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Background Despite advances to prevent and detect cervical cancer, national targets for screening have not been met in the United States. Previous studies suggested that approximately half of women who developed cervical cancer were not adequately screened. This study aimed to provide an updated examination of women's screening and diagnostic practices five years prior to an invasive cervical cancer diagnosis. Methods The study included women age 21 years and older diagnosed with invasive cervical cancer in 2013–2016 from three population‐based state cancer registries in the United States. Medical records ion identified screening history and diagnostic follow‐up. A mailed survey provided sociodemographic data. Screening was a Pap or human papillomavirus (HPV) test between 6 months and 5 years before diagnosis. Adequate follow‐up was defined per management guidelines. Results Of the 376 women, 60% (n = 228) had not been screened. Among women who received an abnormal screening result (n = 122), 67% (n = 82) had adequate follow‐up. Predictors of: (a) being screened were younger age, having a higher income, and having insurance; (b) adequate follow‐up were having a higher income, and (c) stage 1 cervical cancer were being screened and younger age. Conclusion Unlike other cancer patterns of care studies, this study uses data obtained from medical records supplemented with self‐report information to understand a woman's path to diagnosis, her follow‐up care, and the stage of her cervical cancer diagnosis. This study provides findings that could be used to reach more unscreened or under screened women and to continue lowering cervical cancer incidence in the United States. An important risk factor for cervical cancer is not being screened. This study found that 60% of enrolled cervical cancer survivors did not receive appropriate screening in the five years prior to their diagnoses. Increasing screening in rarely and never‐screened women as well as timely follow‐up is crucial to continuing to lower cervical cancer incidence in the U.S.

Background: Screening and timely follow-up have lowered cervical cancer incidence in the US; however, screening coverage, incidence, and death rates have remained fairly stable in recent years. Studies suggest that half of women diagnosed with cervical cancer don’t receive appropriate screening prior to diagnosis; cervical cancer survivors can provide crucial insight into barriers and facilitators to screening. Methods: Participants were cervical cancer survivors ≥21 years, identified through population-based central cancer registries (CR) in 3 US states or a social network (SN), Cervivor. CR participants completed a mailed survey on screening history, barriers, and facilitators to screening and sociodemographic data. SN participants completed the same survey online. Results: CR participants (N = 480) were older, with a lower proportion of non-Hispanic white, married, and insured women compared to SN participants (N = 148). Fifty percent of CR and 79% of SN participants were screened 5 years prior to their diagnoses. Of those screened, 28% in both groups reported not following-up on abnormal results. For both groups, the most frequently identified screening barrier was that participants never imagined they would develop cervical cancer (percent agree CR = 76%; SN = 86%), and the facilitator was wanting to take care of their bodies (CR = 95%; SN = 94%). Conclusion: Addressing key barriers to obtaining screening and timely follow-up related to lack of knowledge of cervical cancer risk and screening tests and addressing insurance coverage in the design or modification of interventions may increase cervical cancer screening and lower cervical cancer incidence in the US.

Illness and mortality related to heat and worsening air quality are core public health concerns associated with climate change projections. We examined the historical relationship between age- and cause-specific mortality rates from 1980 through 2006 and heat events at the 99th percentile of humidex values in the historic period from January 1, 1970 to December 31, 2006 in the greater Seattle area (King, Pierce and Snohomish counties), Spokane County, the Tri-Cities (Benton and Franklin counties) and Yakima County; the relative risks of mortality during heat events were applied to population and climate projections for Washington State to calculate number of deaths above the baseline (1980–2006) expected during projected heat events in 2025, 2045 and 2085. Three different warming scenarios were used in the analysis. Relative risks for the greater Seattle area showed a significant dose-response relationship between heat event duration and daily mortality rates for non-traumatic deaths for persons ages 45 and above, typically peaking at four days of exposure to humidex values above the 99th percentile. The largest number of projected excess deaths in all years and scenarios for the Seattle region was found for age 65 and above. Under the middle warming scenario, this age group is expected to have 96, 148 and 266 excess deaths from all non-traumatic causes in 2025, 2045 and 2085, respectively. We also examined projected excess deaths due to ground-level ozone concentrations at mid century (2045–2054) in King and Spokane counties. Current (1997–2006) ozone measurements and mid-twenty-first century ozone projections were coupled with dose-response data from the scientific literature to produce estimates overall and cardiopulmonary mortality. Daily maximum 8-h ozone concentrations are forecasted to be 16–28% higher in the mid twenty-first century compared to the recent decade of 1997–2006. By mid-century in King County the non-traumatic mortality rate related to ozone was projected to increase from baseline (0.026 per 100,000; 95% confidence interval 0.013–0.038) to 0.033 (95% CI 0.017–0.049). For the same health outcome in Spokane County, the baseline period rate of 0.058 (95% CI 0.030–0.085) was estimated increase to 0.068 (95% CI 0.035–0.100) by mid-century. The cardiopulmonary death rate per 100,000 due to ozone was estimated to increase from 0.011 (95% CI 0.005–0.017) to 0.015 (0.007–0.022) in King County, and from 0.027 (95% CI 0.013–0.042) to 0.032 (95% CI 0.015–0.049) in Spokane County. Public health interventions aimed at protecting Washington’s population from excessive heat and increased ozone concentrations will become increasingly important for preventing deaths, especially among older adults. Furthermore, heat and air quality related illnesses that do not result in death, but are serious nevertheless, may be reduced by the same measures.

Background: Despite the existence of effective screening, colorectal cancer remains the second leading cause of cancer death in the United States. Adults living in rural areas and members of minority populations both experience disparities in colorectal cancer screening. Methods: Cross-sectional prevalence study of Behavioral Risk Factor Surveillance System from the Centers for Disease Control from 1998 to 2005. Primary outcome: Predicted probability of reporting timely colorectal cancer screening. Independent variables: rural residence, race/ethnicity. We adjusted for demographic and socioeconomic characteristics of respondents. Results: After adjustment rural non-Hispanic whites (44.3%), rural African American/blacks (44.8%), urban and rural Hispanic/Latinos (43.7% and 40.8%, respectively), urban and rural American Indian/Alaska Natives (45.8% and 46.8%), and urban and rural Asians (35.4% and 39.6%) had lower compared with urban non-Hispanic whites (49.5%; P < .05% for all comparisons). Urban Asians were least likely to report use of fecal occult blood testing (8.6%, 95% confidence interval = 6.3% to 10.9%) and rural Asians were least likely to report use of endoscopy screening (21.2%, 95% confidence interval = 16.2% to 26.2%). Discussion: Rural minorities may face different barriers to colorectal cancer screening than urban minorities or rural non-Hispanic whites. Further research to develop interventions to improve screening in these populations is warranted.

Despite the existence of effective screening, colorectal cancer remains the second leading cause of cancer death in the United States. Identification of disparities in colorectal cancer screening will allow for targeted interventions to achieve national goals for screening. The objective of this study was to contrast colorectal cancer screening rates in urban and rural populations in the United States. The study design comprised a cross‐sectional study in the United States 1998–2005. Behavioral Risk Factor Surveillance System data from 1998 to 2005 were the method and data source. The primary outcome was self‐report up‐to‐date colorectal cancer screening (fecal occult blood test in last 12 months, flexible sigmoidoscopy in last 5 years, or colonoscopy in last 10 years). Geographic location (urban vs. rural) was used as independent variable. Multivariate analysis controlled for demographic and health characteristics of respondents. After adjustment for demographic and health characteristics, rural residents had lower colorectal cancer screening rates (48%; 95% CI 48, 49%) as compared with urban residents (54%, 95% CI 53, 55%). Remote rural residents had the lowest screening rates overall (45%, 95% CI 43, 46%). From 1998 to 2005, rates of screening by colonoscopy or flexible sigmoidoscopy increased in both urban and rural populations. During the same time, rates of screening by fecal occult blood test decreased in urban populations and increased in rural populations. Persistent disparities in colorectal cancer screening affect rural populations. The types of screening tests used for colorectal cancer screening are different in rural and urban areas. Future research to reduce this disparity should focus on screening methods that are acceptable and feasible in rural areas. Colorectal cancer screening is effective, yet underused. Rural residents may face increased barriers to screening compared with urban residents. We describe significant urban–rural colorectal cancer screening disparities in the United States.

Objective: The objective of this study was to assess rural-urban differences in mammography and Papanicolaou (Pap) smear screening. Methods: Data from the Behavioral Risk Factor Surveillance System (1994-2000, 2002, 2004) were used to examine trends in these two tests by rural-urban residence location. Results: In 2004, 70.8 percent of rural and 75.7 percent of urban respondents had received timely mammography; this difference remained significant in adjusted analyses and was greatest for women in remote rural locations. Although overall participation in mammography increased over time, a persistent rural-urban gap was identified. In contrast, in 2004, while 83.1 percent of rural and 86.1 percent of urban respondents had received a timely Pap test, the adjusted difference was not significant and Pap testing did not improve over time. Advanced age and low socioeconomic status were associated with a lack of screening. Conclusions: Over an 11-year interval, mammography screening improved nationally, but women living in rural locations remained less likely than their urban counterparts to receive this test. However, no secular improvement in Pap testing was found, and no significant rural-urban differences were observed. Policy Implications: Interventions to improve breast cancer screening are needed for rural women. Such efforts should target older women and those with low socioeconomic status.

Background: The unabated rise in medication costs particularly affects older persons with chronic conditions that require long-term medication use, but how prescription benefits affect medication adherence for such persons has received limited study. Objective: We sought to study the relationship among prescription benefit status, health, and medication acquisition in a sample of elderly HMO enrollees with 1 or more common, chronic conditions. Research Design: We implemented a cross-sectional cohort study using primary survey data collected in 2000 and administrative data from the previous 2 years. Subjects: Subjects were aged 67 years of age and older, continuously enrolled in a Medicare + Choice program for at least 2 years, and diagnosed with 1 or more of hypertension, diabetes, congestive heart failure, and coronary artery disease (n = 3073). Measures: Outcomes were the mean daily number of essential therapeutic drug classes and refill adherence. Results: In multivariate models, persons without a prescription benefit acquired medications in 0.15 fewer therapeutic classes daily and experienced lower refill adherence (approximately 7 fewer days of necessary medications during the course of 2 years) than those with a prescription benefit. A significant interaction revealed that, among those without a benefit, persons in poor health acquired medications in 0.73 more therapeutic classes daily than persons in excellent health; health status did not significantly influence medication acquisition for those with a benefit. Conclusions: Coverage of prescription drugs is important for improving access to essential medications for persons with the studied chronic conditions. A Medicare drug benefit that provides unimpeded access to medications needed to treat such conditions may improve medication acquisition and, ultimately, health.

Context: Obesity is a fast‐growing threat to public health in the U.S., but information on trends in professional advice to lose weight is limited. Objective: We studied whether rising obesity prevalence in the U.S. was accompanied by an increasing trend in professional advice to lose weight among obese adults. Design and Participants: We used the Behavioral Risk Factor Surveillance System, a cross‐sectional prevalence study, from 1994 (n=10,705), 1996 (n=13,800), 1998 (n=18,816), and 2000 (n=26,454) to examine changes in advice reported by obese adults seen for primary care. Measurements: Self‐reported advice from a health care professional to lose weight. Results: From 1994 to 2000, the proportion of obese persons receiving advice to lose weight fell from 44.0% to 40.0%. Among obese persons not graduating from high school, advice declined from 41.4% to 31.8%; and for those with annual household incomes below $25,000, advice dropped from 44.3% to 38.1%. In contrast, the prevalence of advice among obese persons with a college degree or in the highest income group remained relatively stable and high (>45%) over the study period. Conclusions: Disparities in professional advice to lose weight associated with income and educational attainment increased from 1994 to 2000. There is a need for mechanisms that allow health care professionals to devote sufficient attention to weight control and to link with evidence‐based weight loss interventions, especially those that target groups most at risk for obesity.

Climate change is expected to bring potentially significant changes to Washington State’s natural, institutional, cultural, and economic landscape. Addressing climate change impacts will require a sustained commitment to integrating climate information into the day-to-day governance and management of infrastructure, programs, and services that may be affected by climate change. This paper discusses fundamental concepts for planning for climate change and identifies options for adapting to the climate impacts evaluated in the Washington Climate Change Impacts Assessment. Additionally, the paper highlights potential avenues for increasing flexibility in the policies and regulations used to govern human and natural systems in Washington.

Despite the existence of effective screening, colorectal cancer remains the second leading cause of cancer death in the U nited S tates. Identification of disparities in colorectal cancer screening will allow for targeted interventions to achieve national goals for screening. The objective of this study was to contrast colorectal cancer screening rates in urban and rural populations in the U nited S tates. The study design comprised a cross‐sectional study in the U nited S tates 1998–2005. B ehavioral R isk F actor S urveillance S ystem data from 1998 to 2005 were the method and data source. The primary outcome was self‐report up‐to‐date colorectal cancer screening (fecal occult blood test in last 12 months, flexible sigmoidoscopy in last 5 years, or colonoscopy in last 10 years). Geographic location (urban vs. rural) was used as independent variable. Multivariate analysis controlled for demographic and health characteristics of respondents. After adjustment for demographic and health characteristics, rural residents had lower colorectal cancer screening rates (48%; 95% CI 48, 49%) as compared with urban residents (54%, 95% CI 53, 55%). Remote rural residents had the lowest screening rates overall (45%, 95% CI 43, 46%). From 1998 to 2005, rates of screening by colonoscopy or flexible sigmoidoscopy increased in both urban and rural populations. During the same time, rates of screening by fecal occult blood test decreased in urban populations and increased in rural populations. Persistent disparities in colorectal cancer screening affect rural populations. The types of screening tests used for colorectal cancer screening are different in rural and urban areas. Future research to reduce this disparity should focus on screening methods that are acceptable and feasible in rural areas.