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Qualitative and quantitative methods can be used simultaneously for hypothesis generation and testing. A pilot study was conducted in 1991 in three rural Colorado communities to clarify health service delivery problems related to cancer. The analysis focused on the perceptions of three types of respondents in each community related to whether cancer was a major problem, whether health services were adequate in their community, and what perceived solutions could be implemented. Respondents included community influentials, health care providers, and cancer patients or family members. Semistructured phone interviews were used to collect perceptions of these community members. Transcripts from the three communities were combined, coded, and tallied. Several distinct themes emerged from the analysis. These included: cancer was a major problem; public and provider education was needed; community systems and support to identify and solve health problems were lacking; medical networking needed to be expanded; transportation was a problem for remote communities; inability to pay for services was a problem for rural communities. Most respondents identified the problems as relevant to other chronic and acute diseases as well as cancer. This method identified the critical problems for the majority of the people without losing sight of the outlier responses. [ABSTRACT FROM AUTHOR]

We evaluated an intervention to increase participant retention and engagement in community practice settings of the Nurse-Family Partnership (NFP), an evidence-based program of nurse home visiting for low-income, first-time parents. Using a quasi-experimental design (6 intervention and 11 control sites that delivered the NFP), we compared intervention and control sites on retention and number of completed home visits during a 10-month period after the intervention was initiated. Nurses at the five intervention sites were guided in tailoring the frequency, duration, and content of the visits to participants' needs. NFP nurses at the control sites delivered the program as usual. At the intervention sites, participant retention and completed home visits increased from the pre-intervention to intervention periods, while at the control sites, these outcomes decreased from the pre-intervention to intervention periods, leading to a significant intervention-control difference in change in participant retention (hazard ratio, 0.42; p = 0.015) and a 1.4 visit difference in change in completed home visits (p < 0.001, ES = 0.36). We conclude that training nurse home visitors to promote adaptation of program dosage and content to meet families' needs shows promise as a way to improve participant retention and completed home visits.

Participant attrition is a major influence on the effectiveness of evidence-based interventions. Assessing predictors of participant attrition and nurse and site characteristics associated with it could lay a foundation for increasing retention and engagement. We examined this issue in the national expansion of the Nurse-Family Partnership, an evidence-based program of prenatal and infancy home visiting for low-income, first-time mothers, their children, and families. Using a mixed methods approach, we examined participant, nurse, and site predictors of participant attrition and completed home visits. We used mixed multivariate regression models to identify participant, nurse, program, and site predictors of addressable attrition and completed home visits during pregnancy and the first year of the child's life for 10,367 participants at 66 implementation sites. We then conducted semi-structured interviews with nurse home visitors and supervisors at selected sites with the highest (N = 5 sites) and lowest (N = 6 sites) rates of participant addressable attrition and employed qualitative methods to synthesize themes that emerged in nurses' descriptions of the strategies they used to retain participants. Mothers who were younger, unmarried, African American, and visited by nurses who ceased employment had higher rates of attrition and fewer home visits. Hispanic mothers, those living with partners, and those employed at registration had lower rates of attrition. Those who were living with partners and employed had more home visits. Nurses in high retention sites adapted the program to their clients' needs, were less directive, and more collaborative with them. Increasing nurses' flexibility in adapting this structured, evidence-based program to families' needs may increase participant retention and completed home visits.

The primary objective of this report is to examine factors associated with recruitment of physicians in community-based primary care research. Reported results are based on an observational study of physician recruitment efforts undertaken in a randomized controlled trial designed to improve primary care physicians' cancer screening and counseling activities. The Partners for Prevention project was a statewide randomized controlled trial of primary care physicians selected from the state of Colorado. Two-hundred and ten eligible internal medicine and family medicine practices in both rural and urban community settings of the state of Colorado were selected into this study and a sentinel physician was chosen to represent each practice. Only 6% (13/210) of recruited practices initially declined to participate in the study, but the total refusal rate had reached 30% (59/210) by the time the intervention was implemented five months later. Study participants (n = 136) were younger (mean age 45.7 vs. 50.0, p = 0.008) and more often located in a rural area (46% vs. 31%, p = 0.04) than decliners (n = 59), but there was no association with gender of the physician (87% for females vs. 95% for males, p = 0.13). Participants were more often family practice physicians by training rather than internists (75% vs. 56%, p = 0.008), whereas there was no difference in participation rates by practice type (solo versus group, 60% vs. 64%, p = 0.52). Differences in demographic, geographic, and training characteristics between trial participants and decliners suggest the potential for better targeting of recruitment efforts. Viable strategies for recruiting community-based primary care practices to research studies are proposed.

Objective: To evaluate the use of the prostate-specific antigen (PSA) test and digital rectal examination (DRE) in prostate cancer screening by primary care physicians., Study Design: Physician survey and retrospective medical record review., Methods: We randomly selected and reviewed the medical records of 3 cross-sectional samples of male patients and surveyed their primary care physicians at 1-year intervals. All the physicians practiced in Colorado. The study spanned 3 years, including late 1992, when the American Cancer Society recommended the use of PSA in a prostate cancer screening guideline., Results: We reviewed the medical records of 4772 male patients and surveyed 109 primary care physicians. We found that PSA testing for men aged 50 or older increased significantly from 1992 to 1994, from 24% in 1992 to 35% in 1993 and 40% in 1994 (overall odds ratio, 2.94; P < .05). Over the same time period, the DRE rate remained relatively unchanged (39% in 1992, 41% in 1993, and 36% in 1994). Overall PSA use was positively associated with patient age greater than 59 years, patient non-smoking status, physician "readiness to change cancer screening behavior," private insurance status, and nonsolo practice. Before the release of a prostate cancer screening guideline, participating physicians cited the American Cancer Society as the organization that most influenced their practice with respect to cancer screening. The magnitude of the reported influence of the American Cancer Society was correlated with the subsequent use of PSA in 1994 by primary care physicians after adjustment for change in DRE and baseline PSA rates, although the association did not reach statistical significance in multivariable regression models., Conclusions: Primary care physicians in Colorado significantly increased their use of the PSA test from 1992 to 1994, during which time the American Cancer Society issued a guideline recommending the use of PSA for prostate cancer screening. The reported influence of the American Cancer Society on cancer screening practices correlated with the subsequent increase in PSA testing.

Background: African Americans have traditionally made little use of the Cancer Information Service (CIS), an information and education program of the National Cancer Institute, for smoking cessation assistance. This study evaluated whether a targeted communications campaign utilizing strategically placed radio and television advertisements in combination with community outreach could lead more adult African American smokers to call the CIS for smoking cessation information and materials., Methods: Fourteen communities, served by four CIS regional offices, were carefully matched on demographic variables and then randomly assigned to either an experimental or a control group. Six radio advertisements targeting African American smokers to call the CIS for help in quitting smoking were developed and pretested for three different black-oriented formats. One television spot also was produced and pretested. The audio portion of the television ad was utilized as a seventh radio spot for the general programming formats. These advertisements were placed on selected radio and television stations reaching predominantly African American adult audiences. Also, copies of a videotape designed to motivate African American smokers to quit and to call the CIS for help in quitting were widely disseminated through community-based organizations in each experimental market. The aim was to increase the number and proportion of quitting-related calls to the CIS from African Americans within experimental communities., Results: The call volume from African American smokers was significantly higher in the experimental communities than in the control communities (P < 0.008). The call rate from African American men was higher than typically observed. Overall, African Americans in the experimental communities reported radio more often than television as the way they heard about the CIS., Conclusion: The results suggest that paid targeted advertising, using radio as a primary channel, is an effective method of reaching an underserved population at risk. Future research directions are discussed., (Copyright 1998 American Health Foundation and Academic Press.)

Objective: To examine the agreement between nursing phone and provider office management of vulvovaginitis.Methods: Patients who called the Kaiser Permanente Phone Call Center with vulvovaginal complaints were evaluated by a registered nurse, who took a standardized history, and made an assessment and plan; additionally, she made a judgment regarding whether she would have treated the patient over the phone. These patients were seen in the office the same day and examined and treated by a clinician following a protocol that included cultures for typical vaginal and cervical pathogens. Providers also made a judgment about phone treatment. Nurses and providers were blinded to each others' diagnosis and therapy. Kappa coefficients were used to evaluate the interexaminer agreement between nurses on the phone and providers in the office with respect to diagnosis and treatment.Results: Four hundred eighty-five patients underwent phone evaluation. Of these, 253 (52%) completed the study protocol and were considered in the final analysis. Kappa values for the diagnosis of trichomoniasis (0.05), bacterial vaginosis (0.12), candidiasis (0.22), chlamydia, herpes simplex, and urinary tract infections (0.05), and "other" (0.05) demonstrated poor agreement between nurses and providers. There was also poor agreement between phone nurses and providers regarding the necessity of an office visit (0.14).Conclusion: This prospective study challenges the notion that the telephone is an effective tool for diagnosing and treating vulvovaginal complaints. Patients with these complaints should be evaluated in the office. Alternatively, programs should be developed and analyzed to educate nurses involved in telephone triage of vulvovaginitis.

Background: Because of a strong association between health maintenance visits (HMVs) and cancer screening, knowledge of the predictors of an HMV have implications for screening., Objective: To examine the association of an HMV with patient, physician, and practice characteristics in the primary care setting., Design: A statewide study of cancer screening was conducted in Colorado to determine concordance with the National Cancer Institute's guidelines for screening for breast, cervical, prostate, and skin cancer. Medical records form patients were randomly chosen from primary care practices. Predictors of an HMV were determined by fitting a logistic model to baseline data, adjusting for the cluster sampling of patients within practices., Setting: Nonacademic primary care practices in Colorado., Participants: A total of 5746 patients aged 42 to 74 years from 132 primary care practices., Main Outcome Measure: Whether a patient had an HMV in the previous year., Results: Of all patients, 31% had an HMV in the previous year. Patient characteristics associated with having HMVs included nonsmoking status, odds ratio (OR) (95% confidence interval [CI]) of 1.27 (1.11-1.46), age, and sex. Women aged 50 to 69 years were significantly more likely to have an HMV than men aged 50 to 69 years (OR, 1.30; 95% CI, 1.10-1.54). Among adults aged 70 years and older, there were no significant sex differences in receiving HMVs. Physician and practice characteristics associated with providing HMVs included practice size (> or = 3 full-time physicians) (OR, 1.34; 95% CI, 1.01-1.77), physician contemplation of changing approaches to cancer screening (OR, 1.33; 95% CI, 1.04-1.70), and physician female sex (OR, 1.33; 95% CI, 1.04-1.70). Physician age and specialty (general internist or family physician) were not associated with the level of health maintenance delivery., Conclusion: Certain subgroups, such as smokers, patients in smaller practices, and physicians not yet considering changing their approach to cancer screening, could be targeted in future intervention studies designed to provide preventive services in primary care settings.

Objectives: This study evaluates the efficacy of two interventions designed to reduce loss-to-follow-up among women with abnormal Pap smears., Methods: The two interventions were evaluated in two large public hospitals using a randomized 2 x 2 factorial design. One intervention involved an intensive follow-up protocol that relied on multiple attempts (mail and telephone) to contact the patient. The second intervention provided patients with economic vouchers to offset out-of-pocket expenses associated with the follow-up visits. Loss-to-follow-up was addressed by medical chart reviews and telephone interviews., Results: The study population (n = 1453) was primarily Hispanic, married or otherwise living with a significant other, relatively young in age, and with no source of payment for health care. Overall, 30% of the total sample was loss-to-follow-up (i.e., no return visits). Among patients assigned to the control condition, loss-to-follow-up was 36.1% compared with 27.8% for the intensive follow-up condition, 28.8% for the voucher condition, and 29.0% for the intensive follow-up plus voucher condition. Both intervention conditions significantly improved follow-up rates. The odds ratio for intensive follow-up was 1.56 compared with 1.50 for the voucher intervention. The combined intervention condition (intensive follow-up x voucher program) did not have a significant effect after taking into account the main effects of the two interventions. Correlates of loss-to-follow-up included age (younger women had lower return rates), race/ethnicity (African American women had lower return rates), live-in relationship (women who were not married or living as married had lower return rates), and severity of the abnormal Pap smear (less severe abnormalities were associated with lower return rates)., Conclusions: Both interventions were associated with moderate reductions in loss-to-follow-up in this underserved population. The implications of these findings are discussed relative to implementing cervical cancer control programs within state and local health departments.

Process evaluation can identify program components that are related to success, that are generalizable to other settings, and that improve future applications of the program. The Partners for Prevention pilot project tested an office-based system aimed at increasing cancer prevention and screening in primary care offices and involving 17 physicians in private practice. Process evaluation techniques included monitoring systems, satisfaction surveys, and focus groups with the program participants. Each evaluation technique provided different information concerning strategies. The program was difficult to implement on busy days, the materials were useful but needed more flexibility, communication between patient and physician was facilitated, and the office coordinator was a crucial person. Program philosophy was acceptable, but materials needed refinement. The flow sheet and patient health check have been dramatically simplified and customized. New strategies are being tested in a randomized control trial.

In 1987, the Division of Cancer Prevention and Control, National Cancer Institute (NCI), funded a randomized trial of a proactive counseling protocol to promote screening mammography among age-eligible female callers to the Cancer Information Service (CIS). This protocol included interactive counseling by CIS counselors to help callers overcome barriers to screening mammography; this counseling was an extension of usual service and was combined with a 2-week follow-up mailout to reinforce the brief (6-minute) proactive telephone-counseling protocol. The screening-mammography counseling intervention was tested in two regional CIS offices using a randomized two-group design. Callers were randomly assigned to the intervention or control group based on the week of their call to the CIS (n = 1831 eligible female callers). Self-reported adherence to NCI screening-mammography guidelines was assessed from telephone interviews conducted at 12 months' follow-up (87% response rate). Among all CIS callers enrolled in this study, self-reported adherence to screening-mammography guidelines at 12 months' follow-up was 63.5%. The most frequently cited barriers to screening mammography reported by CIS callers were inconvenience/being too busy (52%), cost (36%), lack of physician referral (34%), no symptoms (34%), and fear of radiation (29%). A significant intervention effect on adherence behavior was found but only in one of the two test sites and only among CIS callers reporting total family income of $30,000 or more (odds ratio = 1.38, P = .04). The vast majority (90%) of CIS callers (both intervention and control subjects) endorsed the concept of proactive counseling by the CIS. The implications of these findings for the CIS and future research are discussed.

To be feasible, study designs for most intervention research in primary care settings must limit the number of participating physicians, without sacrificing the statistical power required to test the research hypotheses. A model was developed to examine sample size and statistical power requirements when using the physicians' practice as the unit of analysis. Randomized designs using either matched or unmatched samples of practices were compared under varying conditions. When baseline variability is small or the number of practice pairs is large, matching at best marginally increases power. However, in the typical case when baseline variability is large or the number of practice pairs is small, matching substantially increases the power to find intervention effects with a smaller sample. Thus, matching prior to randomization could improve the design of many intervention studies in primary care settings.

Sensitivity and specificity have clear definitions when there is a single test for one disease, and the test is either positive or negative. This paper presents a unified approach for obtaining posterior probabilities (predictive values) when there are more than two test outcomes and/or more than one disease state. In these cases, sensitivity and specificity do not have clear definitions. Three examples from the literature demonstrate how this approach simplifies the presentation of Bayesian revision of prior probabilities. Use of proper care in data collection for the purpose of estimating conditional probabilities can avoid assumptions of statistical independence.