What makes for successful patient navigation implementation in cancer prevention and screening programs using an evaluation and sustainability framework.

BACKGROUND: Integrating patient navigation into cancer prevention and early detection efforts has been effective in increasing cancer screening rates for the medically underserved. Few publications have focused on how cancer screening interventions in the primary care setting using patient navigation as a primary strategy are implemented, adapted, and sustained. In 2006, the University of Colorado Cancer Center established a statewide colorectal cancer screening program to reduce disparities and improve colorectal cancer (CRC) screening for the medically underserved in partnership with the safety net system. The program, known as the Colorado Cancer Screening Program (CCSP), has provided navigation into preventive screening for more than 35,000 patients. METHODS: To evaluate sustainability and implementation, the Practical, Robust Implementation and Sustainability Model was used to examine the implementation and impact. To complement this model, the CCSP adapted the Program Sustainability Framework and Clinical Sustainability Framework and Assessment Tools to measure the capacity of participating clinics to sustain the program beyond grant funding. RESULTS: The domains most frequently targeted for improvement in the sustainability plans were Workflow Integration (8 clinics), Communication, Planning, and Implementation (8 clinics), and Funding Stability (5 clinics). Activities in the implementation plans included revising workflows for efficiencies, incorporating quality improvement strategies, and building a business case for patient navigation. CONCLUSIONS: Findings from this sustainability planning process provide insight about program outcomes, satisfaction, and illustrate that although funding remains one of the key sustainability questions, many clinic systems have prioritized other specific domains to continue sustainability beyond grant funding.

Women's perceptions of PERSPECTIVE: a breast cancer risk stratification e-platform.

BACKGROUND: Breast cancer risk stratification categorizes a woman's potential risk of developing the disease as near-population, intermediate, or high. In accordance, screening and follow up for breast cancer can readily be tailored following risk assessment. Recent efforts have focussed on developing more accessible means to convey this information to women. This study sought to document the relevance of an informational e-platform developed for these purposes. OBJECTIVE: To begin to assess a newly developed breast cancer risk stratification and decision support e-platform called PERSPECTIVE (PErsonalised Risk Stratification for Prevention and Early deteCTIon of breast cancer) among women who do not know their personal breast cancer risk (Phase 1). Changes (pre- and post- e-platform exposure) in knowledge of breast cancer risk and interest in undergoing genetic testing were assessed in addition to perceptions of platform usability and acceptability. METHODS: Using a pre-post design, women (N = 156) of differing literacy and education levels, aged 30 to 60, with no previous breast cancer diagnosis were recruited from the general population and completed self-report e-questionnaires. RESULTS: Mean e-platform viewing time was 18.67 min (SD 0.65) with the most frequently visited pages being breast cancer-related risk factors and risk assessment. Post-exposure, participants reported  significantly higher breast cancer-related knowledge (p < .001). Increases in knowledge relating to obesity, alcohol, breast density, menstruation, and the risk estimation process remained even when sociodemographic variables age and education were controlled. There were no significant changes in genetic testing interest post-exposure. Mean ratings for e-platform acceptability and usability were high: 26.19 out of 30 (SD 0.157) and 42.85 out of 50 (SD 0.267), respectively. CONCLUSIONS: An informative breast cancer risk stratification e-platform targeting healthy women in the general population can significantly increase knowledge as well as support decisions around breast cancer risk and assessment. Currently underway, Phase 2, called PERSPECTIVE, is seeking further content integration and broader implementation .

Longitudinal outcomes with cancer multigene panel testing in previously tested BRCA1/2 negative patients.

Although multigene panel testing (MGPT) is increasingly utilized in clinical practice, there remain limited data on patient-reported outcomes. BRCA 1/2 negative patients were contacted and offered MGPT. Patients completed pre- and posttest counseling, and surveys assessing cognitive, affective and behavioral outcomes at baseline, postdisclosure and 6 and 12 months. Of 317 eligible BRCA1/2 negative patients who discussed the study with research staff, 249 (79%) enrolled. Decliners were more likely to be older, non-White, and recruited by mail or email. Ninety-five percent of enrolled patients proceeded with MGPT. There were no significant changes in anxiety, depression, cancer specific distress or uncertainty postdisclosure. There were significant but small increases in knowledge, cancer-specific distress and depression at 6-12 months. Uncertainty declined over time. Those with a VUS had significant decreases in uncertainty but also small increases in cancer specific distress at 6 and 12 months. Among those with a positive result, medical management recommendations changed in 26% of cases and 2.6% of all tested. Most BRCA1/2 negative patients have favorable psychosocial outcomes after receipt of MGPT results, although small increases in depression and cancer-specific worry may exist and may vary by result. Medical management changed in few patients.

Pre-implementation adaptation of primary care cancer prevention clinical decision support in a predominantly rural healthcare system.

BACKGROUND: Cancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. However, clinical decision support (CDS) may assist PCPs in addressing patients' cancer prevention and screening needs during short clinic visits. In this paper, we describe pre-implementation study design and cancer screening and prevention CDS changes made to maximize utilization and better fit a healthcare system's goals and culture. We employed the Consolidated Framework for Implementation Research (CFIR), useful for evaluating the implementation of CDS interventions in primary care settings, in understanding barriers and facilitators that led to those changes. METHODS: In a three-arm, pragmatic, 36 clinic cluster-randomized control trial, we integrated cancer screening and prevention CDS and shared decision-making tools (SDMT) into an existing electronic medical record-linked cardiovascular risk management CDS system. The integrated CDS is currently being tested within a predominately rural upper Midwestern healthcare system. Prior to CDS implementation, we catalogued pre-implementation changes made from 2016 to 2018 based on: pre-implementation site engagement; key informant interviews with healthcare system rooming staff, providers, and leadership; and pilot testing. We identified influential barriers, facilitators, and changes made in response through qualitative content analysis of meeting minutes and supportive documents. We then coded pre-implementation changes made and associated barriers and facilitators using the CFIR. RESULTS: Based on our findings from system-wide pre-implementation engagement, pilot testing, and key informant interviews, we made changes to accommodate the needs of the healthcare system based on barriers and facilitators that fell within the Intervention Characteristics, Inner Setting, and Outer Setting CFIR domains. Changes included replacing the expansion of medical assistant roles in one intervention arm with targeted SDMT, as well as altering cancer prevention CDS and study design elements. CONCLUSIONS: Pre-implementation changes to CDS may help meet healthcare systems' evolving needs and optimize the intervention by being responsive to real-world implementation barriers and facilitators. Frameworks like the CFIR are useful tools for identifying areas where pre-implementation barriers and facilitators may result in design changes, both to research studies and CDS systems. TRIAL REGISTRATION: NCT02986230.

Cancer Community Education in Somali Refugees in Nebraska.

Nebraska has one of the highest numbers of refugees per capita in the U.S. A high number of Somalis have resettled in Nebraska due to job opportunities and the low cost of living. In this paper, we report the process and the results of a cervical and breast cancer education program for Somali women conducted through a collaboration among public health, academia, and community entities. The curriculum was built to be suitable for the literacy level and cultural values of this community. Topics include female reproductive anatomy; breast and cervical cancer knowledge and screening; hepatitis C and liver cancer; and preparing for a health screening visit. Two community members trained as lay health workers conducted a pilot and an actual education session. The 2-day education program was attended by 52 women. Qualitative data showed the intervention to be promising for this and other African refugee populations.

Against Colorectal Cancer in Our Neighborhoods, a Community-Based Colorectal Cancer Screening Program Targeting Low-Income Hispanics: Program Development and Costs.

BACKGROUND: Colorectal cancer is the second leading cause of cancer-related death in the United States. Despite universal screening recommendations, screening rates in the United States remain suboptimal, especially among the poor, the uninsured, recent immigrants, and Hispanics. This article describes the development of a large community-based colorectal cancer screening program designed to address these disparities. METHOD: The Against Colorectal Cancer in our Neighborhoods program is a bilingual, evidence-based, theory-guided, multicomponent community screening intervention, targeting the uninsured and developed using a systematic planning process. It combines community health worker-led outreach, bilingual and culturally tailored community education, and no-cost screening with provision of the fecal immunochemical test or colonoscopy and navigation services. A detailed process and outcome evaluation is planned. Program development cost calculated prospectively (in 2011 dollars) using a societal perspective and micro-costing methods was $243,278, of which $180,344 was direct cost. DISCUSSION: The detailed description of the development processes and costs of this health promotion program targeting low-income Hispanics will inform health program decision makers about the resource requirements for planning and developing new programs to reduce disease burden in communities.

Comparison of discrimination performance of 11 lung cancer risk models for predicting lung cancer in a prospective cohort of screening-age adults from Germany followed over 17 years.

Randomized trials have demonstrated considerable reduction in lung cancer (LC) mortality by screening pre-selected heavy smokers with low-dose computed tomography (LDCT). Newer screening guidelines recommend refined LC risk models for selecting the target population for screening. We aimed to evaluate and compare the discrimination performance of LC risk models and previously used trial criteria in predicting LC incidence and mortality in a large German cohort of screening-age adults. Within ESTHER, a population-based prospective cohort study conducted in Saarland, Germany, 4812 ever smokers aged 50-75 years were followed up with respect to LC incidence and mortality for up to 17 years. We quantified the performance of 11 different LC risk models by the area under the curve (AUC) and compared the proportion of correctly predicted LC cases between the best performing models and the LDCT trial criteria. Risk prediction of LC incidence in the ESTHER ever smokers was best for the Bach model, LCRAT and LCDRAT with AUCs ranging from 0.782 to 0.787, from 0.770 to 0.774, and from 0.765 to 0.771 for the follow-up time periods of cases identified at 6, 11, and 17 years, respectively. At cutoffs yielding comparable positivity rates as the LDCT trial criteria, these models would have identified between 11.8 (95% CI 3.0-20.5) and 17.6 (95% CI 10.1-25.2) percent units higher proportions of LC cases occurring during the initial 6 years of follow-up. Use of LC risk models is expected to result in substantially greater potential to identify people at highest risk of LC, suggesting enhanced potential for reducing LC mortality by LC screening.

Prevalence and Correlates of Observed Sun Protection Behaviors Across Different Public Outdoor Settings in Melbourne, Australia.

Skin cancer prevention efforts in Australia have increasingly incorporated a focus on protection during incidental sun exposure. This complements the long-present messages promoting protection in high-risk settings and avoidance of acute intense bouts of sun exposure. Data from two waves of a cross-sectional direct observational survey was used to assess the prevalence and correlates of N = 12,083 adolescents' and adults' sun protection behavior (arm and leg cover, hat, sunglasses, and shade cover). Individuals were observed in public outdoor settings in Melbourne, Australia during peak ultraviolet (UV) times (11 a.m.-3 p.m.) on summer weekends. Settings included pools and beaches, parks and gardens, and for the first time in 2018, outdoor streets and cafés which may capture more incidental forms of sun exposure and represent another public setting where Australians commonly spend time outdoors. Females and older adults were consistently better protected than males and adolescents. Physical activity was strongly associated with low shade cover across settings. Weather was more strongly associated with sun protection at outdoor streets/cafes and parks/gardens than at pools/beaches but use of observed sun protection (particularly arm cover and covering hat) was low across settings. Continued public education about UV risk and its relation to weather and the seasons is needed to promote the routine use of multiple forms of sun protection during outdoor activities in peak UV times, especially among males and adolescents. Findings also highlight the importance of considering activity demands of public spaces in shade planning to optimize sun protection during outdoor activities in public spaces.

Potential of Inflammatory Protein Signatures for Enhanced Selection of People for Lung Cancer Screening.

Randomized trials have demonstrated a substantial reduction in lung cancer (LC) mortality by screening heavy smokers with low-dose computed tomography (LDCT). The aim of this study was to assess if and to what extent blood-based inflammatory protein biomarkers might enhance selection of those at highest risk for LC screening. Ever smoking participants were chosen from 9940 participants, aged 50-75 years, who were followed up with respect to LC incidence for 17 years in a prospective population-based cohort study conducted in Saarland, Germany. Using proximity extension assay, 92 inflammation protein biomarkers were measured in baseline plasma samples of ever smoking participants, including 172 incident LC cases and 285 randomly selected participants free of LC. Smoothly clipped absolute deviation (SCAD) penalized regression with 0.632+ bootstrap for correction of overoptimism was applied to derive an inflammation protein biomarker score (INS) and a combined INS-pack-years score in a training set, and algorithms were further evaluated in an independent validation set. Furthermore, the performances of nine LC risk prediction models individually and in combination with inflammatory plasma protein biomarkers for predicting LC incidence were comparatively evaluated. The combined INS-pack-years score predicted LC incidence with area under the curves (AUCs) of 0.811 and 0.782 in the training and the validation sets, respectively. The addition of inflammatory plasma protein biomarkers to established nine LC risk models increased the AUCs up to 0.121 and 0.070 among ever smoking participants from training and validation sets, respectively. Our results suggest that inflammatory protein biomarkers may have potential to improve the selection of people for LC screening and thereby enhance screening efficiency.

Evaluation of a 2-1-1 Telephone Navigation Program to Increase Cancer Control Behaviors: Results From a Randomized Controlled Trial.

PURPOSE: To evaluate the effectiveness of a telephone navigation intervention for increasing use of cancer control services among underserved 2-1-1 callers. DESIGN: Randomized controlled trial. SETTING: 2-1-1 call centers in Houston and Weslaco, Texas (located in the Rio Grande Valley near the Mexican border). PARTICIPANTS: 2-1-1 callers in need of Pap test, mammography, colorectal cancer screening, smoking cessation counseling, and/or HPV vaccination for a daughter (n = 1,554). A majority were low-income and described themselves as Black or Hispanic. INTERVENTION: Participants were randomly assigned to receive either a cancer control referral for the needed service(s) with telephone navigation from a trained cancer control navigator (n = 995) or a referral only (n = 559). MEASURES: Uptake of each individual service and any needed service. ANALYSIS: Assessed uptake in both groups using bivariate chi-square analyses and multivariable logistic regression analyses, adjusted for sociodemographic covariates. Both per-protocol and intent-to-treat approaches were used. RESULTS: Both interventions increased cancer control behaviors. Referral with navigation intervention resulted in significantly greater completion of any needed service (OR = 1.38; p = .042), Pap test (OR = 1.56; p = .023), and smoking cessation counseling (OR = 2.66; p = .044), than referral-only condition. Other outcomes showed the same trend although the difference was not statistically significant: mammography (OR = 1.53; p = .106); colorectal cancer screening (OR = 1.80; p = .095); and HPV vaccination of a daughter (OR = 1.61; p = .331). CONCLUSION: Adding cancer control referrals and navigation to an informational service like the 2-1-1 program can increase overall participation in cancer control services.

The Association Between Fatalism and Mammography Use in Korean American Immigrant Women.

Fatalism is reported as a salient cultural belief that influences cancer screening disparities in racial and ethnic minority groups. Previous studies provide a range of measures and descriptions of cancer fatalism, but no studies to our knowledge have analyzed how fatalistic views cluster together within subgroups to form distinct profiles, and how these profiles can be predicted. This study identified subgroups of Korean American immigrants with similar fatalistic beliefs toward cancer and examined the influence of fatalism, health belief variables, and health literacy on mammography use. A cross-sectional survey design was used to obtain a convenience sample of 240 Korean American immigrant women in Los Angeles, California. Latent class analysis was used to identify unobserved subgroups of fatalism. Hierarchical logistic regression models were used to identify predisposing, enabling, and need factors associated with recent mammography use. The latent class analysis model identified three cancer fatalism subgroups: high fatalism (17.8%), moderate fatalism (36.7%), and low fatalism (45.5%). Women in the high fatalism subgroup were more likely to have had a mammogram within the past 2 years than women in the low fatalism subgroup. Regression analysis revealed three facilitators of recent mammogram use: level of fatalism, perceived barriers to mammogram, and family history of cancer. Although cultural beliefs can have a powerful influence on health-seeking behavior, it is important to weigh individual and contextual factors that may weaken or mediate the relationship between fatalism and engaging in preventive care such as having a mammogram.

Bayo Lapawol (Let Their Voices Be Heard): Haitian Women's Barriers to and Facilitators of Cervical Cancer Prevention and Control.

This study aimed to increase understanding of barriers to cervical cancer prevention and control in Haitian women using photovoice methodology. Consented participants were (1) trained to use a digital camera and encouraged to capture their screening barriers, (2) interviewed to unpack and analyze their images, and (3) invited to participate in follow-up focus groups for refined discussion and data triangulation for content analysis using NVivo software. The sample included women (n = 25) who were on average 42 years (SD = 9.8, range: 26-57) and born and raised in Haiti. Results highlighted multiple barriers, including gendered family responsibilities, concerns about quality of care, financial and time constraints, worries about discomfort and exam efficacy, and emotional deterrents such as frustration. Framed by the PEN-3 model's dimensions of cultural identity, relationships and expectations, and cultural empowerment, women's recommendations to overcome barriers spanned education, evaluation, and empowerment, respectively, across individual, interpersonal, and institutional systems. Study results call for more extensive examination of the diversity present in the groups of African origin to unearth transnational, multifaceted determinants of health by biology, beliefs, and behaviors including sociocultural and socioenvironmental access. Future interventions must include development of proactive policies, which deliberately pressure the government and global community to prioritize health infrastructure while simultaneously educating women about and dispelling fear of cervical cancer, thus empowering Haitian women to live their healthiest lives. Accordingly, this study may contribute to understanding global health equity advances and improving public health infrastructure in underresourced settings in low- and middle-income countries in the Caribbean.

Demographic and psychosocial factors associated with limited health literacy in a community-based sample of older Black Americans.

OBJECTIVES: Individuals with limited health literacy often experience suboptimal health outcomes. This study examined the frequency of limited health literacy and demographic and psychosocial factors associated with limited health literacy in a sample of older Black Americans. METHODS: Participants (n = 330) enrolled in a community-based intervention to promote colorectal cancer (CRC) screening completed baseline surveys assessing health literacy with the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) test, CRC awareness, cancer fatalism, Preventive Health Model (PHM) constructs, and demographics. RESULTS: Approximately 52% of participants had limited health literacy, the REALM-R score was 5.4 (SD = 2.7). Univariable correlates of limited health literacy were gender, employment, income, prior screening, cancer fatalism, CRC awareness, and PHM constructs (religious beliefs, salience/coherence, perceived susceptibility). Multivariable correlates of limited health literacy were male gender (OR = 2.3, CI = 1.4-3.8), unable to work (OR = 2.8, CI = 1.3-6.1), lower household income (OR = 3.0, CI = 1.6, 5.5), and higher PHM religious beliefs (OR = 1.1, CI = 1.0-1.2). CONCLUSION: Limited health literacy was associated with multiple complex factors. Interventions should incorporate patient health literacy and low-literacy materials that can be delivered through multiple channels. PRACTICE IMPLICATIONS: Future studies are needed to understand the role of health literacy in an individual's health behavior and the provision of effective healthcare.

Two Peas in a Pod? An Exploratory Examination Into Cancer-Related Psychosocial Characteristics and Health Behaviors Among Black Immigrants and African Americans.

Introduction. Most studies lump Black immigrants (BIs) and African Americans (AAs) as "Black/African American" during investigation. Such categorization assumes that the sociocultural determinants that influence BIs are the same as for AAs. This study attempts to disentangle the AA and BI subgroups to recognize the differences in cancer-related psychosocial characteristics and health behaviors. Methods. Merged data from the Health Information National Survey (2011-2017) were used. Two groups were created: those who identified as AA and those who identified as AA but were born outside the United States (BI). Between-group differences were assessed with Mann-Whitney U and chi-square tests. Results. Positive communication patterns with health care providers were significantly higher among AAs (M [mean] = 3.41, SD [standard deviation] = 0.68) compared with BIs (M = 3.28, SD = 0.71) (p = .004). A greater proportion of BIs indicated that their health was excellent (14.2%), compared with AAs (7.9%). AAs reported higher cancer family history (75.1%) than BIs (46.5%). More AAs had smoked at least 100 cigarettes in their lifetime (41.5%) than BIs (16.7%). BIs consumed significantly more fruits each day (M = 2.77, SD = 1.43) than AAs (M = 2.40, SD = 1.44) (p < .001). BIs also reported more physical activity (M = 2.62, SD = 2.15) than AAs (M = 2.37, SD = 2.18) (p = .030). AA women were more likely to have had a pap smear test (M = 2.07, SD = 1.44) compared with BI women (M = 1.73, SD = 1.21) (p = .002). Discussion. Evidence suggests the need to disentangle the "Black/African American" ethnic grouping. Lumping the BI populations together with the AAs, who have been in the United States for generations, may limit the ability to uncover and consequently address culturally driven disease prevention efforts and promote understanding of the biological, environmental, and psychosocial risk factors within Black heterogeneous populations.

Socio-demographic Moderators of Associations Between Psychological Factors and Latinas' Breast Cancer Screening Behaviors.

This study tested whether socio-demographic factors moderated associations between psychological factors and Latinas' breast cancer screening behaviors. 222 churchgoing Latinas (40-65 years) in San Diego, CA completed surveys assessing socio-demographics (e.g., income and acculturation), psychological factors (e.g., perceived barriers to screening), and cancer screening behaviors. Multilevel models examined associations of socio-demographic and psychological factors (and their interactions) with adherence to annual mammography or clinical breast exam (CBE) screening. Although no main effects were found, there were moderation effects. Acculturation moderated associations between perceived barriers to screening and both screening outcomes, with inverse associations only among the high-acculturation group. Education moderated the relationship between perceived barriers to screening and CBE screening, with an inverse association only among the low-education group. Marital status moderated the relationship between depressive symptoms and CBE screening, with an inverse association only among single/non-partnered participants. Interventions are needed targeting psychological barriers to breast cancer screening among Latinas.

Assessing Levels and Correlates of Implementation of Evidence-Based Approaches for Colorectal Cancer Screening: A Cross-Sectional Study With Federally Qualified Health Centers.

Multiple evidence-based approaches (EBAs) exist to improve colorectal cancer screening in health clinics. The success of these approaches is tied to effective implementation. Therefore, the purpose of this study was to assess the implementation of EBAs for colorectal cancer screening and clinic-level correlates of implementation in federally qualified health centers (FQHCs). We conducted descriptive and cross-sectional analyses using data collected from FQHC clinics across seven states ( n = 51). A clinic representative completed electronic surveys about clinic characteristics (e.g., size, patient characteristics, and medical record system characteristics) and the implementation of Community Guide recommended EBAs (e.g., client reminders, small media, and provider assessment and feedback). We used bivariate Spearman correlations to assess clinic-level correlates with implementation outcomes. Most clinics were planning to implement, in the early implementation stages, or inconsistently implementing EBAs. No EBA was fully implemented by more than nine (17.6%) clinics. Clinic size variables were inversely related to implementation levels of one-on-one education; medical record variables were directly related to implementation levels of client and provider reminders as well as provider assessment and feedback; and rapid and timely feedback from clinic leaders was directly associated with implementation levels of four out of six EBAs. Given the varying levels of implementation, clinics need to assess current use of implementation strategies and improve effective program delivery to increase colorectal cancer screening among their patients. In addition, clinics should also consider how their characteristics may support or serve as a barrier to implementation in their respective settings.

Sun Protection Among New Zealand Primary School Children.

Schools are an important setting for raising skin cancer prevention awareness and encouraging sun protection. We assessed the clothes worn and shade used by 1,278 children in eight schools in the Wellington region of New Zealand. These children were photographed for the Kids'Cam project between September 2014 and March 2015 during school lunch breaks. Children's mean clothing coverage (expressed as a percentage of body area covered) was calculated. Data on school sun-safety policies were obtained via telephone. Mean total body clothing coverage was 70.3% (95% confidence interval = 66.3%, 73.8%). Body regions with the lowest mean coverage were the head (15.4% coverage), neck (36.1% coverage), lower arms (46.1% coverage), hands (5.3% coverage), and calves (30.1% coverage). Children from schools with hats as part of the school uniform were significantly more likely to wear a hat (52.2%) than children from schools without a school hat (2.7%). Most children (78.4%) were not under the cover of shade. Our findings suggest that New Zealand children are not sufficiently protected from the sun at school. Schools should consider comprehensive approaches to improve sun protection, such as the provision of school hats, sun-protective uniforms, and the construction of effective shade.

Entertainment-Education Narrative Versus Nonnarrative Interventions to Educate and Motivate Latinas to Engage in Mammography Screening.

BACKGROUND: The evidence is limited comparing the effects of entertainment-education (E-E) narrative versus nonnarrative interventions to educate and motivate Latinas to engage in mammography screening. AIMS: This study compared an E-E narrative intervention to two nonnarrative interventions' effects among Latinas on breast cancer knowledge and motivation, as measured by changes in self-efficacy, behavioral norms, and behavioral intentions to engage in mammography screening. METHOD: A sample of 141 Spanish-speaking Latinas was randomly assigned to one of three arms: an E-E narrative video, a nonnarrative educational video, and printed educational materials. Using a repeated measures design, the influence of the E-E narrative on pretest to posttest measures was assessed and compared to the influence of the other two interventions. RESULTS: The E-E narrative and nonnarrative interventions significantly increased Latinas' breast cancer knowledge, mammography self-efficacy, and behavioral norms from pretest to posttest. However, the E-E narrative participants' pretest to posttest difference in mammography self-efficacy was significantly higher when compared to the difference of the other two interventions. The effect of the E-E narrative intervention on self-efficacy and behavioral norms was moderated by the participants' absorption in the story and identification with the story characters. CONCLUSION: E-E narrative and nonnarrative interventions significantly educated and motivated Latinas to engage in mammography screening. The effects on mammography self-efficacy, an important precursor to behavior change, can be more strongly influenced by E-E narratives. DISCUSSION: Although E-E narrative and nonnarrative interventions were effective, the need still exists to assess if they can ultimately influence lifesaving breast cancer screening behaviors.

Estimating Acceptability of Financial Health Incentives.

A growing body of evidence suggests that financial incentives can influence health behavior change, but research on the public acceptability of these programs and factors that predict public support have been limited. A representative sample of U.S. adults ( N = 526) were randomly assigned to receive an incentive program description in which the funding source of the program (public or private funding) and targeted health behavior (smoking cessation, weight loss, or colonoscopy) were manipulated. Outcome variables were attitude toward health incentives and allocation of hypothetical funding for incentive programs. Support was highest for privately funded programs. Support for incentives was also higher among ideologically liberal participants than among conservative participants. Demographics and health history differentially predicted attitude and hypothetical funding toward incentives. Incentive programs in the United States are more likely to be acceptable to the public if they are funded by private companies.

Use of Theory in Behavior Change Interventions.

OBJECTIVE: Theory use may enhance effectiveness of behavioral interventions, yet critics question whether theory-based interventions have been sufficiently scrutinized. This study applied a framework to evaluate theory use in physical activity interventions for breast cancer survivors. The aims were to (1) evaluate theory application intensity and (2) assess the association between extensiveness of theory use and intervention effectiveness. METHODS: Studies were previously identified through a systematic search, including only randomized controlled trials published from 2005 to 2013, that addressed physical activity behavior change and studied survivors who were <5 years posttreatment. Eight theory items from Michie and Prestwich's coding framework were selected to calculate theory intensity scores. Studies were classified into three subgroups based on extensiveness of theory use (Level 1 = sparse; Level 2 = moderate; and Level 3 = extensive). RESULTS: Fourteen randomized controlled trials met search criteria. Most trials used the transtheoretical model ( n = 5) or social cognitive theory ( n = 3). For extensiveness of theory use, 5 studies were classified as Level 1, 4 as Level 2, and 5 as Level 3. Studies in the extensive group (Level 3) had the largest overall effect size ( g = 0.76). Effects were more modest in Level 1 and 2 groups with overall effect sizes of g = 0.28 and g = 0.36, respectively. CONCLUSIONS: Theory use is often viewed as essential to behavior change, but theory application varies widely. In this study, there was some evidence to suggest that extensiveness of theory use enhanced intervention effectiveness. However, there is more to learn about how theory can improve interventions for breast cancer survivors.