Health care avoidance among rural populations: results from a nationally representative survey.

BACKGROUND: Previous research suggests that certain populations, including rural residents, exhibit health care avoidant behaviors more frequently than other groups. Additionally, health care avoidance is related to sociodemographics, attitudes, social expectations, ability to pay for care, and prior experiences with providers. However, previous studies have been limited to specific geographic areas, particular health conditions, or by analytic methods. METHODS: The 2008 Health Information Trends Survey (HINTS) was used to estimate the magnitude of health care avoidance nationally and, while controlling for confounding factors, identify groups of people in the United States who are more likely to avoid health care. Chi-square procedures tested the statistical significance (P < .05) of bivariate relationships. Multivariable analysis was conducted through a weighted multiple logistic regression with backward selection. RESULTS: For 6,714 respondents, bivariate analyses revealed differences (P < .05) in health care avoidance for multiple factors. However, multiple regression reduced the set of significant factors (P < .05) to rural residence (OR = 1.69), male sex (OR = 1.24), younger age (18-34 years OR = 2.34; 35-49 years OR = 2.10), lack of health insurance (OR = 1.43), lack of confidence in personal health care (OR = 2.24), lack of regular provider (OR = 1.49), little trust in physicians (OR = 1.34), and poor provider rapport (OR = 0.94). CONCLUSION: The results of this study will help public health practitioners develop programs and initiatives targeted and tailored to specific groups, particularly rural populations, which seek to address avoidant behavior, thereby reducing the likelihood of adverse health outcomes.

A pilot study for using fecal immunochemical testing to increase colorectal cancer screening in Appalachia, 2008-2009.

INTRODUCTION: The Appalachian region of the United States has disproportionately high colorectal cancer (CRC) death rates and low screening rates. The purpose of this pilot study was to assess acceptability of a take-home fecal immunochemical test (FIT) and the effect of follow-up telephone counseling for increasing CRC screening in rural Appalachia. METHODS: We used a prospective, single-group, multiple-site design, with centralized laboratory reports of screening adherence and baseline and 3-month questionnaires. Successive patients, aged 50 or older, at average CRC risk and due for screening were enrolled during a routine visit to 3 primary care practices in rural Appalachian Pennsylvania and received a free take-home FIT and educational brochure. Those who had not returned the test 2 weeks later were referred for telephone counseling. RESULTS: Of 232 patients approached, 200 (86.2%) agreed to participate. Of these, 145 (72.5%) completed the FIT as recommended (adherent) and 55 (27.5%) were referred for telephone counseling (nonadherent), of whom 23 (41.8%) became adherent after 1 to 2 counseling sessions, an 11.5 percentage-point increase in screening after telephone counseling and 84% FIT adherence overall. Lack of CRC-related knowledge and perceived CRC risk were the screening barriers most highly associated with nonadherence. Although not statistically significant, the rate of conversion to screening adherence was higher among participants who received telephone counseling compared to an answering machine reminder. CONCLUSION: If confirmed in future randomized trials, provider-recommended take-home FIT and follow-up telephone counseling may be methods to increase CRC screening in Appalachia.

An increase in HPV-related knowledge and vaccination intent among parental and non-parental caregivers of adolescent girls, age 9-17 years, in Appalachian Pennsylvania.

A theory and community-based educational intervention was designed to increase HPV-related knowledge and intent to vaccinate adolescent girls, against human papillomavirus (HPV) in Appalachia, a region with high cervical cancer incidence and mortality. An HPV educational session was conducted with immediate pre-/post-test questionnaires and 1-month follow-up telephone interview. McNemar tests and paired t tests evaluated change in individual knowledge variables and change in overall knowledge and intent to vaccinate against HPV, respectively. Of 117 attendees, 38 (32.5%) were parents of vaccine-eligible daughters and 79 (67.5%) non-parental caregivers. HPV-related knowledge increased for all participants (p < 0.0001) and among parents (p < 0.0001). Intent to vaccinate daughters within 1 month increased among parents (p = 0.002). Of nine (23.7%) parents who completed the follow-up interview, 100% reported the intervention as helpful and 44.4% reported that they started vaccination. Our education intervention was associated with increased HPV-related knowledge and intent to vaccinate girls in Appalachia against HPV.

Academic detailing to increase colorectal cancer screening by primary care practices in Appalachian Pennsylvania.

BACKGROUND: In the United States, colorectal cancer (CRC) is the third most frequently diagnosed cancer and second leading cause of cancer death. Screening is a primary method to prevent CRC, yet screening remains low in the U.S. and particularly in Appalachian Pennsylvania, a largely rural area with high rates of poverty, limited health care access, and increased CRC incidence and mortality rates. Receiving a physician recommendation for CRC screening is a primary predictor for patient adherence with screening guidelines. One strategy to disseminate practice-oriented interventions is academic detailing (AD), a method that transfers knowledge or methods to physicians, nurses or office staff through the visit(s) of a trained educator. The objective of this study was to determine acceptability and feasibility of AD among primary care practices in rural Appalachian Pennsylvania to increase CRC screening. METHODS: A multi-site, practice-based, intervention study with pre- and 6-month post-intervention review of randomly selected medical records, pre- and post-intervention surveys, as well as a post-intervention key informant interview was conducted. The primary outcome was the proportion of patients current with CRC screening recommendations and having received a CRC screening within the past year. Four practices received three separate AD visits to review four different learning modules. RESULTS: We reviewed 323 records pre-intervention and 301 post-intervention. The prevalence of being current with screening recommendation was 56% in the pre-intervention, and 60% in the post-intervention (p=0.29), while the prevalence of having been screened in the past year increased from 17% to 35% (p<0.001). Colonoscopies were the most frequently performed screening test. Provider knowledge was improved and AD was reported to be an acceptable intervention for CRC performance improvement by the practices. CONCLUSIONS: AD appears to be acceptable and feasible for primary care providers in rural Appalachia. A ceiling effect for CRC screening may have been a factor in no change in overall screening rates. While the study was not designed to test the efficacy of AD on CRC screening rates, our evidence suggests that AD is acceptable and may be efficacious in increasing recent CRC screening rates in Appalachian practices which could be tested through a randomized controlled study.