Transcript Penn State Cancer Institute

Colorectal Cancer Survivorship
in Rural Communities: Assessment and
Plan Development
April 19, 2007
Eugene J. Lengerich, VMD, MS
Associate Professor
Epidemiology Division, Department of Public Health Sciences
Department of Health Policy and Administration
Penn State University
Director, Community Outreach and Education
Penn State Cancer Institute
Outline
• Background
• Methods
• Preliminary Results
• Limitations, Discussion, and
Acknowledgements
The Appalachia Community Cancer Network
Supported by the National Cancer Institute’s
Center to Reduce Cancer Health Disparities
1 U01 CA114622 (2005-2010)
ACCN Appalachian
Areas of 7 States
(KY, MD, NY, OH,
PA, VA, WV)
Background
National Guidance
• Lance Armstrong Foundation and
Centers for Disease Control and Prevention
A National Action Plan for Cancer Survivorship: Advancing
Public Health Strategies
• Institute of Medicine
From Cancer Patient to Cancer Survivor: Lost in Transition
• President’s Cancer Panel
• Living Beyond Cancer: Finding a New Balance
State Comprehensive Cancer Control
• Pennsylvania
• New York
Northern Appalachia Cancer Network,
A Region of the Appalachia Community Cancer Network
Setting
• Appalachia
52 Counties in Pennsylvania
14 Counties in New York
•
•
•
•
Largely rural
Increased poverty
Limited access to health care
Began in 1992
Approach
• Community-based participatory research (CBPR)
• Evidence-based strategies
• Advisory Committee
• Academic, state (PA and NY), professional and community
members
2006 Community Planning Grant
from the Lance Armstrong Foundation
with support from the Penn State Cancer Institute
Objectives
• Facilitate CRC screening by coalitions and
partnerships
• Assist coalitions and partnerships to
improve CRC survivorship
• Prepare for community-based participatory
research in CRC survivorship
Specific Aims
•
Increase the CRC survivorship-related
knowledge and beliefs of teams of three
members from each of six local cancer
coalitions or partnerships
•
Create a local CRC survivorship plan,
including a resource directory, to address local
barriers and enhance CRC survivorship in the
communities represented by the six teams
Significance
Test
•
Equip
•
a local approach to complement national and state
cancer control plans
rural coalitions and partnerships in CRC
survivorship (and screening)
Enable
• community-based participatory research on CRC
survivorship in rural communities
Methods
Design
• Design:
• Pre-post, multi-level, community intervention study
• CBPR approach
• Outcomes:
• Individual-level: Knowledge and beliefs in public
health and CRC-survivorship among individual
members of coalitions and partnerships
• Community-level: Presence and content of
community plans and resource directories for CRC
survivorship
• Analysis
• Change in knowledge and beliefs – McNemar’s
test (p<0.05)
• Content analysis by multiple reviewers (n=3)
Study Schema
Technical Assistance from NACN / PSCI / ACS
Recruit and
Prepare
(Proposed 6
coalitions)
Train on
Colorectal
Cancer
Survivorship
and Process
for Plan
Development
(Conference 1:
May 2006)
Assess
Barriers &
Needs;
Develop Plan
ASSESSMENT
Public health and
survivorship knowledge and
beliefs
Revised 5/11/06
Present CRC
Survivorship
Plans and
Resource
Directory
Disseminate,
Implement, and
Research
(Conference 2:
October 2006)
ASSESSMENT
Knowledge and beliefs;
Survivorship Plans and Resource
Directories
PRECEDE-PROCEED
Planning
Model
Starts with
outcomes
and works
back to
strategies
Assessment=
PRECEDE
Community
Intervention=
PROCEED
Possible Assessment Methods
Coalition/Hospital Discussions
Key-informant interviews
Survivor interviews
Community forum
Focus groups
Survey
Preliminary Results
Participation
Recruited
– 11 coalitions (8 in PA; 3 in NY) and 4 hospitals (all in
PA)
– 32 individuals at initial conference (range 1-4 per
coalition/hospital)
MD’s; RN’s; Health Educators
Hospital Administrators
Survivors
Completed
– 11 coalitions and 3 hospitals (93.3%)
– 16 of 32 individuals at initial conference returned to
second conference (50.0%)
Increase in Correct Responses
Pre-Training versus Immediate Post-Training
Pre-Training
Immediate
Post-Training
Knowledge …
Total
N (%)
N (%)
p-value1
that PRECEED-PROCEED is a community
health planning model2
30
8 (26.7)
25 (83.3)
<0.0001
that an enabling factor is an internal or
external condition in health promotion
theory
25
13 (52.0)
20 (80.0)
0.0391
of the sponsors of National Action Plan
28
1 (3.6)
11 (39.3)
0.0020
of the percentage of U.S. cancer survivors
had CRC
28
12 (42.9)
25 (89.3)
0.0010
of the point at which CRC survivorship
begins
28
21 (75.0)
27 (96.4)
0.0313
of the benefit of laparotomies as a
treatment for CRC
24
9 (37.5)
19 (79.2)
0.0063
that memory problems are not common in
CRC survivors2
27
14 (51.9)
23 (85.2)
0.0117
1McNemar’s
Test. 2Statistically significant increase at long-term assessment
Assessment Methods
Used by Coalitions/Hospitals
Number
Percentage
Resource Assessment
14
100.0
Cancer Data Review
14
100.0
Interviews of Survivors
12
85.7
Survey of Survivors, Community, Providers
12
85.7
Coalition/Partnership Discussion
11
78.6
Key Informant Interviews
11
78.6
Community Barriers to CRC Survivorship
•
•
•
•
•
Lack of transportation (n=11; 79%)
Lack of psychosocial care (n=8; 57%)
Low level of knowledge of community
information and resources (n=7; 50%)
Lack of ability to pay and coverage with health
insurance (n=7; 50%)
Lack of access to medical/surgical care (n=5;
36%)
Previously Unknown Resources
in the Community
• Psychosocial care (n=10; 71%)
• Medical/surgical care (n=4; 29%)
• Transportation (n=3; 21%)
• Financial and insurance assistance (n=3; 21%)
Contents of the Plans
• Public knowledge of community resources (n=13; 93%)
• Public access to community resources (n=8; 57%)
• Public knowledge about CRC treatment and side effects
•
•
•
•
(n=5; 36%)
Payment/insurance for CRC treatment and care (n=4; 29%)
Public knowledge about screening guidelines (n=4; 29%)
Provider knowledge about screening guidelines (n=3; 21%)
Access to psychosocial care for CRC (n=3; 21%)
Posters and Abstracts
At The Third Annual Summit of the
Pennsylvania Cancer Control Consortium
• Posters
• Coalition for People Against
Cancer (CPAC) (Clearfield
County)
• Indiana County Cancer
Coalition
• Abstracts
– Elk County Cancer and
Tobacco Education Coalition
– Lawrence County Cancer
Coalition
– York Cancer Center
Limitations
• Reliance upon donated time and resources
• Capacity and process measures
• Assessment methods were not mandated
• CRC survivorship issues were broadened by
some participants to be general cancer
survivorship issues
Summary
• Surpassed aims, with a high response rate
• Increased knowledge of key community members
• Conducted 14 community assessments
• Identified barriers and previously unknown resources
• Developed community plans and resource directories
• Employed methods of CBPR and PRECEDE-PROCEED
• Linked CRC screening to survivorship issues
CRC Survivorship Coalitions
and Hospitals
ACTION Health Colorectal
Cancer Task Force (Columbia,
Montour, Northumberland,
Snyder, and Union Counties)
(PA)
Chautauqua County Partners for
Prevention (NY)
Coalition for People Against
Cancer (CPAC) (Clearfield
County) (PA)
Crawford County Cancer Coalition
(PA)
Delaware County Cancer
Coalition (NY)
Elk County Cancer and Tobacco
Education Coalition (PA)
Greene County Cancer Coalition
(PA)
Indiana County Cancer Coalition
(PA)
Lancaster General Hospital (PA)
Lawrence County Cancer Coalition
(PA)
Mount Nittany Medical Center (PA)
Wellness Council of the Southern
Tier (NY)
Wyoming County Cancer/Tobacco
Coalition (PA)
York Cancer Center (PA)
CRC Survivorship Planning Committee
NACN
• Regina Allen
• Marcy Bencivenga
• Brenda Kluhsman
• Eugene Lengerich
Community Coalitions
• Marcia Anderson
PSCI Community Outreach and
Education
• Diane Sheehan
CRC Survivor
• Mary Beth Miele
American Cancer Society
• Deirdre Weaver
Centers for Disease Control and
Prevention
• Laura Zauderer
Lance Armstrong Foundation
• Haley Justice
PSCI Survivorship Program
• Elana Farace
PSU Continuing Education
• Bonnie Bixler
References
Butterfoss FD, Kegler MC. Toward a comprehensive understanding of community coalitions: moving
from practice to theory. In: DiClemente RJ, Crosby RA, Kegler MC, editors. Emerging theories
in health promotion practice and research. San Francisco (CA): Jossey-Bass; 2002. p. 157–
93.
Green LW, Kreuter MW. CDC’s planned approach to community health as an application of PRECEDE
and an inspiration for PROCEED. J Health Educ1992;23(3):140-7.
Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing
partnership approaches to improve public health. Annu Rev Public Health 1998;19:173-202.
Huan B, Wyatt S, Tucker T, Bottorff D, Lengerich E, Hall HI. Cancer death rates – Appalachia, 199498. 1994-1998. MMWR 2002;51(24):527-9.
Klushman BC, Bencivenga M, Ward AJ, Lehman E, Lengerich EJ. Initiatives of eleven rural
Appalachian cancer coalitions in Pennsylvania and New York. Prev Chronic Dis. [serial online]
2006 Oct. Available from: http://www.cdc.gov/pcd/issues/2006/oct/06_0045.htm.
Lengerich EJ, Tucker T, Powell RK, Colsher P, Lehman E, Ward AJ, Siedlecki JC, Wyatt SW. Cancer
incidence in Kentucky, Pennsylvania, and West Virginia: Disparities in Appalachia. J Rural
Health 2005:21(1);39-47.
Lengerich EJ, Wyatt SJ, Rubio A, Beaulieu J, Coyne CA, Fleisher L, Ward AJ, Brown PK. The
Appalachia Cancer Network: cancer control research among a rural, medically underserved
population. J Rural Health 2004:20(2);181-87.
Ward AJ, Coffey Kluhsman B, Lengerich EJ, Piccinin AM. The impact of cancer coalitions on the
dissemination of colorectal cancer materials to community organizations in rural Appalachia.
Prev Chronic Dis [serial online] 2006 Apr. Available from:
http://www.cdc.gov/pcd/issues/2006/apr/05_0087.htm.