A community-based randomized trial of a faith-placed intervention to reduce cervical cancer burden in Appalachia

Objective

Faith Moves Mountains assessed the effectiveness of a faith-placed lay health advisor (LHA) intervention to increase Papanicolaou (Pap) test use among middle-aged and older women in a region disproportionately affected by cervical cancer and low screening rates (regionally, only 68% screened in prior 3 years).

Method

This community-based RCT was conducted in four Appalachian Kentucky counties (December 2005-June 2008). Women aged 40-64 and overdue for screening were recruited from churches and individually randomized to treatment (n = 176) or wait-list control (n = 169). The intervention provided LHA home visits and newsletters addressing barriers to screening. Self-reported Pap test receipt was the primary outcome.

Results

Intention-to-treat analyses revealed that treatment group participants (17.6% screened) had over twice the odds of wait-list controls (11.2% screened) of reporting Pap test receipt post-intervention, OR = 2.56, 95% CI: 1.03-6.38, p = 0.04. Independent of group, recently screened participants (last Pap > 1 but < 5 years ago) had significantly higher odds of obtaining screening during the study than rarely or never screened participants (last Pap ≥ 5 years ago), OR = 2.50, 95% CI: 1.48-4.25, p = 0.001.

Conclusions

The intervention was associated with increased cervical cancer screening. The faith-placed LHA addressing barriers comprises a novel approach to reducing cervical cancer disparities among Appalachian women.     

Diet components can suppress inflammation and reduce cancer risk

Epidemiology studies indicate that diet or specific dietary components can reduce the risk for cancer, cardiovascular disease and diabetes. An underlying cause of these diseases is chronic inflammation. Dietary components that are beneficial against disease seem to have multiple mechanisms of action and many also have a common mechanism of reducing inflammation, often via the NFκB pathway. Thus, a plant based diet can contain many components that reduce inflammation and can reduce the risk for developing all three of these chronic diseases. We summarize dietary components that have been shown to reduce cancer risk and two studies that show that dietary walnut can reduce cancer growth and development. Part of the mechanism for the anticancer benefit of walnut was by suppressing the activation of NFκB. In this brief review, we focus on reduction of cancer risk by dietary components and the relationship to suppression of inflammation. However, it should be remembered that most dietary components have multiple beneficial mechanisms of action that can be additive and that suppression of chronic inflammation should reduce the risk for all three chronic diseases.     

Assessing intervention effects in a community-based trial to reduce self-harm: a methodological case study

This paper considers the assessment of the impact of a community-based randomized controlled trial to reduce repeat deliberate self-harm. It considers the drawbacks in simplistic applications of conventional significance testing procedures, as well as possible failures regarding the statistical assumptions underlying such tests. Instead, the paper considers how relevant prior information might be incorporated within a fully Bayesian-model-based assessment procedure. The model includes a latent trait approach to patient morbidity; controlling for morbidity and other patient characteristics enhances the impact of the intervention (measured by a hazard rate ratio). If allowance is made for external information (e.g. ethical approval of the treatment), the weight of evidence shifts towards a positive intervention effect.     

Dietary intervention studies to reduce risk factors related to cardiovascular diseases and cancer

This article reviews data obtained from a series of dietary intervention studies conducted in the United States, Finland, and Italy. The objectives were to determine the effects of reducing animal fat consumption while moderately increasing polyunsaturated fatty acid (PUFA), on blood pressure and lipoproteins. Although the diet was modified to improve risk factors related to cardiovascular disease, it is apparent that the dietary intervention would also apply to cancer. The results obtained for men and women, ages 35-65 years, indicate that plasma total cholesterol and low-density and high-density lipoprotein cholesterol were reduced; blood pressure was reduced among both normotensives and hypertensives; daily intake of meat and dairy products were not reduced but were much lower in fat; carbohydrates were substituted as fruits, vegetables, and grains, which provided more vitamins and minerals; and salt intake was maintained at a level of 8-12 g per day. From the data obtained for lowering blood pressure, it would appear that the requirement for PUFA is between 5 and 10 en%, which is somewhat higher than the recommended dietary allowances but lower than that recommended by health agencies. The results of these studies give support to current dietary recommendations to reduce the risk of cardiovascular disease as well as cancer by dietary intervention.     

The Finnmark Intervention Study: Design, Methods and effects of a 2 year community-based intervention

Two fishing municipalities with a total population of 6,500in Finnmark county were exposed to different hearth interventionprogrammes, both aiming at minimizing inequalities in healththrough empowerment and community involvement. One intervention(Nordkapp) was mainly focused on factors related to the workingenvironment of fishermen and within the fishing industry, whilethe other (Bitsfjord) addressed the population as a whole indefining health problems, setting priorities and planning strategiesand implementation. This paper describes the design and methodsof intervention and evaluation and examines effects regardingknowledge about and discussions of the projects, acquisitionof new information, attitudes and serf-reported behaviour changesafter 2 years of intervention in a randomized sample of almost2,000 individuals in the 2 communities. In Nordkapp, 27% ofthe men and 20% of the women knew about the project, with thehighest level being among fishermen and the male employees inthe fishing industry. The corresponding percentages for BStsfjordwere 77 and 82%. Approximately 1 in 5 in Nordkapp and 2 in 5in Bitsfjord had discussed the projects with somebody. In particular,in Bitsfjord knowledge about and discussion of the projectsincreased with the length of formal education, whereas acquisitionof new information and self-reported behaviour change was highestamong those with the lowest level of education in both communities.Approximately 40% of those aware reported behaviour change dueto the interventions. These findings suggest that the projectshave favoured the target groups of the intervention.     

Gamma-tocopherol as a possible marker for nutrition-related risk: results from four National Diet and Nutrition Surveys in Britain

Relationships between vitamin E status (alpha and gamma-tocopherol and their ratio in plasma), anthropometric and biochemical indices, and food and nutrient intakes, were studied in four British National Diet and Nutrition Surveys: children aged 1.5-4.5 years, young people aged 4.0-18.0 years, adults 19.0-64.0 years and adults aged > or = 65.0 years. gamma-Tocopherol:alpha-tocopherol ratio declined with age. In older women gamma-tocopherol and gamma-tocopherol:alpha-tocopherol ratios were directly related to indices of obesity. In young men alpha- and gamma-tocopherols were directly correlated with obesity, but gamma-tocopherol:alpha-tocopherol ratio was not. For young people and toddlers, fewer obesity indices were available and relationships were weaker. Other fat- and water-soluble vitamin indices correlated directly with alpha-tocopherol and inversely with gamma-tocopherol and gamma-tocopherol:alpha-tocopherol ratio. Whereas alpha-tocopherol correlated directly with 'healthy' nutrient choices (such as intrinsic sugars, dietary fibre, vitamins and potassium) and inversely with 'unhealthy' choices (extrinsic sugars and monounsaturated fats, i.e. avoidance of polyunsaturated fat), gamma-tocopherol and the gamma-tocopherol:alpha-tocopherol ratio related inversely with 'healthy' choices. Food groups had analogous relationships; thus, alpha-tocopherol related directly to use of polyunsaturated fats, fresh fruits and fruit juices, and inversely to non-polyunsaturated fats and extrinsic sugar. The reverse was true for gamma-tocopherol and gamma-tocopherol:alpha-tocopherol ratio. Although the mechanisms underlying these relationships are obscure, the gamma-tocopherol:alpha-tocopherol ratio may reveal poor dietary choices, status predictors and a propensity for obesity in later life, especially in women.     

Application of Intervention Mapping to develop a community-based health promotion pre-pregnancy intervention for adolescent girls in rural South Africa: Project Ntshembo (Hope)

Background

South Africa (SA) is undergoing multiple transitions with an increasing burden of non-communicable diseases and high levels of overweight and obesity in adolescent girls and women. Adolescence is key to addressing trans-generational risk and a window of opportunity to intervene and positively impact on individuals’ health trajectories into adulthood. Using Intervention Mapping (IM), this paper describes the development of the Ntshembo intervention, which is intended to improve the health and well-being of adolescent girls in order to limit the inter-generational transfer of risk of metabolic disease, in particular diabetes risk.

Methods

This paper describes the application of the first four steps of IM. Evidence is provided to support the selection of four key behavioural objectives: viz. to eat a healthy, balanced diet, increase physical activity, reduce sedentary behaviour, and promote reproductive health. Appropriate behaviour change techniques are suggested and a theoretical framework outlining components of relevant behaviour change theories is presented. It is proposed that the Ntshembo intervention will be community-based, including specialist adolescent community health workers who will deliver a complex intervention comprising of individual, peer, family and community mobilisation components.

Conclusions

The Ntshembo intervention is novel, both in SA and globally, as it is: (1) based on strong evidence, extensive formative work and best practice from evaluated interventions; (2) combines theory with evidence to inform intervention components; (3) includes multiple domains of influence (community through to the individual); (4) focuses on an at-risk target group; and (5) embeds within existing and planned health service priorities in SA.

     

Diet and cancer: assessing the risk

Globally, colorectal cancer (CRC) is a leading cause of mortality from malignant disease. Case-control and cohort studies provide strong support for a role of diet in the aetiology of CRC. However to establish causal relationships and to identify more precisely the dietary components involved, intervention studies in human subjects are required. Cancer is an impractical endpoint in terms of numbers, cost, study duration and ethical considerations. Consequently, intermediate biomarkers of the disease are required. This review aims to provide an overview of the intermediate endpoints available for the study of CRC, particularly non-invasive faecal biomarkers. Examples of their use in dietary intervention studies are given.     

The costs of a community-based intervention to promote maternal health

The costs of community-level interventions are rarely reported, although such insights are needed if intervention research is to be useful to practitioners seeking to understand what might be involved in replicating interventions in different contexts. We report the costs of a 2-year community-based intervention to promote the health of recent mothers in Victoria, Australia. Program of Resources, Information and Support for Mothers was an integrated programme of primary care and community-based strategies. It had health care professional training, health education and community development components as well as an emphasis on creating 'mother-friendly' environments. Costs included the programme costs [primarily the salaries of the community development officers (CDO) in the field] and also 'induced' costs that relate to the CDOs' successes in attracting additional resources to the intervention from the local community. The total cost averaged A$272,490 per rural community and A$313,900 per urban community, equivalent to A$172.40 and A$128.70 per mother, respectively. For every A$10 of public funds initially invested in the project, the CDOs were able to attract a further A$1-2 worth of local resources, predominantly in the form of volunteer time or donated services.     

Diet intervention methods to reduce fat intake: nutrient and food group composition of self-selected low-fat diets

A multicentered pilot study was conducted to test an intervention protocol designed to reduce fat intake to 15% of energy intake. Eligible subjects were postmenopausal women with stage II breast cancer whose baseline fat intake was more than 30% of energy intake. The low-fat diet intervention protocol consisted of bi-weekly individual counseling sessions with emphasis on substitution of lower-fat foods for high-fat foods and maintenance of nutritional adequacy. Nutrient intakes were calculated from 4-day food records collected at baseline and after 3 months of diet intervention. Mean daily fat intake for the 17 patients on the low-fat diet dropped significantly from 38.4 +/- 4.3% of energy intake at baseline to 22.8 +/- 7.8% at 3 months (p less than .001). A 25% reduction in mean energy intake, from 1,840 +/- 419 kcal at baseline to 1,365 +/- 291 kcal at 3 months, was accompanied by significant increases in protein and carbohydrate as percent of energy intake. A mean weight loss of 2.8 kg and a 7.7% reduction in serum cholesterol were observed; both changes were significant at the p less than .01 level. Absolute intakes of zinc and magnesium were significantly reduced. However, mean intake on the low-fat diet for 14 vitamins and minerals, including zinc and magnesium, exceeded two-thirds of the 1989 Recommended Dietary Allowances (RDAs). When expressed as nutrient density (i.e., amount of nutrient per 1,000 kcal), increases were observed for all micronutrients. These results support the hypothesis that a nutritionally adequate low-fat diet can be successfully implemented in a highly motivated, free-living population.     

Interactive video behavioral intervention to reduce adolescent females' STD risk: a randomized controlled trial

A longitudinal randomized design was used to evaluate the impact of a theoretically based, stand-alone interactive video intervention on 300 urban adolescent girls' (a) knowledge about sexually transmitted diseases (STDs), (b) self-reported sexual risk behavior, and (c) STD acquisition. It was compared to two controls, representing high-quality informational interventions. One used the same content in book form; the other used commercially available brochures. Following randomization, the interventions were administered at baseline, with booster sessions at 1, 3, and 6 months. Self-reports revealed that those assigned to the interactive video were significantly more likely to be abstinent in the first 3 months following initial exposure to the intervention, and experienced fewer condom failures in the following 3 months, compared to controls. Six months after enrollment, participants in the video condition were significantly less likely to report having been diagnosed with an STD. A non-significant trend in data from a clinical PCR assay of Chlamydia trachomatis was consistent with that finding.     

Diet in relation to endometrial cancer risk: a case-control study in Greece

The risk of endometrial cancer is positively associated with obesity, but the role of specific nutrients remains unclear. Given the distinct characteristics of the Greek diet and the low incidence of this form of cancer among Greek women, we undertook a case-control study to investigate the association of endometrial cancer with food groups and micronutrients. Cases were 84 women with histologically confirmed endometrial cancer and controls were 84 women with intact uterus admitted to the same teaching hospital in Athens, Greece. Consumption of pulses, nuts, and seeds was significantly inversely related to the risk for endometrial cancer. No other significant association with food groups was detected, although a protective effect of added lipids, which in the Greek diet are primarily represented by olive oil, was highly suggestive. Retinol, nicotinic acid, vitamin B- 6, and riboflavin were inversely associated with the disease. These findings need to be replicated, because this was a relatively small study with the statistical power to detect only strong associations between cases and controls; they appear, however, to support a role of diet in the etiology of endometrial cancer.     

Developing a community-based neonatal care intervention: a health facility assessment to inform intervention design

Community-based interventions are an important way of improving health in low-income countries. A necessary prerequisite for the design of such interventions is an understanding of the local health system. This will inform intervention design, help ensure the community-intervention forms part of a continuum of care, and provide information about health system strengthening activities that may be necessary for success. Such formative research processes, however, are seldom reported in the literature. We present the results of a health facility assessment used in the design stage of Newhints, a community-based intervention to improve neonatal survival in rural Ghana. We illustrate the methodology, findings and how these were used to inform the design and implementation of Newhints. The assessment involved key informant interviews with staff members at seven health facilities within the study area, including a brief inventory of available drugs and equipment. The key informant interviews identified that practices and health promotion messages at the health facilities were not consistent with one of the key target behaviours of the Newhints intervention - thermal care through delayed infant bathing. Health workers were bathing neonates soon after delivery and also advising women to do the same, which is a potential cause of hypothermia for the newborn. We found that health centres other than large district hospitals were ill-equipped to treat serious complications of labour or illness in the newborn, which had implications for advice on health seeking behaviour within the intervention. As a result of the health facility assessment, it was deemed necessary to undertake both health worker training and sensitisation activities. We demonstrate that important information can be yielded from a relatively simple health facility assessment involving key informant interviews.     

Fruit and Vegetable Dietary Behavior in Response to a Low-Intensity Dietary Intervention: The Rural Physician Cancer Prevention Project

ABSTRACT:  Context: Increased fruit and vegetable intake can reduce cancer risk. Information from this study contributes to research exploring health disparities in high-risk dietary behavior. Purpose: Changes in fruit and vegetable behavior were evaluated to assess the effects of a low-intensity, physician-endorsed dietary intervention in a rural population. Methods: The study was a randomized trial of 754 patients from 3 physician practices in rural Virginia. Low-literacy nutrition education materials and personalized dietary feedback were administered by mail and telephone. Mixed model analysis of variance was used to determine the effect of the intervention on fruit and vegetable intake behavior, knowledge, intentions, and self-efficacy at 1, 6, and 12 months. Findings: The intervention effect was moderated by age, race, sex, and education. Intake at 1 and 6 months was increased for older and younger participants and those with some college, and further maintained at 12 months by those who did not complete high school. African Americans in the intervention group displayed significantly greater intentions to increase fruit/vegetable intake than whites/others. Knowledge of fruit/vegetable recommendations significantly increased in the intervention group at 12 months, particularly for men. Conclusions: For the rural population, a low-intensity physician-endorsed self-help dietary intervention was successful in initiating fruit and vegetable dietary changes at 1 and 6 months post-intervention, and increasing intentions to change in African Americans. The relationship of the moderating effects of age, race, sex and education need to be further explored in relation to dietary intervention and dietary behavior change for the rural population.     

Evaluation of a community-based effort to reduce blueberry harvesting injury

BACKGROUND: Harvesting of blueberries is associated with musculoskeletal injury. This study assessed the effects of several alternative designs of the harvesting rake. METHODS: A community-based work team selected rake design for intervention and pilot tested potential design modifications to the blueberry harvesting rake. An "extended" handle design was selected for comparison with the traditional short-handle rake. Tested rakes were of two widths (70 and 80 tines) and four handle lengths (short handle; extended: 10, 14, or 16 in.). Workers rated each of five configurations after 4 hr of use. Evaluators tracked qualitative and quantitative indicators of the community-based approach throughout. RESULTS: Data from 29 subjects were analyzed using two-factor analysis of variance. There was increased productivity (P = 0.041); greater acceptability (P < 0.0001); less force (P < 0.001); and less pain (P < 0.0001) with the extended handle designs. The 80 tine width was favored over the 70. Process evaluation identified problems that generally could be addressed. Outcome evaluation indicated successful achievement of all stated goals. CONCLUSIONS: The "extended" handle rake may prove effective in reducing musculoskeletal injury associated with blueberry harvesting. A community-based approach to migrant farmworker injuries can be effective, particularly if employers participate.     

Evaluation of a community-based intervention to increase breastfeeding prevalence

BACKGROUND: The aim of the study was to determine whether peer counselling in the antenatal and post-natal period would increase the prevalence and duration of breastfeeding among low-income women in Glasgow. METHODS: The study was designed as a quasi-experimental evaluation of a community-based breastfeeding promotion programme. The intervention comprised peer counselling of pregnant women, support of breastfeeding mothers and local awareness-raising activities. The study subjects were all women attending the antenatal booking clinic resident in either the intervention or control area. Data were collected by means of four self-completion questionnaires, two administered antenatally and two post-natally. The proportions intending to breastfeed or breastfeeding in the intervention and control groups were compared at each assessment and over time. RESULTS: Of the 995 women enrolled in the study, data were available for analysis on 919 (92 per cent) to 6 weeks postnatally. At booking, 18 per cent of the intervention group and 21 per cent of the control group stated an intention to breastfeed. At delivery, the proportions initiating breastfeeding were 23 per cent of the intervention subjects and 20 per cent of the controls, and by 6 weeks post-natally, the proportion providing any breast milk had declined to 10 per cent of the intervention group and 8 per cent of the control group. Using multivariate analysis to adjust for factors (such as socio-economic status) known to influence breastfeeding, the breastfeeding prevalence was significantly higher in the intervention group relative to the controls at delivery [odds ratio (OR) 2.0; 95 per cent confidence interval (CI) 1.2-3.1, p = 0.006]. By 6 weeks post-natally the difference between the two groups was not statistically significant (OR 1.8; 95 per cent CI 1.0-3.4, p=0.07). CONCLUSIONS: As the impact of the intervention was not sustained even for the modest duration of 6 weeks postnatally, it would be premature to justify widespread use of peer support programmes to increase the prevalence of breastfeeding in socially disadvantaged communities.