Transcript Exploring “Appalachian” Identity in Women from the CARE Study

CARE Risky Sexual
Behavior Index
Paul Reiter, MPH, Electra Paskett, PhD,
Mira Katz, PhD, Amy Ferketich, PhD,
and Mack Ruffin, MD, MPH
Cells to Society:
Overcoming Health Disparities
CPHHD Transdisciplinary
Research Framework:
Emerging Cross-Center Themes
Community
Engagement
Neighborhood/Community Context
Biomarker &
Animal Model
Studies
Genetics,
Biological Basis of
Disparities,
Biomarkers for
Risk Assessment
and Screening
Preclinical
and Clinical
Studies
Etiology,
Screening,
Treatment
Impact on
Patient and
Community
Dissemination of
Research, Quality
of Life, Access to
Care, Policy
Reducing Disparities in
Cervical Abnormalities in
Appalachia
P50-CA105632
The Ohio State University
National Cancer Institute
OSU Center For Population
Health
And Health Disparities
Goal
To understand why Appalachian
Ohio women have high
incidence and mortality rates
for cervical cancer.
Average, Annual, Age-Adjusted Cervical
Cancer Incidence and Mortality Rates,
Appalachia Ohio, per 100,000 Females,
>14y, Whites, 2000-2004
Region
United States
Ohio
Non-Appalachia
Ohio
Appalachia Ohio
Incidence
Rates
11.2
10.9
10.3
Mortality
Rates
2.3
2.7
2.5
14.5
3.8
Theoretical Framework:
Social Determinants of Health
Social Structure
Education
Health Care Delivery
Material Factors
Income
Transportation
Work
Occupation
Regulations
Early life
Health Behavior
Cervical screening
Genes
Tobacco Use
Sexual activity
Contraception
Culture
Appalachian Norms
Alcohol use
Diet
Marmot and Wilkinson, 2001
Social Environment
Social capital
Social cohesion
Social network
Neighborhood disadvantage
Psychological
Motivation
Knowledge/ Risk
Brain
Stress
Depression
Nicotine
dependence
Pathophysiological Changes
HPV
CIN
Carcinogenesis
Morbidity/Mortality
Health Status/Outcomes
General Health
Cervical Health
Cervical Cancer
Risky
Screening
Behaviors - Pap Smear
- HPV
- Smoking
Follow-up
Of Abnormalities
Rationale

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

Certain behaviors put women at increased risk for
cervical abnormalities and HPV infection
Cervical cancer “risk” from sexual behaviors has
not been quantified in a manner like other types
of “risk”, e.g. breast cancer
An easy to use tool could be used to identify
and target high risk women for education,
surveillance, screening, and interventions
The CARE study provides an opportunity to
develop and validate such a tool for cervical
cancer in a high risk population
14 Clinics
Observational Study
N=571
Multi-level factors associated with tobacco use and Pap testing
Project 1
N=281
Project 2
N=301
RCT testing LHA vs. usual care
Smoking cessation:
Pap smear use:
•Risk appropriate
guidelines
•Barriers counseling
Project 3
N=1360
Case-control study
•HPV testing, Pap smear, EBV
titers, Cotinine
•TGF-alpha receptor
•Biochemical
validation
•Pharma-based
intervention with
behavioral
component
Regions 1-4
4
COLUMBIANA
3
CARROLL
HOLMES
JEFFER
2
SON
TUSCARAWAS
COSHOCTON
HARRISON
8
1
6
5
BELMONT
GUERNSEY
7
MUSKINGHAM
MONROE
NOBLE
PERRY
MORGAN
HOCKING
WASHINGTON
9
ROSS
ATHENS
Clinic locations
VINTON
13
HIGHLAND
CLER
MONT
MEIGS
PIKE
Region 1
JACKSON
12
BROWN
ADAMS
GALLIA
SCIOTO
14
10
LAWRENCE
11
Region 2
Region 3
Region 4
Eligibility Criteria
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Age 18 and older
No history of cervical cancer
English speaking
Not pregnant
Randomly selected from clinic population
Agree to participate
Baseline Survey

Face-to-Face Interview
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
Home interview administered using CAPI
system with an audio portion to collect
sensitive data
Conducted with research interviewer present
and averaged 1.5 hours to complete
Self-Administered Survey

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Given/mailed to participant to complete
Completed surveys given to interviewer
or mailed to OSU
Methods

Creation (n=300): Association of 8 individual
risky sexual behaviors with history of abnormal
Pap smear was used to determine weights
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Overall scores calculated using weighting scheme
and history of each behavior
Validation (n=128): Goodness-of-fit in model
containing overall index scores and history of
abnormal Pap smear
Lowess curve examined (n=428) to determine
cutoff points for high, medium, low group
Results
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Past STI=20
Age at 1st sexual
intercourse and number
of lifetime sexual
partners=5
Condom use, sex for
money, partners with IV
drug use, male partners
sex with other men,
partners past STI=1
Validation Sample:
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Risky Sexual
Behahavior Index
Classification (n=428)
Weighting Scheme:
Hosmer-Lemshow test
did not indicate lack
of fit (p=0.2999)
Cutoff Points:
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Low=5 or less
Medium=6 – 10
High=11+
60
Percent (%)

50
40
30
20
10
0
Low
n=134
Med
n=131 n=163
Overall Level
Mean = 9.71
High
Abnormal Pap
Median = 6.00
Future Use


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Predict who is more likely to develop
cervical abnormalities/compare by
population group
Target women with higher scores for more
frequent Pap tests and HPV vaccination
Direct interventions to high risk women
to reduce risk
Educate women about their risk for
cervical abnormalities
Center For Population Health And Health Disparities
“Reducing Cervical Cancer In Appalachia”
College of Public Health
Comprehensive Cancer Electra Paskett
Mary Ellen Wewers
Center
Stanley Lemeshow
Cathy Tatum
Center For
Mira Katz
Cecilia DeGraffinreid
Biostatistics
Amy Ferketich
Melissa Hicks
Amy Lehman
Ann McAlearney
Darla Fickle
Erinn Hade
Jill Oliveri
Bryan Ball
College of Nursing
Dale Rhoda
Karen Ahijevych
College of Medicine
Judy Harness
David Cohn
Pamela Salsberry
Douglas Post
University of Michigan
Mack Ruffin
Department of Economics
Paula Lantz
Patricia Reagan
Consultants
Beti Thompson
Department of Pathology
Elizabeth Unger
Scott Jewell