Peer Reviewed: Development of a Community-Based Participatory Colorectal Cancer Screening Intervention to Address Disparities,Arkansas, 2008-2009

Background

The death rate from colorectal cancer is high and affects poor and medically underserved populations disproportionately. In the United States, health disparities are particularly acute in the Lower Mississippi River Delta region. Because many in the region have limited access to basic health care resources, they are not screened for cancer, even though screening is one of the most effective strategies to prevent colorectal cancer. Community-based participatory research is a promising approach to prevent colorectal cancer in this population.

Community Context

The Empowering Communities for Life program was implemented in 2 underserved counties in the Arkansas Lower Mississippi River Delta. The program arose from a 9-year partnership between the University of Arkansas for Medical Sciences and 9 cancer councils across Arkansas.

Methods

Empowering Communities for Life is a community-based participatory intervention designed to increase colorectal cancer screening in rural, underserved communities through fecal occult blood testing. Community and academic partners collaborated to develop research infrastructure, intervention materials and methods, and the assessment instrument.

Outcome

Project outcomes were strengthened community-academic partnerships, certification of community partners in conducting human subjects research, development of a randomized controlled design to test the intervention''s efficacy, an interactive PowerPoint presentation, an informational pamphlet, the certification of 6 lay health advisors and 22 role models to provide the intervention, and an assessment tool using an audience response system.

Interpretation

Lessons learned in working collaboratively with diverse groups include the importance of meeting face to face and listening.     

Peer Reviewed: Mapping Cancer for Community Engagement

Introduction

Two research strategies may reduce health disparities: community participation and the use of geographic information systems. When combined with community participation, geographic information systems approaches, such as the creation of disease maps that connect disease rates with community context, can catalyze action to reduce health disparities. However, current approaches to disease mapping often focus on the display of disease rates for political or administrative units. This type of map does not provide enough information on the local rates of cancer to engage community participation in addressing disparities.

Methods

We collaborated with researchers and cancer prevention and control practitioners and used adaptive spatial filtering to create maps that show continuous surface representations of the proportion of all colorectal cancer cases diagnosed in the late stage. We also created maps that show the incidence of colorectal cancer.

Results

Our maps show distinct patterns of cancer and its relationship to community context. The maps are available to the public on the Internet and through the activities of Iowa Consortium for Comprehensive Cancer Control partners.

Conclusion

Community-participatory approaches to research are becoming more common, as are the availability of geocoded data and the use of geographic information systems to map disease. If researchers and practitioners are to engage communities in exploring cancer rates, maps should be made that accurately represent and contextualize cancer in such a way as to be useful to people familiar with the characteristics of their local areas.     

Primary Care Physicians and Disparities in Colorectal Cancer Screening in the Elderly

Objective

To examine whether having a primary care physician (PCP) is associated with reduced ethnic disparities for colorectal cancer (CRC) screening and whether clustering of minorities within PCPs contributes to the disparities.

Data Sources/Study Setting

Retrospective cohort study of Medicare beneficiaries age 66–75 in 2009 in Texas.

Study Design

The percentage of beneficiaries up to date in CRC screening in 2009 was stratified by race/ethnicity. Multilevel models were used to study the effect of having a PCP and PCP characteristics on the racial and ethnic disparities on CRC screening.

Data Collection/Extraction Methods

Medicare data from 2000 to 2009 were used to assess prior CRC screening.

Principal Findings

Odds of undergoing CRC screening were more than twice as high in patients with a PCP (OR = 2.05, 95 percent CI 2.03–2.07). After accounting for clustering and PCP characteristics, the black–white disparity in CRC screening rates almost disappears and the Hispanic–white disparity decreases substantially.

Conclusions

Ethnic disparities in CRC screening in the elderly are mostly explained by decreased access to PCPs and by clustering of minorities within PCPs less likely to screen any of their patients.     

Peer Reviewed: Exploring Perceptions of Colorectal Cancer and Fecal Immunochemical Testing Among African Americans in a North Carolina Community

Introduction

African Americans have a lower colorectal cancer screening rate than whites and higher disease incidence and mortality. Despite wide acceptance of colonoscopy for accurate screening, increasing promotion of high-sensitivity stool test screening, such as the fecal immunochemical test (FIT), may narrow racial, ethnic, and socioeconomic disparities in screening. This study provides formative research data to develop an intervention to increase colorectal cancer screening among underinsured and uninsured African Americans in central North Carolina.

Methods

We held 4 focus groups to explore knowledge, beliefs, and attitudes about colorectal cancer screening, particularly FIT. Participants (n = 28) were African American adults recruited from neighborhoods with high levels of poverty and unemployment. Constructs from the diffusion of innovation theory were used to develop the discussion guide.

Results

In all groups, participants noted that lack of knowledge about colorectal cancer contributes to low screening use. Attitudes about FIT sorted into 4 categories of "innovation characteristics": relative advantage of FIT compared with no screening and with other screening tests; compatibility with personal beliefs and values; test complexity; and test trialability. A perceived barrier to FIT and other stool tests was risk of incurring costs for diagnostic follow-up.

Conclusion

Community-based FIT screening interventions should include provider recommendation, patient education to correctly perform FIT, modified FIT design to address negative attitudes about stool tests, and assurance of affordable follow-up for positive FIT results.     

Geographic and Demographic Disparities in Late-stage Breast and Colorectal Cancer Diagnoses Across the US

Problem

In 2009, breast cancer was the most common cancer in women, and colorectal cancer was the third most common cancer in both men and women. Currently, the majority of colorectal and almost 1/3 of breast cancers are diagnosed at an advanced stage in the US, which results in higher morbidity and mortality than would obtain with earlier detection. The incidence of late-stage cancer diagnoses varies considerably across the US, and few analyses have examined the entire US.

Purpose

Using the newly available US Cancer Statistics database representing 98% of the US population, we perform multilevel analysis of the incidence of late-stage cancer diagnoses and translate the findings via bivariate mapping, answering questions related to both Why and Where demographic and geographic disparities in these diagnoses are observed.

Methods

To answer questions related to Why disparities are observed, we utilize a three-level, random-intercepts model including person-, local area-, and region- specific levels of influence. To answer questions related to Where disparities are observed, we generate county level robust predictions of late-stage cancer diagnosis rates and map them, contrasting counties ranked in the upper and lower quantiles of all county predicted rates. Bivariate maps are used to spatially translate the geographic variation among US counties in the distribution of both BC and CRC late-stage diagnoses.

Conclusions

Empirical modeling results show demographic disparities, while the spatial translation of empirical results shows geographic disparities that may be quite useful for state cancer control planning. Late stage BC and CRC diagnosis rates are not spatially random, manifesting as place-specific patterns that compare counties in individual states to counties across all states. Providing a relative comparison that enables assessment of how results in one state compare with others, this paper is to be disseminated to all state cancer control and central cancer registry program officials.     

Vital Signs: Colorectal Cancer Screening Test Use — United States, 2012

Background

Strong evidence exists that screening with fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy reduces the number of deaths from colorectal cancer (CRC). The percentage of the population up-to-date with recommended CRC screening increased from 54% in 2002 to 65% in 2010, primarily through increased use of colonoscopy.

Methods

Data from the 2012 Behavioral Risk Factor Surveillance System survey were analyzed to estimate percentages of adults aged 50–75 years who reported CRC screening participation consistent with United States Preventive Services Task Force recommendations.

Results

In 2012, 65.1% of U.S. adults were up-to-date with CRC screening, and 27.7% had never been screened. The proportion of respondents who had never been screened was greater among those without insurance (55.0%) and without a regular care provider (61.0%) than among those with health insurance (24.0%) and a regular care provider (23.5%). Colonoscopy was the most commonly used screening test (61.7%), followed by FOBT (10.4%). Colonoscopy was used by more than 53% of the population in every state. The percentages of blacks and whites up-to-date with CRC screening were equivalent. Compared with whites, a higher percentage of blacks across all income and education levels used FOBT.

Conclusions

Many age-eligible adults did not use any type of CRC screening test as recommended. Organized, population-based approaches might increase CRC screening among those who have never been screened. Promoting both FOBT and colonoscopy as viable screening test options might increase CRC screening rates and reduce health disparities.     

Breast Cancer Screening,Area Deprivation,and Later-Stage Breast Cancer in Appalachia: Does Geography Matter?

Objective

To model the relationship of an area-based measure of a breast cancer screening and geographic area deprivation on the incidence of later stage breast cancer (LSBC) across a diverse region of Appalachia.

Data Source

Central cancer registry data (2006–2008) from three Appalachian states were linked to Medicare claims and census data.

Study Design

Exploratory spatial analysis preceded the statistical model based on negative binomial regression to model predictors and effect modification by geographic subregions.

Principal Findings

Exploratory spatial analysis revealed geographically varying effects of area deprivation and screening on LSBC. In the negative binomial regression model, predictors of LSBC included receipt of screening, area deprivation, supply of mammography centers, and female population aged >75 years. The most deprived counties had a 3.31 times greater rate of LSBC compared to the least deprived. Effect of screening on LSBC was significantly stronger in northern Appalachia than elsewhere in the study region, found mostly for high-population counties.

Conclusions

Breast cancer screening and area deprivation are strongly associated with disparity in LBSC in Appalachia. The presence of geographically varying predictors of later stage tumors in Appalachia suggests the importance of place-based health care access and risk.     

Radiation Therapy Resources and Guideline‐Concordant Radiotherapy for Early‐Stage Breast Cancer Patients in an Underserved Region

Objective

To examine the relationship between radiation therapy resources and guideline-concordant radiotherapy after breast-conserving surgery (BCS) in Kentucky.

Data Sources

The SEER registry and Area Resource File provided county-level data describing cancer care resources and socioeconomic conditions of Kentucky residents.

Study Design

The outcome variable was rate of BCS without radiotherapy in each county for 2000–2007. Eight-year weighted average rates of radiation therapy providers and hospitals per 100,000 residents were explanatory variables of interest. Exploratory spatial data analyses and spatial econometric models were estimated.

Principal Findings

Appalachian counties in Kentucky had significantly fewer radiation oncologists, hospitals with radiation therapy facilities, and surgeons per 100,000 residents than non-Appalachian counties. The likelihood of BCS without radiation was significantly higher among Appalachian compared to non-Appalachian women (42.5 percent vs. 29.0 percent, p < .001). Higher proportions of women not receiving recommended radiotherapy after BCS were clustered in Eastern Kentucky around Lexington. This geographic disparity was partially explained by significantly fewer radiation therapy facilities in Appalachian Kentucky in adjusted analyses.

Conclusions

Scarce radiation therapy resources in Appalachian Kentucky are associated with disparities in receipt of guideline-concordant radiotherapy, suggesting that policy action is needed to improve the cancer treatment infrastructure in disadvantaged mountainous areas.     

Peer Reviewed: Using Small-Area Estimation to Describe County-Level Disparities in Mammography

Introduction

Breast cancer control efforts could benefit from estimating mammography prevalence at the substate level because studies have primarily analyzed health survey data at the national and state levels. The purpose of this study was to evaluate the extent to which geographic disparities exist in mammography use across counties in the contiguous United States.

Methods

We estimated county-level prevalence of recent mammography (past 2 years) for women aged 40 to 79 years by using synthetic regression, a small-area estimation method. The 2000 Behavioral Risk Factor Surveillance System (BRFSS), 2000 Census, Area Resource File, and Food and Drug Administration mammography facility data were merged by BRFSS respondents'' county of residence. We conducted separate analyses to produce county-level prevalence estimates for each race and age group.

Results

Mammography use varied geographically, and the magnitude of geographic disparities differed by race and age. Nonwhite women showed the lowest prevalence of mammography and widest range in county-level estimates. Women aged 40 to 49 had generally lower prevalence than other age groups, while women aged 65 to 79 showed the greatest variation in county-level mammography estimates.

Conclusions

Small-area estimation using BRFSS data is advantageous for surveillance of mammography use at the county level. This method allows documentation of geographic disparities and improves our understanding of the spatial distribution of mammography prevalence. Future interventions should consider this county-level geographic variation, targeting women in the neediest counties.     

A case study of the South Puget Intertribal Planning Agency's comprehensive cancer control planning and community mobilization process

Background

The high rates of cancer among American Indians and Alaska Natives are of growing concern.

Context

In response to high cancer rates, national, state, and tribal organizations have worked to assess knowledge, attitudes, beliefs, and screening practices related to cancer in American Indian and Alaska Native communities and to increase awareness and use of cancer screening. The National Comprehensive Cancer Control Program (NCCCP) of the Centers for Disease Control and Prevention is one such effort. NCCCP''s comprehensive cancer control (CCC) planning process provides a new approach to planning and implementing cancer control programs. The CCC process and components for American Indians and Alaska Natives are not yet fully understood because this is a fairly new approach for these communities. Therefore, the purpose of our case study was to describe the CCC process and its outcomes and successes as applied to these communities and to identify key components and lessons learned from the South Puget Intertribal Planning Agency''s (SPIPA''s) CCC planning and community mobilization process.

Methods

We used interviews, document reviews, and observations to collect data on SPIPA''s CCC planning and community mobilization process.

Consequences

We identified the key components of SPIPA''s CCC as funding and hiring key staff, partnering with outside organizations, developing a project management plan and a core planning team, creating community cancer orientations, conducting community cancer surveys, developing a community advisory committee, ongoing training and engaging of the community advisory committee, and supporting the leadership of the communities involved.

Interpretation

The CCC planning process is a practicable model, even for groups with little experience or few resources. The principles identified in this case study can be applied to the cancer control planning process for other tribes.     

Peer Reviewed: Collaboration to Increase Colorectal Cancer Screening Among Low-Income Uninsured Patients

Background

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. CRC screening allows for prevention through the removal of precancerous lesions and early detection of cancer.

Community Context

Ride for Life Alaska (RFL), a nonprofit organization that raises funds to fight cancer, and the Anchorage Neighborhood Health Center (ANHC), which is Alaska''s largest community health center, joined efforts to provide CRC screening and outreach to an ethnically diverse group of low-income underinsured or uninsured patients residing in and around Anchorage, Alaska.

Methods

RFL and ANHC worked with gastroenterologists, medical practices, and pathology services to contribute pro bono and reduced-fee services for CRC screening. Information to patients was distributed through signs in the clinic, flyers, and the ANHC website.

Outcomes

CRC screening was increased in this population. During 2007-2009, there were 2,561 immunochemical fecal occult blood tests given to patients, and 1,558 were completed (61%); 24% were positive. Sixteen gastroenterologists, 4 medical practices, and 2 laboratories provided 111 follow-up colonoscopies and pathology services to patients identified through the CRC screening program who did not have other funding resources available for follow-up care.

Interpretation

This program provides a model for leveraging scarce screening resources by drawing on multiple partners to increase CRC screening. Recommendations for those seeking to initiate similar programs are to have memoranda of agreement in place and a clear scope of work for all participating people and organizations to avoid delays in program implementation; hire a screening care coordinator to manage patient care and collaborate with medical practices; and identify program champions who have the energy and persistence to craft such partnerships.     

Peer Reviewed: Using Multiple Sources of Data to Assess the Prevalence of Diabetes at the Subcounty Level,Duval County,Florida, 2007

Introduction

Diabetes rates continue to grow in the United States. Effectively addressing the epidemic requires better understanding of the distribution of disease and the geographic clustering of factors that influence it. Variations in the prevalence of diabetes at the local level are largely unreported, making understanding the disparities associated with the disease more difficult. Diabetes death rates during the past 15 years in Duval County, Florida, have been disproportionately high compared with the rest of the state.

Methods

We analyzed multiple sources of secondary data related to diabetes illness and death in Duval County, including data on hospital discharge, emergency department (ED) use, and vital statistics. We accessed diabetes and diabetes-related ED use and hospitalization and death data by using codes from the International Classification of Diseases versions 9 and 10. We analyzed data from the Behavioral Risk Factor Surveillance System survey for Duval County and adapted Centers for Disease Control and Prevention weighting formulas for subcounty analysis. We used relative risk-type disease ratios and geographic information systems mapping to analyze data.

Results

The urban, mostly minority, low-socioeconomic area of Duval County had twice the rate of diabetes-related illness and death as other areas of the county, and the inner-city, poor area of the county had almost 3 times the rate of hospitalization and ED use for diabetes and diabetes-related conditions compared with the other areas of the county.

Conclusion

Our analyses show that diabetes-related disparities affect not only people and their families but also the community that absorbs the costs associated with the disproportionate health care use that results from these disparities. Analyzing data at the subcounty level has implications for health care planning and public health policy development at the local level.     

Development and testing of models of tuberculosis contact tracing in rural southern Africa

Setting:

A regional hospital in rural Swaziland.

Objectives:

To evaluate a hospital-based contact screening programme and test approaches to improve its effectiveness.

Design:

An evaluation and quality improvement study of tuberculosis (TB) contact tracing services.

Results:

Hospital-based TB contact tracing led to screening of 157 (24%) of 658 contacts; of these, 4 (2.5%) were diagnosed with TB. Of 68 contacts eligible for human immunodeficiency virus (HIV) testing and counselling, 45 (66%) were tested and 7/45 (16%) were identified as HIV-positive. Twelve (50%) of 24 screened contacts aged <5 years were provided isoniazid prophylaxis. Three enhanced models of TB contact tracing were piloted to screen contacts in the community. Although some enhanced models screened large numbers of contacts, no contacts were diagnosed with TB.

Conclusion:

Contact tracing of household members conducted in TB clinics within hospital settings is effective in high-burden, low-income settings, and can be provided using current resources. Enhanced household contact tracing models that followed up contacts in the community were not found to be effective. Additional resources would be required to provide household TB contact tracing in the community.     

Geographic and Racial Disparities in Breast Cancer–Related Outcomes in Georgia

Objective

To measure the effects of race/ethnicity, area measures of socioeconomic status (SES) and geographic residency status, and health care supply (HCS) characteristics on breast cancer (BC)-related outcomes.

Data Sources/Study Setting

Female patients in Georgia diagnosed with BC in the years 2000–2009.

Study Design

Multilevel regression analysis with adjustment for variables at the county, census tract (CT), and individual level. The county represents the spatial unit of analysis for HCS. SES and geographic residency status were grouped at the CT level.

Principal Findings

Even after controlling for area-level characteristics, racial and ethnic minority women suffered an unequal BC burden. Despite inferior outcomes for disease stage and receipt of treatment, Hispanics had a marginally significant decreased risk of death compared with non-Hispanics. Higher CT poverty was associated with worse BC-related outcomes. Residing in small, isolated rural areas increased the odds of receiving surgery, decreased the odds of receiving radiotherapy, and decreased the risk of death. A higher per-capita availability of BC care physicians was significantly associated with decreased risk of death.

Conclusions

Race/ethnicity and area-level measures of SES, geographic residency status, and HCS contribute to disparities in BC-related outcomes.     

Sociopsychological Tailoring to Address Colorectal Cancer Screening Disparities: A Randomized Controlled Trial

PURPOSE

Interventions tailored to sociopsychological factors associated with health behaviors have promise for reducing colorectal cancer screening disparities, but limited research has assessed their impact in multiethnic populations. We examined whether an interactive multimedia computer program (IMCP) tailored to expanded health belief model sociopsychological factors could promote colorectal cancer screening in a multiethnic sample.

METHODS

We undertook a randomized controlled trial, comparing an IMCP tailored to colorectal cancer screening self-efficacy, knowledge, barriers, readiness, test preference, and experiences with a nontailored informational program, both delivered before office visits. The primary outcome was record-documented colorectal cancer screening during a 12-month follow-up period. Secondary outcomes included postvisit sociopsychological factor status and discussion, as well as clinician recommendation of screening during office visits. We enrolled 1,164 patients stratified by ethnicity and language (49.3% non-Hispanic, 27.2% Hispanic/English, 23.4% Hispanic/Spanish) from 26 offices around 5 centers (Sacramento, California; Rochester and the Bronx, New York; Denver, Colorado; and San Antonio, Texas).

RESULTS

Adjusting for ethnicity/language, study center, and the previsit value of the dependent variable, compared with control patients, the IMCP led to significantly greater colorectal cancer screening knowledge, self-efficacy, readiness, test preference specificity, discussion, and recommendation. During the followup period, 132 (23%) IMCP and 123 (22%) control patients received screening (adjusted difference = 0.5 percentage points, 95% CI −4.3 to 5.3). IMCP effects did not differ significantly by ethnicity/language.

CONCLUSIONS

Sociopsychological factor tailoring was no more effective than nontailored information in encouraging colorectal cancer screening in a multiethnic sample, despite enhancing sociopsychological factors and visit behaviors associated with screening. The utility of sociopsychological tailoring in addressing screening disparities remains uncertain.     

Peer Reviewed: Socioeconomic Disparities in Breast Cancer Screening in Hawaii

Introduction

Despite evidence that breast cancer screening reduces morbidity and mortality, many women do not obtain mammograms. Our objective was to analyze the relationship between income and mammography screening for members enrolled in a large health plan in Hawaii.

Methods

We analyzed claims data for women (N = 46,328) aged 50 to 70 years during 2003 and 2004. We used parametric and nonparametric regression techniques. We used probit estimation to conduct multivariate analysis.

Results

At the 5th percentile of the earnings distribution, the probability of mammography is 57.1%, and at the 95th percentile, it is 67.7%. Movement from the 5th percentile to the 35th percentile of the earnings distribution increases the probability of mammography by 0.0378 percentage points. A similar movement from the 65th percentile to the 95th percentile increases the probability by 0.0394 percentage points. Also, we observed an income gradient within narrowly defined geographic regions where physical access to medical care providers is not an issue.

Conclusion

We observed a steep income gradient in mammography screening in Hawaii. Because of the prevalence of measurement error, this gradient is probably far greater than our estimate. We cannot plausibly attribute our findings to disparities in coverage because 100% of our sample had health insurance coverage. The gradient also does not appear to result from poorer people residing in areas that are geographically isolated from providers of medical care.     

Peer Reviewed: Feasibility of an Evidence-Based Weight Loss Intervention for a Faith-Based, Rural, African American Population

Background

African Americans and rural residents are disproportionately affected by obesity. Innovative approaches to address obesity that are sensitive to the issues of rural African Americans are needed. Faith-based and community-based participatory approaches show promise for engaging racial/ethnic minorities to change health outcomes, but few faith-based weight loss interventions have used a community-based participatory approach.

Community Context

A faith-based weight loss intervention in the Lower Mississippi Delta arose from a 5-year partnership between academic and community partners representing more than 30 churches and community organizations.

Methods

Community and academic partners translated the 16 core sessions of the Diabetes Prevention Program for rural, church-going African American adults. The feasibility of the lay health advisor–led delivery of the 16-week (January-May 2010), 16-session, adapted intervention was assessed in 26 participants from 3 churches by measuring recruitment, program retention, implementation ease, participant outcomes, and program satisfaction.

Outcome

Twenty-two of 26 participants (85%) provided 16-week follow-up data. Lay health advisors reported that all program components were easy to implement except the self-monitoring component. Participants lost an average of 2.34 kg from baseline to 16-week follow-up, for a mean weight change of −2.7%. Participants reported enjoying the spiritual and group-based aspects of the program and having difficulties with keeping track of foods consumed. The intervention engaged community partners in research, strengthened community-academic partnerships, and built community capacity.

Interpretation

This study demonstrates the feasibility of delivering this adapted intervention by lay leaders through rural churches.     

Statistical analyses in Swedish randomised trials on mammography screening and in other randomised trials on cancer screening: a systematic review

Objectives

We compared calculations of relative risks of cancer death in Swedish mammography trials and in other cancer screening trials.

Participants

Men and women from 30 to 74 years of age.

Setting

Randomised trials on cancer screening.

Design

For each trial, we identified the intervention period, when screening was offered to screening groups and not to control groups, and the post-intervention period, when screening (or absence of screening) was the same in screening and control groups. We then examined which cancer deaths had been used for the computation of relative risk of cancer death.

Main outcome measures

Relative risk of cancer death.

Results

In 17 non-breast screening trials, deaths due to cancers diagnosed during the intervention and post-intervention periods were used for relative risk calculations. In the five Swedish trials, relative risk calculations used deaths due to breast cancers found during intervention periods, but deaths due to breast cancer found at first screening of control groups were added to these groups. After reallocation of the added breast cancer deaths to post-intervention periods of control groups, relative risks of 0.86 (0.76; 0.97) were obtained for cancers found during intervention periods and 0.83 (0.71; 0.97) for cancers found during post-intervention periods, indicating constant reduction in the risk of breast cancer death during follow-up, irrespective of screening.

Conclusions

The use of unconventional statistical methods in Swedish trials has led to overestimation of risk reduction in breast cancer death attributable to mammography screening. The constant risk reduction observed in screening groups was probably due to the trial design that optimised awareness and medical management of women allocated to screening groups.     

Peer Reviewed: Case Study of Capacity Building for Smoke-Free Indoor Air in Two Rural Wisconsin Communities

Background

Despite national declines in smoking prevalence, disparities that pose challenges to tobacco control efforts exist among rural manufacturing populations. This community case study sought to better understand the dynamics and nuances that facilitate or impede capacity-building efforts in rural communities.

Context

Two rural manufacturing communities in Wisconsin with similar demographic characteristics were chosen for study. One represented farming communities with close proximity to a metropolitan area, and the other represented more isolated communities.

Methods

The qualitative case study used a collaborative approach to collect data in four areas of research: 1) community context, 2) coalition functioning, 3) partnerships, and 4) strategy implementation. Data were analyzed using standard content analysis and triangulated for clarity and consistency.

Consequences

Although not all the factors found to influence capacity-building efforts were unique to rural environments, the effects were impacted by rural isolation, small population sizes, local attitudes and beliefs, and lack of diversity and resources. Differences in coalition leadership and strategy implementation influenced the effectiveness of the capacity-building efforts in each community, bringing attention to the unique nature of individual contexts.

Interpretation

Implementing capacity-building efforts in rural communities requires skilled and dedicated local leaders who have ready access to training and support (i.e., technical, emotional, and financial). Pairing of rural communities with greater use of distance technologies offers a cost-effective approach to reduce isolation and the constraints of financial and human resources.