Celia Kaplan

The success of cervical cancer control programs depends on regular screening with the Pap smear test and prompt and appropriate treatment of early neoplastic lesions. Recognizing the potentially grave consequences of lack of follow-up for abnormal Pap smears, numerous intervention studies have tested the impact of a variety of strategies to increase return for follow-up. The majority of these studies were evaluated under controlled experimental conditions. Despite the encouraging findings of these trials, the next step in the research continuum requires that the effectiveness of these interventions be demonstrated in real world settings before full implementation is initiated. We report the results of an evaluation study assessing the combined effectiveness of three intervention modalities found effective in prior randomized studies: a tracking follow-up protocol, transportation incentives, and financial incentives. This study used a before-after, nonequivalent control group design ...

Use of mobile health (mHealth) tools has expanded rapidly but little research has been done on its acceptability by low-income, diverse, older patient populations. To assess the attitudes of a diverse group of underserved women on the acceptability and usability of mHealth tools in a clinical setting using a breast health questionnaire application (app) at a public hospital mammography clinic. Semi-structured interviews were conducted in a breast-imaging center of an urban safety net institution from July-August 2012. Interviews included pre- and post-questions. Women completed the Athena breast health questionnaire app on an iPad and were asked about their experience and ways to improve the tool. Fifteen women age 45-79 years from diverse ethnic and educational backgrounds were interviewed. The majority of women, 11 of 15, preferred the Athena app over a paper version and all the women thought the app was easy to use. Two Spanish-speaking Latinas preferred paper; and two women, wit...

Evaluating smoking prevention and cessation programs requires valid data collection. This study examined two survey modes—face-to-face (FTF) interview and self-administered questionnaire (SAQ)—comparing response rates, sample characteristics, data quality, and response effects. From two family planning clinics, 601 female Latina and African American clients ages 12 to 21 were recruited and randomized to either group. Results reveal that neither mode is

Although the majority of studies examining racial/ethnic disparities in health care have focused on the characteristics of the individual, more recently there has been growing attention to the notion that an individual's health practices could be influenced by the characteristics of the place where they reside. The objective of this study was to examine whether access to care for individuals of different racial/ethnic groups varies by the prevalence of blacks and the prevalence of Latinos in their county of residence. We conducted a cross-sectional cohort. Individuals from the 1996 Medical Expenditure Panel Survey, a nationally representative sample of U.S. households, who described their race/ethnicity as white, black, or Latino, and who resided in 1 of 677 counties (n = 14740) were studied. Counties were assigned to 6 groups based on the prevalence of blacks and Latinos who resided there (<6% referred to as "low prevalence," 6-39% referred to as "midprevalence," >or=40% referred to as "high prevalence" separately for both blacks and Latinos). Outcomes included whether during the past year any family members: 1). experienced difficulty obtaining any type of health care, delayed obtaining care, or did not receive health care they thought they needed (referred to as "difficulty obtaining care"); or (2). did not receive a…

Anxiety following an abnormal mammogram result can be substantial. We examined whether the time to the first diagnostic test was associated with anxiety. We surveyed 449 women at 2 and 8 months after an abnormal mammogram result, and we reviewed their medical records. Twenty-six percent of women reported being very anxious about their abnormal mammogram result at the time of the two-month interview, and 22% reported persistent anxiety after 8 months. After adjustment, the number of days until the first diagnostic test was not associated with anxiety at the 2-month interview. By the second interview, women who received their first diagnostic test within the first week were significantly more anxious, as were women who did not receive their first test for at least 60 days after their results. Further work is needed to ascertain how to minimize the anxiety associated with the evaluation of an abnormal mammogram.

Summary Background: Demographic and socioeconomic factors associated with smoking behavior were evaluated in a nationwide household survey in Argentina to describe the status of the tobacco epidemic. Methods: Face-to-face interviews with adults, age 20 and older, assessed smoking status, frequency, and age of initiation. Multivariate logistic regression was used to compare social and demographic characteristics. Results: Of the 43,863 participants,

Objectives. We examined the effect of race, socioeconomic status, and health insur- ance status on the prevalence of overweight among children and adolescents. Methods. We studied an observational cohort from the 1996 Medical Expenditure Panel Survey Household Component. Results. In the younger group, both Black and Latino children had a greater likelihood of being overweight compared with White children. Among

JOURNAL OF WOMEN'S HEALTH Volume 4, Number 2, 1995 Mary Ann Liebert, Inc. ... Individual and System Factors Affecting Follow-up ... CELIA PATRICIA KAPLAN, Dr.PH, MA,1 ROSHAN BASTANI, Ph.D.,2 ALFRED MARCUS, Ph.D.,3 LESTER BRESLOW, MD, MPH,1 ...

Although a substantial literature compares data on health-related behaviors collected by face-to-face and telephone interview formats, little attention has been paid to the comparability of responses regarding cigarette-smoking-related behavior, particularly among Latino youth. This study compares telephone and face-to-face interview methods for assessing smoking behaviors, attitudes, and beliefs among Latina adolescents. Data indicated no significant differences in demographic characteristics or smoking-related behaviors between the face-to-face and telephone groups. However, respondents interviewed face-to-face were significantly more likely to express dislike of smokers and state that quitting smoking was easy.

An abnormal mammography finding constitutes a stressful event that may increase vulnerability by developing or intensifying pre-existing psychological morbidity. We evaluated depressive symptoms using the Composite International Diagnostic Interview among women of four ethnic groups who had an abnormal mammography result controlling for the effect of demographic, psychosocial and medical factors on recent onset of depressive symptoms. Telephone surveys were conducted among women aged 40-80 years recruited from four clinical sites in the San Francisco Bay Area after receiving a screening mammography result that was classified as abnormal but probably benign, suspicious or highly suspicious, or indeterminate using standard criteria. Among the 910 women who completed the interview, mean age was 56 (S.D.=10), 42% were White, 19% Latina, 25% African American, and 14% Asian. Prevalence of lifetime depressive symptoms was 44%, and 11% of women had symptoms in the previous month. Multivariate logistic regression models showed that Asian ethnicity, annual income >$10 000 and weekly attendance at religious services were significantly associated with decreased depressive symptoms. Having an indeterminate result on mammography and being on disability were significantly associated with more depressive symptoms. Reporting a first episode of depression more than a year before the interview was associated with significant increase in depressive symptoms in the month prior to the interview regardless of mammography result. Women with an indeterminate interpretation on mammography were at greater risk of depressive episode in the month prior to the interview compared to women with probably benign results (odds ratio=2.41; 95% CI=1.09-5.31) or with a suspicious finding. Clinicians need to consider depression as a possible consequence after an abnormal mammography result.

To examine differences in treatment decision-making participation, satisfaction, and regret among Latinas and non-Latina whites with DCIS. Survey of Latina and non-Latina white women diagnosed with DCIS. We assessed women's preferences for involvement in decision-making, primary treatment decision maker, and participatory decision-making. We examined primary outcomes of satisfaction with treatment decision-making and treatment regret by ethnic-language group. Among 745 participants (349 Latinas, 396 white) Spanish-speaking Latinas (SSL) had the highest mean preference for involvement in decision-making score and the lowest mean participatory decision-making score and were more likely to defer their final treatment decision to their physicians than English-speaking Latinas or whites (26%, 13%, 18%, p<0.05). SSLs reported lower satisfaction with treatment decision-making (OR 0.4; CI 95%, 0.2-0.8) and expressed more regret than whites (OR 6.2; CI 95%, 3.0-12.4). More participatory decision-making increased the odds of satisfaction (OR 1.5; CI 95%, 1.3-1.8) and decreased the odds of treatment regret (OR 0.8; CI 95%, 0.7-1.0), independent of ethnicity-language. Language barriers impede the establishment of decision-making partnerships between Latinas and their physicians, and result in less satisfaction with the decision-making process and more treatment regret. Use of professional interpreters may address communication-related disparities for these women.

In a large randomized trial involving over 2,000 women with abnormal cervical cytology (pap smear), three clinic-based interventions were tested as strategies to increase return rates for screening follow-up: 1) a personalized follow-up letter and pamphlet; 2) a slide-tape program on pap smears; and 3) transportation incentives (bus passes/parking permits). The three interventions were evaluated using a 2 x 2 x 2 factorial design. Results of this study confirm a high rate of loss to screening follow-up (i.e., no return visits) among women with abnormal pap smears (29% overall), with substantial variability among the 12 participating clinics (13% to 42/%). For the sample as a whole, both transportation incentives and the combined intervention condition of personalized follow-up and slide-tape program had a significant positive impact on screening follow-up. However, transportation incentives emerged as the dominant intervention condition among patient subgroups that can be characterized as more disadvantaged socioeconomically and at higher risk of developing cervical cancer, including patients receiving care from the county health department (odds ratio (OR) = 1.51; P less than .05); patients without health insurance (OR = 1.77; P less than .01); and patients with more severe pap smear results (OR = 1.71; P less than .05). In contrast, among patient subgroups that can be characterized as relatively more advantaged and at lower risk of developing cervical cancer, only the combined intervention condition of personalized follow-up and slide-tape program was associated with a higher patient return rate. Subgroups reflecting this pattern included patients seen in noncounty clinics (OR = 4.54; P less than .05) and patients with less severe pap smear results (OR = 5.16; P less than .01). The implications of these findings are discussed in terms of designing clinic-based interventions to improve screening follow-up.

To assess factors affecting follow-up care among low-income women after identification of a breast abnormality. Women with a newly discovered breast abnormality were selected from one public hospital and two comprehensive health centers (CHCs) in Los Angeles county. Twelve months later, a telephone survey and medical chart review were conducted. Of the 535 respondents, 8.6% received no follow-up care. Among those with follow-up care, 29.4% received inadequate care (did not initiate follow-up in a timely manner or did not complete all recommended procedures). Factors affecting receipt of any follow-up care included having the index visit at a CHC vs. a hospital (OR 2.79, CI 1.20-6.50), patient uncertainty about where to receive care (OR 0.24, CI 0.07-0.77), and recommendation of a clinical breast examination (CBE) (OR 0.12, CI 0.04-0.40) or 6-month mammogram (OR 0.11, CI 0.04-0.31) vs. a diagnostic mammogram as a first follow-up procedure. Factors affecting receipt of adequate follow-up care included index visit at a CHC vs. a hospital (OR 1.90, CI 1.13-3.20), being white/Asian Pacific Islander/other vs. Latina (OR 5.33, CI 1.71-16.68), recommendation of a 6-month mammogram vs. a diagnostic mammogram (OR 0.06, CI 0.02-0.14), and a family history of breast cancer (OR 0.44, CI 0.22-0.89). To maximize return for follow-up among low-income women with a breast abnormality, clear information should be provided about where to obtain care, particularly to patients in hospital settings. The importance of complete and timely follow-up care should be emphasized, especially with referrals for clinical breast examinations or 6-month mammograms.

The accuracy of a woman's perception of her risk of developing breast cancer has gained importance as more options for primary prevention have become available for those at increased risk. Conversely, women at average risk who perceive themselves as at increased risk may suffer from avoidable anxiety or unnecessary treatment. This study examined characteristics associated with perception of breast cancer risk among women at average and increased risk. We included 1700 women 40-74 years old without a history of breast cancer. The outcome variable was a woman's perceived lifetime risk of developing breast cancer. The Gail model was used to categorize a woman's actual risk as average or high. Multivariate logistic regression models were used to model a woman's perception that her risk was (1) higher than average for those whose Gail score indicated average risk (<1.67% 5-year risk) and (2) accurate for those whose Gail score indicated increased risk (> or = 1.67% 5-year risk). Of women at average risk, 72%, but only 43% of those at high risk, accurately perceived their risk. Among women at average risk, those who were younger, had a family history of breast cancer, had no history of childbirth, or had more frequent exposure to lay media information about breast health were more likely than women without these characteristics to overestimate their future risk. Among women at increased risk, younger women and those with a family history of breast cancer were more likely than women without these characteristics to accurately perceive their increased risk. African American women were less likely than white women to accurately perceive their risk. A majority of women at high risk of developing breast cancer underestimate their risk, and a substantial proportion of women at average risk perceive they are at increased risk.

Physical inactivity, poor diet, excessive alcohol consumption, and smoking are modifiable risk factors associated with development of chronic diseases. Although the prevalence of diseases associated with these detrimental lifestyle behaviors is high among women in the United States, they may not receive adequate counseling from physicians. To predict physicians' lifestyle counseling practices, we assessed personal, professional, and health behavior characteristics from responses to a self-administered survey of breast cancer risk reduction practices. Subjects were California physicians identified through AMA Masterfile, in family practice, internal medicine, or obstetrics/gynecology, who were asked to report the percentages of women patients they counseled on physical activity, diet, alcohol, and smoking. Of 1647 eligible physicians, 822 (50.0%) responded. Fifty-six percent reported counseling at least 75% of patients about physical activity, 54.6% about diet, and 44.8% about alcohol. More than three quarters (78.7%) counseled at least 75% of patients about smoking. In logistic regression analyses, woman gender, family practice, and internal medicine specialties emerged as significant predictors of counseling for all lifestyle behaviors. Older age was associated with dietary and alcohol counseling. Race/ethnicity was associated only with smoking counseling, and country of medical school was associated with counseling for physical activity and smoking. Sources of new medical knowledge emerged as predictors for all types of counseling, whereas physicians' own level of physical activity only predicted counseling about physical activity. Physicians' personal, professional, practice, and health behavior characteristics were associated with reported lifestyle counseling of women patients. Results reveal important directions for future physician-based interventions to improve counseling.

To assess the effects of receiving a research informational pamphlet produced by the federal Office for Human Research Protections on telephone survey participation rates of older Latinos, and illustrate the feasibility of nesting recruitment studies within other funded studies when stand alone funding for recruitment studies is limited. Latino patients aged ≥50 with ≥1 visit during the preceding year (N=1314) were sampled from three community clinics and a multi-specialty medical group. Patients were randomly assigned to receive or not receive a pamphlet that contained information on research participation in the initial mailing for the telephone survey study. Survey participation rates were compared between the pamphlet and no pamphlet groups. In a multivariate model, women (OR=1.4; 95% CI 1.1, 1.8), and those with public insurance (vs. no insurance; OR=1.7; 95% CI 1.1, 2.5) were more likely to participate, while those age 65+ (vs. age 50-54; OR=0.6; 95% CI 0.4, 0.8) were less likely to participate; there was no significant difference by pamphlet group (OR=0.8; 95% CI 0.7, 1.1). Nesting of the randomized trial of the recruitment pamphlet within the funded study required minimal additional resources. Recruitment methods that are more intensive than a pamphlet may be needed to enhance survey participation rates among older Latinos. Nesting recruitment trials within funded studies is a promising and efficient approach for testing recruitment strategies.

Use of chemoprevention to prevent development of breast cancer among high-risk women has been limited despite clinical evidence of its benefit. Our goals were to determine whether knowledge of the benefits and risks of tamoxifen affects a woman's willingness to take it to prevent breast cancer, to define factors associated with willingness to take tamoxifen, and to evaluate race/ethnic differences. Women, ages 50-80, who identified as African American, Asian, Latina, or White, and who had at least one visit to a primary care physician in the previous 2 years, were recruited from ambulatory practices. After a screening telephone survey, women completed an in-person interview in their preferred language. Multivariate regression models were constructed to examine the associations of demographic characteristics, numeracy, breast cancer history, and health knowledge with willingness to take tamoxifen. Over 40% of the women reported they would likely take tamoxifen if determined to be at high risk, and 31% would be somewhat likely to do so. Asian women, those with no insurance, and those with less than high school education were significantly more likely to be willing to take tamoxifen. Higher scores on numeracy and on breast cancer knowledge were also associated with willingness to take tamoxifen. A higher tamoxifen knowledge score was inversely related to willingness to take the drug. Factors affecting women's willingness to take breast cancer chemoprevention drugs vary and are not determined solely by knowledge of risk/benefit or risk perception.

Jennifer C. Livaudais, MPH; Anna Napoles-Springer, PhD; Susan Stewart, PhD; Celia Patricia Kaplan, DrPH, MA ... Objective: To assess baseline factors associat-ed with having ever drunk alcohol, smoked, and having had sex two years later among a sample of Latino ...

To investigate family physicians' and pediatricians' practice of and perceived barriers to smoking cessation counseling among patients 18 years and younger. Cross-sectional mail survey conducted between November 1, 1997, and January 31, 1998. A stratified random sample selected from the 1997 American Medical Association Physician Masterfile of 1000 family physicians and pediatricians who practice in urban California, work at least 10% of the time in ambulatory care, and have at least 10% of patients 18 years and younger. Physicians' adherence to 5 components of the National Cancer Institute's smoking cessation counseling recommendations (anticipate, ask, advise, assist, and arrange) and their perceived barriers to smoking cessation counseling. A total of 429 physicians participated in the study. Physicians of both specialties were more likely to anticipate, ask, and advise patients about smoking than to assist with and arrange cessation activities. Family physicians were more likely than pediatricians to assist and arrange, including scheduling follow-up visits to discuss quitting (25.1% vs 11.7%; odds ratio [OR], 3.07; 95% confidence interval [CI], 1.22-7.73) and directing nursing staff to counsel patients (17.1% vs 10.9%; OR, 3.70; 95% CI, 1.30-10.60). The most common perceived barrier to counseling was the belief that children would provide inaccurate responses due to either the presence of parents (86.4%) or the fear that parents would be notified of their answers (74.0%). Pediatricians reported lack of counseling skills as a barrier to providing smoking interventions in greater proportion than did family physicians (24.9% vs 54.8%; OR, 0.29; 95% CI, 0.14-0.63; P<.001). Improvement in smoking cessation counseling skills and practices is needed among physicians treating children and adolescents.