Translation of a Ski School Sun Safety Program to North American Ski and Snowboard Schools.

Health promotion programs that develop and implement strategies to promote sun safety practices to children have the potential to reduce skin cancer occurrence later in life. Go Sun Smart (GSS), a sun safety program for employees and guests of ski areas, was distributed to determine if an enhanced dissemination strategy was more effective than a basic dissemination strategy at reaching parents at ski and snowboard schools. On-site observations of GSS use and surveys of 909 parents/caregivers with children enrolled in ski and snowboard schools at 63 ski areas were conducted and analyzed using techniques for clustered designs. No differences were identified by dissemination strategy. Greater implementation of GSS (>5 messages posted) was associated with greater parental recall, 36.6% versus 16.7%, of materials, but not greater sun protection practices. Greater recall of messages, regardless of level of implementation, resulted in greater sun protection practices including applying sunscreen (p < .05), providing sunglasses and goggles (p < .01), and more use of all sun protection practices (p < .01). Ski areas with more program materials appeared to reach parents with sun safety advice and thus convinced them to take more precautions for their children. Sun safety need not be at odds with children's outdoor recreation activities.

Prevalence and diffusion of helmet use at ski areas in Western North America in 2001-02.

OBJECTIVE: The purpose of this study was to examine diffusion of and predictors of helmet use among skiers and snowboarders in the Western United States and Canada. DESIGN: 6400 skiers and snowboarders at 29 ski resorts in the Western United States and Canada were interviewed on chair lifts and observed for helmet use during two consecutive ski seasons (winters 2001 and 2002). SETTING: Skiers and snowboarders were observed and interviewed at 29 ski resorts in Alaska, California, Colorado, Idaho, Montana, New Mexico, Nevada, Oregon, Utah, and British Columbia as part of a sun protection project. SUBJECTS: Participants completing the survey consisted of 3525 adult skiers and snowboarders in the 2002 season and 2978 adult skiers and snowboarders in the 2001 season. MAIN OUTCOME MEASURE: The outcome measure for all analyses was prevalence of helmet use by skiers and snowboarders. RESULTS: Helmet use by skiers and snowboarders is increasing and is most prevalent among snowboarders, experts, and more frequent skiers/snowboarders. No evidence was found for the hypothesis that helmet use is diffusing more rapidly among earlier adopters of helmets than later adopters. CONCLUSIONS: Although controversy remains, helmets are rapidly diffusing as a safety device at western North American ski resorts. Expert and more frequent skiers and snowboarders are more likely to wear helmets, which may indicate that helmets are recognized as a safety device.

Native American cancer education: genetic and cultural issues.

BACKGROUND: The authors met with intertribal groups to learn about cultural issues related to cancer genetics. The information gathered from these meetings identified issues that are incorporated into the Genetic Education for Native Americans (GENA) interactive, innovative and multidisciplinary curriculum. METHODS: To address the diverse cultural and scientific issues, the faculty presented customized workshops during conferences for Native American college students. RESULTS: The authors discuss current issues and techniques in cancer education in Native American communities. CONCLUSIONS: Better understanding of tribal culture among researchers will enhance Native Americans' collaboration in research.

Formative research activities to provide Web-based nutrition education to adults in the Upper Rio Grande Valley.

The Internet is a promising new tool for disseminating cancer prevention information. Barriers to full implementation include disparities in access and skill and availability of information relevant at the local level. A nutrition education Web site to promote fruit and vegetable intake is being produced for a tri-ethnic adult population in Colorado and New Mexico. Development is guided by findings from formative research including focus groups with local residents, a survey on computer and Internet use with 200 adults in 1998, an assessment of public access computer sites, and in-depth discussion with local community computer skills trainers.

Dual Tobacco use among Native American adults in southeastern North Carolina.

OBJECTIVE: While patterns of smokeless tobacco (ST) use and cigarette smoking are well documented, the epidemiology of simultaneous use of both tobacco products is less well studied, particularly among Native American populations. This study examines correlates of dual tobacco use among Lumbee Indian adults in southeastern North Carolina. METHODS: A telephone survey among 400 adult Lumbee Indians in Pembroke, North Carolina, collected information on demographics, current tobacco use, amounts of tobacco used, and tobacco related attitudes. RESULTS: Total of 241 (60.3%) individuals did not currently use tobacco, 104 (26%) currently smoked, 74 (18.5%) currently used ST, and 19 (4.8%) used both products. Thus, 19 of 104 (18.3%) current smokers and 19 of 74 (25.7%) current ST users reported dual tobacco use. Compared to exclusive users of either tobacco product, dual tobacco users were intermediate in age and frequency of church attendance, had lower levels of education, and were the highest proportion of subjects reporting no friends and few close relatives. There was no difference by gender or marital status by tobacco use categories. While exclusive cigarette smokers reported smoking more cigarettes per day than dual tobacco users, overall, dual tobacco users had higher estimated daily nicotine exposure levels. Logistic regression analysis showed that younger age and infrequent church attendance predicted exclusive cigarette smoking, while older age and less education predicted exclusive ST use. Dual tobacco use was predicted only by less education. CONCLUSIONS: Simultaneous use of ST and cigarettes is comparatively more common among Lumbee Indian adults than the general population and has an epidemiology distinct from either exclusive cigarette smoking or ST use. These data are the first to explore social support as well as tobacco-related attitudes among dual tobacco users in a Native American population. Recognition of these patterns of dual tobacco use would be important in any future tobacco intervention among Lumbee Indian adults.

Association between smokeless tobacco use and breast cancer among Native-American women in North Carolina.

BACKGROUND: Cigarette smoking and smokeless tobacco use have been associated with the development of a variety of cancers. While cigarette smoking may be associated with breast cancer, smokeless tobacco use has never been evaluated as a breast cancer risk factor. This study explores such an association. METHODS: A complete census was carried out among Eastern Band Cherokee women aged 18 years and older, residing on tribal lands in western North Carolina. Self-reported alcohol, cigarette and smokeless tobacco use, demographic information, and personal history of breast cancer (stratified by age of onset < 55 years or > or = 55 years) were obtained by questionnaire. RESULTS: 1,070 out of 1,408 (76%) eligible women were interviewed. Current and former smokeless tobacco use was common (6% and 21%, respectively). Five cases of breast cancer were identified in women under the age of 55 years and 3 cases were found in women at > or = 55 years. Only the odds ratio (OR) for younger-onset breast cancer among ever-users of smokeless tobacco was significantly elevated (OR = 7.79, 95% CI = 1.05-66.0). While the ORs for younger onset breast cancer were elevated among ever-smokers or women reporting at least monthly alcohol use, these were not significant (OR 8.49, 95% CI = 0.09-200; and OR = 1.72, 95% CI = 0.19-15.2, respectively). No ORs were significantly elevated for breast cancer among older women. CONCLUSIONS: These preliminary data are the first to document an apparent relationship between smokeless tobacco use and breast cancer risk, but should be confirmed in other studies due to the small number of cases. The nearly 8-fold increase in risk suggests that smokeless tobacco is not a safe alternative to cigarette smoking.

Native American recruitment into breast cancer screening: the NAWWA project.

BACKGROUND: American Indian women's historically low breast cancer incidence and mortality rates have gradually increased such that in many parts of the United States they equal "U.S. All Races" rates. Thus, American Indian women need screening to maintain their low rates. METHODS: In an outreach program, local American Indian women were trained as lay health advisers, "Native Sisters," to locate and contact American Indian women in the Denver metropolitan area and provide education and encouragement to increase participation in mammography screening. Participation was monitored and interviews collected descriptive information and information about risk factors for breast cancer. An interrupted-time-series design was used to assess changes in mammography participation. RESULTS: The NAWWA program increased recruitment of American Indian women (p < 0.05). Women recruited by the Native Sisters were more likely to be currently on hormone replacement therapy and to be menopausal. CONCLUSIONS: The lay health adviser program was effective in recruiting American Indian women to have screening mammography. Barriers to participation were complex and often involved cultural values and beliefs.

Psychosocial factors associated with the use of breast cancer screening by women age 60 years or over.

This study examined psychosocial factors related to breast cancer screening among older women. Data for the study were obtained from interviews with 719 women age 60 years or over attending rural and urban primary care clinics in North Carolina. The results indicated that 50% of the women had mammograms in the past year, 65% reported clinical breast examinations in the past year, and 31% said they practiced breast self-examinations once a month. Several psychosocial factors were significant predictors of a lower likelihood of being screened. Multivariate analysis confirmed the importance of psychosocial factors as predictors of breast cancer screening. Educational intervention to increase screening for breast cancer in this population is needed, and the results provide specific suggestions regarding the content of effective educational materials and approaches for older women.

Epidemiology of tobacco use among Lumbee Indians in North Carolina.

BACKGROUND: Little is known regarding tobacco use among the Lumbee Indians in southeastern North Carolina, despite high prevalence of use and ties to tobacco-related agriculture. This report describes current and early childhood tobacco use in this population. METHODS: A cross-sectional telephone survey of 400 adult Lumbee Indians was done in Pembroke, Robeson County, NC. Information was collected on demographics, tobacco use, knowledge and practices related to tobacco agriculture, and ceremonial tobacco use. RESULTS: 17.8% and 18.2% of the sample reported current and former smokeless tobacco (ST) use, and 26% and 19.5% reported current and former cigarette (CG) use, respectively. 17.3% reported ever use of both CG and ST. Current ST use was associated with older age, childhood involvement in tobacco-related agriculture, and less education. Current CG use was associated with younger age, male sex, less education, having never been married, infrequent church attendance, and fewer close friends or relatives. Early initiation of ST and CG use was more common among women, while early initiation of CG use was more common among persons who were younger and had lower levels of education. CONCLUSIONS: Current ST use is unusually common among Lumbee adults, while CG use reflects rates found in other populations. These data show different patterns of CG use and ST use, and suggest that strategies for tobacco use cessation must target each specific product.

Church-related correlates of tobacco use among Lumbee Indians in North Carolina.

BACKGROUND: Although minority populations suffer a disproportionately higher burden of tobacco-attributable morbidity and mortality, the church appears to be a promising avenue through which to pursue tobacco-cessation interventions in these communities. This report describes church-related correlates of tobacco use among the Lumbee Indians in North Carolina, a population with a high prevalence of tobacco use, strong ties to tobacco-related agriculture, and high levels of church participation. METHODS: A cross-sectional telephone survey of 400 adult Lumbee Indians was carried out in Pembroke, a town in Robeson County, NC. The questionnaire elicited information on tobacco use, demographic and social support information, knowledge and practices related to tobacco agriculture and traditional Native American tobacco use and church participation. RESULTS: Sixty-three percent of participants were church members and 82% said the church is "very important" to the Lumbee community. In bivariate analysis, church attendance over the past year correlated with age, education, gender, number of close friends and relatives, marital status and current smoking status. Church attendance was not related to current smokeless tobacco use or participation in tobacco-related agriculture. Current smokers who had not attended church in the past year smoked significantly more cigarettes per day than current smokers attending church more often. In logistic regression, participants attending church weekly or more often were 73% less likely to be current smokers (adjusted odds ratio [AOR] = 0.27, 95% confidence interval [CI] = 0.11-0.68). Among ever-smokers, participants having attended church infrequently in the past year were 79% less likely to have quit (AOR = 0.21, 95% CI = 0.07-0.65). Having participated in tobacco agriculture as a child predicted current Christian views on tobacco use. DISCUSSION: Tobacco use, common among Lumbee adults, correlates with a variety of demographic and social support variables. In addition, these data are the first to uncover a dose-response relationship between church attendance and number of cigarettes smoked per day by current smokers, and the relationship between childhood participation in tobacco agriculture and Christian views on tobacco use. Our results should be useful in designing a church-based tobacco-cessation intervention among Lumbee Indians.

Health education to increase screening for cervical cancer among Lumbee Indian women in North Carolina.

Although age-adjusted mortality rates from cancer among Native-Americans are generally lower than for the US population as a whole, cervical cancer mortality rates are higher. This report presents results from a National Cancer Institute-funded health education program conducted among the Lumbee tribe in North Carolina that was designed to increase the proportion of women, age 18 and older, who receive Pap smears to screen for cervical cancer. The Solomon Four Group research design was used for this project. Participants were selected at random from the enrollment records of the Lumbee tribe and data collection was carried out during face-to-face interviews. The health education program was provided one-on-one in women's homes by a trained lay health educator and included verbal, print and videotape information. A total of 979 women were enrolled in the study, and 125 were lost to follow-up between the pre-test and post-test. Women who received the education program were found to be more likely to have knowledge of the Pap smear and to report a Pap smear in the past year at the post-test than those in the control group, regardless of whether they received the pre-test interview, P < 0.05. Women most likely to respond to the education program were also likely to have reported that they receive an annual physical examination. Women with better knowledge of the Pap smear tended to have more education, higher income and greater identification with Native-American culture than those with less knowledge. We conclude that the health education program was associated with greater knowledge about cervical cancer prevention and higher proportions of Lumbee women obtaining Pap smears in the past year.

Prevalence and predictors of tobacco use among Lumbee Indian women in Robeson County, North Carolina.

Tobacco use among some Native American tribes is high compared to the overall US population. Little is known, however, about tobacco use among Native Americans in North Carolina, a state with strong economic ties to tobacco. To assess the epidemiology of tobacco use in this population, data from the North Carolina Native American Cervical Cancer Project was reviewed. Nine hundred eighty-two Lumbee Indian women in Robeson County provided general demographic information as well as information on cancer risk knowledge, attitudes and behaviors during the 5-year study. Women were selected from the community using a random sample of 5200 persons from the tribal roll of approximately 40,000 persons. 20.6% of women were current smokeless tobacco users, while 23.7% were current smokers. Demographic and social support predictors were unique for the different types of tobacco use. Cigarette smoking was associated with younger age, higher education, excellent or good self-reported health, having a recent physical exam, separated or divorced marital status, low church participation, and alcohol consumption. Conversely, use of smokeless tobacco was associated with older age, lower education level, fair or poor self-reported health, widowed marital status, and having a high number of friends. These data show a high prevalence of smokeless tobacco use among women in this population, and a contrast in the predictors of tobacco use by source. Intervention programs for tobacco use cessation should be sensitive to these differences.

Correlates of tobacco use among Native American women in western North Carolina.

OBJECTIVES: This study examined correlates of tobacco use among Cherokee women. METHODS: Prevalence rates were analyzed for 614 randomly selected Eastern Band Cherokee women. RESULTS: The prevalence rates for current smokeless tobacco use and smoking were 8% and 39%, respectively. Smokeless tobacco use correlates included lower education and having consulted an Indian healer. Smoking correlates included younger age, alcohol use, no yearly physical exam, separated or divorced marital status, and lack of friends or church participation. CONCLUSIONS: Smoking rates among these women were slightly above national rates. The association of smokeless tobacco use with having consulted an Indian healer may help in understanding Cherokee women's smokeless tobacco use.

Skin cancer prevention and early detection practices in a sample of rural women.

BACKGROUND: The incidence of skin cancer in the United States is rapidly increasing, and current estimates suggest that about one in five persons will be diagnosed with skin cancer in their lifetime. However, comparatively little is still known about the prevention and early detection behaviors of healthy individuals. This study presents information on prevention and early detection practices for a sample of non-Hispanic rural white women. METHOD: Interviews were conducted with 1,295 women age 20 or older who were patients in six public health departments and one primary-care clinic serving a low-income population, all located in rural western North Carolina. RESULTS: Both prevention and early detection behaviors were found to be infrequent in this population. Low knowledge of skin cancer, younger and older ages, and low education characterized women least likely to practice prevention. Low knowledge, younger age, and low education characterized women least likely to practice early detection. Perceived barriers to cancer screening including cost, lack of symptoms, and denial also were predictive of a low likelihood of both prevention and early detection behavior. Fatalism and fear of the stigma associated with cancer also were predictive of lower participation in selected early detection behaviors. A summary general barriers score was significantly associated with all prevention and early detection behaviors examined in the study. CONCLUSIONS: The results indicate a need for skin cancer education among this population.

Factors associated with participation in a preventive cardiology service by patients with coronary heart disease.

A free preventive cardiology service for patients and their asymptomatic family members was established at a large teaching hospital in the southeastern United States to provide medical triage and risk reduction counseling for prevention of coronary heart disease. Patients and families were informed about the service and invited to attend during a personal visit from members of the preventive cardiology consultation service. Our study was designed to explore determinants of decisions to attend the clinic. We conducted telephone interviews with 62 consecutive patients to collect data on individual perceptions of health risks, factors that modify perceptions of health risks and ability to make behavior changes, and actions taken to reduce risk of disease. Of the 62 patients interviewed, 39% had attended the clinic. Patients hospitalized for myocardial infarction or bypass surgery were more likely to attend the clinic than those who had angioplasty or catheterization without bypass surgery.

Evaluation of health education programs: current assessment and future directions.

Recently there has been an increase in the different types of strategies used in health education interventions, including an emphasis on broadening programs focused on individual behavior change to include larger units of practice. There has also been an increasing critique of the traditional physical science paradigm for evaluating the multiple dimensions inherent in many interventions. Additionally, there is a growing recognition of the importance of involving multiple stakeholders in designing, implementing, and evaluating interventions. Each of these factors carries specific evaluation challenges. With the overall aim of strengthening the evaluation of health education programs, this article aims to (a) present conceptual and technical design issues and options, (b) describe different approaches to evaluation, (c) highlight evaluation approaches that have been effective, (d) critique the limitations of traditional evaluation approaches, (e) examine promising approaches and implications for future evaluations, and (f) provide recommendations for evaluation designs, data collection methods, roles, responsibilities, and principles for evaluating interventions.

Factors influencing the return rate in a direct mail campaign to inform minority women about prevention of cervical cancer.

The Forsyth County Cervical Cancer Prevention Project was a 5-year community-based health education program funded by the National Cancer Institute. The program was developed to reduce cervical cancer mortality among black women in Forsyth County, and it was targeted to those ages 18 and older. The program tried to educate the target population through a combination of mass media and direct education. This paper reports on an experiment conducted to investigate sources of influence on the effectiveness of direct mail, a technique used to augment mass media health education. Direct mail has shown promise as a method for reaching target populations that are difficult to reach with other mass media approaches. Using commercially prepared mailing lists sorted by zip code and other characteristics of the resident, health-related materials can be targeted to persons at their homes. A randomized experiment involving 1,000 households was carried out to estimate the influence of type of postage and address (name versus "resident or occupant") on the response rate to direct mail. Results indicated that there was no significant advantage from use of first class over bulk rate postage, but the return was significantly greater when the envelope bore a name rather than "resident or occupant."

Cultural issues in the development of cancer control programs for American Indian populations.

Cancer is the third-leading cause of death among American Indians. The persistent disadvantage in cancer survival rates among American Indian populations emphasizes the importance of developing effective cancer control programs for prevention and early detection. However, substantial cultural differences between American Indians and whites can affect the success of these programs. This paper examines the concept of cultural sensitivity in the context of developing cancer control programs for American Indian populations. It explores fundamental differences in beliefs, behaviors, and values between American Indian and white majority cultures, and presents examples of culturally sensitive health education programs. The paper highlights insights and experiences gained in developing the North Carolina Native American Cervical Cancer Prevention Project, and gives recommendations for the development of future programs.