Health Education & Behavior

Mammography use has increased over the past 20 years, yet more than 30% of women remain inadequately screened. Structural barriers can deter individuals from screening, however, cognitive, emotional, and communication barriers may also prevent mammography use. This study sought to identify the impact of number and type of barriers on mammography screening status, and to examine whether number and type of barriers are different for never-screened and off-schedule women. A total of 182 women aged 40 years or older completed a computer kiosk facilitated survey as part of a larger patient navigator intervention. Logistic regression analysis indicated that breast cancer knowledge predicted whether a woman had ever had a mammogram (odds ratio [OR] = 1.04, 95% confidence interval [CI] = 1.02-1.06, p = .0003), while the number of emotional, structural, and communication barriers predicted whether a woman was on-schedule for mammograms (OR = 0.79, 95% CI = 0.65-0.95, p = .0127). The results suggest that to increase the use of mammography at recommended regular intervals, interventions should be tailored toward current screening status.

Objective. To assess colorectal cancer screening (CRCS) prevalence and psychosocial correlates of CRCS among Latinos in South Texas. Method. Using multivariable analyses, we examined the association of perceived susceptibility, self-efficacy, pros and cons, subjective norms, knowledge and fatalism on CRCS among 544 Latinos (50 years and older). Results. In this socioeconomically disadvantaged population, 40% had never heard of any CRCS test, only 34% reported ever completing any type of CRCS, and only 25% were adherent to CRCS guidelines. Insurance status, gender, perceived cons, CRCS self-efficacy, and CRCS norms were significantly associated with CRCS. Conclusion. CRCS interventions in this population should focus on improving access, increasing self-efficacy and perceived norms, and decreasing negative perceptions of CRCS.

Purpose. Colorectal cancer is the second most common cause of cancer death in the United States, and rates of screening for colorectal cancer are low. We sought to gather the perceptions of clinic personnel at Latino-serving Federally Qualified Health Centers (operating 17 clinics) about barriers to utilization of screening services for colorectal cancer. Method. We conducted one-on-one interviews among 17 clinic personnel at four Latino-serving Federally Qualified Health Center networks in Oregon. All interviews were recorded, transcribed, and coded, and themes were grouped by influences at three levels: the patient, the organization, and the external environment. Results. Estimated proportions of eligible patients who are underscreened for colorectal cancer ranged from 20% to 70%. Underscreening was thought to occur among low-income, underinsured, and undocumented patients and patients having multiple health concerns. Limited funding to pay for follow-up testing in patients with positive screens was cited as the key factor contributing to underscreening. Conclusions. We identified health care provider perceptions about the underutilization of screening services for colorectal cancer; our findings may inform future efforts to promote guideline-appropriate cancer screening.

The Internet has been used extensively to offer health education content and also for social support. More recently, we have seen the advent of Internet-based health education interventions that combine content with structured social networking. In many ways this is the Internet equivalent to small group interventions. While we have some knowledge about the efficacy of these interventions, few studies have examined how participants engage with programs and how that might affect outcomes. This study seeks to explore (a) the content of posts and (b) the nature of participant engagement with an online, 6-week workshop for cancer survivors and how such engagement may affect health outcomes. Using methodologies related to computational linguistics (latent Dirichlet allocation) and more standard statistical approaches, we identified (a) discussion board themes; (b) the relationship between reading and posting messages and outcomes; (c) how making, completing, or not completing action plans is related to outcome; and (d) how self-tailoring relates to outcomes. When considering all posts, emotional support is a key theme. However, different sets of themes are expressed in the first workshop post where participants are asked to express their primary concern. Writing posts was related to improved outcomes, but reading posts was less important. Completing, but not merely making, action plans and self-tailoring are statistically associated with future positive health outcomes. The findings from these exploratory studies can be considered when shaping future electronically mediated social networking interventions. In addition, the methods used here can be used in analyzing other large electronically mediated social-networking interventions.

Financial barriers can substantially delay medical care seeking. Using patient narratives provided by 252 colorectal cancer patients, we explored the experience of financial barriers to care seeking. Of the 252 patients interviewed, 84 identified financial barriers as a significant hurdle to obtaining health care for their colorectal cancer symptoms. Using verbatim transcripts of the narratives collected from patients between 2008 and 2010, three themes were identified: insurance status as a barrier (discussed by n = 84; 100% of subsample), finding medical care (discussed by n = 30; 36% of subsample) and, insurance companies as barriers (discussed by n = 7; 8% of subsample). Our analysis revealed that insurance status is more nuanced than the categories insured/uninsured and differentially affects how patients attempt to secure health care. While barriers to medical care for the uninsured have been well documented, the experiences of those who are underinsured are less well understood. To improve outcomes in these patients it is critical to understand how financial barriers to medical care are manifested. Even with anticipated changes of the Affordable Care Act, it remains important to understand how perceived financial barriers may be influencing patient behaviors, particularly those who have limited health care options due to insufficient health insurance coverage.

Background. Disparities in breast and cervical cancer screening by socioeconomic status persist in the United States. It has been suggested that social support may facilitate screening, especially among women of low socioeconomic status. However, at present, it is unclear whether social support enables mammogram and Pap test compliance. Purpose. This study examines the association between social support and compliance with mammogram and Pap test screening guidelines, and whether social support provides added value for women of low education. Method. Data were from a countywide 2009-2010 population-based survey, which included records of 2,588 women 40 years and older (mammogram) and 2,123 women 21 to 65 years old (Pap test). Compliance was determined using the guidelines in effect at the time of data collection. Results. Social support was significantly related to mammogram (adjusted odds ratio = 1.43; 95% confidence interval [1.16, 1.77]) and Pap test (adjusted odds ratio = 1.71; 95% confidence interval [1.27, 2.29]) compliance after controlling for age, race, having a regular health care provider, and insurance status. The interaction between social support and education had a significant effect on Pap test compliance only among women younger than 40; the effect was not significant for mammogram compliance. Conclusion. Social support is associated with breast and cervical cancer screening compliance. The association between education and cancer screening behavior may be moderated by social support; however, results hold only for Pap tests among younger women. Practitioners and researchers should focus on interventions that activate social support networks as they may help increase both breast and cervical cancer screening compliance among women with low educational attainment.

More than 60% of cancer-related deaths in the United States are attributable to tobacco use, poor nutrition, and physical inactivity, and these risk factors tend to cluster together. Thus, strategies for cancer risk reduction would benefit from addressing multiple health risk behaviors. We adapted an evidence-based intervention grounded in social cognitive theory and principles of motivational interviewing originally developed for smoking cessation to also address physical activity and fruit/vegetable consumption among Latinos exhibiting multiple health risk behaviors. Literature reviews, focus groups, expert consultation, pretesting, and pilot testing were used to inform adaptation decisions. We identified common mechanisms underlying change in smoking, physical activity, and diet used as treatment targets; identified practical models of patient-centered cross-cultural service provision; and identified that family preferences and support as particularly strong concerns among the priority population. Adaptations made to the original intervention are described. The current study is a practical example of how an intervention can be adapted to maximize relevance and acceptability and also maintain the core elements of the original evidence-based intervention. The intervention has significant potential to influence cancer prevention efforts among Latinos in the United States and is being evaluated in a sample of 400 Latino overweight/obese smokers.

Background. Dementia health literacy is low among the public and likely poses a significant barrier to Alzheimer’s disease (AD) symptom recognition and treatment, particularly among minority populations already facing higher AD burden. We evaluated the pilot phase of a novel AD health education program, Old SCHOOL (Seniors Can Have Optimal Aging and Ongoing Longevity) Hip-Hop (OSHH), which is designed to enable children to be AD health educational conduits in the home (“child-mediated health communication”). Method. OSHH applied our stroke-validated model of engaging, dynamic, and age- and culturally appropriate curriculum delivered to elementary school-age children (fourth/fifth grades, ages 9-11 years). We assessed AD knowledge among the children at baseline, immediately following the intervention (1-hour program delivered daily over 3 consecutive days), and 3 months later. For key AD symptoms, we developed the FLOW mnemonic (forget, lose, overlook, write/wander); students were additionally taught action plans for recognized symptoms. Results. Seventy-five students completed baseline assessments, and 68 completed posttesting. AD symptoms in FLOW were not well known at baseline (individually ranging from 16% to 71% correct) but were highly learned after 3 days (89% to 98% correct) and retained well after 3 months (80% to 95% correct, p ≤ .01 for all comparisons vs. baseline). AD localization, including its effect on memory and the hippocampus, was also highly learned and retained (p < .001). Eighteen students (24%) reported having a close friend/family member with AD. Conclusions. This study suggests our hip-hop health education model may be an effective method to improve AD health literacy.

The objective of this secondary analysis was to evaluate the utility of several participant adherence indicators for predicting changes in clinical, anthropometric, dietary, fitness, and physical activity (PA) outcomes in a lifestyle intervention, HUB City Steps, conducted in a southern, African American cohort in 2010. HUB City Steps was a 6-month, community-engaged, multicomponent, noncontrolled intervention targeting hypertension risk factors. Descriptive indicators were constructed using two participant adherence measures, education session attendance (ESA) and weekly steps/day pedometer diary submission (PDS), separately and in combination. Analyses, based on data from 269 primarily African American adult participants, included bivariate tests of association and multivariable linear regression to determine significant relationships between seven adherence indicators and health outcome changes, including clinical, anthropometric, dietary, fitness, and PA measures. ESA indicators were significantly correlated with four health outcomes: body mass index (BMI), fat mass, low-density lipoprotein (LDL), and PA (–.29 ≤ r ≤ .23, p < .05). PDS indicators were significantly correlated with PA (r = .27, p < .001). Combination ESA/PDS indicators were significantly correlated with five health outcomes: BMI, percentage body fat (%BF), fat mass, LDL, and PA (r = −.26 to .29, p < .05). Results from the multivariate models indicated that the combination ESA/PDS indicators were the most significant predictors of changes for five outcomes—%BF, fat mass, LDL diastolic blood pressure (DBP), and PA—while ESA performed best for BMI only. For DBP, a one-unit increase in the continuous-categorical ESA/PDS indicator resulted in 0.3 mm Hg decrease. Implications for assessing participant adherence in community-based, multicomponent lifestyle intervention research are discussed.

Objective. Motivation is not sufficient to actually use condoms, as self-regulatory processes are needed to translate motivation into action. Buying condoms and carrying them constitute preparatory behaviors that may serve as proximal predictors of action. Whether or not such preparatory behaviors operate as mediators between intention and action within a broader behavior change framework has been examined. Method. A sample of 150 heterosexual men between ages 18 and 25 years responded at three points in time to a computer-based survey that assessed behavior as well as social-cognitive antecedents. A structural equation model was specified that included preparatory behaviors and self-efficacy as mediators at Time 2. Results. Preparatory behaviors were the most proximal predictors of condom use, and they were, themselves, predicted by self-efficacy and intention. The latter was partly determined by positive emotional outcome expectancies. Conclusion. To bridge the intention-behavior gap, preparatory behaviors play a mediating role, and they represent a side of planning that constitutes the most proximal predictor of condom use.

Socioecological theory suggests that there are a range of influences that affect the physical activity levels of children, including parents’ perceptions of the neighborhood. A questionnaire instrument to quantify parental neighborhood perceptions was developed for the Location of Children’s Activity in Their Environment study as a potential predictor of children’s physical activity. A literature review revealed a lack of appropriate instruments, many containing highly localized items. Following initial instrument development including pretesting, where items showed face and content validity, a two-phase pilot study was undertaken. Pilot testing investigated test–retest reliability (overall intraclass correlation coefficient = .75) and internal consistency (α = .62 and α = .73 for the two phases, respectively), finding that the instrument was acceptable overall although some changes in wording were made to specific items with low reliability and/or internal consistency. Using data from the first year of the Location of Children’s Activity in Their Environment study, the instrument showed acceptable internal consistency (overall α = .73) and predictive validity (associated with time living in residence and walking to school) to be used in future studies. The scale was not found to be associated with child physical activity, which may be due to activity displacement. Proposed subscales for the neighborhood infrastructure and social aspects were marginal for internal consistency and a safety subscale was not acceptable in this regard. Given the impact of parental perceptions of the neighborhood, and its potential modifiable nature, a measure of it should be included in studies looking at the intensity and location of children’s physical activity.

Approximately 8.3% of the U.S. population (25.8 million people) is affected by type 2 diabetes. The burden of diabetes is disproportionately greater in the African American community. Compared with non-Hispanic Caucasian adults, the risk of diagnosed type 2 diabetes was 77% higher among non-Hispanic Blacks, who are 27% more likely to die of diabetes complications than either Caucasians or Hispanics. The purpose of this longitudinal community intervention was to promote healthy lifestyles among African American participants through multiple channels, including individualized point-of-testing counseling, and weekly exercise and nutrition classes led by trained community health mentors. Data collection procedures were guided by the World Health Organization’s STEPS approach, which includes gathering demographic and health information, collecting anthropometric measurements, and analyzing biochemical blood work. Changes in body mass index were assessed from in-person measurements and changes in blood lipids and glucose were examined by biochemical analyses. A total of 157 individuals participated in this study. Results showed that weight gain during the intervention was prevented, glucose levels decreased (−10.88 mg/dL), and low-density lipoprotein cholesterol decreased (−8.8 mg/dL), while high-density lipoprotein increased (+3.2 mg/dL). Lifestyle interventions and point-of-testing counseling can be successful in reducing risk factors for type 2 diabetes among the African American population. The results of this intervention indicate that the use of community health mentors and point-of-testing counseling may be effective in fostering healthy lifestyle changes, which can halt the progression of type 2 diabetes among non-Hispanic Black populations.

Girls struggling to be successful in middle school are often dealing with negative life experiences that affect their ability to achieve academically. Frequently, their academic failures and problem behaviors are associated with feeling overwhelmed by difficult and challenging life circumstances. In the absence of intervention, these patterns may contribute to girls chronically underperforming in school, dropping out of school, and becoming involved in delinquent and high-risk behaviors. This article describes a quasi-experimental, mixed-methods study of the REAL Girls program. REAL Girls was designed to help struggling middle school girls develop resilience—particularly academic self-efficacy, school connectedness, and identity—and achieve successful outcomes in school and life. In this study, using a crossover design, 48 girls identified as experiencing academic failure, school behavior problems, or truancy participated in one of two implementations of this 3-day intervention. Findings based on both quantitative and qualitative data suggest that REAL Girls contributed to positive increases in academic self-efficacy, school connectedness, and identity. Repeated measures analysis of variance and paired t tests suggest significant increases in each outcome variable, both immediately after program delivery and 2 weeks later, and effect size estimates suggest moderate to large program impact. Focus groups conducted 90 days after implementation of the program confirmed the quantitative findings and support the efficacy of the REAL Girls program and approach.