colorectal cancer survivorship in rural communities: assessment and plan development april 19, 2007...
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Colorectal Cancer Survivorshipin Rural Communities: Assessment and
Plan Development
April 19, 2007
Eugene J. Lengerich, VMD, MS
Associate ProfessorEpidemiology 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 The Appalachia Community Cancer NetworkNetworkSupported by the National Cancer Institute’sSupported by the National Cancer Institute’sCenter to Reduce Cancer Health DisparitiesCenter to Reduce Cancer Health Disparities
1 U01 CA114622 (2005-2010)1 U01 CA114622 (2005-2010)
ACCN - ACCN - Appalachian Appalachian
Areas of 7 States Areas of 7 States (KY, MD, NY, OH, (KY, MD, NY, OH,
PA, VA, WV)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 Pennsylvania14 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• a local approach to complement national and state
cancer control plansEquip
• 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)
Recruit and Prepare (Proposed 6 coalitions)
Train on Colorectal
Cancer Survivorship and Process
for Plan Development
(Conference 1:May 2006)
Present CRC Survivorship
Plans and Resource Directory
(Conference 2:October 2006)
Assess Barriers &
Needs; Develop Plan
ASSESSMENTKnowledge and beliefs;
Survivorship Plans and Resource Directories
Disseminate, Implement, and
Research
Technical Assistance from NACN / PSCI / ACS
Study Schema
ASSESSMENTPublic health and
survivorship knowledge and beliefs
Revised 5/11/06
PRECEDE-PROCEEDPRECEDE-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 ResultsPreliminary 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 EducatorsHospital AdministratorsSurvivors
Completed– 11 coalitions and 3 hospitals (93.3%)– 16 of 32 individuals at initial conference returned to
second conference (50.0%)
Increase in Correct ResponsesPre-Training versus Immediate Post-Training
Knowledge … Total
Pre-TrainingImmediate
Post-Training
p-value1N (%) N (%)
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 MethodsUsed 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 Resourcesin 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
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