women (n = 869) to investigate correlates of the frequency of breast self-examination (BSE) in two young, relatively low risk populations, undergraduate and graduate women. The findings from this study compared to those from studies on older women suggest that certain factors are associated with BSE frequency for women of all ages (i.e., confidence in one's ability to perform the exam and exposure to information on breast cancer). There also appear to be distinct factors associated with the frequency of BSE performances among women within specific age-groups. For the younger, undergraduate women, attitudinal barriers; medical services use; skill knowledge; perception of personal control in detecting lumps; reinforcement through clinical breast exam; and the discussion of BSE with others were important factors in accounting for the variation in frequency of BSE performance. For the graduate women, in addition to confidence in one's ability to perform the test and exposure to breast cancer messages, one's perceived susceptibility, knowledge of risk factors, and perception of personal control in detecting lumps were important. The independent variables examined within each age-group accounted for a substantial amount of the variance in the dependent measure (34 percent and 42 percent, respectively, for undergraduate and graduate women), as compared to previous research, which has explained only 7-15 percent of the variance in BSE performance. This tends to validate our approach of using a multidimensional conceptual framework drawn from existing theoretical orientations.(ABSTRACT TRUNCATED AT 250 WORDS)

Breast self-examination by young women: II. Characteristics associated with proficiency.

Studying a stratified random sample of university women (n = 869) we investigated the correlates of proficiency (i.e., the correctness or competence) of breast self-examination (BSE). A 19-item BSE quality index score was developed based on the recommended steps a woman should perform when doing the exam in the three BSE positions. A comprehensive set of independent variables including knowledge, attitudes and perceptions, personal characteristics, and environmental factors were studied. While proficiency scores for both undergraduates and graduates were relatively low, the mean score for graduates was significantly higher than for undergraduates. This study corroborates the few recent studies that indicate that frequency of performance is not highly correlated with proficiency (relationships were r = .14 and .04, respectively, for undergraduate and graduate women). Bivariate and multivariate regression analyses demonstrate that the relevance of such factors varies by age (undergraduate and graduate). Results of the regression model indicate that the skill knowledge variable regarding time of month BSE should be performed, awareness of BSE, perceived effect of cancer detection, and perceived benefit of BSE were predictors of more proficient practice for undergraduates. Knowledge of time of month to do BSE and mammogram as a detection technology and discussion of BSE with others were important for graduate women. The independent variables examined accounted for 22 percent and 30 percent of the variance, respectively, for undergraduate and graduate women.(ABSTRACT TRUNCATED AT 250 WORDS)

REACT theory-based intervention to reduce treatment-seeking delay for acute myocardial infarction. Rapid Early Action for Coronary Treatment.

Coronary heart disease (CHD) remains the leading cause of mortality in the U.S. Innovations in reperfusion therapies can potentially reduce CHD morbidity and mortality associated with acute myocardial infarction (AMI) when treatment is initiated within the first few hours of symptom onset. However, delay in seeking treatment for AMI is unacceptably lengthy, resulting in most patients being ineligible for reperfusion therapies. The Rapid Early Action for Coronary Treatment (REACT) Trial is a four-year, 20-community, randomized trial to design and test the effectiveness of a multi-component intervention to reduce patient delay for hospital care-seeking for AMI symptoms. This manuscript describes the development and content of the theoretically-based REACT intervention and summarizes: (1) the research literature used to inform the intervention; (2) the behavioral theories used to guide the development, implementation, and evaluation of the intervention; (3) the formative research undertaken to understand better decision-making processes as well as barriers and facilitators to seeking medical care as perceived by AMI patients, their families, and medical professionals; (4) the intervention design issues that were addressed; (5) the synthesis of data sources in developing the core message content; (6) the conceptualization for determining the intervention target audiences and associated intervention components and strategies, their integration with guiding theoretical approaches and implementation theories for the study, and a description of major intervention materials developed to implement the intervention; and (7) the focus of the outcome, impact, and process measurement based on the intervention components and theories on which they were developed.

Effect of a community health center intervention on breast cancer screening among Hispanic American women.

OBJECTIVE: A multiple component intervention in a community health center is presented, and its effect on breast cancer screening participation by Hispanic American women between the ages of 45 and 75 years is discussed. DATA SOURCES/STUDY SETTING: In 1990, data were collected through a retrospective audit (at least as far back as 1987) of community health center medical records, as well as from a client referral log. The health center, located in a small Massachusetts city, primarily serves clients of Latino heritage. STUDY DESIGN: The study used a nonexperimental pretest-posttest intervention design to document clients' screening activities. To control for uneven length of enrollment, aging of the population, and sporadic utilization, the unit of analysis chosen for the principle study variables was an "eligible year." DATA COLLECTION: Variables of interest included screening (clinical breast exam and mammography), periodicity of screening, and compliance with referrals. PRINCIPAL FINDINGS: Postintervention, considerably greater screening mammography occurred among all age groups, more women had at least one screening mammogram during the period, more clinical breast exams included a mammogram referral, and the compliance rate improved. The rate of clinical breast exam did not significantly improve, showing a downward trend.

Social network, support and influence: relationships with drug use and protective AIDS behavior.

One reason for difficulty in long-term maintenance of behavior changes by injection drug users (IDUs) is the concomitant support or distraction from the IDUs social environment. This study explored the relationship of social factors--e.g., encouragement from friends, beliefs about social norms--with drug injection behaviors. Subjects were clients in a short-term residential detoxification program. Self-reports of drug and AIDS-protective behaviors were gathered at baseline and at least 6 months following a trial of enhanced vs. informational educational interventions. Results provide support both for the general hypothesis about the influence of peers and drug-use partners prior and subsequent to detoxification and for the greater effectiveness of the enhanced intervention on social factors. Particularly important to improved drug use behavior were decreased number of friends who inject drugs (social network), increased number of people to talk with when upset (social support), and increased argument skills about safe drug use (social influence).

HIV-1 antibody testing among drug users participating in AIDS education.

This study aimed to identify factors which predict participation of drug users in HIV-1 antibody testing. The study was part of a randomized controlled trial of three small group AIDS educational programs, in a 21-day in-patient drug detoxification and rehabilitation program. Subjects (n = 497) were clients admitted to the program who consented to participate in the evaluation and who completed baseline data collection. All subjects received pre-test counseling. Testing was offered after 1 week in treatment; 52% decided to be tested. Factors which predicted participation in testing included: no previously reported positive result, a longer stay in treatment, a greater frequency of injection, a greater perceived probability of being infected, and the type of AIDS education. Both actual and perceived level of risk, and the type of AIDS education provided can affect participation in testing programs.

Missed opportunities to impact fast response to AMI symptoms.

The potential for reducing cardiovascular disease mortality rates lies both in prevention and treatment. The earlier treatment is administered, the greater the benefit. Thus, duration of time from onset of symptoms of acute myocardial infarction to administration of treatment is important. One major factor contributing to failure to receive efficacious therapy is the delay time from acute myocardial infarction (AMI) symptom onset to hospital arrival. This paper examines the relationship of several factors with regard to intentions to seek care promptly for symptoms of AMI. A random-digit dialed telephone survey (n = 1294) was conducted in 20 communities located in 10 states. People who said they would wait until they were very sure that symptoms were a heart attack were older, reported their insurance did not pay for ambulance services, and reported less confidence in knowing signs and symptoms in themselves. When acknowledging symptoms of a heart attack, African-Americans and people with more than a high school education reported intention to act quickly. No measures of personal health history, nor interaction with primary care physicians or cardiologists were significantly related to intention to act fast. The study confirms the importance of attribution and perceived self-confidence in symptom recognition in care seeking. The lack of significant role of health history (i.e. those with chronic conditions or risk factors) and clinician contact highlights missed opportunities for health care providers to educate and encourage patients about their risk and appropriate action.

Relationships of patient satisfaction with experience of system performance and health status.

This article investigates the relationship between three types of measures obtained from consumer surveys: satisfaction, health status, and report of systems performance. Analyses demonstrate that patient reports of the quality of processes of care or system performance (such as receiving results of tests or receiving conflicting information from staff members) are significantly related to satisfaction independently of perception of health status. Since dissatisfaction is known to be associated with disenrollment, patient reports of system performance are of great interest to health plans.

Physician-based smoking intervention: a rededication to a five-step strategy to smoking research.

It is well established that physicians can have a significant effect on the smoking behavior of their patients. To do this, attention must be paid to putting in place multiple strategies or mechanisms in the organization where the physician practices, as well as in the macroenvironment (i.e., social and public policy). It has been questioned whether or not there is stagnation in the field of clinical smoking intervention requiring a rededication to basic research regarding smoking. With respect to physician-based smoking intervention, we alternatively suggest that recommitment to all phases of research is essential for moving forward physician-based smoking interventions in the rapidly changing health services and social environment. In this article, we first review the essential framework of the National Cancer Institute's research science approach to cancer prevention and control. Evidence concerning physician-based interventions is then reviewed, followed by a schematic of a comprehensive framework for thinking about the process and intervention components needed for physician-based smoking intervention to take place in the health-care setting, the impact they have, and the eventual outcome of such interventions. There is a discussion of the challenges for the delivery of smoking-cessation services presented by the rapidly changing healthy delivery system of the 1990s. Finally, we present recommendations concerning research priorities for physician-based smoking intervention and the research funding process.

Methodological issues for health-related surveys of multicultural older women.

Given concerns about survey nonresponse bias as well as the need to plan resources for participant recruitment, this study tracked each step of the recruitment process (location, response, consent, and completion) of sociodemographically diverse older women for a survey concerning mammography experience. Younger, less educated poor women were likely to be lost due to inability to locate them, while older middle- and upper-economic-group women were more likely to be lost due to refusal to participate. Hispanic and Black women were significantly more likely to respond on successive attempts to recruit them than were White, non-Hispanic women. There was no significant difference in refusal rates by minority women over the successive contacts, as contrasted with White women, who refused at significantly higher rates with each attempt.

Physicians and smoking cessation. Development of survey measures.

Data from a mailed survey to primary care physicians (N = 122) were used to construct and evaluate psychosocial scales related to performance of smoking cessation counseling. Scales measuring counseling barriers, self-efficacy, and motivation demonstrated considerable promise with excellent or reasonable internal consistency. The correlation for each scale with performance of cessation counseling and with stage of change was statistically significant. Physicians who report they are currently assisting patients had higher performance and self-efficacy rating. Physicians who had participated in formal smoking cessation training had higher self-efficacy; however, their scores on the Barriers, Motivation, and Performance Scales did not differ. Further study with a representative group is encouraged.

Validity and reliability of psychosocial factors related to breast cancer screening.

This research explored the construct validity of hypothesized survey items and data reduction procedures for selected psychosocial constructs which are frequently used in breast cancer screening research. Factor analysis was used to validate relationships between survey items and hypothesized constructs suggested by several theories of behavior change. These constructs included perceived barriers and benefits of breast cancer screening compliance behavior. Reliability analyses were then used to evaluate the consistency of the resultant scales applied across three data sets, resulting from surveys conducted by two different methods (telephone and in-person interview) over three time periods. These analyses found reliability coefficients ranging from .53 to .69.

Gynecological services utilization by contraceptive clients: a cost analysis.

PIP: A cost analysis of gynecological service use by students enrolled in a prepaid health plan at the University of Massachusetts revealed that pregnancy and abortion-related services account for almost half of total costs. The medical records of 495 randomly selected students who presented for diaphragm care during 1980-81 were reviewed and 78% of these women were interviewed. 27% had had at least 1 pregnancy; in 15% of these cases, the pregnancy was diaphragm-related, yielding a Pearl Index of 9.75 pregnancies/100 woman-years of use. Overall, 25% of students (33% of seniors) had an abortion while at college. Study subjects made a total of 1483 visits to the gynecological service and saw an average of 3.3 practitioners. 67% of contraception-related visits were for diaphragm fits, checks, or replacements; 24% involved a change to pills. The average cost per visit for diaphragm fit or method change was $31.20 if the provider was a physician ($22.60 for a nurse practitioner); the cost for diaphragm follow up by a physician was $23.60 ($16.60 for a nurse practitioner). For seniors, the average cost to the health plan over 3.4 years of visits was $83.10 for contraception, $47.43 for pregnancy-related care and abortion counseling, and $100.51 for other gynecological problems (e.g., vaginitis, menstrual disorders) and the annual examination. The $231.04 total cost/senior represents half of the $460 paid in direct premiums. Further analysis is recommended to determine whether increased resource allocation to contraceptive counseling would reduce pregnancy-related costs.^ieng