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Using data from the Louisiana Department of Public Health, we explored the spatial relationships between the Social Vulnerability Index (SVI) and COVID-19-related vaccination and mortality rates. Publicly available COVID-19 vaccination and mortality data accrued from December 2020 to October 2021 was downloaded from the Louisiana Department of Health website and merged with the SVI data; geospatial analysis was then performed to identify the spatial association between the SVI and vaccine uptake and mortality rate. Bivariate Moran’s I analysis revealed significant clustering of high SVI ranking with low COVID-19 vaccination rates (1.00, p p

Methamphetamine-associated cardiomyopathy is the leading cause of death linked with illicit drug use. Here we show that Sigmar1 is a therapeutic target for methamphetamine-associated cardiomyopathy and defined the molecular mechanisms using autopsy samples of human hearts, and a mouse model of “binge and crash” methamphetamine administration. Sigmar1 expression is significantly decreased in the hearts of human methamphetamine users and those of “binge and crash” methamphetamine-treated mice. The hearts of methamphetamine users also show signs of cardiomyopathy, including cellular injury, fibrosis, and enlargement of the heart. In addition, mice expose to “binge and crash” methamphetamine develop cardiac hypertrophy, fibrotic remodeling, and mitochondrial dysfunction leading to contractile dysfunction. Methamphetamine treatment inhibits Sigmar1, resulting in inactivation of the cAMP response element-binding protein (CREB), decreased expression of mitochondrial fission 1 protein (FIS1), and ultimately alteration of mitochondrial dynamics and function. Therefore, Sigmar1 is a viable therapeutic agent for protection against methamphetamine-associated cardiomyopathy., Chowdhury Abdulla and Richa Aishwarya et al. report that methamphetamine exposure in mice leads to cardiomyopathy via the signaling receptor Sigmar1. They find that methamphetamine inhibits Sigmar1, which alters mitochondrial function, and show that their findings are consistent with observations in hearts from human methamphetamine users.

BACKGROUND: Evidence of the effectiveness of treatment for obesity delivered in primary care settings in underserved populations is lacking. METHODS: We conducted a cluster-randomized trial to test the effectiveness of a high-intensity, lifestyle-based program for obesity treatment delivered in primary care clinics in which a high percentage of the patients were from low-income populations. We randomly assigned 18 clinics to provide patients with either an intensive lifestyle intervention, which focused on reduced caloric intake and increased physical activity, or usual care. Patients in the intensive-lifestyle group participated in a high-intensity program delivered by health coaches embedded in the clinics. The program consisted of weekly sessions for the first 6 months, followed by monthly sessions for the remaining 18 months. Patients in the usual-care group received standard care from their primary care team. The primary outcome was the percent change from baseline in body weight at 24 months. RESULTS: All 18 clinics (9 assigned to the intensive program and 9 assigned to usual care) completed 24 months of participation; a median of 40.5 patients were enrolled at each clinic. A total of 803 adults with obesity were enrolled: 452 were assigned to the intensive-lifestyle group, and 351 were assigned to the usual-care group; 67.2% of the patients were Black, and 65.5% had an annual household income of less than $40,000. Of the enrolled patients, 83.4% completed the 24-month trial. The percent weight loss at 24 months was significantly greater in the intensive-lifestyle group (change in body weight, −4.99%; 95% confidence interval [CI], −6.02 to −3.96) than in the usual-care group (−0.48%; 95% CI, −1.57 to 0.61), with a mean between-group difference of −4.51 percentage points (95% CI, −5.93 to −3.10) (P

We examined knowledge of Alzheimer’s disease and related dementias (ADRD), resources, and research opportunities among older African American (AA) and Caucasian caregivers. A mixed methods design integrated qualitative (focus group) and quantitative (survey) data from Northwest Louisiana. Eight focus groups (59 adults, 92% female, 78% AA, 25% rural) revealed limited knowledge. Quantitative findings from 117 ADRD caregivers (83% female, 72% AA, 30% limited heath literacy, 27% low income) indicated participants obtained information from providers (54%), friends and relatives (32%), and the internet (37%). Barriers to care were cost (24%) and lack of family agreement (17%). Few families used adult daycare (8%) or support groups (28%). Concerns about research participation were violation of privacy (30%) and fear of patient distress (27%). Distrust of doctors was minimal (3%). Findings did not vary by race. There is a need for clear, literacy-appropriate information about ADRD, caregiver resources, and clinical trials.

Examine COVID-19 knowledge, concerns, behaviors, stress, and sources of information among patients in a safety-net health system in Louisiana. Research assistants surveyed participants via structured telephone interviews from April to October 2020. The data presented in this study were obtained in the pre-vaccine availability period. Of 623 adult participants, 73.5% were female, 54.7% Black, and 44.8% lived in rural small towns; mean age was 48.69. Half (50.5%) had spoken to a healthcare provider about the virus, 25.8% had been tested for COVID-19; 11.4% tested positive. Small town residents were less likely to be tested than those in cities (21.1% vs 29.3%, p = 0.05). Knowledge of COVID-19 symptoms and ways to prevent the disease increased from (87.9% in the spring to 98.9% in the fall, p

Purpose The majority of colorectal cancer (CRC) research using the fecal immunochemical test (FIT) has studied short-term screening results in predominantly urban areas. The purpose of this study was to evaluate the effectiveness of 2 outreach strategies embedded in a health literacy intervention on repeat CRC screening in rural community clinics. Methods A 2-arm randomized controlled trial was conducted in 4 rural clinics in Louisiana. During a regularly scheduled clinic visit, participants ages 50-75 received a FIT kit and brief educational intervention. Participants were randomized to receive an automated call or a personal call by a prevention counselor after 4 weeks and 8 weeks if FIT kits were not returned. In year 2, materials were mailed, and follow-up calls were conducted as in year 1. The primary outcome was repeat FIT-the return of the FIT kit in both years. Participants Of 568 eligible participants, 55% were female, 67% were African American, and 39% had low health literacy. Findings Repeat FIT rates were 36.5% for those receiving the automated call and 33.6% for those receiving a personal call (P = .30). No annual FITs were returned in 30% of participants, while only 1 FIT was returned by 35% of participants (31% only year 1 and 4% only year 2). Conclusion Sustaining CRC screening with FIT is challenging in rural clinics. A lower cost automated call was just as effective as the personal call in promoting repeat annual screening. However, more intensive strategies are needed to improve long-term FIT screening among rural participants.

While the opioid epidemic has garnered significant attention, the use of methamphetamines is growing worldwide independent of wealth or region. Following overdose and accidents, the leading cause of death in methamphetamine users is cardiovascular disease, because of significant effects of methamphetamine on vasoconstriction, pulmonary hypertension, atherosclerotic plaque formation, cardiac arrhythmias, and cardiomyopathy. In this review, we examine the current literature on methamphetamine-induced changes in cardiovascular health, discuss the potential mechanisms regulating these varied effects, and highlight our deficiencies in understanding how to treat methamphetamine-associated cardiovascular dysfunction.

Background Significant disparities exist in colorectal cancer (CRC) screening rates among those of low socioeconomic status, with fewer years of education, lacking health insurance, or living in rural areas. Methods A randomized controlled trial was conducted to compare the effectiveness of 2 follow-up approaches to a health literacy intervention to improve CRC screening: automated telephone call or personal call. Patients aged 50 to 75 years residing in 4 rural community clinics in Louisiana were given a structured interview that assessed demographic, health literacy and CRC screening barriers, knowledge, and attitudes. All were given health literacy-informed CRC education, a patient-friendly CRC screening pamphlet, simplified fecal immunochemical test (FIT) instructions, and a FIT kit, and a "teach-back" method was used to confirm understanding. Patients were randomized to 1 of 2 telephone follow-up arms. If they did not mail their FIT kit within 4 weeks, they received a reminder call and were called again at 8 weeks if the test still was not received. Results A total of 620 patients were enrolled. Approximately 55% were female, 66% were African American, and 40% had limited literacy. The overall FIT completion rate was 68%: 69.2% in the automated telephone call arm and 67% in the personal call arm. Greater than one-half of the patients (range, 58%-60%) returned the FIT kit without receiving a telephone call. There was no difference noted with regard to the effectiveness of the follow-up calls; each increased the return rate by 9%. Conclusions Providing FIT kits and literacy-appropriate education at regularly scheduled clinic visits with a follow-up telephone call when needed was found to increase CRC screening among low-income, rural patients. The lower cost automated call was just as effective as the personal call.

Proper diabetes self-care requires patients to have considerable knowledge, a range of skills, and to sustain multiple health behaviors. Self-management interventions are needed that can be readily implemented and sustained in rural clinics with limited resources that disproportionately care for patients with limited literacy. Researchers on our team developed an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care that includes: 1) the American College of Physicians (ACP) Diabetes Guide that uses plain language and descriptive photographs to teach core diabetes concepts and empower patients to initiate behavior change; 2) a brief counseling strategy to assist patients in developing short-term, explicit and attainable goals for behavior change ('action plans'); and 3) a training module for health coaches that prepares them to assume educator/counselor roles with the Diabetes Guide as a teaching tool. While the intervention has previously been field tested and found to significantly improve patient knowledge, self-efficacy, and engagement in related health behaviors, its optimal implementation is not known. This project took advantage of a unique opportunity to modify and disseminate the ACP health literacy intervention among patients with type 2 diabetes cared for at rural clinics in Arkansas that are Patient-Centered Medical Homes (PCMH). These practices all had health coaches that could be leveraged to provide chronic disease self-management mostly via phone, but also at the point-of-care. Hence we conducted a patient-randomized, pragmatic clinical trial in 6 rural PCMHs in Arkansas, targeting individuals with uncontrolled type 2 diabetes.

Background: Intensive lifestyle interventions (ILIs) are the first-line approach to effectively treat obesity and manage associated cardiometabolic risk factors. Because few people have access to ILIs in academic health centers, primary care must implement similar approaches for a meaningful effect on obesity and cardiometabolic disease prevalence. To date, however, effective lifestyle-based obesity treatment in primary care is limited. We examined the effectiveness of a pragmatic ILI for weight loss delivered in primary care among a racially diverse, low-income population with obesity for improving cardiometabolic risk factors over 24 months. Methods: The PROPEL trial (Promoting Successful Weight Loss in Primary Care in Louisiana) randomly allocated 18 clinics equally to usual care or an ILI and subsequently enrolled 803 (351 usual care, 452 ILI) adults (67% Black, 84% female) with obesity from participating clinics. The usual care group continued to receive their normal primary care. The ILI group received a 24-month high-intensity lifestyle-based obesity treatment program, embedded in the clinic setting and delivered by health coaches in weekly sessions initially and monthly sessions in months 7 through 24. Results: As recently demonstrated, participants receiving the PROPEL ILI lost significantly more weight over 24 months than those receiving usual care (mean difference, −4.51% [95% CI, −5.93 to −3.10]; P P P =0.76). Increases in high-density lipoprotein cholesterol were greater in the ILI than in the usual care group at both time points (mean difference at 24 months, 4.6 mg/dL [95% CI, 2.9–6.3]; P z score) decreased more in the ILI group than in the usual care group at both time points, with significant mean differences of the change of −0.31 (95% CI, −0.47 to −0.14; P P =0.01) at 24 months, respectively. Changes in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and blood pressure did not differ significantly between groups at any time point. Conclusions: A pragmatic ILI consistent with national guidelines and delivered by trained health coaches in primary care produced clinically relevant improvements in cardiometabolic health in an underserved population over 24 months. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02561221.

Introduction The purpose of this report is to describe barriers and solutions to the implementation and optimization of a pragmatic trial that tests an evidence-based, patient-centered, low literacy intervention promoting diabetes self-care in rural primary care clinics. Methods The two-arm pragmatic trial has been implemented in six rural family medicine clinics in Arkansas. It tests a self-management education and counseling intervention for patients with type 2 diabetes compared to enhanced usual care. Barriers and solutions were identified as issues arose and through interviews with clinic directors and clinic administrators and a focus group, interviews, and tracking reports with clinic health coaches who delivered the intervention. Results Barriers to optimizing enrollment, intervention delivery, and data collection were addressed through targeted education of and relationship building with leadership, changing enrollment oversight, and ongoing training of health coaches. Conclusions Successful implementation and optimization of this pragmatic clinical trial in rural primary care clinics was achieved through establishing common goals with clinic leadership, minimizing demands on clinic staff and administration, frequent contact and ongoing support of health coaches, and collaborative troubleshooting of issues with delivering the intervention.

Underserved and minority populations suffer from a disproportionately high prevalence of obesity and related comorbidities. Effective obesity treatment programs delivered in primary care that produce significant weight loss are currently lacking. The purpose of this trial is to test the effectiveness of a pragmatic, high intensity lifestyle-based obesity treatment program delivered within primary care among an underserved population. We hypothesize that, relative to patients who receive usual care, patients who receive a high-intensity, health literacy- and culturally-appropriate lifestyle intervention will have greater percent reductions in body weight over 24 months. Eighteen clinics (N = 803 patients) serving low income populations with a high proportion of African Americans in Louisiana were randomized to the intervention or usual car. Patients in the intervention participate in a high-intensity lifestyle program delivered by health coaches employed by an academic health center and embedded in the primary care clinics. The program consists of weekly (16 in-person/6 telephone) sessions in the first six months, followed by sessions held at least monthly for the remaining 18 months. Primary care practitioners in usual care receive information on weight management and the current Centers for Medicare and Medicaid Services reimbursement for obesity treatment. The primary outcome is percent weight loss at 24 months. Secondary outcomes include absolute 24-month changes in body weight, waist circumference, blood pressure, fasting glucose and lipids, health-related quality of life, and weight-related quality of life. The results will provide evidence on the effectiveness of implementing high-intensity lifestyle and obesity counseling in primary care settings among underserved populations. Trial Registration: ClinicalTrials.gov Identifier NCT02561221

The purpose of this pilot study was to assess Chronic Myeloid Leukemia (CML) patients’ adherence to, beliefs about, and barriers to oral anticancer agents (OAC) using brief self-report measures in community-based cancer clinics. Patients completed a structured interview including a health literacy assessment, a Brief Medication Questionnaire, two single-item self-report adherence questions, and the Medications Adherence Reasons Scale. Of the 86 participants, 88.4% were white, 55.8% male, mean age, 58.7 years, and 22.1% had limited health literacy. Nonadherence (missing at least one dose in the last week) was reported by 18.6% of participants and associated (p &lt, 0.003) with less-than-excellent perceived ability to take CML medications (16.3%). Black participants reported more difficulty taking CML medications than white participants (28.6% vs. 8.3%, p = 0.053). Among all participants, 43.0% reported their CML medicine was ineffective and 24.4% that taking CML pills was somewhat to very hard. The most common reasons for missing a dose were simply missed it (24.4%) and side effects (18.6%). Most patients perceived their ability to take CML medication was good to excellent, yet nearly one in five reported missing at least one dose in the last week. Brief, no-cost self-report assessments to screen CML patients’ OAC adherence, barriers, and beliefs could facilitate counseling in busy community cancer clinics.

While the opioid epidemic has garnered significant attention, the use of methamphetamines is growing worldwide independent of wealth or region. Following overdose and accidents, the leading cause of death in methamphetamine users is cardiovascular disease, because of significant effects of methamphetamine on vasoconstriction, pulmonary hypertension, atherosclerotic plaque formation, cardiac arrhythmias, and cardiomyopathy. In this review, we examine the current literature on methamphetamine-induced changes in cardiovascular health, discuss the potential mechanisms regulating these varied effects, and highlight our deficiencies in understanding how to treat methamphetamine-associated cardiovascular dysfunction.

Clinical health outcomes and health disparities can be improved through interprofessional collaborations among multidisciplinary clinicians, health care services researchers, and patients. Bridging gaps between community clinics and urban academic centers allows added valuable perspectives that can lead to improved care and extend clinical research. Nurse practitioners (NPs) who serve as primary care providers in many rural community clinics can facilitate access to clinical trials for patients who are rarely included in health care services research as well as coordinate interprofessional research team collaboration. A NP working in a rural clinic can assist academic-based research teams in designing feasible strategies to address disparities and improve health care of underserved populations. The purpose of this article was to provide an example of a rural provider/urban academic research team collaborating to conduct a health literacy-directed randomized controlled trial to improve colorectal cancer screening in isolated rural community clinics.

This study investigated associations between cardiovascular health (CVH), adiposity, and food insecurity by race, sex, and health literacy in a sample of 800 underserved patients with obesity (body mass index [BMI] &ge, 30 kg/m2). CVH was assessed using American Heart Association Life&rsquo, s Simple 7 (LS7) and adiposity was estimated using BMI and waist circumference (WC). Mixed models including interaction terms between food insecurity and sex, race, and health literacy were analyzed for LS7, BMI, and WC. Stratified models were analyzed as indicated by significant interactions. Mean BMI and WC were 37.3 kg/m2 (4.6 SD) and 113.5 cm (12.4 SD), respectively. Among patients, 31% were food insecure and 31% had low health literacy. There were significant positive associations between food insecurity and BMI (p = 0.03) and WC (p = 0.03) in the overall sample. In sex-stratified models, women who were food insecure had higher BMI (p = 0.02) and WC (p = 0.007) than their food secure counterparts. Further, food insecure patients with better health literacy had greater BMI (p = 0.004) and WC (p = 0.007) than their food secure counterparts. Results suggest that adiposity is a greater burden in food insecure patients, which may be an important consideration for obesity treatment in underserved populations.

Disparities exist in enrollment in clinical trials and biorepositories among adults with low socioeconomic status, racial and ethnic minority groups and individuals who live in rural areas. Diverse participation is necessary to identify the most effective treatments in different groups. The purpose of this study was to use qualitative methods to identify factors that may affect the likelihood that members of underrepresented groups choose to participate in clinical trials and/or biobanking. We conducted 14 focus groups and seven telephone interviews in urban and rural areas of Louisiana to: (1) identify barriers and facilitators to participation; and (2) elicit input in crafting clear, culturally appropriate language and recruitment strategies. Of 103 participants, 25 were safety-net healthcare providers, 18 were primary care or oncology clinic patients, and 60 were members of social and faith-based groups. Patients and community participants were English-speaking, 79% were African American, 81% were female and 24% lived in rural areas. Barriers to participation identified were lack of knowledge about clinical trials and biobanks; limited specific information and access to participation, trust and privacy concerns about clinical trials and biobanking Facilitators included: altruism, high interest in medical research particularly studies that might benefit them or their families; plain language, culturally appropriate information; convenient access to studies; and input of a trusted provider. In addition, all primary care providers were interested in having clinical trial options available for their patients but did not have time to search for available trials. Results of this study can inform the development of education materials and strategies to increase participation of underrepresented groups in clinical trial and biobanking.

Objectives Our objective was to determine the effectiveness of 3 approaches to encourage completion of fecal occult blood testing (FOBT) in the third year of the intervention. Methods Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Clinics were randomly assigned to enhanced care (screening recommendation and FOBT kit mailed annually), education (patients additionally received a health literacy appropriate pamphlet and simplified FOBT instructions), or nurse support (same as education but with nurse follow-up). Participants included 206 patients with negative FOBTs in years 1 and 2; ages 50-85, 80% female, 70% African American, and 52% had limited health literacy. The main outcome measure was completion of a third annual FOBT. Results Third-year FOBT rates were 48% overall, 34.2% enhanced care, 59.6% education, and 47.4% nurse support (p = .21), even after adjustment for sex, marital status, and health literacy. Conclusion All mailed interventions were similarly effective in sustaining rates of FOBT screening. Post hoc analyses of the results analyzed by health literacy skills found that patients with both limited and adequate health literacy skills were more likely to complete FOBTs when mailed simplified instructions.

This three arm study was designed to make CRC screening with FOBTs more accessible, understandable and actionable for patients cared for in predominantly rural Federally Qualified Health Centers. Patients in an enhanced version of usual care received an annual CRC recommendation and FOBT kit; those in the education arm additionally received brief literacy and culturally appropriate education and those in the nurse arm received the education by a nurse manager who followed up by telephone. Baseline FOBT rates in this population were 3 %. We evaluated if FOBT rates could be sustained over 3 years. A three-arm, quasi-experimental evaluation was conducted among eight clinics in Louisiana. Screening efforts included: (1) enhanced usual care, (2) literacy-informed education of patients, and (3) education plus nurse support. Overall, 961 average-risk patients, ages 50-85, eligible for routine CRC screenings were recruited. The primary outcome was completing three annual FOBT tests. Of 961 patients enrolled, 381 (39.6 %) participants did not complete a single FOBT, 60.4 % completed at least one FOBT of which 318 (33.1 %) completed only one, 162 (16.9 %) completed two and 100 (10.4 %) completed three FOBTs over the 3-year period (the primary study outcome). The primary outcome, return of three FOBT kits over the 3-year period, was achieved by 4.7 % in enhanced care, 11.4 % in education and 13.6 % in the nurse arm (p = 0.005). Overall 3-year FOBT screening rates were not sustained with any of the three interventions, despite reports of promising interim results at years 1 and 2. New strategies for sustaining FOBT screening over several years must be developed.

Introduction: Colorectal cancer (CRC), the second leading cause of cancer death in the United States, can be significantly reduced if it is detected early. Although overall CRC screening rates have increased significantly, disparities persist among low-income individuals, adults with low literacy and those living in rural areas. These groups all have screening completion rates below 50%. Objectives: To assess patient knowledge, beliefs, and self-efficacy about CRC screening and compare the effectiveness of two health literacy informed telephone follow-up strategies to improve annual screening over a three-year period with fecal immunochemical test (FIT) in rural community clinics. Methods: A two-arm, randomized controlled trial is being implemented in four community clinics. Clinics reported CRC baseline screening rates of 3% to 5%. Eligible patients, age 50-75, were recruited at the clinic prior to a scheduled appointment. A research assistant (RA) conducted a baseline structured interview measuring CRC screening knowledge, beliefs, and self-efficacy. The RA then recommended screening and gave brief literacy and culturally appropriate education using a pamphlet (4th-grade level), the FIT kit with preaddressed envelope, simplified instructions (3rd-grade level) and a demonstration of how to use it. At four weeks patients who had not returned their kit received either 1) a personal follow-up call (PC) from a central prevention coordinator using motivational interviewing skills and reminding them to complete and mail FIT kits, or 2) an automated follow-up call (AC) using plain language and motivational messages encouraging patients to complete and mail the FIT. Outcomes include FIT completion after intervention, and again at 12 and 24 months. Results: 620 patients not up-to-date were enrolled: 308/AC and 306/PC; 66% were African American, 55% women; 40% had limited literacy. During Year 1, 69% completed screening in AC arm versus 67% in PC arm. During Year 2, percentage screened decreased: 40% screened in AC arm and 37% in PC arm. Number of patients who needed at least one follow-up call increased: 74% in both arms needed at least 1 reminder call. Among those called, 19% in the AC arm completed their kit versus 15% in the PC arm. To date in Year 3, 32% screened in AC and 34% in PC. Conclusions: Simplified instructions accompanied by a face-to-face demonstration of FIT, and use of “teach back” to confirm understanding with a follow-up call if needed, facilitated completion rates of all patients, particularly those with limited literacy. Providing FIT + literacy appropriate education at regularly scheduled clinic visit with follow-up call (if needed) increased CRC screening rates of low-income, rural patients. Sustaining annual screening with FIT is challenging. In year 2 < 40% completed FIT. Follow-up calls were essential. Only 1/4 completed FIT without phone prompt. Lower-cost automated call has proven to be just as effective as personal call in both years 1 and 2. FIT is only effective if completed annually. This abstract is also being presented as Poster B099. Citation Format: Connie L. Arnold, Terry C. Davis, James Morris, Peggy Murphy, Glenn Mills. CRC screening in rural community clinics using the fecal immunochemical test (FIT): Issues with repeat screening [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr PR12.

Our previous three-arm comparative effectiveness intervention in community clinic patients who were not up-to-date with screening resulted in mammography rates over 50% in all arms.Our aim was to evaluate the effectiveness and cost-effectiveness of the three interventions on improving biennial screening rates among eligible patients.A three-arm quasi-experimental evaluation was conducted in eight community clinics from 2008 to 2011. Screening efforts included (1) enhanced care: Participants received an in-person recommendation from a research assistant (RA) in year 1, and clinics followed usual clinic protocol for scheduling screening mammograms; (2) education intervention: Participants received education and in-person recommendation from an RA in year 1, and clinics followed usual clinic protocol for scheduling mammograms; or (3) nurse support: A nurse manager provided in-person education and recommendation, scheduled mammograms, and followed up with phone support. In all arms, mammography was offered at no cost to uninsured patients.Of 624 eligible women, biennial mammography within 24-30 months of their previous test was performed for 11.0% of women in the enhanced-care arm, 7.1% in the education- intervention arm, and 48.0% in the nurse-support arm (p0.0001). The incremental cost was $1,232 per additional woman undergoing screening with nurse support vs. enhanced care and $1,092 with nurse support vs. education.Biennial mammography screening rates were improved by providing nurse support but not with enhanced care or education. However, this approach was not cost-effective.

Breast and colorectal cancer (CRC) screening in safety-net settings is underused.1-3 Screening rates for these cancers remain persistently lower among disadvantaged populations including low-income women, those with no health insurance, those with lower health literacy and fewer years of education, racial and ethnic minorities, and those who live in rural areas.4-14 The reduction of these screening disparities is a national public health priority.15 The Community Preventive Service Task Force's systematic review on the effectiveness of joint interventions to increase the rates of breast, cervical, and CRC screening found that one-on-one education, patient reminders, and enhancing access to screening services were effective.16 Another systematic review looking at multiple cancer screening also found that provider audits and culturally appropriate mail and telephone outreach improved breast and CRC screening rates.17 Few initiatives have been specifically developed to improve multiple-cancer screening rates in safety-net primary care clinics. In community clinics that participate in a county-funded health plan in Florida, a cancer screening office reminder system using chart stickers was effective in increasing joint rates of mammograms and fecal occult blood tests (FOBTs).18 Mammogram and FOBT screening rates among inner-city patients in Rochester, New York, increased with the use of a multimodal intervention of repeated letters and automated phone calls and a mailed FOBT kit with a point-of-care prompt if the patient had an appointment.19 An expansion of that study found that personal patient reminder calls and provider and patient prompts delivered at a patient-initiated visit were more effective in improving screening rates among poor and minority inner-city patients than were reminder letters alone or letters with automated calls.20 Although all of those interventions targeted 2 or more cancers, none targeted rural areas. Our team developed and evaluated a health literacy-informed intervention designed to promote mammogram and FOBT screening in rural and inner-city populations that were at higher risk for not undergoing cancer screening: low-income and uninsured women who were cared for in Federally Qualifed Health Centers (FQHCs) in Louisiana that were not participating in state or national screening programs. FQHCs are located in areas designated as medically underserved and provide care nationally to 20 million individuals regardless of their insurance status.21 The objective of this study was to test 3 strategies to promote joint breast and CRC screening: enhanced care, which ensured that women received screening recommendations and access to both tests; health literacy-informed educational materials with accompanying “teach back” to confirm comprehension; 22, 23 or use of the health literacy-informed education strategy with telephone follow-up by a nurse. All of the strategies promoted use of mammography at a rural community hospital or the nearest public hospital and of the FOBT, the most feasible, cost-effective screening option for CRC in low-income and uninsured patients.24-25 This report looks at whether women completed both tests. Given the resource-constrained FQHCs environment, we also evaluated the cost effectiveness of the interventions targeting breast and CRC. Cancer screening interventions are a priority in Louisiana because the state has high rates of cancer mortality, ranking third among states in breast cancer deaths and fourth in colon cancer deaths.26

BACKGROUND: This study was designed to develop and validate a brief adolescent health literacy assessment tool (Rapid Estimate of Adolescent Literacy in Medicine Short Form [REALM-TeenS]). METHODS: We combined datasets from 2 existing research studies that used the REALM-Teen (n = 665) and conducted an item response theory analysis. The correlation between scores on the original 66-item REALM-Teen and the proposed REALM-TeenS was calculated, along with the decision consistency across forms with respect to grade level assignment of each adolescent and coefficient α. The proposed REALM-TeenS was validated with original REALM-Teen data from a third independent study (n = 174). RESULTS: Items with the largest discriminations across the scale, from low to high health literacy, were selected for inclusion in REALM-TeenS. From those, a set of 10 items was selected that maintained a reasonable level of SE across ability estimates and correlated highly (r = 0.92) with the original REALM-Teen scores. The coefficient α for the 10-item REALM-TeenS was .82. There was no evidence of model misfit (root mean square error of approximation < 0.001). In the validation sample, REALM-TeenS scores correlated highly with scores on the original REALM-Teen (r = 0.92), and the decision consistency across both forms was 80%. In pilot testing, administration took ∼20 seconds. CONCLUSIONS: The REALM-TeenS offers researchers and clinicians a brief validated screening tool that can be used to assess adolescent health literacy in a variety of settings. Scoring guidelines ensure that reading level assessment is appropriate by age and grade.

Objectives To improve patient colonoscopy bowel preparation with a newly developed simplified instruction sheet in a safety-net hospital system. Methods Bowel preparation quality was compared in a retrospective chart review of 543 patients, 287 of whom received standard instructions (9th grade reading level) between November 2015 and February 2016, and 256 of whom received simplified instructions (6th grade level) between March and May 2016. Instructions were mailed to all patients. The primary outcome was bowel preparation quality recorded by the endoscopist as optimal or suboptimal preparation. Results 543 medical records were reviewed and results indicated a significant association between the instructions used and preparation quality with patients receiving simplified instructions being significantly more prepared (69.1% vs 65.5%) and having a lower cancellation rate (4.7% vs 10.5%), p = .042. Conclusions A no-cost simplified colonoscopy instruction sheet improved bowel preparation among patients in an academic safety-net health system.

Background: Rural women lag rural men and urban women in colon cancer (CRC) screening completion. Objective: To identify rural female patients’ knowledge, beliefs, barriers, self-efficacy, prior recommendation and completion of CRC screening using an FOBT and to compare these factors by health literacy (HL) level. Methods: This descriptive study was conducted between 2015 and 2016 in 4 rural community clinics in South Lousiana. Patients overdue for screening were given a structured interview by a research assistant. Results: 339 women were enrolled, mean age 58.5, 32% had limited HL, 66% were African American. Most (91.7%) had heard of CRC, yet only 71% knew of any CRC screening tests. Women with adequate HL had greater knowledge of specific tests than those with limited HL (78.4% vs 56.6%, p

Objective: The objective in this pre- and post-survey assessment was to compare the effectiveness of a health literacy-directed intervention designed to increase knowledge, beliefs, barriers, self-efficacy and behavior associated with CRC screening with FOBT among patients cared for in predominantly rural community clinics and the change in these characteristics over the first 15 months after enrolling in a study designed to assess screening strategies. Methods: Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Patients were orally administered a 15-minute survey at enrollment by a clinic research assistant (RA) and at 15 months by phone by a central RA. Participants included 428 community clinic patients aged 50-85 (mean 58.5); the majority (79%) were female, 69% were African American, and 54% had limited health literacy. Results: There was significant improvement across all groups with the number of patients reporting they had been given information /education on CRC testing (p83%) as confirmed by study records.

Background: A comparative effectiveness intervention by this team improved initial fecal occult blood testing (FOBT) rates from 3% to 53% among community clinic patients. The purpose of this study was to evaluate the effectiveness and costs associated with a literacy-informed intervention on repeat FOBT testing. Methods: Between 2008 and 2011, a three-arm quasi-experiential comparative effectiveness evaluation was conducted in eight community clinics in Louisiana. Clinics were randomly assigned to receive: enhanced care, a screening recommendation, and FOBT kit annually; a brief educational intervention where patients additionally received a literacy appropriate pamphlet and simplified FOBT instructions; or nurse support where a nurse manager provided the education and followed up with phone support. In year 2, all materials were mailed. The study consisted of 461 patients, ages 50 to 85 years, with a negative initial FOBT. Results: Repeat FOBT rates were 38% enhanced care, 33% education, and 59% with nurse support (P = 0.017). After adjusting for age, race, gender, and literacy, patients receiving nurse support were 1.46 times more likely to complete repeat FOBT screening than those receiving education [95% confidence interval (CI), 1.14–1.06; P = 0.002] and 1.45 times more likely than those in enhanced care but this was not significant (95% CI, 0.93–2.26; P = 0.10). The incremental cost per additional person screened was $2,450 for nurse over enhanced care. Conclusion: A mailed pamphlet and FOBT with simplified instructions did not improve annual screening. Impact: Telephone outreach by a nurse manager was effective in improving rates of repeat FOBT, yet this may be too costly for community clinics. Cancer Epidemiol Biomarkers Prev; 23(1); 134–43. ©2013 AACR.

BACKGROUND We evaluated the effectiveness and cost-effectiveness of alternative interventions designed to promote mammography in safety-net settings.

35 Background: Colorectal cancer (CRC), the second leading cause of cancer death in the US, can be significantly reduced if it is detected early. Although overall CRC screening rates have increased significantly, disparities persist among low income individuals, adults with low literacy and those living in rural areas. Methods: Randomized controlled trial to assess the effectiveness of 2 health literacy informed phone follow-up strategies to improve annual screening with Fecal Immunochemical Test (FIT) in 4 rural community clinics. Eligible patients, age 50-75, were recruited. After consenting, a research assistant (RA) recommended screening and gave literacy and culturally appropriate education using a pamphlet, the FIT kit, simplified instructions and a demonstration of how to use it, At 4 weeks patients who had not returned their kit receive either 1) a personal follow-up call (PC) from a central RA using motivational interviewing skills and reminding them to complete FIT kits; or 2) an automated follow-up call (AC) using plain language and motivational messages encourages patients to complete the FIT. During years 2 and 3, FIT kits were mailed to patients. Follow-up call procedures previously used were followed. Results: 620 patients not up-to-date were enrolled: 308/AC & 306/PC; 66% were African American, 55% women; 40% had limited literacy. During Year 1, 69% completed screening in AC arm versus 67% in PC arm. During Year 2, percentage screened decreased: 40% screened in AC arm and 37% in PC arm. Number of patients that needed at least one follow-up called increased: 74% in both arms needed at least 1 reminder call. Among those called, 19% in the AC arm completed their kit versus 15% in the PC arm. To date in Year 3, 32% screened in AC and 34% in PC. Conclusions: Simplified instructions accompanied by a face-to-face demonstration of FIT, use of “teach back” to confirm understanding with a follow-up call if needed, facilitated completion rates of all patients, particularly those with limited literacy. The less costly and time consuming automated call was equally effective as a personal call. Screening rates in years 2 and 3 declined. CRC screening with FIT is only effective when completed annually. Clinical trial information: RSG-13-021-01 - CPPB.

Background We evaluated the effectiveness and cost-effectiveness of two interventions designed to promote colorectal cancer (CRC) screening in safety-net settings.

This article examines the relationship between literacy and colorectal cancer (CRC) screening knowledge, beliefs, and experiences, with a focus on fecal occult blood tests (FOBTs). Participants were 975 patients in 8 Louisiana federally qualified health centers. Participants were 50 years of age or older and not up to date with CRC screening; approximately half (52%) had low literacy (less than a 9th-grade level). Participants with low literacy were less likely than were those with adequate literacy to be aware of advertisements promoting CRC screening (58.7% vs. 76.3%, p < .0001) or to believe it was very helpful to find CRC early (74.5% vs. 91.9%, p < .0001). The majority of participants had positive beliefs about the benefits of CRC screening using FOBTs. Participants with low literacy had more perceived barriers to FOBT completion and were more likely to strongly agree or agree that FOBTs would be confusing, embarrassing, or a lot of trouble; however, none of these remained significant in multivariate analyses controlling for relevant covariates. Confidence in being able to obtain an FOBT kit was high among those with low and adequate literacy (89.8% vs. 93.1%, respectively, p = .20); yet multivariate analyses revealed a significant difference in regard to literacy (p = .04) with low-literacy participants indicating less confidence. There was no significant difference by literacy in ever receiving a physician recommendation for CRC screening (38.4% low vs. 39.0% adequate, p = .79); however, multivariate analyses revealed significant differences in FOBT completion by literacy (p = .036). Overall, findings suggest that literacy is a factor in patients’ CRC knowledge, beliefs, and confidence in obtaining a FOBT.

Between a third and one half of eligible adults in the United States have not received recommended colorectal cancer (CRC) screening services, with socioeconomically disadvantaged, racial/ethnic minority, and rural individuals at greatest risk for not being screened.1–6 Barriers have been extensively studied and include patient (eg, knowledge and awareness of screening, motivation, transportation, health insurance coverage),4,7–11 health system (physician shortages, insurance), and provider (rates of screening recommendation) factors.12–17 Previous research has found that low-income, medically underserved patients, despite provider perceptions, are aware of CRC, want to know if they have cancer, and have positive beliefs about fecal occult blood test (FOBT).7,9,16 This suggests that cost-effective interventions centered around annual occult blood testing can be a convenient method of screening and detecting CRC for safety net clinics such as Federally Qualified Health Centers (FQHCs) whose patients disproportionately face cost and access barriers to colonoscopy.7,18 Identifying effective, efficient, and sustainable practices that can improve CRC screening among less educated (and lower literate), lower-income adults could dramatically advance public health preventive practices and reduce known disparities. To date, a diverse set of interventions has been tried with variable success and intensity. These interventions range from public health strategies that usually involve mailed reminders or test kits to primary care-based education using decision aids, multimedia tools, or targeted provider education to promote recommendation and organizational change such as nurses giving FOBT cards, instructions, and reminders.7,11,12,19 To our knowledge, no research investigation has currently deconstructed the value of core elements that have been perceived as requisite components to primary care screening strategies to best understand exactly which activities are necessary to engage patients in screening. In this study, our purpose was to determine the effect of common components of primary care-based CRC screening interventions on FOBT completion within rural and urban community clinics, including: (1) a physician’s spoken recommendation, (2) providing information or education about FOBTs, and (3) a physician providing the FOBT kit. Each of these components may appear simple and easily administered, although each can be challenging to deliver and sustain in safety net environments. Therefore, a second purpose was to determine the relative effect of these interventions within rural and urban FQHCs. Finally, comparison of the effect of each intervention between rural and urban clinics was investigated to provide tailored guidance to support the development and implementation of CRC screening promotions for both low-income urban and rural patients in order to best achieve health care equity.

Background: Disparities exists in recruitment in clinical trials and biorepositories among minority groups, rural residents and individuals with low SES.Objective. Identify barriers and facilitators to awareness, understanding and acceptance of clinical trials and biobanking among safety-net patients and providers and support group participants and African American (AA) social and church groups. Methods: We conducted 14 focus groups and 7 individual interviews January - May 2017 in urban and rural communities in Louisiana. Sites included safety-net oncology and primary care clinics, social service agencies, social and faith based groups. Themes were identified. Results: 103 individuals participated: 78 clinic patient and community participants, 25 providers; 24% participants lived in rural areas. Patients and community members ranged in age from 45-88; 85% were female, 78% AA. Participants had an increasing awareness of clinical trials and personalized medicine due to ads on TV. Low income and minority patients were open to participating in genomic trials and biobanking even if it would not benefit them directly. Cancer patients and Alzheimer family caregivers were highly interested in clinical trials that might benefit them or their family. Community participants were less trusting of clinical trials than patients. All said information and recommendations about clinical trials would be most effective and actionable if it comes from a trusted physician. Terms such as clinical trials and biobanking were scary to some and not understood - medical studies and a bank to store blood and tissue were clearer. African American participants indicated that a recruitment message needs to be “ALL people are needed for studies to improve treatments” rather than “AA have been underrepresented and most treatments based on whites” which raises suspicion. Some participants were concerned with who would see data and if it would be a barrier to jobs or insurance - despite being told of protections in place for confidentiality. Rural and urban providers (n=25) were interested in being more involved in clinical trials. They lacked time to identify trials and explain them to patients. They wanted brief, plain language handouts with talking points and a card to give patients to call for more information. Transportation to academic centers is a barrier to patient participation in clinical trials. Very few patients, caregivers or providers had looked for clinical trials on the internet or social media. Conclusions: African American and white adults were interested in clinical trials but not clear how to learn about them. Most were willing to participate but had never been asked. Recommendation to participate in a clinical trial is most effective coming from a trusted physician. Methods for getting community providers and the public useful information needs to be created with target audiences. Citation Format: Terry Davis, Connie Arnold, Lucio Miele, Glenn Mills. Biobanking and genomic research: Understanding and acceptance of safety-net patients, primary care providers and minority groups [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3010.

Introduction: Colorectal cancer (CRC), the second leading cause of cancer death in the United States, can be significantly reduced if it is detected early. Although overall CRC screening rates have increased significantly, disparities persist among low income individuals, adults with low literacy and those living in rural areas. Objectives: To assess the effectiveness of two health literacy informed telephone follow-up strategies to improve annual repeat screening with Fecal Immunochemical Test (FIT) in rural community clinics. Methods: A two-arm, randomized controlled trial is being implemented in four community clinics. Clinics reported CRC baseline screening rates of 1% to 3%. Eligible patients, age 50-75, were recruited at the clinic prior to a scheduled appointment. A research assistant (RA) conducted a baseline structured interview. The RA then recommended screening and gave brief literacy and culturally appropriate education using a pamphlet (4th grade level), the FIT kit with pre-addressed envelope, simplified instructions (3rd grade level) and a demonstration of how to use it, At four weeks patients who had not returned their kit receive either 1) a personal follow-up call (PC) from a central prevention coordinator using motivational interviewing skills and reminding them to complete and mail FIT kits; or 2) an automated follow-up call (AC) using plain language and motivational messages encourages patients to complete and mail the FIT. During years 2 and 3, FIT kits were mailed to patients along with previous literacy and culturally appropriate education. Follow-up call procedures previously used at weeks 4 and 8 were followed. Results: 620 patients not up-to-date with screening were enrolled; 66% were African American, 55% women; 40% had limited literacy. Screening results: 1st Year Screening: 620 patients enrolled - (6 withdrew before completing test) AC Arm (n=308) 213 (69%) completed kits [23 (7%) positive] 124 (40%) people needed at least one follow-up call [29 (24%) returned FIT after call] PC Arm (n=306) 205 (67%) completed kits [21 (7%) positive] 127 (41%) people needed at least one follow-up call [26 (20%) returned FIT after call] 2nd Year Screening: 568 Second kits mailed (4 withdrew and no previous positives included) AC Arm (n=285) 111 (40%) completed kits [9 (8%) positive] 212 (74%) people needed at least one follow-up call [40 (19%) returned FIT after call]PC Arm (n=283) 104 (37%) completed kits [8 (8%) positive] 209 (74%) people needed at least one follow-up call [31 (15%) returned FIT after call] Discussion: Simplified instructions accompanied by a face-to-face demonstration of FIT, use of “teach back” to confirm understanding with a follow-up call if needed, facilitated completion rates of all patients, particularly those with limited literacy. The less costly and time consuming automated call was equally effective as a personal call. Citation Format: Connie L. Arnold, Terry C. Davis, James Morris, Alfred Rademaker, Glenn Mills. Strategies to improve repeat CRC screening in rural community clinics using the fecal immunochemical test (FIT) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 594.

Introduction: Colorectal cancer (CRC), the second leading cause of cancer death in the United States, can be significantly reduced if it is detected early. Although overall CRC screening rates have increased significantly, disparities persist among low-income individuals, adults with low literacy, and those living in rural areas. These groups all have screening completion rates below 50%. Objectives: To assess patient knowledge, beliefs, and self-efficacy about CRC screening and compare the effectiveness of two health literacy informed telephone follow-up strategies to improve annual screening over a three-year period with fecal immunochemical test (FIT) in rural community clinics. Methods: A two-arm, randomized controlled trial is being implemented in four community clinics. Clinics reported CRC baseline screening rates of 3% to 5%. Eligible patients, age 50-75, were recruited at the clinic prior to a scheduled appointment. A research assistant (RA) conducted a baseline structured interview measuring CRC screening knowledge, beliefs, and self-efficacy. The RA then recommended screening and gave brief literacy and culturally appropriate education using a pamphlet (4th-grade level), the FIT kit with preaddressed envelope, simplified instructions (3rd-grade level), and a demonstration of how to use it. At four weeks patients who had not returned their kit received either 1) a personal follow-up call (PC) from a central prevention coordinator using motivational interviewing skills and reminding them to complete and mail FIT kits, or 2) an automated follow-up call (AC) using plain language and motivational messages encouraging patients to complete and mail the FIT. Outcomes include FIT completion after intervention, and again at 12 and 24 months. Results: 620 patients not up to date with screening were enrolled: 64% African American, 56% women, 40% inadequate literacy. Although 90% reported having heard of CRC, only 64% knew a test to check for CRC. 70% reported that a provider had recommended CRC screening in the past and 91% reported they would want to know if they have CRC. Self-efficacy was high, with over 90% indicating they would return the kit to the lab. Screening results: 620 patients enrolled (AC: n=308 / PC: n=306); 418 (68%) completed tests (AC: n=213 (69%) / PC: n=205 (67%)). Follow-up calls for unreturned kits--AC: 124 (40%) people called--29 returned FIT (9.4% of people called completed FIT). PC: 127 (41%) people called--26 returned FIT (9.4% of people called completed FIT). 2nd-year screening: 255 second kits mailed out to date (AC: n=128/PC: n=125); 98 (38.5%) completed tests (AC: n=49 (38%) / PC: n=49 (39%)). Follow-up calls for unreturned kits--AC: 89 (70%) people called—19 returned FIT (14.8% of people called completed FIT). PC: 82 (66%) people called—17 returned FIT (13.6% of people called completed FIT). Discussion: Implementing health literacy influenced CRC education, and screening strategies using the FIT and phone reminders dramatically increased FIT completion in rural community clinics. The less costly and time-consuming automated call was equally effective as a personal call. Citation Format: Connie L. Arnold, Terry C. Davis, Alfred Rademaker, James Morris, Glenn Mills. Sustaining annual colorectal cancer screening in rural community health clinics using the fecal immunochemical test (FIT) [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B11.

In this pilot study, we evaluated the impact of providing patients with a literacy-appropriate diabetes education guide accompanied by brief counseling designed for use in primary care.We provided the Living with Diabetes guide and brief behavior change counseling to 250 English and Spanish speaking patients with type 2 diabetes. Counseling sessions using collaborative goal setting occurred at baseline and by telephone at 2 and 4 weeks. We measured patients' activation, self-efficacy, diabetes distress, knowledge, and self-care at baseline and 3-month follow-up.Statistically significant (por=0.001) and clinically important (effect sizes=0.29-0.42) improvements were observed in participants' activation, self-efficacy, diabetes-related distress, self-reported behaviors, and knowledge. Improvements were similar across literacy levels. Spanish speakers experienced both greater improvement in diabetes-related distress and less improvement in self-efficacy levels than English speakers.A diabetes self-management support package combining literacy-appropriate patient education materials with brief counseling suitable for use in primary care resulted in important short-term health-related psychological and behavioral changes across literacy levels.Coupling literacy-appropriate education materials with brief counseling in primary care settings may be an effective and efficient strategy for imparting skills necessary for diabetes self-management.

Objective To assess the efficacy of a literacy-appropriate weight loss intervention targeting providers and patients in improving physicians’ weight loss counseling and patients’ self-reported beliefs, and self-efficacy. Methods The study took place in a public hospital nephrology clinic. The intervention included two physician workshops and a small group patient education. Physician–patient communication was observed and coded. Structured interviews assessed patient recall of weight loss recommendations, weight-related beliefs, and self-efficacy. Results 64 patient visits were observed before and after the intervention. 75% of patients were African American, 96% lacked private insurance, 71% had low literacy skills; mean body mass index (BMI) of 35 kg/m2. Physician counseling improved significantly post-intervention, particularly in assessing, supporting and advising patients about weight loss and exercise. Patients reported increases in recall of weight loss recommendations and were more likely to report greater confidence about losing weight (52% vs. 70%, p Conclusions This pilot study offers promising directions to address provider and patient barriers to weight loss education and counseling in a public hospital. Practice implications Hospital-based weight loss interventions need to target both physicians and patients.

OBJECTIVES. The purpose of this study was to identify what stakeholders considered best practices for parent-provider communication regarding newborn hearing screening and diagnosis. We used consensus data to develop educational materials for parents. METHODS. We conducted 29 focus groups and 23 individual interviews between October 2003 and May 2004. Participants included (1) English- and Spanish-speaking parents of infants RESULTS. Communication to parents about hospital-based newborn hearing screening was limited. Most parents first learned about the screening in the hospital, but all stakeholders thought a more opportune time for education was before the birth. For parents of infants who did not pass the newborn hearing screening, stakeholders recommended direct communication about the urgency of diagnostic testing. They also indicated that primary care providers needed current information regarding hearing screening, diagnostic testing, and early intervention. All stakeholders thought that a brief brochure for parents to take home would be helpful for hospital-based screening and, if necessary, subsequent diagnostic testing. Primary care providers requested basic, to-the-point information. CONCLUSIONS. The most opportune time to begin discussion of newborn hearing screening is before the birth. Providers need up-to-date information on current standards of hearing screening, diagnosis, and intervention. User-friendly patient education materials, such as those we developed, could assist providers in educating parents.

OBJECTIVE. The purpose of this study was to measure the readability and user-friendliness (clarity, complexity, organization, appearance, and cultural appropriateness of materials) of parent education brochures on newborn screening.METHODS. We studied English-language versions of the brochures that state newborn screening programs prepare and distribute. We obtained brochures from 48 states and Puerto Rico. We evaluated each brochure for readability with the Flesch reading ease formula. User-friendliness of the brochures was assessed with an instrument we created that contained 22 specific criteria grouped into 5 categories, ie, layout, illustrations, message, manageable information, and cultural appropriateness.RESULTS. Most current newborn screening brochures should be revised to make them more readable and user-friendly for parents. Ninety-two percent of brochures were written at a reading level that is higher than the average reading level of US adults (eighth-grade level). In most brochures, the essential information for parents was buried. Although all brochures were brief and focused on the newborn screening tests being performed, 81% needed improvement in getting to the point quickly and making it easy for parents to identify what they needed to know or to do. None of the brochures scored high in all 22 criteria on the user-friendliness checklist.CONCLUSIONS. Parent education materials about newborn screening should be revised to be easier to read and more user-friendly, by lowering the reading difficulty to eighth-grade level and focusing on issues such as layout, illustrations, message, information, and cultural appropriateness. It is important that state newborn screening programs and organizations work with parents to develop and to evaluate materials to ensure that they are user-friendly.