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Appalachian Kentucky, a 32-county region in the eastern part of the state, has elevated colon cancer mortality rates. While recommended as the standard of care, access to adjuvant chemotherapy treatment is limited in this region due to scarce health services and significant social and geographical barriers. The purpose of this investigation was to improve understanding of barriers that cancer patients residing in rural areas not served directly by tertiary medical systems must overcome in completing adjuvant therapy. Participants were recruited from two medical centers: A tertiary care NCI designated Cancer Center and a regional hospital. Participants underwent a 15-20 minute interview to assess factors associated with adherence to adjuvant treatment recommendations. Grounded theory identified themes related to patient behaviors and non-adherence to standard of care recommendations. Data were collected in 45 telephone and in-person patient interviews, 26 from an NCI-designated cancer center and 19 from a rural hospital. Statistically the two groups were equivalent in terms of age, subjective health status, and medical comorbidities. Six themes were identified from analysis of the transcribed interviews including: confidence in my care provider, communication, treatment issues, distrust, faith, and barriers to obtaining healthcare. Participants completing adjuvant therapy were more likely to express trust in their provider and describe fewer barriers to obtaining healthcare than those not completing adjuvant therapy. Barriers to completing adjuvant therapy may differ between rural and urban healthcare systems which may yield opportunities for targeted interventions to improve rates of completion of colon cancer adjuvant chemotherapy.

Background Implementing evidence-based interventions for population-level benefit can be challenging in resource-limited primary care settings. Research is needed to identify, specify, and systematically study implementation strategies that address the multilevel, contextual influences on implementation in these settings. This study reviewed and compared the implementation strategies proposed by Research Projects (RPs) funded through the Accelerating Colorectal Cancer Screening through Implementation Science (ACCSIS) initiative. ACCSIS research projects implemented multilevel interventions to increase colorectal cancer screening and follow-up among their local populations. Methods Participating AC`CSIS RPs provided structured information about activities proposed to facilitate the implementation of evidence-based interventions to increase colorectal cancer screening, follow-up, and referral across project phases (i.e., exploration, preparation, implementation, sustainment). Three implementation science experts reviewed and matched program data to implementation strategies and domains using the Expert Recommendations for Implementing Change (ERIC) classification. ACCSIS RP teams then reviewed and validated matched strategies. Analyses examined similarities and differences among implementation strategies used by each RP and tracked across the screening continuum. Results Seven ACCSIS RPs participated in this analysis. Collectively, they reported 89 unique activities that matched 68 ERIC implementation strategies (range: 3 to 17 per site). Several similarities were noted across RPs, such as: four RPs developed and distributed educational materials and three used external facilitation as an implementation strategy. Of the nine domains under which the ERIC strategies are classified, most strategies used by the ACCSIS RPs fell under the domain of using evaluative and iterative strategies (e.g., conducting a local need assessment), followed by training and education (e.g., provider education). All RPs used strategies focused on screening and six used strategies to ensure screening follow-up; only one RP used strategies to improve access to treatment. Most strategies were reported in the preparation and implementation phases. Conclusions Systematically documenting and collating implementation strategies across ACCSIS RPs contributes to the evidence base of how multilevel interventions can be implemented to reduce the burden of colorectal cancer through screening and follow-up. Study findings can be used to guide real-world implementation efforts, including future scale-up and sustainment.

Background Screening for colorectal cancer (CRC) is widely recommended but underused, even though CRC is the third most diagnosed cancer and the second leading cause of cancer death in the USA. The mPATH™ program is an iPad-based application designed to identify patients due for CRC screening, educate them on the commonly used screening tests, and help them select their best option, with the goal of increasing CRC screening rates. Methods The mPATH™ program consists of questions asked of all adult patients at check-in (mPATH™-CheckIn), as well as a module specific for patients due for CRC screening (mPATH™-CRC). In this study, the mPATH™ program is evaluated through a Type III hybrid implementation-effectiveness design. Specifically, the study consists of three parts: (1) a cluster-randomized controlled trial of primary care clinics comparing a “high touch” evidence-based implementation strategy with a “low touch” implementation strategy; (2) a nested pragmatic study evaluating the effectiveness of mPATH-CRC™ on completion of CRC screening; and (3) a mixed-methods study evaluating factors that facilitate or impede the maintenance of interventions like mPATH-CRC™. The primary objective is to compare the proportion of patients aged 50–74 who are eligible for CRC screening who complete mPATH™-CRC in the 6th month following implementation between the “high touch” and “low touch” implementation strategies. Effectiveness of mPATH™-CRC is evaluated by comparing the proportion who complete CRC screening within 16 weeks of their visit to the clinic between a pre-implementation cohort (8 months before implementation) and a post-implementation cohort (8 months after implementation). Discussion This study will provide data on both the implementation of the mPATH™ program and its effectiveness in improving screening rates for CRC. In addition, this work has the potential to have an even broader impact by identifying strategies to support the sustained use of other similar technology-based primary care interventions. Trial registration ClinicalTrials.gov NCT03843957. Registered on 18 February 2019.

The relationships among breast density, age, and use of hormone replacement therapy (HRT) in breast cancer detection have not been fully evaluated. To determine how breast density, age, and use of HRT individually and in combination affect the accuracy of screening mammography. Prospective cohort study. 7 population-based mammography registries in North Carolina; New Mexico; New Hampshire; Vermont; Colorado; Seattle, Washington; and San Francisco, California. 329 495 women 40 to 89 years of age who had 463 372 screening mammograms from 1996 to 1998; 2223 women received a diagnosis of breast cancer. Breast density, age, HRT use, rate of breast cancer occurrence, and sensitivity and specificity of screening mammography. Adjusted sensitivity ranged from 62.9% in women with extremely dense breasts to 87.0% in women with almost entirely fatty breasts; adjusted sensitivity increased with age from 68.6% in women 40 to 44 years of age to 83.3% in women 80 to 89 years of age. Adjusted specificity increased from 89.1% in women with extremely dense breasts to 96.9% in women with almost entirely fatty breasts. In women who did not use HRT, adjusted specificity increased from 91.4% in women 40 to 44 years of age to 94.4% in women 80 to 89 years of age. In women who used HRT, adjusted specificity was about 91.7% for all ages. Mammographic breast density and age are important predictors of the accuracy of screening mammography. Although HRT use is not an independent predictor of accuracy, it probably affects accuracy by increasing breast density.

The purpose of this study was to learn community members' perspectives about digital storytelling after viewing a digital story created by a Community Health Aide/Practitioner (CHA/P). Using a qualitative research design, we explored digital storytelling likeability as a health-messaging tool, health information viewers reported learning and, if viewing, cancer-related digital stories facilitated increased comfort in talking about cancer. In addition, we enquired if the digital stories affected how viewers felt about cancer, as well as if viewing the digital stories resulted in health behaviour change or intent to change health behaviour. A total of 15 adult community members participated in a 30-45 minute interview, 1-5 months post-viewing of a CHA/P digital story. The majority (13) of viewers interviewed were female, all were Alaska Native and they ranged in age from 25 to 54 years with the average age being 40 years. Due to the small size of communities, which ranged in population from 160 to 2,639 people, all viewers knew the story creator or knew of the story creator. Viewers reported digital stories as an acceptable, emotionally engaging way to increase their cancer awareness and begin conversations. These conversations often served as a springboard for reflection, insight, and cancer-prevention and risk-reduction activities.

Exclusive breastfeeding (EBF) is the most efficacious form of infant feeding and nutrition. Hispanic mothers in the US are more likely than mothers of other racial/ethnic groups to supplement with formula in the first 2 days of life. The purpose of this study was to explore infant feeding intentions during the prenatal period as a predictor of EBF at postpartum discharge in a sample of Hispanic women (n = 99). At discharge, 51 % of the women were EBF, 44 % were breastfeeding and supplementing with formula, and 5 % were feeding only formula. Intention to breastfeed was found to be a strong and potentially modifiable predictor of breastfeeding behavior, showing a significant association with EBF upon discharge from the hospital after birth when linked with acceptance of pregnancy and method of delivery. Prenatal care offers a unique opportunity to enhance intentions to breastfeed that may lead to improved EBF in this health vulnerable population.

Using data from a longitudinal study of breastfeeding in Hispanics, this study evaluated the influence of early skin-to-skin contact (SSC) on initiation and sustained exclusive breastfeeding (EBF) at 1 month postpartum. Two-thirds of the women in the sample participated in early SSC. At discharge, over half of the women were EBF; this proportion decreased to one-third at 1 month postpartum. Controlling for demographic and clinical variables in the model, participation in early SSC was associated with a greater than sevenfold increase in the odds of EBF at discharge (p =. 005) but was not predictive of EBF at 1 month post-discharge (p = .7). Younger maternal age and increased prenatal infant feeding intention were associated with an increased likelihood of EBF across both timepoints. Promoting early SSC may help with initiation of EBF, while further breastfeeding support may be needed to maintain EBF following discharge for this vulnerable population.

Background The cervical cancer burden is high among women living in Appalachia. Cigarette smoking, a cervical cancer risk factor, is also highly prevalent in this population. This project aims to increase smoking cessation among women living in Appalachia by embedding a smoking cessation program within a larger, integrated cervical cancer prevention program. Methods The broader program, the Take CARE study, is a multi-site research collaborative designed to address three risk factors for cervical cancer incidence and mortality: tobacco use, human papillomavirus (HPV) infection, and cervical cancer screening. Break Free is a primary care clinic-based implementation program that aims to promote smoking cessation among female smokers in Appalachia by standardizing clinical practice protocols. Break Free includes: (1) implementation of a tobacco user identification system in the Electronic Health Record, (2) clinic staff and provider training on the Ask, Advise and Refer (AAR) model, (3) provider implementation of AAR to identify and treat women who want to quit smoking within the next 6 months, (4) facilitated access to cessation phone counseling plus pharmacotherapy, and (5) the bundling of Break Free tobacco cessation with HPV vaccination and cervical cancer screening interventions in an integrated approach to cervical cancer prevention. The study spans 35 Appalachian health clinics across 10 healthcare systems. We aim to enroll 51 adult female smokers per health system (total N = 510). Baseline and follow-up data will be obtained from participant (provider and patient) surveys. The primary outcome is self-reported 12-month point prevalence abstinence among enrolled patients. All randomized patients are asked to complete follow-up surveys, regardless of whether they participated in tobacco treatment. Data analysis of the primary aims will follow intent-to-treat methodology. Secondary outcomes will assess program implementation and cost effectiveness. Discussion Addressing high tobacco use rates is critical for reducing cervical cancer morbidity and mortality among women living in Appalachia. This study evaluates the implementation and effectiveness of a smoking cessation program in increasing smoking cessation among female smokers. If results demonstrate effectiveness and sustainability, implementation of this program into other health care clinics could reduce both rates of smoking and cervical cancer. Trial registration NCT04340531 (April 9, 2020)