Role of the clinical learning environment in preparing new clinicians to engage in quality improvement efforts to eliminate health care disparities.

PURPOSE: The National Collaborative for Improving the Clinical Learning Environment offers guidance to health care leaders for engaging new clinicians in efforts to eliminate health care disparities. SUMMARY: To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. Engaging new clinicians is a key element of any systems-based approach, as new clinicians will shape the future of health care delivery. Clinical learning environments, or the hospitals, medical centers, and ambulatory care clinics where new clinicians train, have an important role in this process. Efforts may include training in cultural humility and cultural competency, education about the organization's vulnerable populations, and continuous interprofessional experiential learning through comprehensive, systems-based QI efforts focused on eliminating health care disparities. CONCLUSION: By preparing and supporting new clinicians to engage in systems-based QI efforts to eliminate health care disparities, clinical learning environments are instilling skills and supporting behaviors that clinicians can build throughout their careers-and helping pave the road towards equity throughout the US health care system.

Fatalism moderates the relationship between family history of cardiovascular disease and engagement in health-promoting behaviors among at-risk rural Kentuckians.

PURPOSE: In rural communities that experience high rates of cardiovascular disease (CVD) morbidity and mortality, family history education may enhance risk awareness and support engagement in healthy behaviors but could also engender fatalism. This study was conducted to assess if the relationship between family history and adherence to healthy lifestyle behaviors is moderated by fatalism. METHODS: Baseline data were obtained from 1,027 adult participants in the HeartHealth in Rural Kentucky study. Multiple linear regression was used to determine whether fatalism moderated the relationship between high-risk family history of CVD and adherence to healthy lifestyle behaviors, controlling for sociodemographic variables and CVD risk factors. The relationship between family history and healthy behaviors was assessed for subgroups of participants divided according to the upper and lower quartiles of fatalism score. FINDINGS: The relationship between high-risk family history of CVD and adherence to healthy behaviors was moderated by fatalism. Among those with the highest quartile of fatalism scores, high-risk family history predicted greater adherence to healthy behaviors, while among those in the lowest quartile, and among those with the middle 50% of fatalism scores, there was no association between family history and healthy behavior scores. CONCLUSIONS: Family history education can provide people at increased risk for CVD important information to guide health practices. This may be particularly relevant for those with a high degree of fatalistic thinking. In rural communities with limited health resources, family history education, combined with assessment of fatalism, may support better targeted interventions to enhance engagement in healthy behaviors.

Rural Appalachian perspectives on heart health: social ecological contexts.

OBJECTIVE: To explore factors associated with cardiovascular disease (CVD) risk in Central Appalachia Kentucky to guide development of a culturally appropriate risk reduction intervention. METHODS: Based on community-based participatory research principles, 7 focus groups were conducted with 88 healthcare employees and residents from 6 Appalachian counties. Sessions were audio-recorded and transcribed. Thematic analysis was used to identify themes and sub-themes. RESULTS: Participants most frequently attributed CVD risk to behaviors including unhealthy diets, physical inactivity, and smoking, and to inadequate preventive care. Intrapersonal, interpersonal, sociocultural, environmental, organizational, and policy level influences on risk were identified. CONCLUSION: Comprehensive intervention guided by a social ecological framework is needed to address CVD risk reduction in Appalachian Kentucky communities.

Recommendations for a national agenda to substantially reduce cervical cancer.

PURPOSE: Prophylactic human papillomavirus (HPV) vaccines and new HPV screening tests, combined with traditional Pap test screening, provide an unprecedented opportunity to greatly reduce cervical cancer in the USA. Despite these advances, thousands of women continue to be diagnosed with and die of this highly preventable disease each year. This paper describes the initiatives and recommendations of national cervical cancer experts toward preventing and possibly eliminating this disease. METHODS: In May 2011, Cervical Cancer-Free America, a national initiative, convened a cervical cancer summit in Washington, DC. Over 120 experts from the public and private sector met to develop a national agenda for reducing cervical cancer morbidity and mortality in the USA. RESULTS: Summit participants evaluated four broad challenges to reducing cervical cancer: (1) low use of HPV vaccines, (2) low use of cervical cancer screening, (3) screening errors, and (4) lack of continuity of care for women diagnosed with cervical cancer. The summit offered 12 concrete recommendations to guide future national and local efforts toward this goal. CONCLUSIONS: Cervical cancer incidence and mortality can be greatly reduced by better deploying existing methods and systems. The challenge lies in ensuring that the array of available prevention options are accessible and utilized by all age-appropriate women-particularly minority and underserved women who are disproportionately affected by this disease. The consensus was that cervical cancer can be greatly reduced and that prevention efforts can lead the way towards a dramatic reduction in this preventable disease in our country.

Predictors of initial uptake of human papillomavirus vaccine uptake among rural Appalachian young women.

Women in Appalachian Kentucky experience a high burden of cervical cancer and have low rates of human papillomavirus (HPV) vaccination. The purpose of this study was to identify normative influences predicting initial HPV vaccine uptake among a sample of young women in southeastern Kentucky. Women (N = 495), ages 18 through 26 years, were recruited from clinics and community colleges. After completing a questionnaire, women received a free voucher for HPV vaccination. Whether women redeemed the voucher for Dose 1 served as the primary outcome variable. Hierarchical logistic regression was used to estimate the influence of healthcare providers, friends, mothers, and fathers on vaccine uptake. One-quarter of the total sample (25.9%) received Dose 1. Uptake was higher in the clinic sample (45.1%) than in the college sample (6.9%). On multivariate analysis, women indicating that their healthcare provider suggested the vaccine, that their friends would "definitely" want them to be vaccinated, and that their fathers would "definitely" want them to receive the vaccine all were 1.6 times more likely to receive Dose 1. Interaction effects occurred between recruitment site (clinic vs. community college) and all three of the normative influences retaining multivariate significance, indicating that the associations only applied to the clinic sample. HPV vaccine interventions may benefit from highlighting paternal endorsement, healthcare provider recommendation, and peer support.

"1-2-3 Pap" Intervention Improves HPV Vaccine Series Completion among Appalachian Women.

Completion of the Human Papillomavirus (HPV) vaccine series is a national priority. This study not only identified correlates of intent to complete the vaccine series and actual series completion, but also tested the efficacy of a DVD intervention to promote series completion. Women's beliefs that all three doses reduced cancer risk predicted intent and completion. Intention predicted completion, as did the belief that having a friend accompany the woman would promote completion. Beyond these effects, women assigned to the intervention were 2.44 times more likely than women in the control group to complete the series. Thus, in controlled analyses, a theory-grounded DVD intervention successfully promoted HPV series completion in a community setting. This method of intervention has high translational potential.

Uptake of free HPV vaccination among young women: a comparison of rural versus urban rates.

PURPOSE: To contrast rates of initial HPV vaccine uptake, offered at no cost, between a rural clinic, a rural community college, and an urban college clinic and to identify rural versus urban differences in uptake of free booster doses. METHODS: Young rural women attending rural clinics (n = 246), young women attending a rural community college (n = 251) and young women attending an urban university health clinic (n = 209) were recruited in Kentucky. After completing a brief questionnaire, women received a free voucher for HPV vaccination. Whether women redeemed the voucher for the initial dose of vaccine served as the study outcome variable. FINDINGS: In controlled analyses, the contrast in initial uptake between urban clinic women (reference category) and rural college women was significant (P < .0001). However, the contrast in initial uptake between urban clinic women (reference category) and rural clinic women was not significant (P = .42). The model predicting uptake of subsequent doses among those with initial uptake (n = 235) also indicated significant differences as a function of recruitment location, with rural clinic women being about 7 times more likely than urban clinic women (P < .0001) to not return for at least 1 follow-up dose. The contrast between urban clinic women and rural college women was also significant (P = .014). CONCLUSION: Initial uptake of free HPV vaccination among young rural college women may be problematic. Moreover, uptake of subsequent free doses among rural women may be problematic regardless of whether contact is made in a clinic or through college recruitment.

HPV-related risk perceptions and HPV vaccine uptake among a sample of young rural women.

Appalachia Kentucky is recognized for increased cervical cancer incidence, morbidity and mortality and lower rates of Pap testing. Understanding the predictors of Human Papillomavirus (HPV) vaccine uptake is warranted among this population. The purpose of this exploratory research is to determine associations between HPV-related risk perceptions and uptake of free Gardasil offered to rural Appalachian women ages 18-26 attending regional health clinics. Young women (N = 247) were recruited from health clinics in Southeastern, Kentucky from March 2008 through September 2009. After completing a brief interview assessing seven HPV-related risk perceptions, women received a HPV vaccine voucher which provided the entire three-dose vaccine series free of charge. Whether women redeemed the voucher for dose one of Gardasil served as the study outcome variable. Hierarchical logistic regression was used to estimate the independent effects of each predictor variable on vaccine uptake. Less than 50% redeemed the voucher to receive dose one of the HPV vaccine. Five of the seven variables significantly predicted uptake. In a controlled analysis, only two predictors remained significant: "in general, vaccines are a good thing" (P = .02) and "I believe that getting the vaccine will be painful" (P = .03). The remaining three predictor variables (worry about having HPV [P = .07], HPV is serious enough for vaccination [P = .43], and not sure vaccine is safe [P = .22]) were not significant in the model. Health promotion programs designed for this population may enhance HPV vaccine uptake by creating more realistic perceptions about the inherent value of vaccines and by improving perceptions relative to injection pain.

Strength of tobacco control in rural communities.

PURPOSE: This study aimed to: (a) describe the Strength of Tobacco Control (SoTC) capacity, efforts and resources in rural communities, and (b) examine the relationships between SoTC scores and sociodemographic, political, and health-ranking variables. METHODS: Data were collected during the baseline preintervention phase of a community-based randomized, controlled trial. Rural counties were selected using stratified random sampling (n = 39). Key informant interviews were employed. The SoTC, originally developed and tested with states, was adapted to a county-level measure assessing capacity, efforts, and resources. Univariate analysis and bivariate correlations assessed the SoTC total score and construct scores, as well as their relationships. Multiple regression examined the relationships of county-level sociodemographic, political, and health-ranking variables with SoTC total and construct scores. FINDINGS: County population size was positively correlated with capacity (r = 0.44; P < .01), efforts (r = 0.54; P= .01), and SoTC total score (r = 0.51; P < .01). Communities with more resources for tobacco control had better overall county health rankings (r = .43; P < .01). With population size, percent Caucasian, tobacco production, and smoking prevalence as potential predictors of SoTC total score, only population size was significant. CONCLUSIONS: SoTC scores may be useful in determining local tobacco control efforts and appropriate planning for additional public health interventions and resources. Larger rural communities were more likely to have strong tobacco control programs than smaller communities. Smaller rural communities may need to be targeted for training and technical assistance. Leadership development and allocation of resources are needed in all rural communities to address disparities in tobacco use and tobacco control policies.

COPD prevalence in southeastern Kentucky: the burden of lung disease study.

BACKGROUND: The Burden of Obstructive Lung Disease (BOLD) initiative provides a standardized way of measuring the prevalence of COPD. METHODS: We used the BOLD survey to estimate the prevalence of COPD in adults aged >or= 40 years in a target population of 325,000 in Southeastern Kentucky. Testing was done at survey centers and homes and included questionnaires on respiratory symptoms, risk factors for COPD, and health status. Postbronchodilator spirometry was used to classify subjects. We determined the prevalence of COPD along with the relation of COPD and comorbid disease and physical and mental quality of life measures. RESULTS: The final study population was 508, with a participation response rate of 25.2%. Overall, 19.6% of subjects met criteria for Global Initiative for Chronic Obstructive Lung Disease stage 1 or higher COPD, and an additional 17.6% met criteria for restriction. Diabetes, heart disease, and hypertension were significantly increased in subjects with restriction. Physical quality of life was significantly decreased in all respiratory impairment categories, compared to normal subjects, whereas mental quality of life measures were not affected. CONCLUSIONS: In this population, respiratory impairment is highly prevalent and associated with comorbid disease and physical, but not mental, dysfunction.