Formative research for developing targeted skin cancer prevention programs for children in multiethnic Hawaii.

Skin cancer is a significant and increasing public health problem. Improvement in sun protection practices among children holds great promise for prevention, and parents and caregivers play important roles. Health promotion programs are most likely to succeed when based on a systematic planning process including an understanding of current practices, beliefs, social norms and environments. This article describes formative research used to help develop the SunSmart skin cancer prevention program in Hawaii. Group discussions and interviews were conducted with 216 children in grades 1, 2 and 3, 15 parents, and 27 recreation staff. Children's discussion groups took place in intact classrooms. A combination of quantitative and qualitative methods was used. Multiple raters and an iterative process were used to analyze data from survey forms, observer impressions and audio tapes, and to draw the main conclusions. Sun protection practices in all groups were inconsistent, though general awareness about prevention was widespread. Children reported a reluctance to cover up with long pants and sleeves, and wide-brim hats, and did not understand what skin cancer was. Parents and recreation staff were supportive of education and policy supports, to improve both their own and the children's prevention habits. They were enthusiastic about interactive and creative activities. We conclude that targeted skin cancer prevention messages and strategies for Hawaii's children should promote gradual changes, provide environmental supports, and involve parents and recreation staff. Both the findings and procedures have implications for prevention elsewhere.     

Factors associated with age at natural menopause in a multiethnic sample of midlife women

An unprecedented number of women will experience menopause in the next decade. Although the timing of menopause affects long-term disease risk, little is known about factors that affect this timing. In the present 1995--1997 cross-sectional study, the Study of Women's Health Across the Nation, the relation of demographic and lifestyle factors to age at natural menopause was examined in seven US centers and five racial/ethnic groups. All characteristics were self-reported by women aged 40--55 years (n = 14,620). Cox proportional hazards models were used to estimate the probability of menopause by age. Overall, median age at natural menopause was 51.4 years, after adjustment for smoking, education, marital status, history of heart disease, parity, race/ethnicity, employment, and prior use of oral contraceptives. Current smoking, lower educational attainment, being separated/widowed/divorced, nonemployment, and history of heart disease were all independently associated with earlier natural menopause, while parity, prior use of oral contraceptives, and Japanese race/ethnicity were associated with later age at natural menopause. This sample is one of the largest and most diverse ever studied, and comprehensive statistical methods were used to assess factors associated with age at natural menopause. Thus, this study provides important insights into this determinant of long-term disease risk in women.     

Factors associated with pesticide safety practices in farmworkers

BACKGROUND: Farmworkers and their families are exposed to pesticides through multiple pathways. Few studies have examined the frequency with which farmworkers engage in pesticide safety practices and the factors associated with their adoption. METHODS: Using a large sample of farmworkers (n = 554), we evaluated relationships between pesticide safety behaviors and farmworkers' beliefs, training history, handling of pesticides at work, perceived occupational exposure, and employers' provision of personal protective equipment. RESULTS: Performing behaviors at work was determined largely by whether personal protective equipment was provided. For home behaviors, female gender, living in a labor camp, being trained in the last 5 years, handling pesticides directly, and not perceiving organizational barriers to protecting oneself were associated with taking more precautions. CONCLUSIONS: These findings call for interventions that involve and engage multiple stakeholders to increase adoption of pesticide safety behaviors and reduce pesticide exposure in farmworkers.     

Implementation of a cancer prevention program for working class, multiethnic populations

BACKGROUND: This paper describes the implementation of the Healthy Directions-Health Centers intervention and examines the characteristics of participants associated with completion of intervention activities. Healthy Directions-Health Centers was designed to address social contextual factors relevant to cancer prevention interventions for working class, multi-ethnic populations. METHODS: Ten community health centers were paired and randomly assigned to intervention or control. Patients who resided in low income, multi-ethnic neighborhoods were approached for participation. This study targeted fruit and vegetable consumption, red meat consumption, multi-vitamin intake, and physical activity. The intervention components consisted of: (1) a brief study endorsement from a clinician; (2) an in-person counseling session with a health advisor; (3) four follow-up telephone counseling sessions; and (4) multiple distributions of tailored materials. RESULTS: Among the 1,088 intervention group participants, 978 participants (90%) completed at least five out of six intervention activities. Participants who missed clinical appointments were less likely to complete all components of the intervention. Participant characteristics that predicted receipt of clinician endorsement differed from characteristics that predicted completion of health advisor activities. Low acculturation did not present a barrier to delivery of the intervention once the participant was enrolled. CONCLUSIONS: Collection and reporting on process evaluation results can help explain variations in program implementation.     

Limited English proficiency and breast and cervical cancer screening in a multiethnic population

OBJECTIVES: We examined the relationship between ability to speak English and receipt of Papanicolaou tests, clinical breast examinations, and mammography in a multiethnic group of women in the United States. METHODS: We used longitudinal data from the Study of Women Across the Nation to examine receipt of breast and cervical cancer screening among Chinese, Japanese, Hispanic, and White women who reported reading and speaking (1) only a language other than English, (2) another language more fluently than English, or (3) only English or another language and English with equal fluency. Logistic regression was used to analyze the data. RESULTS: Reading and speaking only a language other than English and reading and speaking another language more fluently than English, were significantly and negatively associated with receipt of breast and cervical cancer screening in unadjusted models. Although these findings were attenuated in adjusted models, not speaking English well or at all remained negatively associated with receipt of cancer screening. CONCLUSIONS: These findings suggest that language barriers contribute to health disparities by impeding adequate health communication.     

Factors associated with functional decline and improvement in a very elderly community-dwelling population.

The objective of this study was to analyze the factors associated with functional decline and improvement in a community-dwelling population of people aged 75 years and older. A representative sample of elderly people living at home in the city of Sherbrooke (Quebec, Canada) was assessed yearly on three occasions (1991-1993) by a nurse. A health questionnaire, together with standardized instruments measuring disabilities, cognitive status, and depressive mood, was administered on the three assessments. From the 655 subjects who agreed to participate, a total of 504 subjects completed the study. The most important factors associated with functional decline were the number of days off regular activities (odds ratio (OR) = 1.31), the number of hot meals per day (OR = 1.59), and cognitive status (OR = 0.96), whereas weight loss (OR = 0.37) and living alone (OR = 0.54) were significant protective factors. Previous declines in functional autonomy, cognitive state, or mood were not independent risk factors. The most important factors associated with functional improvement were the disability score (OR = 1.08), previous functional decline (OR = 6.06), and decline in the disability score (OR = 1.09). Perceiving health to be worse than it was the previous year was a significant factor against improvement (OR = 0.24). This study identifies risk factors that can be helpful for targeting high-risk subgroups within the very elderly population who may benefit from a preventive program.     

Factors associated with regular aerobic exercise in an elderly population.

BACKGROUND: Little is known regarding the characteristics of elderly persons who do not regularly exercise. This lack of knowledge limits the design and marketing of exercise programs to persons who could benefit from regular exercise. METHODS: We compared characteristics of regular exercisers and nonexercisers among 561 randomly selected persons aged 65 years and older who were enrollees of a health maintenance organization. Baseline data were obtained on sociodemographics, health attitudes, and medical conditions. RESULTS: Of the 561 persons studied, 192 (34 percent) were regular exercisers. Exercisers were slightly younger than nonexercisers and reported more positive health perceptions. Nonexercisers tended to report lower incomes and lower educational levels than did exercisers. Exercisers were less likely to report hypertension, arthritis, or two or more of the following medical conditions: heart disease, hypertension, arthritis, and emphysema (odds ratio 0.49; confidence interval 0.28 to 0.86). Sex differences were present. In logistic regression analysis, higher reported income, better perception of current health, and fewer than two medical conditions were associated with regular exercise status. CONCLUSIONS: Specific characteristics are present in persons who regularly exercise compared with those who do not. These findings may prove useful in understanding the dynamics of exercise behavior in this age group and in designing exercise interventions for this population.     

Factors associated with colorectal cancer screening among the US urban Japanese population

OBJECTIVES: The author examined the prevalence and predictors of colorectal cancer screening among the urban Japanese population of the United States. METHODS: A sample of Japanese residents of major US metropolitan areas completed a self-administered mailed survey. RESULTS: Physician recommendation, acculturation, and perceived psychological costs were consistent predictors of screening for colorectal cancer. Gender and marital status were related to screening via fecal occult blood testing; age, susceptibility, and health insurance were related to sigmoidoscopy/colonoscopy screening. CONCLUSIONS: Colorectal cancer screening among the urban Japanese population could be increased with interventions seeking to promote physician recommendations for screening, alleviate perceived psychological costs among patients, and improve physician-patient communication.     

Carbohydrate intake and HDL in a multiethnic population

BACKGROUND: Ethnic differences in serum lipids are not explained by genetics, central adiposity, lifestyle, or diet, possibly because dietary carbohydrate has not been considered. OBJECTIVE: The aim was to evaluate the relation between carbohydrate intake and HDL and triacylglycerol concentrations in a multiethnic population. DESIGN: We conducted a population-based cross-sectional study of 619 Canadians of Aboriginal, South Asian, Chinese, and European origin with no previously diagnosed medical conditions. Energy-adjusted carbohydrate intake was measured by a validated food-frequency questionnaire. RESULTS: South Asians consumed the most carbohydrate, followed by European, Aboriginal, and Chinese persons. Mean (95% CI) HDL concentrations in the lowest and highest categories of carbohydrate intake after adjustment for age, sex, ethnicity, physical activity, smoking, the waist-to-hip ratio, body mass index, alcohol intake, and intakes of total energy, protein, and fiber were 1.21 mmol/L (1.16, 1.27 mmol/L) and 1.08 mmol/L (1.02, 1.13 mmol/L), respectively, and HDL cholesterol was significantly (P < 0.01) higher in the lowest tertile of carbohydrate intake than in the highest tertile. High carbohydrate intake was associated with higher fasting triacylglycerols (P = 0.04); the adjusted mean fasting triacylglycerol concentrations in the lowest and highest categories of carbohydrate intake were 1.43 mmol/L (1.28, 1.60 mmol/L) and 1.71 mmol/L (1.57, 1.87 mmol/L), respectively. Fewer servings of sugar-containing soft drinks, juices, and snacks were associated with higher HDL (P for trend = 0.02); the multivariate-adjusted mean HDL in the lowest and highest categories of carbohydrate intake was 1.22 mmol/L (1.17, 1.27 mmol/L) and 1.11 mmol/L (1.06, 1.26 mmol/L), respectively. CONCLUSIONS: Differences in HDL and triacylglycerols observed in different ethnic groups may be due in part to carbohydrate intake. Reducing the frequency of intake of sugar-containing soft drinks, juices, and snacks may be beneficial.     

Causes of infant mortality in a multiethnic population

Causes of infant mortality and their change over time in five ethnic groups were investigated using linked infant death and live birth certificates from the State of Hawaii, 1968-1983. Over the study period, there were 3,324 deaths of which 31 percent were to Whites, 26 percent to Hawaiians, 17 percent to Asians, 15 percent to Filipinos and 10 percent to other ethnic groups. Significant changes in the proportion of deaths by cause occurred over the period. Perinatal causes remained the most frequent, but their relative contribution to annual infant deaths declined from 61 percent to 47 percent. The proportion of deaths from congenital anomalies increased from 19 percent to 30 percent, while the proportion of deaths from infectious diseases declined from 14 percent to 4 percent. There was a significant difference in the proportion of deaths by cause between ethnic groups in the early years of the study period. However, during the last four years 1980-1983, no significant difference between ethnic groups was observed.     

Dietary fat, cooking fat, and breast cancer risk in a multiethnic population

Our objective was to examine the association between dietary fat intake, cooking fat usage, and breast cancer risk in a population-based, multiethnic, case-control study conducted in the San Francisco Bay area. Intake of total fat and types of fat were assessed with a food frequency questionnaire among 1,703 breast cancer cases diagnosed between 1995 and 1999 and 2,045 controls. In addition, preferred use of fat for cooking was assessed. Unconditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). High fat intake was associated with increased risk of breast cancer (highest vs. lowest quartile, adjusted OR = 1.35, 95% CI = 1.10-1.65, P(trend) < 0.01). A positive association was found for oleic acid (OR = 1.55, 95% CI = 1.14-2.10, P(trend) < 0.01) but not for linoleic acid or saturated fat. Risk was increased for women cooking with hydrogenated fats (OR = 1.58, 95% CI = 1.20-2.10) or vegetable/corn oil (rich in linoleic acid; OR = 1.30, 95% CI = 1.06-1.58) compared to women using olive/canola oil (rich in oleic acid). Our results suggest that a low-fat diet may play a role in breast cancer prevention. We speculate that monounsaturated trans fats may have driven the discrepant associations between types of fat and breast cancer.     

Factors associated with participation in cancer prevention and control studies among rural Appalachian women

Rural Appalachian women bear a disproportionate burden from many types of cancer yet often are underrepresented in cancer research. This article uses 2 case studies to illustrate barriers faced and strategies used when recruiting hard-to-reach rural participants. Recruitment barriers include the population's competing demands and lack of trust of outsiders. Strategies employed include involving insider advocates, highlighting the positive experiences of early participants, spending extensive time in the community, and emphasizing potential community benefits of the study. We suggest recruitment strategies to better involve rural women and others who, by virtue of being "hard-to-reach," often are overlooked.     

Cancer screening in a middle-aged general population: factors associated with practices and attitudes

Background  

The aim of this study was to identify factors associated with cancer screening practices and with general attitudes toward cancer screening in a general population.     

Factors associated with infant feeding practices after hospital discharge

OBJECTIVE: To assess factors associated with infant feeding practices on the first day at home after hospital discharge. METHODS: A total of 209 women, who had a child aged four months or less and were living in Itapira, Brazil, were interviewed during the National Immunization Campaign Day in 1999. Statistical analysis was performed using the Chi-square test and a logistic regression model was used for verifying an association between dependent and independent variables. RESULTS: Women aged 25.5 years on average and 18.2% were teenagers. Fifty-three percent of the women delivered vaginally and most vaginal deliveries (78.5%) took place in the public hospital. The prevalence of exclusive breastfeeding on the first day at home was 78.1% and 11.6% of the infants were receiving formula at this time. The only factor associated with EBF on the first day at home was being a teenaged-primiparous mother (OR=9.40; 95% CI: 1.24-71.27). This association remained statistically significant even after controlling for type of delivery and hospital where the birth took place. Feeding formula on the first day at home was only significantly associated with the hospital (i.e., birth at the city hospital was a protective factor (OR=0.33; 95% CI: 0.13-0.86), even after controlling for vaginal delivery. CONCLUSIONS: On the first day at home after hospital discharge, teenaged-primiparous mothers were more likely to exclusive breastfeeding as well as those infants born in the municipal public hospital. Further studies are needed from a multidisciplinary approach.     

Promoting skin cancer prevention counseling by pharmacists.

OBJECTIVES: This study evaluated the effects of an intervention on rates of skin cancer prevention counseling by pharmacists. METHODS: Fifty-four pharmacies were randomly assigned to intervention or control conditions. Intervention consisted of training, feedback, and prompts. Counseling rates before and after the intervention were obtained from study confederates. RESULTS: At pretest, the proportions of control and intervention sites providing counseling at least once were 7.4% and 0%, respectively (NS). At posttest, these proportions were 3.7% and 66.7%, respectively (P < .001). CONCLUSIONS: The results indicated that the intervention was successful and that pharmacists can play an important role in educating the public about skin cancer prevention strategies.     

Physical activity in a multiethnic population of third graders in four states.

OBJECTIVES: This research assessed the amount of daily physical activity in a multiethnic sample of US third-grade students. METHODS: Physical activity interviews were conducted with 2410 third graders from 96 schools in four states. Blood pressure, cholesterol, body mass index, timed run for distance, physical-activity self-efficacy, and perceived support for physical activity were also assessed. RESULTS: Students reported a daily average of 89.9 minutes of moderate to vigorous physical activity, 34.7 minutes of vigorous activity, and 120.4 minutes of sedentary behavior; however, 36.6% obtained less than 60 minutes of moderate to vigorous physical activity daily, and 12.8% reported less than 30 minutes. Boys reported more physical and sedentary activity than girls; White children reported more activity than Black or Hispanic children; California children reported the most activity and Louisiana children the least. Geographic location, male gender, lower cholesterol, higher perceived efficacy in physical activity, and higher social support were associated with more physical activity. CONCLUSIONS: Average reported activity met the Year 2000 objectives; however, many students reported less than recommended amounts of activity. These findings support the need for health promotion programs that increase the number of physically active children.     

Patients' understanding of anticoagulant therapy in a multiethnic population

To investigate whether knowledge and perceptions of antithrombotic therapy differ between ethnic groups in the UK, we conducted a cross-sectional questionnaire survey of patients attending anticoagulation clinics in three Birmingham teaching hospitals. 180 consecutive patients were recruited-135 white European, 29 Indo-Asian, 16 Afro-Caribbean. The average knowledge score was 5.5 out of 9, with no significant differences between the groups. Indo-Asians were significantly less likely than the other groups to know the name of the anticoagulant they were taking (warfarin) and Afro-Caribbeans to know the condition for which they were being anticoagulated. Few patients of any group were able to specify more than one side-effect of warfarin or the dose they were on. In logistic regression analysis the factors associated with a low score were age >61 years, having been born outside the UK, and the perception of difficulty in comprehension. Nearly half the Indo-Asians felt unable to understand what was said to them in the clinic, and 62% expressed a preference for a doctor of the same ethnic group. Although there were no significant between-group differences, this study points to gaps in the knowledge of patients from ethnic minorities and to deficiencies in the provision of information. In patient education, these groups should receive special attention.