Determinants of First-Time Cancer Examinations in a Rural Community: A Mechanism for Behavior Change.

OBJECTIVES: After conducting a media campaign focusing on the importance of oral and pharyngeal cancer (OPC) examinations, we assessed mechanisms of behavior change among individuals receiving an OPC examination for the first time. METHODS: We used data from 2 waves of telephone surveys of individuals residing in 36 rural census tracts in northern Florida (n = 806). The second survey occurred after our media intervention. We developed media messages and modes of message delivery with community members via focus groups and intercept interviews. We performed a mediation analysis to examine behavior change mechanisms. RESULTS: Greater exposure to media messages corresponded with heightened concern about OPC. Heightened concern, in turn, predicted receipt of a first-time OPC examination, but only among men. CONCLUSIONS: We extended earlier studies by measuring an outcome behavior (receipt of an OPC examination) and demonstrating that the putative mechanism of action (concern about the disease) explained the link between a media intervention and engaging in the target behavior. Improving the quality of media campaigns by engaging community stakeholders in selecting messages and delivery methods is an effective strategy in building public health interventions aimed at changing behaviors.

Predicting Scheduling and Attending for an Oral Cancer Examination.

BACKGROUND: Oral and pharyngeal cancer is highly treatable if diagnosed early, yet late diagnosis is commonplace apparently because of delays in undergoing an oral cancer examination. PURPOSE: We explored predictors of scheduling and attending an oral cancer examination among a sample of Black and White men who were at high risk for oral cancer because they smoked. METHODS: During an in-person interview, participants (N = 315) from rural Florida learned about oral and pharyngeal cancer, completed survey measures, and were offered a free examination in the next week. Later, participants received a follow-up phone call to explore why they did or did not attend their examination. RESULTS: Consistent with the notion that scheduling and attending an oral cancer exam represent distinct decisions, we found that the two outcomes had different predictors. Defensive avoidance and exam efficacy predicted scheduling an examination; exam efficacy and having coping resources, time, and transportation predicted attending the examination. Open-ended responses revealed that the dominant reasons participants offered for missing a scheduled examination were conflicting obligations, forgetting, and confusion or misunderstanding about the examination. CONCLUSIONS: The results suggest interventions to increase scheduling and attending an oral cancer examination.

Physical activity behavior, barriers to activity, and opinions about a smartphone-based physical activity intervention among rural residents.

BACKGROUND: Rural Americans engage in less physical activity (PA) and experience higher rates of consequent health problems (i.e., obesity, cardiovascular disease) than urban Americans. Although geographic barriers have historically made this population hard to reach, rural individuals are increasingly gaining access to smartphones. Thus, the purpose of this study was to evaluate PA behavior and barriers to PA among rural residents and to gauge their receptiveness to a smartphone-based PA intervention that is currently in the development stage. MATERIALS AND METHODS: Rural Floridian adults (n=113), 18 years of age and older, completed surveys to assess PA behavior, PA barriers, and opinions about an intervention to increase PA. Specifically, they were asked to imagine a program that would require them to do PA with their mobile phones and whether they viewed intended aspects of the program as helpful. The present work is therefore formative research that sought to determine the feasibility and acceptability of a smartphone-based intervention among rural residents. RESULTS of the survey will inform the development of a tailored, smartphone-based PA intervention. RESULTS: The 37.2% of participants with low PA levels (<600 metabolic equivalent [MET]-min per week) were more likely to report personal and environmental barriers to PA than the 47.8% of participants with moderate PA levels (≥600 MET-min per week). More barriers were reported among participants who self-reported as white and among participants of older age, lower education level, and lower socioeconomic status. Additionally, 75.9% of participants reported features of the intervention as at least somewhat helpful. CONCLUSIONS: The growing ubiquity of smartphones among rural residents, combined with participants' positive response to the program description, supports the acceptability of a smartphone-based PA intervention for rural communities. Given the participants' receptiveness, future research should evaluate the efficacy of smartphone-delivered health behavior interventions among this population.

Health literacy: a pathway to better oral health.

OBJECTIVES: We examined whether health literacy was associated with self-rated oral health status and whether the relationship was mediated by patient-dentist communication and dental care patterns. METHODS: We tested a path model with data collected from 2 waves of telephone surveys (baseline, 2009-2010; follow-up, 2011) of individuals residing in 36 rural census tracts in northern Florida (final sample size n = 1799). RESULTS: Higher levels of health literacy were associated with better self-rated oral health status (B = 0.091; P < .001). In addition, higher levels of health literacy were associated with better patient-dentist communication, which in turn corresponded with patterns of regular dental care and better self-rated oral health (B = 0.003; P = .01). CONCLUSIONS: Our study showed that, beyond the often-reported effects of gender, race, education, financial status, and access to dental care, it is also important to consider the influence of health literacy and quality of patient-dentist communication on oral health status. Improved patient-dentist communication is needed as an initial step in improving the population's oral health.

A survey of barriers to screening for oral cancer among rural Black Americans.

OBJECTIVE: Research documents a disparity between Black and White Americans in mortality for oral cancer that appears to result in part from behaviors such as lower oral cancer screening among Black Americans. We examined barriers to oral cancer screening among Black Americans. METHODS: We surveyed Black Americans (N = 366) living in rural Florida to identify barriers to getting screened for oral cancer. RESULTS: Low knowledge/social attention, lack of resources, and fear/defensive avoidance predicted screening intentions, with lack of resources emerging as the largest barrier. Participants also reported that a recommendation from their provider was most likely to increase screening intentions, whereas encountering financial barriers was most likely to decrease screening intentions. CONCLUSIONS: Low knowledge/social attention, lack of resources, and fear/defensive avoidance emerged as independent barriers to oral cancer screening, with the latter two barriers accounting for the most variance in intentions to get screened.

Barriers to oral cancer screening: a focus group study of rural Black American adults.

OBJECTIVE: Mortality from mouth and throat cancer (MTC) is higher among Black Americans than White Americans partially because of late stage detection through screening. The disparity in mortality is particularly problematic among Black Americans living in rural areas who have limited access to preventative resources. Our study explored barriers to screening for MTC among Black Americans. METHODS: We conducted nine focus groups among rural Black Americans age 40 years and older (N = 80). RESULTS: Content coding of the transcripts of the focus groups revealed three primary barriers to screening. Lack of knowledge (e.g., not knowing about MTC and not knowing MTC symptoms) accounted for 31.8% of all barriers mentioned, lack of resources (e.g., lack of money and health insurance) accounted for 25.0% of all barriers mentioned, and fear (e.g., fear of screening and diagnosis) accounted for 22.9% of all barriers mentioned. CONCLUSIONS: We placed these barriers within the Theory of Planned Behavior and conclude that interventions aimed at increasing MTC screening among rural Black Americans should first focus on changing people's attitudes about screening by increasing knowledge about MTC and reducing fear.

Increasing screening intentions for oral and pharyngeal cancer.

BACKGROUND: Oral and pharyngeal cancer is a serious health threat that goes unnoticed by most people. Increasing screenings for oral and pharyngeal cancer is essential to achieving early detection when the disease is most treatable. PURPOSE: We tested the effectiveness of a media campaign designed to increase intentions to seek an oral and pharyngeal cancer screening. We further examined whether concern and knowledge of oral and pharyngeal cancer mediated screening intentions. METHODS: Participants in the intervention condition received messages on posters, handheld fans, pamphlets, and magnets displayed on the sides of cars or trucks. Participants in the intervention and comparison conditions (N = 1,790) were surveyed prior to and after the intervention. RESULTS: Intervention participants reported greater intentions to seek free oral and pharyngeal cancer screenings. Concern about oral and pharyngeal cancer partially mediated the effect whereas knowledge did not. CONCLUSIONS: Our media campaign successfully increased screening intentions by heightening concerns.

Selecting a sample size for studies with repeated measures.

Many researchers favor repeated measures designs because they allow the detection of within-person change over time and typically have higher statistical power than cross-sectional designs. However, the plethora of inputs needed for repeated measures designs can make sample size selection, a critical step in designing a successful study, difficult. Using a dental pain study as a driving example, we provide guidance for selecting an appropriate sample size for testing a time by treatment interaction for studies with repeated measures. We describe how to (1) gather the required inputs for the sample size calculation, (2) choose appropriate software to perform the calculation, and (3) address practical considerations such as missing data, multiple aims, and continuous covariates.

The burden of chronic diseases in a rural North Florida sample.

BACKGROUND: The degree of health disparities present in rural communities is of growing concern and is considered "urgent" since rural residents lag behind their urban counterparts in health status. Understanding the prevalence and type of chronic diseases in rural communities is often difficult since Americans living in rural areas are reportedly less likely to have access to quality health care, although there are some exceptions. Data suggest that rural residents are more likely to engage in higher levels of behavioral and health risk-taking than urban residents, and newer evidence suggests that there are differences in health risk behavior within rural subgroups. The objective of this report is to characterize the prevalence of four major and costly chronic diseases (diabetes, cardiovascular disease, cancer, and arthritis) and putative risk factors including depressive symptoms within an understudied rural region of the United States. These four chronic conditions remain among the most common and preventable of health problems across the United States. METHODS: Using survey data (N = 2526), logistic regression models were used to assess the association of the outcome and risk factors adjusting for age, gender, and race. RESULTS: Key findings are (1) Lower financial security was associated with higher prevalence of cardiovascular disease, arthritis, and diabetes, but not cancer. (2) Higher levels of depressive symptoms were associated with higher prevalence of cardiovascular disease, arthritis, and diabetes. (3) Former or current smoking was associated with higher prevalence of cardiovascular disease and cancer. (4) Blacks reported higher prevalence of diabetes than Whites; Black women were more likely to report diabetes than all other groups; prevalence of diabetes was greater among women with lower education than among women with higher education. (5) Overall, the prevalence of diabetes and arthritis was higher than that reported by Florida and national data. CONCLUSIONS: The findings presented in this paper are derived from one of only a few studies examining patterns of chronic disease among residents of both a rural and lower income geographic region. Overall, the prevalence of these conditions compared to the state and nation as a whole is elevated and calls for increased attention and tailored public health interventions.

Variation in the gene TAS2R13 is associated with differences in alcohol consumption in patients with head and neck cancer.

Variation in responsiveness to bitter-tasting compounds has been associated with differences in alcohol consumption. One strong genetic determinant of variation in bitter taste sensitivity is alleles of the TAS2R gene family, which encode chemosensory receptors sensitive to a diverse array of natural and synthetic compounds. Members of the TAS2R family, when expressed in the gustatory system, function as bitter taste receptors. To better understand the relationship between TAS2R function and alcohol consumption, we asked if TAS2R variants are associated with measures of alcohol consumption in a head and neck cancer patient cohort. Factors associated with increased alcohol intake are of strong interest to those concerned with decreasing the incidence of cancers of oral and pharyngeal structures. We found a single nucleotide polymorphism (SNP) located within the TAS2R13 gene (rs1015443 [C1040T, Ser259Asn]), which showed a significant association with measures of alcohol consumption assessed via the Alcohol Use Disorders Identification Test (AUDIT). Analyses with other SNPs in close proximity to rs1015443 suggest that this locus is principally responsible for the association. Thus, our results provide additional support to the emerging hypothesis that genetic variation in bitter taste receptors can impact upon alcohol consumption.

Psychosocial factors associated with mouth and throat cancer examinations in rural Florida.

OBJECTIVES: We examined the knowledge and prevalence of mouth and throat cancer examinations in a sample drawn from rural populations in north Florida. METHODS: Telephone interviews were conducted across rural census tracts throughout north Florida in 2009 and 2010, in a survey that had been adapted for cultural appropriateness using cognitive interviews. The sample consisted of 2526 respondents (1132 men and 1394 women; 1797 Whites and 729 African Americans). RESULTS: Awareness of mouth and throat cancer examination (46%) and lifetime receipt (46%) were higher than reported in statewide studies performed over the past 15 years. Only 19% of the respondents were aware of their examination, whereas an additional 27% reported having the examination when a description was provided, suggesting a lack of communication between many caregivers and rural patients. Surprisingly, anticipated racial/ethnic differences were diminished when adjustments were made for health literacy and several measures of socioeconomic status. CONCLUSIONS: These findings support the notion that health disparities are multifactorial and include characteristics such as low health literacy, lack of access to care, and poor communication between patient and provider.

Selecting a comparison group for 5-year oral and pharyngeal cancer survivors: two methods.

BACKGROUND: To assess potential long-term consequences of cancer treatment, studies that include comparison groups are needed. These comparison groups should be selected in a way that allows the subtle long-range effects of cancer therapy to be detected and distinguishes them from the effects of aging and other risk factors. The purpose of this investigation was to test two methods of recruiting a comparison group for 5-year oral and pharyngeal cancer survivors (peer-nominated and listed sample) with emphasis on feasibility and the quality of the match. METHODS: Participants were drawn from a pool of 5-year survivors treated at a large Southeastern hospital. A peer-nominated sample was solicited from the survivors. A listed sample matched on sex, age, and zip code was purchased. Telephone interviews were conducted by a professional call center. RESULTS: The following represent our key findings: The quality of matching between survivors and listed sample was better than that between survivors and peer-nominated group in age and sex. The quality of matching between the two methods on other key variables did not differ except for education, with the peer method providing a better match for the survivors than the listed sample. The yield for the listed sample method was greater than for the peer-nominated method. The cost per completed interview was greater for the peer-nominated method than the listed sample. CONCLUSION: This study not only documents the methodological challenges in selecting a comparison group for studies examining the late effects of cancer treatment among older individuals but also documents challenges in matching groups that potentially have disproportionate levels of comorbidities and at-risk health behaviors.

Human papillomavirus, smoking, and head and neck cancer.

AIMS: Smoking and human papillomavirus (HPV) are both distinct risk factors for head and neck cancer, but the nature of interaction between these 2 risk factors in the development of head and neck cancer remains unclear. The purpose of this review is to determine the potential effect of smoking in causation of HPV-related head and neck carcinoma. METHOD: A literature search was carried out using the keywords human papillomavirus, head and neck cancer, smoking, tobacco, and cervical cancer. The English-language articles, references, and other relevant studies evaluating the association of smoking, HPV, and risk of head and neck cancer were collected and analyzed. CONCLUSION: Overall, our review points to smoking tobacco posing an additional risk for development of head and neck cancer in the presence of HPV infection. This is consistent with available laboratory data that show evidence of biological plausibility for interaction between smoking and progression of HPV infection to carcinogenesis. It is therefore important that cessation of smoking is promoted in smokers with HPV infection.

Trends in incidence of oral and pharyngeal carcinoma in Florida: 1981-2008.

OBJECTIVE: While the overall incidence rates of oral and pharyngeal squamous cell carcinoma (SCC) have decreased in the United States, there is evidence of increasing incidence at selected anatomic sites, particularly among younger adults. The objective of this study was to examine trends in incidence rates of oral and pharyngeal cancers in Florida. METHODS: Using data from the Florida Cancer Data System, we examined the incidence of oral and pharyngeal carcinomas in Florida from 1981 through 2008. Factors of interest included sex, race, and trends over time. Percent change (PC) and annual percent change (APC) were computed to characterize trends over time. RESULTS: A total of 53,648 cases of oral or pharyngeal cancer were identified from 1981 through 2008. Significant increasing trends were observed only for pharyngeal cancers in males, with significant decreasing trends for pharyngeal cancer in females and oral cancer for both sexes. For tonsil and base of tongue cancers, increasing trends were detected for white males only. Further investigation among white males showed that, except for base of tongue cancer in the 20-44 age group, the incidence of both cancers increased across all age groups, with the largest increase for both sites found in the 45-64 age group. CONCLUSIONS: This study supports the finding of increasing incidence of SCC of the tonsil and base of tongue in males, in contrast to decreasing trends for most oral and pharyngeal carcinomas. However, we observed that this increase occurred in white males only and the most dramatic increase occurred in the 45-64 age group.

Effects of analgesics on orthodontic pain.

INTRODUCTION: Our objective was too assess the effectiveness of 3 analgesics (ibuprofen, naproxen sodium, and acetaminophen) and a placebo administered before and after the placement of separators in reducing the severity of postseparator placement pain. We also examined the impact of treatment on chewing efficiency at 24 hours after separator placement. METHODS: Twenty-four subjects participated in the study. Each subject received 3 of 4 treatments: ibuprofen, naproxen sodium, acetaminophen, or placebo in random order at monthly intervals. The dosing times were 1 hour before separator placement and 3 and 7 hours after separator placement. Before placement, the subjects completed a masticatory efficiency test and a visual analog scale (VAS) for expected pain and pain experienced. A VAS pain diary was kept for 24 hours. Subjects returned to the clinic after 1 week for separator removal. RESULTS: VAS pain summary scores after separator placement were significantly affected by the administration of ibuprofen (P = 0.0298) and the time after separator placement (P <0.0001). Administering ibuprofen before and after separator placement significantly reduced pain compared with the placebo. The analgesic effects diminished by day 2, resulting in peak pain levels and decreased chewing efficiency. The expected pain after separator placement also played a role in experienced pain; subjects expecting more pain experienced more pain. CONCLUSIONS: Ibuprofen was superior to the placebo in relieving postseparator pain as measured by the VAS pain summary scores, whereas acetaminophen and naproxen sodium did not significantly differ from the placebo.

Effectiveness of a social marketing media campaign to reduce oral cancer racial disparities.

OBJECTIVES: The purpose of this study was to provide a systematic evaluation of a theory-driven oral cancer awareness media campaign. METHODS: We surveyed a cohort of residents in an intervention city (250) and a control city (250) immediately prior to and after the media campaign. Participants (125 black/African American and 125 white) in each city completed surveys at baseline and follow-up. Oral cancer campaign awareness was assessed in both cities, along with 4 hypothetical health campaigns. Oral cancer awareness, oral cancer exam awareness, intent to receive an oral cancer exam, interest in exam, and receipt of exam were also assessed in both cities, both at baseline and follow-up. RESULTS: Intervention city residents showed a significant increase in recognition of the campaign, awareness of the oral cancer exam, and interest in getting an exam, while no significant changes in those topics were found for the control city. Blacks/African Americans in the intervention city were significantly more likely than whites to demonstrate increases in awareness of the campaign, oral cancer awareness, and interest in receiving an oral cancer exam. CONCLUSIONS: A theory-driven media campaign was successful in increasing awareness of the oral cancer exam and interest in the exam among blacks/African Americans.

Effects of preoperative ibuprofen on pain after separator placement.

INTRODUCTION: Many patients experience pain with orthodontics, but there is no widely accepted standard of care for controlling orthodontic pain. Previous studies were inconclusive as to the most effective way to manage orthodontic pain. The purpose of this study was to assess the effectiveness in reducing pain of preemptive ibuprofen added to an ibuprofen regimen administered after separator placement. We also examined the contributions of psychological factors and sex to the experience of pain. METHODS: The subjects were randomly assigned to group A, 400 mg of ibuprofen 1 hour before separator placement (D1), 3 hours after placement (D2), and 7 hours after placement (D3); group B, placebo at D1, 400 mg of ibuprofen at D2 and D3; or group C, placebo at D1, D2, and D3. Before separator placement, the subjects completed 2 psychological surveys, a masticatory efficiency test, and a visual analog scale for expected pain and experienced pain during the masticatory efficiency test. After placement, the subjects recorded their actual pain, kept a pain diary for 24 hours after separator placement, and performed a 24-hour follow-up masticatory efficiency test. RESULTS: Group A, receiving ibuprofen before and after separator placement, experienced significantly less pain (P <0.05) at 6 hours, at bedtime, and at awakening on the second day. No contributions to pain were found for psychological factors or sex. CONCLUSIONS: Preemptive administration of analgesics should be recommended to orthodontic patients before separator placement.