Colorectal cancer risk perceptions and screening intentions in a minority population.

This is a 2-year follow-up to a previously reported baseline paper. We focused on a predominantly low-income African-American population from a community health center and investigated the relationships among perceptions of perceived risks for colorectal cancer (CRC), concerns about getting CRC, screening intentions, and whether participants had a fecal occult blood test (FOBT) on schedule at follow-up. Baseline absolute risk did not predict screening intentions or being on schedule (15% of sample), nor did it predict follow-up perceived absolute risk, comparative risk, or CRC concerns. Participants who expressed greater perceived absolute risk, comparative risk, and concerns at follow-up were more likely to report thinking about or definitely planning to get an FOBT within the next 2 years (49% of the sample). In addition, baseline absolute risk and whether or not a person had an FOBT on schedule at baseline did not predict being on schedule at follow-up. A significant percentage of the population (20%) were not able to state whether their CRC risk was below average, average, or above average. In addition, 44% of the population viewed their risks as lower than their peers, and 58% reported being not at all or slightly concerned about getting CRC. These results suggest that educational efforts are needed especially for low-income minority populations to enhance knowledge and accuracy of risk perceptions for CRC and interventions that explicitly manipulate risk are needed to assess to what extent risk perceptions can be modified and subsequently affect screening.

Using tailored interventions to enhance smoking cessation among African-Americans at a community health center.

This prospective randomized study examined the impact of three tailored intervention approaches to increase quitting rates among African-American smokers who were clients of a community health center that serves primarily low-income and indigent persons. Smokers were randomized to one of three groups: (1) health care provider prompting intervention alone, (2) health care provider prompting intervention with tailored print communications, and (3) health care provider prompting intervention with tailored print communications and tailored telephone counseling. Among the 160 smokers who completed the study, 35 (21.8%) had quit smoking at follow-up. Smokers who received the provider prompting intervention with tailored print materials were more likely to report having quit than smokers who received the provider intervention alone (32.7% vs. 13.2%, p < 0.05). Smokers who received all three intervention components were not more likely to report having quit at follow-up than those who only received the provider intervention (19.2% vs. 13.2%). Smokers who at baseline were less educated, smoked less than half a pack of cigarettes per day, had a stronger desire to quit, felt more efficacious, and had thought about quitting were more likely to report having quit at follow-up. These results provide support for continued refinement of tailored communications to aid smoking cessation among African-American smokers.

Computerized prompts for cancer screening in a community health center.

BACKGROUND: We describe the implementation and subsequent use of a computerized health maintenance tracking system in a large, urban, North Carolina community health center (Lincoln Community Health Center) as part of a larger study designed to increase rates of mammography, Papanicolaou tests, and smoking cessation in low-income African-Americans. METHODS: Clinicians from the Lincoln Community Health Center were involved in the design and implementation of the computer system. At each office visit, clinicians received a computerized encounter form indicating needed screening tests, counseling, and immunizations for each randomly selected study patient (n = 1318). RESULTS: Initial clinician compliance rates with filling out the form were 95 percent (mammography), 82 percent (Papanicolaou test), 77 percent (clinician breast examination), and 55 percent (smoking cessation). Cumulative compliance leveled off at 21 months to 65 percent, 57 percent, 53 percent, and 38 percent, respectively, despite multiple reminder strategies. When surveyed, most clinicians thought it was a good reminder system but said they did not always complete the form because of time demands. Costs of adapting and implementing the system were $23,332.08 ($17.70 per study). Per-patient costs would have been reduced further if more patients had been included in the project. CONCLUSIONS: State-of-the-art computer prompting systems can be useful in a community health center; however, even with prompting, clinicians still only addressed health maintenance with their patients about 50 percent of the time. Additional interventions will be needed, particularly in low-income populations, to meet the Healthy People 2000 goals in health promotion.

Readiness to change smoking behavior in a community health center population.

This study examines predictors of readiness to change smoking behavior in a sample of smokers who receive care at a community health center that serves a predominantly low income African American population. Prior to initiating interventions we conducted a telephone survey with a random sample of 1318 adult users who had visited the center in the last 18 months; 379 (28.8%) were current smokers (40.3% of males, 23.9% of females, 42.7% of Whites, and 25.3%, of African Americans). Multiple logistic regression analysis showed nine factors significantly associated with readiness to change smoking behavior: male gender; a previous quit attempt; a perception of risk of lung cancer from smoking; greater desire to quit smoking; a perception that smoking bothers others; doctor advice to stop smoking at last health visit; records kept for scheduling doctor appointments; thinking that losing a pleasure would not be a problem if quit smoking; and poorer self-reported health status. These findings provide direction for developing interventions for similar low income, high risk populations. The results indicate that it may be useful to heighten awareness of the risks of smoking and to assure that smokers receive clear quit smoking messages from their providers. Women need special attention since they are less ready to quit than men.

Colorectal screening patterns and perceptions of risk among African-American users of a community health center.

This study investigated risk perceptions and screening patterns for colorectal cancer among predominately low-income African-Americans age 50 and older who used a community health center. The majority of respondents either rated their risk as below average (36%) or did not know their risk (37%) for colorectal cancer. Individuals who provided a risk estimate versus those who did not know their risk were younger and held more accurate beliefs about colorectal cancer. Attributions of perceived risk best distinguished respondents who evaluated their risk to be below average versus average and above average. Compared to respondents who could not explain their risk, those who provided psychological, personal action, and heredity causes were more likely to view their risk as below average than average or above average. In comparison to national norms, these subjects reported higher frequencies of ever having had a digital rectal exam (DRE, 90%), fecal occult blood test (FOBT, 75%) and sigmoidoscopy (SIG, 33%). Moreover, 63%, 53%, and 81% reported their most recent screening for DRE, FOBT, and SIG, respectively, in accordance with ACS and NCI recommended guidelines. However, a subsequent medical audit failed to confirm these self-reports. These results suggest that: 1) educational efforts are needed to enhance knowledge and accuracy of risk perceptions for colorectal cancer; 2) further studies on attributions of risk are needed that may prove useful for developing intervention programs, and 3) studies need to interpret self-report data for colorectal cancer with caution.

Cancer screening practices among women in a community health center population.

BACKGROUND: Cancer takes a disproportionate toll on disadvantaged Americans. Poverty and low education are risk factors for underuse of cancer screening. METHODS: In this report, we discuss predictors of adherence to cancer screening (mammography, clinical breast exam [CBE], and Pap tests) among 926 women who receive care at a community health center that serves a predominantly low-income and minority population. We examine predictors for each of the tests and for a composite measure of overall cancer screening test compliance. In studying multiple screening behaviors we not only investigate factors associated with each individual behavior, but we also identify consistently effective factors across several behaviors. RESULTS: The analysis indicates consistent effects of age, education, and insurance status on cancer screening. In addition, decisional balance, a measure of a person's beliefs about the pros and cons of complying with the screening test, is associated strongly with adherence. We have extended earlier findings about the positive relationship between decisional balance and mammography to include decisional balance and Pap tests, as well. This finding suggests that behavioral interventions that target decisional balance can effectively promote adherence to cancer screening tests.

Gardnerella vaginalis infection and sexual contact in female children.

Gardnerella vaginalis (GV) infection has been reported as being acquired via sexual contact in adults and as an indicator of sexual contact in female children (DeJong, 1985). The purpose of this study was to determine if GV infection was more commonly found in 191 female children who gave a history of sexual contact and/or were infected with Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT) (Group 1), compared with 144 female children evaluated for possible sexual abuse and found to have no such history or infection with GC or CT (Group 2), or 31 female children (friends of the authors) without such a history or GC or CT infection (Group 3). Vaginal GV was found in 5.3% of Group 1, 4.9% of Group 2 and 6.4% of Group 3 (p > .05). Also, vaginal GV infection was not related to the type of sexual contact or race, but did increase with age in white female children. Because vaginal GV infection is not more commonly found in children with a history of sexual contact than those without such a history, the finding of GV in a vaginal culture in an individual case would not be a reliable marker of sexual contact. Routine culturing for GV is not recommended as part of a sexual abuse workup.

Epidemiology of adult sexually transmitted disease agents in children being evaluated for sexual abuse.

This prospective study describes the epidemiology of adult sexually transmitted disease agents in 1538 children ages 1 to 12 years being evaluated for possible sexual abuse. Infections with these agents were related to the presence or absence of a history of sexual contact. Neisseria gonorrhoeae (GC) was found in 2.8% (41 of 1469); human papillomavirus presenting as condyloma acuminata, 1.8%; Chlamydia trachomatis, 1.2% (17 of 1473); Treponema pallidum (syphilis), 0.1% (1 of 1263); and herpes simplex virus, 0.1%. Overall a history of sexual contact was present in 83% of children with N. gonorrhoeae; condyloma acuminata, 43%; Chlamydia trachomatis, 94%; syphilis, 0%; and herpes simplex virus, 50%. Selected vaginal discharges were examined for Trichomonas vaginalis and bacterial vaginosis. In children comprehending questions regarding sexual contact (i.e. were "verbal"), 89% with N. gonorrhoeae, 100% with Chlamydia trachomatis and 63% with condyloma acuminata had a history of sexual contact, indicating that in "verbal" children any infection with N. gonorrhoeae or C. trachomatis was highly associated with sexual contact.

Vaginal introital diameter in the evaluation of sexual abuse.

Physical objective markers to aid in the diagnosis of sexual abuse are few. We therefore studied 242 females, ages 1 through 12 years, to determine if the vaginal introital diameter is useful in evaluating a child for sexual abuse. The children were divided into three groups: Group I, history of sexual contact and/or Neisseria gonorrhoeae; Group II, no history of sexual contact but at risk; and Group III, nonabused. A vaginal introital transverse diameter of greater than 4 mm was more prevalent among children in Group I (94%) than in Group II, (5%); or in Group III (0%) (chi 2, p less than .001). Eighty-eight percent of children who complained of penile-vaginal penetration had a vaginal introital diameter greater than 4 mm as compared to 18% of children with no penetration (chi 2, p less than .001). Forty-six percent of children who complained of fondling with penetration had a vaginal introital diameter of greater than 4 mm as compared to 14% in those without a history of penetration (chi 2, p less than .008). Fifty-eight percent of children with more than one encounter had a vaginal introital diameter greater than 4 mm as compared to 29% in those with one encounter (chi 2, p less than .006). In a logarithmic regression analysis, the greatest proportion of children with a vaginal introital diameter greater than 4 mm was observed in the penile-vaginal contact group (chi 2, p less than .00003). The test is not very sensitive but highly specific. The sensitivity drops precipitously at greater than 5 mm without losing the specificity. A vaginal introital diameter of greater than 4 mm is highly associated with sexual contact in children less than 13 years of age.

Childhood vaginal infections: association of Chlamydia trachomatis with sexual contact.

To determine whether infections with Chlamydia trachomatis in children were significantly associated with previous sexual contact, we studied 124 female children ages 1 through 12 years with previous sexual contact and 90 female children without previous sexual contact. Vaginal, pharyngeal and rectal cultures for C. trachomatis were performed. Ten children with previous sexual contact and none without previous sexual contact had vaginal infections (P = 0.022, chi square test with 2 degrees of freedom). Rectal infections (three) and pharyngeal infections (two) were too few to relate statistically to sexual contact. We recommend that all female children being evaluated for sexual abuse be cultured for C. trachomatis, inasmuch as vaginal C. trachomatis is an excellent marker of sexual contact.