Colorectal Cancer Screening in Vulnerable Patients

Low-income, low-literacy, limited English–proficient populations have low colorectal cancer (CRC) screening rates and experience poor patient–provider communication and decision-making processes around screening. The purpose of this study was to test the effect of a CRC screening decision aid on screening-related communication and decision making in primary care visits

Comparing the effect of a decision aid plus patient navigation with usual care on colorectal cancer screening completion in vulnerable populations: study protocol for a randomized controlled trial

Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screening is underutilized in vulnerable patient populations, particularly among Latinos. Patient-directed decision aids can increase CRC screening knowledge, self-efficacy, and intent; however, their effect on actual screening test completion tends to be modest. This is probably because decision aids do not address some of the patient-specific barriers that prevent successful completion of CRC screening in these populations. These individual barriers might be addressed though patient navigation interventions. This study will test a combined decision aid and patient navigator intervention on screening completion in diverse populations of vulnerable primary care patients. We will conduct a multisite, randomized controlled trial with patient-level randomization. Planned enrollment is 300 patients aged 50 to 75 years at average CRC risk presenting for appointments at two primary clinics in North Carolina and New Mexico. Intervention participants will view a video decision aid immediately before the clinic visit. The 14 to 16 minute video presents information about fecal occult blood tests and colonoscopy and will be viewed on a portable computer tablet in English or Spanish. Clinic-based patient navigators are bilingual and bicultural and will provide both face-to-face and telephone-based navigation. Control participants will view an unrelated food safety video and receive usual care. The primary outcome is completion of a CRC screening test at six months. Planned subgroup analyses include examining intervention effectiveness in Latinos, who will be oversampled. Secondarily, the trial will evaluate the intervention effects on knowledge of CRC screening, self-efficacy, intent, and patient-provider communication. The study will also examine whether patient ethnicity, acculturation, language preference, or health insurance status moderate the intervention effect on CRC screening. This pragmatic randomized controlled trial will test a combined decision aid and patient navigator intervention targeting CRC screening completion. Findings from this trial may inform future interventions and implementation policies designed to promote CRC screening in vulnerable patient populations and to reduce screening disparities.https://doi.org/10.1186/1745-6215-15-27

A community based participatory approach to improving health in a Hispanic population

ABSTRACT: BACKGROUND: The Charlotte-Mecklenburg region has one of the fastest growing Hispanic communities in the country. This population has experienced disparities in health outcomes and diminished ability to access healthcare services. This city is home to an established practice-based research network (PBRN) that includes community representatives, health services researchers, and primary care providers. The aims of this project are: to use key principles of community-based participatory research (CBPR) within a practice-based research network (PBRN) to identify a single disease or condition that negatively affects the Charlotte Hispanic community; to develop a community-based intervention that positively impacts the chosen condition and improves overall community health; and to disseminate findings to all stakeholders. METHODS/DESIGN: This project is designed as CBPR. The CBPR process creates new social networks and connections between participants that can potentially alter patterns of healthcare utilization and other health-related behaviors. The first step is the development of equitable partnerships between community representatives, providers, and researchers. This process is central to the CBPR process and will occur at three levels -- community members trained as researchers and outreach workers, a community advisory board (CAB), and a community forum. Qualitative data on health issues facing the community -- and possible solutions -- will be collected at all three levels through focus groups, key informant interviews and surveys. The CAB will meet monthly to guide the project and oversee data collection, data analysis, participant recruitment, implementation of the community forum, and intervention deployment. The selection of the health condition and framework for the intervention will occur at the level of a community-wide forum. Outcomes of the study will be measured using indicators developed by the participants as well as geospatial modeling.On completion, this study will: determine the feasibility of the CBPR process to design interventions; demonstrate the feasibility of geographic models to monitor CBPR-derived interventions; and further establish mechanisms for implementation of the CBPR framework within a PBRN

The ins and outs of provider-parent communication: perspectives from adolescent primary care providers on challenges to forging alliances to reduce adolescent risk.

PURPOSE: For several decades, the goal to protect adolescents\u27 confidentiality in addition to state and professional mandates to provide confidential health services have sometimes outweighed the interest of involving parents in risk reduction efforts. More recently, experts acknowledge that a balance must be found between maintaining adolescent confidentiality and involving parents in preventing poor adolescent outcomes resulting from risky behaviors. The purpose of this research was to elucidate the challenges in and identify solutions to realizing this newer vision in the primary care setting. METHODS: We conducted a qualitative study featuring in-depth interviews with 37 primary care providers among whom a significant component of their practice involved adolescent patients. Purposeful sampling was aimed at a diversity of gender, practice specialty, practice venues, and geographic areas. RESULTS: We identified individual and structural barriers and facilitators to involving parents in their adolescents\u27 primary care. Barriers included parents\u27 lack of knowledge and awareness of their children\u27s risk behaviors; providers time constraints and competing clinical demands, concerns for confidentiality and developing a trusting relationship with the child; and legal and system requirements that limit engagement with parents. Facilitators included interest and for some, planned approaches by the provider to engage the parent; encouragement by the provider to the adolescent to communicate with a trusted adult about their risky behavior; and opportunities to educate the parent about risk reduction in general. CONCLUSION: Opportunities for further research on strategies to improve communication and develop a partnership between providers and parents are described

Evaluation for community-based programs: The integration of logic models and factor analysis

Purpose To discuss the utility of and value of the use of logic models for program evaluation of community-based programs and more specifically, the integration of logic models and factor analysis to develop and revise a survey as part of an effective evaluation plan.Principal results Diverse stakeholders with varying outlooks used a logic model as a framework to reach agreement on a plan for a state-wide evaluation. This evaluation plan utilized a survey of sixth grade students, administered before and after exposure to a year-long abstinence education program. Components of the logic model were linked to specific survey questions. Exploratory factor analysis was then used to assess whether and how the questions in the survey fit with the constructs of the model; confirmatory factor analysis was used to test the hypothesis that the factors identified in the exploratory analysis were consistently represented in the survey.Major conclusions A logic model is a tool that engages stakeholders to link evaluation instruments more closely to specific program objectives. Thus, stakeholders can more closely assess the extent to which project outcomes have been achieved. In addition, use of factor analysis in the evaluation process can help the stakeholders better understand whether evaluation instruments such as a survey adequately assess program effectiveness. Lastly, a logic model process can help to achieve consensus among diverse stakeholders, by allowing them to focus on objectives that are concrete, measurable, and mutually acceptable.Logic models Evaluation Evaluation instruments Factor analysis

Residential segregation and emergency department utilization among an underserved urban emergency department sample in North Carolina

Background: Residential segregation is a spatial manifestation of structural racism. Racial disparities in emergency department (ED) utilization mirror social inequity in the larger community. We evaluated associations between residential segregation and ED utilization in a community with known disparities and geographically concentrated social and health risk. Methods: Cross-sectional data were collected from electronic medical records of 101 060 adult ED patients living in Mecklenburg County, North Carolina in 2017. Community context was measured as residential segregation using the dissimilarity index, categorized into quintiles (Q1–Q5) using 2013–2017 American Community Survey estimates, and residency in a public health priority area (PHPA). The outcome was measured as total ED visits during the study period. Associations between community context and ED utilization were modeled using Anderson’s behavioral model of health service utilization, and estimated using negative binomial regression, including interaction terms by race. Results: Compared to areas with the lowest proportions of Black residents (Q1), living in Q4 was associated with higher rates of ED utilization among Black/Other (AME = 0.11) and White (AME = 0.23) patients, while associations with living in Q5 were approximately equivalent (AME = 0.12). PHPA residency was associated with higher rates of ED utilization among Black/Other (AME = 0.10) and White patients (AME = 0.22). Limitations: Associations should not be interpreted as causal, or be generalized to the larger community without ED utilization. Health system leakage is possible but limited. Conclusions: Residential segregation is associated with higher rates of ED utilization, as are PHPA residency and other individual-level determinants