Neighborhood poverty and self-reported health among low-income, rural women, 50 years and older.

We examined the relationship between neighborhood socioeconomic context and self-reported health among low-income, rural women aged 50+ years, without a history of breast cancer. Tract-level census data were linked to individual level data from the baseline survey of a community trial to increase breast cancer screening rates. Generalized estimating equations were used to analyze data for 1988 women and 56 census tracts. Neighborhood poverty was associated with a greater likelihood of poor self-reported health, adjusted for age, race and socioeconomic status (OR=1.35, 95% CI=1.08-1.68). This effect was greatest for individuals with incomes below the median neighborhood income.

State gun control advocacy tactics and resources.

CONTEXT: Enacting state laws to regulate firearm use, availability, or manufacture is one plausible strategy for preventing firearm-related injuries. Organizations that use a wide range of advocacy tactics may be successful in promoting gun control policies. OBJECTIVES: To describe tactics commonly used by groups that advocate for state gun control laws and to assess whether financial resources were associated with groups' use of these advocacy tactics. DESIGN/PARTICIPANTS: We identified 679 local and state organizations potentially active on state-level gun control issues in 1998 and mailed a 153-item questionnaire to the groups' leaders. MAIN OUTCOMES: Organizations' use of 35 gun control advocacy tactics. RESULTS: Seventy-nine percent (n=538) of groups responded to our survey, and, of those eligible, eighty-one percent (n=207) completed questionnaires. Organizations commonly used public education, media, and legislative lobbying tactics, and fewer engaged in electioneering and litigation. Except for lobbying, no associations were found between groups' use of advocacy tactics and their level of financial resources. CONCLUSIONS: Organizations advocating for state gun control laws have a varied tactical repertoire, with fewer using electioneering and litigation than other approaches. Financial resources do not appear to be the determining factor in the advocacy methods employed.

The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening?

OBJECTIVES: This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population. METHODS: In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties. RESULTS: Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income). CONCLUSIONS: Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.

Expanding the role of mammographers: a training strategy to enhance mammographer-patient interaction.

The use of routine mammography screening is associated with earlier breast cancer detection and decreased mortality. Several researchers have identified mammographers as potentially effective agents for encouraging patients to engage in routine screening. Mammographers are particularly well situated within the health care system to address patients' knowledge, psychological, and cultural barriers to routine screening. Few opportunities exist, however, for mammographers to acquire skills in providing culturally-sensitive patient education and emotional assessment to help women overcome such barriers. In 1997 the North Carolina Breast Cancer Screening Program (NC-BCSP) developed and implemented an innovative, two-hour training program to help mammographers address the educational and psychosocial needs of rural, African American women in eastern North Carolina. NC-BCSP's extensive survey data (n=2000), as well as qualitative data from 25 focus groups conducted with more than 200 rural African American women, were used to develop a curriculum titled Expanding the Role of Mammographers. It was the first American Society of Radiologic Technologists (ASRT) accredited training program for mammographers in North Carolina that solely addressed psychosocial topics. The curriculum emphasized mammographers' potential impact on women's attitudes and behavioral intentions, and taught communication strategies to enhance mammographer-patient interaction. It included supplemental learning materials, skill-building exercises, and patient education materials to assist participants in applying new skills and knowledge. Of the 33 mammographers invited to the training, 19 attended. A structured evaluation form, completed by 18 participants, conveyed positive reactions to the intervention. This training workshop was conducted as part of NC-BCSP's much larger, community-based intervention; as such, it was not independently evaluated. NC-BCSP's broader intervention appears to be associated, however, with positive population-level changes in breast cancer awareness and mammography use.

Trust and collaboration in the prevention of sexually transmitted diseases.

High rates of sexually transmitted diseases (STDs) are sustained in communities by a relatively small group of people, referred to as the core of transmission. Definitions of the core vary but inevitably include people who are socially marginalized and who distrust people in authority, such as public health practitioners and university researchers. Having an effect on a marginalized group usually depends on effective collaboration with people they trust. Researchers from the University of North Carolina School of Public Health developed a trust-based collaboration with community members of a rural county in North Carolina to implement an STD prevention program that, in turn, relied on trust in local social networks. As part of the STD prevention demonstration project, the research team established a community resource group made up of local African Americans who helped design, implement, and evaluate the intervention. The group identified 21 women to whom others in the community turned for advice on sex and STDs. These women were trained as lay health advisors to disseminate information and skills for preventing STDs among their social networks. Through face-to-face structured interviews before and after the intervention, the authors measured improvements in STD treatment and prevention behaviors. The proportion of people practicing each of the targeted behaviors improved during the evaluation period. In addition to disseminating information through their own social networks, the lay health advisors demonstrated new skills and a desire to interact with local care providers to influence the provision of care for STDs for low-income African Americans in this county. Each participant in the collaboration played a role in establishing or building upon trust with others. These trusting relationships were critical for empowering a marginalized group at high risk for STDs.

Communicating results of diagnostic mammography: what do patients think?

RATIONALE AND OBJECTIVES: The purpose of this study was to investigate women's preferences for who (radiologist or referring physician) should communicate the results of diagnostic mammography. MATERIALS AND METHODS: Data from 153 women presenting to two sites for diagnostic mammography between February and June 1995 were collected with a 24-item, self-administered, closed-ended survey. For both normal and abnormal hypothetical results, contingency tables with chi2 tests and multiple logistic regression were used to determine the association, if any, between women's characteristics and their preferences. RESULTS: Women undergoing diagnostic mammography preferred that their radiologists disclose their normal (90%) and abnormal (88%) mammogram results to them immediately after their examination, rather than have their referring physicians disclose results at a later time. In the case of normal findings, women whose regular physicians were specialists were less likely to want to hear first from their radiologists (odds ratio [OR] = 0.06; 95% confidence interval [CI] = 0.01, 0.77; P = .03), but women who were nervous about learning their results were more likely to want to hear first from their radiologists (OR = 4.5; 95% CI = 1.2, 17.3; P = .03). CONCLUSION: Radiologists may want to consider assessing women's preferences for who communicates their mammogram results, as most women in this study preferred to hear these results from their radiologists rather than waiting to hear from their referring physicians.

Frequent re-infection in a community with hyperendemic gonorrhoea and chlamydia: appropriate clinical actions.

In a cohort of 1200 individuals experiencing an index infection of gonorrhoea or chlamydia in a rural North Carolina county, we studied the risk factors for re-infection within 16 months. The occurrence of asymptomatic re-infection was estimated from a sample of controls. Re-infection with either of the two STDs occurred in one-quarter (24%) of the study participants and 22% of the controls. The factors associated with re-infection were age less than 25 years, African-American race, male sex, and infection prior to the index infection. The behavioural and attitudinal variables tested were not associated with re-infection. The patterns of re-infection in this study do not provide guidance for targeting resources toward a subgroup of the clinic population. Structuring clinical services to make them more available and acceptable to all potential clinic clients can contribute to decreasing the duration of infections. Lowering the community prevalence in this way will then decrease the likelihood of re-infection rates.

The sexual behavior of married Mexican immigrant men in North Carolina.

In the southern United States, North Carolina has attracted an unprecedented influx of Hispanic immigrants in the 1990s. Detailed data on the sexual behavior of these recent immigrants are lacking. This exploratory study used two methods, a survey and qualitative interviews. For both methods, participants were recruited using convenience sampling. All study participants were first-generation Mexican immigrants who had lived in North Carolina for at least six consecutive months. The survey, administered face-to-face, explored the sexual attitudes and behavior of 43 married Mexican men living in North Carolina. The qualitative interviews, conducted with men (n = 20) and women (n = 19), explored immigrants' perceptions of extramarital sex and sexually transmitted diseases (STDs). The study's results suggest that the sexual behavior of 'unaccompanied' married Mexican immigrant men, living alone in North Carolina, differs, at least in degree if not in kind, from that of 'accompanied' married men, residing in the state with their wives. Unaccompanied men who participated in the survey reported more lifetime sexual partners, more partners in the previous year, more extramarital partners and more contact with prostitutes than accompanied survey respondents. The qualitative interviews suggest that unaccompanied men's peculiar status as 'single' men in North Carolina may provide them with both motive and opportunity to have extramarital sexual relationships and that few married Mexican men and women perceive STDs as relevant to their lives. Overall, the study supports the need for male- and couple-focused STD prevention interventions for Hispanic immigrants.

Evaluation and lessons learned from a lay health advisor programme to prevent sexually transmitted diseases.

We implemented a lay health advisor (LHA) intervention to decrease rates of sexually transmitted disease (STD) among rural low income African-Americans. Twenty-one women identified by their peers as natural helpers were trained as LHAs to disseminate information, change attitudes, and improve skills among their social networks in the neighbourhoods with the highest STD rates. The behaviours they targeted involved care-seeking and condom use. The outcome evaluation included cross-sectional household surveys conducted before the intervention and after 18 months of activity. The proportion seeking prompt care for an STD increased 60%; those seeking screening for infection after suspecting exposure increased 25%. Consistent condom use with main partners increased by 23%. An LHA intervention in this population appears efficacious for improving STD-related care seeking behaviours but the effect on condom use with main partners is less clear.

The role of physician recommendation in women's mammography use: is it a 2-stage process?

OBJECTIVE: To explore the use of a 2-stage model in explaining the role of physician recommendation in women's use of mammography screening and to provide an integrated framework for understanding the mammography-use process. METHODS: Data on 1,301 women aged > or =52 years from the North Carolina Breast Cancer Screening Program (NC-BCSP) questionnaire were combined with information from 91 of their physicians from the North Carolina Medical Board. A 2-stage system of equations using women's characteristics (demographic, health, access), physicians' characteristics (demographic, practice), women's beliefs, and women's report of a physician recommendation was created and statistically tested. The model was estimated using 2-stage logistic and probit estimation. RESULTS: The 2-stage approach produced different results compared with the single pooled model. In the second-stage mammography-use model, younger age, family history of breast cancer, and a woman's having ever requested a mammogram retained significance (P < or = 0.05) in addition to the predicted value of physician recommendation obtained from the first stage. Women's characteristics significantly associated with physician recommendation in the first stage included some access, health risk, and demographic variables as well as physician age and race (P < or = 0.05). CONCLUSIONS: A 2-stage model for estimating mammography use among women with regular physicians may be more informative than a single model. These results imply that programs designed to increase mammography rates should focus on ensuring appropriate physician recommendations in addition to encouraging women to request screening. Future research should consider using an integrated framework for evaluating utilization of mammography and other preventive services.

Lay health advisor activity levels: definitions from the field.

One type of lay health advisor model assumes that an effective mechanism for reaching the underserved is through informal advice-givers called natural helpers. Despite the growing use of this approach, few programs have defined what an active lay health advisor does within the natural helping process. To explore perceptions and definitions of lay health advisors' activity, we conducted semistructured, in-person interviews with four field staff who coordinate the advisors' activities in a breast cancer screening program. These staff viewed lay health advisor activity as fluctuating over the course of a year, occurring along a continuum of participation (inactive, moderately active, active, and superactive), and reflecting varying degrees of proactivity and participation in multiple activities. These results suggest an empirical process for refining the definition of an active lay health advisor, improving advisors' productivity in achieving outreach objectives, and managing and monitoring their ongoing activities.

Community physicians who provide terminal care.

BACKGROUND: Most dying patients are treated by physicians in community practice, yet studies of terminal care rarely include these physicians. OBJECTIVE: To examine the frequency of life-sustaining treatment use and describe what factors influence physicians' treatment decisions in community-based practices. METHODS: Family members and treating physicians for decedents 65 years and older who died of cancer, congestive heart failure, chronic lung disease, cirrhosis, or stroke completed interviews about end-of-life care in community settings. RESULTS: Eighty percent of eligible family and 68.8% of eligible physicians participated (N = 165). Most physicians were trained in primary care and 85.4% were primary care physicians for the decedents. Physicians typically knew the decedent a year or more (68.9%), and 93.3% treated them for at least 1 month before death. In their last month of life, 2.4% of decedents received cardiopulmonary resuscitation, 5.5% received ventilatory support, and 34.1% received hospice care. Family recalled a discussion of treatment options in 78.2% of deaths. Most discussions (72.1%) took place a month or more before death. Place of death, cancer, and having a living will were independent predictors of less aggressive treatment before death. Physicians believed that advanced planning and good relationships were the major determinants of good decision making. CONCLUSIONS: Community physicians use few life-sustaining treatments for dying patients. Treatment decisions are made in the context of long-term primary care relationships, and living wills influence treatment decisions. The choice to remain in community settings with a familiar physician may influence the dying experience.

What lay health advisors do: An evaluation of advisors' activities.

PURPOSE: Since the 1970s, health promotion and disease prevention programs that rely on lay health advisors have proliferated, making it important to ascertain the levels and types of activity that can reasonably be expected from such advisors. This report describes the activities of lay health advisors participating in a program to increase mammography screening by older African American women and shares lessons that the authors learned about evaluating advisors' activities. DESCRIPTION OF STUDY: Between September 1994 and January 1996, 144 lay health advisors, associated with the North Carolina Breast Cancer Screening Program, were asked to complete, on a periodic basis, a standardized, self-administered activity report that asked about group presentations in the past 3 months and one-on-one contacts in the past week. Eighty-five advisors submitted one or more reports. The authors tabulated responses for lay health advisors overall, for those turning in one or more reports, and for those reporting a specific type of activity. RESULTS: The responses showed that North Carolina Breast Cancer Screening Program lay health advisors made approximately one group presentation every 3 months and had one to three individual contacts per week. Group presentations were commonly in churches and homes, and focused on who needs a mammogram, how then, and where to get one. During one-on-one encounters, advisors primarily encouraged women to get mammograms or discussed fears about mammograms. CLINICAL IMPLICATIONS: Information about lay health advisor activities serves several important purposes. Such information allows programs to identify the types of messages that lay health advisors transmit and the number of contacts they make, while also identifying the groups that are more and less difficult to reach, and the topics and locations favored by advisors and the women they contact. Activity data may indicate what resources or other support the advisors need, whether in-service training is necessary, and how to enhance the recruitment and training of additional lay health advisors.

Promoting breast cancer screening in rural, African American communities: the "science and art" of community health promotion.

Implementing community health promotion programs can be a daunting task for social workers. Aside from the practical skills necessary for engaging diverse groups, it requires an understanding of the complex interplay of several theoretical constructs. Using an eight-year breast cancer prevention project, the North Carolina Breast Cancer Screening Program, as a case study, this article describes both the "science and art" of community health promotion. The article provides examples illustrating the "art" of generating participation by both lay and professional communities and concludes with guidelines for social workers who plan to conduct their own community health promotion programs.

Partner-specific sexual behaviors among persons with both main and other partners.

CONTEXT: If men and women engage in different sexual behavior with main partners than with other types of partners, then programs aimed at preventing the spread of sexually transmitted diseases (STDs) may need to address individuals' differential risk with each partner type. METHODS: Relationship characteristics, partner risk behaviors and sexual behaviors are examined among 123 male and 106 female STD clinic patients who had both main and other partners. Individual-level comparisons are made for two types of partner pairs: main vs. other frequent (side) partners and main vs. casual partners. RESULTS: Among men and women with both main and side partners, the proportion who had known only their main partner for at least a year (48% of men and 41% of women) was significantly higher than the proportion who had known only their side partner for that long (2% and 9%, respectively); no other variable differed significantly by partner type. Among those with main and casual partners, both men and women were more likely to use alcohol or drugs before or during sex with main partners only (15%) than with casual partners only (1-3%). Women with main and casual partners were more likely to have oral sex only with main partners than only with casual partners (37% vs. 3%), and were more likely to use condoms only with casual partners than only with main partners (33% vs. 4%). CONCLUSIONS: Providers need to ask individuals about their sexual behaviors with different partner types, and should tailor prevention messages to an individual's risks and reproductive intentions with each partner.

PIP: Having multiple sex partners may increase a person's chance of having sex with someone who is infected with HIV. Moreover, a person may have a certain sexual behavior with his or her primary sex partner which differs from that shared with other secondary partners. Sexually transmitted disease (STD) prevention and control programs may therefore need to address individuals' differential risk with each partner type. Relationship characteristics, partner risk behaviors, and sex behaviors were studied among 123 male and 106 female STD clinic patients who had both main and other partners. Among men and women with both main and other frequent partners, 48% of men and 41% of women had known their main partner, but not their other partners, for at least 1 year. These proportions compare to 2% of men and 9% of women who had known their other frequent partners, but not their main partner, for at least 1 year. Among those with main and casual partners, both men and women were more likely to use alcohol or drugs before or during sex with main partners only (15%) than with casual partners only (1-3%). Women with main and casual partners were more likely to have oral sex only with main partners than only with casual partners (37% vs. 3%), and were more likely to use condoms only with casual partners than only with main partners (33% vs. 4%).

Screening mammography behavior after a false positive mammogram.

This pilot study describes women's interpretations of the experience of a false positive mammogram followed by a negative biopsy and the impact of this experience on subsequent participation in screening mammography. A 25-min, open-ended telephone interview was administered in 1992 to 30 women over age 39 who had negative biopsies in 1987 preceded by abnormal mammograms. Almost twice as many women reported getting regular mammograms after the biopsy (60%) as did before 1987 (33%). Most received their next mammogram after the biopsy within the recommended interval (73%), and those getting regular mammograms prior to the biopsy experience were more likely than those who did not have a prior habit of undergoing mammography to continue to get them afterwards. These preliminary findings suggest that a negative breast biopsy after a positive mammogram does not reduce a patient's likelihood of undergoing screening in the future. In fact, it may serve as an impetus for increased compliance with screening recommendations.

Bringing down the barriers to mammography: a review of current research and interventions.

Although mammography screening is effective in reducing breast cancer mortality, major challenges still remain in increasing rates of initial mammography and in improving subsequent adherence to mammography screening. Behavioral science theories offer insights into the potential for individual, organizational, community, and population-level interventions to address these challenges. In this review, we draw on social ecological approaches to health promotion to suggest a conceptual framework for such interventions. After discussing theories of who is and is not screened regularly, and why, we consider selected barriers to mammography and corresponding interventions to overcome them. We conclude with an illustration of the North Carolina Breast Cancer Screening Program (NC-BCSP), a series of interventions informed by the social ecological perspective.

Lay health advisors: a strategy for getting the word out about breast cancer.

Transforming natural helpers into lay health advisors (LHAs) is a complex undertaking. Using the North Carolina Breast Cancer Screening Program (NC-BCSP) as a case study, this article describes the steps involved in developing, implementing, and evaluating an LHA intervention, considering factors that make the LHA approach appropriate for the NC-BCSP's population, setting, and health focus. The authors review five phases of implementation (start-up, training, LHA activities, follow-up, resource mobilization) and discuss the NC-BCSP's evaluation strategies and tools in light of difficulties involved in assessing natural helping processes and impact. Program challenges related to resource needs, identification of natural helpers, and LHA monitoring and support also are considered. The authors describe ways in which one large group of older, rural, African American LHAs are helping establish countywide partnerships between health care providers, agencies, and local communities that support and sustain individual changes in health behavior.

Race and mammography use in two North Carolina counties.

OBJECTIVES: This study investigated racial differences in mammography use and their association with physicians' recommendations and other factors. METHODS: The study used 1988 survey data for 948 women 50 years of age and older from the New Hanover Breast Cancer Screening Program. Racial differences in terms of physician recommendation, personal characteristics, health characteristics, and attitudes toward breast cancer and mammography were examined. Factors at least minimally associated with race and use were included in multivariate logistic regression analyses to examine the effect of race while controlling for other factors. RESULTS: In comparison with White women. Black women were half as likely to report ever having had a mammogram (27% vs 52%) and having a mammogram in the past year (17% vs 36%). Black women also significantly less often reported physician recommendation (25% vs 52%). Although Black and White women differed significantly in other characteristics, multivariate logistic regression analyses indicated that physician recommendation accounted for 60% to 75% of the initial racial differences in mammography use. CONCLUSIONS: Understanding physicians' recommendations for breast cancer screening is a critical first step to increasing mammography use in disadvantaged populations.

The development of an instrument for assessing the quality of life of people with diabetes. Diabetes-39.

OBJECTIVES: The aim of this 2-year research project was to develop an instrument specifically designed to assess the quality of life of people with diabetes. METHODS: The project was divided into two phases. In the first phase, information from a detailed literature review, from existing quality-of-life instruments, and from interviews with health professionals and people with diabetes was used to develop an initial instrument of 92 items considered to address important aspects of patients' lives. This questionnaire was mailed to 1,000 people with diabetes, and data from the 516 respondents were used to select the most important and useful items. Fifty items were excluded, leaving 42 items that constituted the pilot instrument. During phase 2, the pilot instrument was used to assess the quality of life of 427 diabetic patients who completed the revised questionnaire. After analyzing this data, three additional items were dropped. The final instrument consists of 39 items and covers five dimensions of patients' lives: Energy and Mobility, Diabetes Control, Anxiety and Worry, Social Burden, and Sexual Functioning. RESULTS: The results of validity and reliability tests conducted to date testify to the relevance of the 39-item questionnaire (Diabetes-39) as a valid discriminative instrument, one which shows significant correlations with an overall quality-of-life assessment, the pattern of diabetes severity, and comorbidity. Further, the results from Diabetes-39 correlate well with the results from the established generic quality-of-life instrument, the Medical Outcomes Study 36-Item Short-Form Health Survey. CONCLUSIONS: Validation of a quality-of-life instrument, however, is an ongoing process. Further research is required to corroborate these early findings and to ensure that this is an instrument that can capture data of greatest relevance to the diabetic patient and that is responsive to change in quality of life.