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Objective: Determine the relationship characteristics, sexual health attitudes, and demographic factors associated with dual contraceptive use among college students. Participants: September–Octobe...

Background Cognitive decline can be an early indicator for dementia. Using quantitative methods and national representative survey data, we can monitor the potential burden of disease at the population-level. Methods BRFSS is an annual, nationally representative questionnaire in the United States. The optional cognitive decline module is a six-item self-reported scale pertaining to challenges in daily life due to memory loss and growing confusion over the past twelve months. Respondents are 45+, pooled from 2015-2020. Latent class analysis was used to determine unobserved subgroups of subjective cognitive decline (SCD) based on item response patterns. Multinomial logistic regression predicted latent class membership from socio-demographic covariates. Results A total of 54,771 reported experiencing SCD. The optimal number of latent classes was three, labeled as Mild, Moderate, and Severe SCD. Thirty-five percent of the sample belonged to the Severe group. Members of this subgroup were significantly less likely to be older (65+ vs. 45-54 OR = 0.29, 95% CI: 0.23-0.35) and more likely to be non-Hispanic Black (OR = 1.80, 95% CI: 1.53-2.11), have not graduated high school (OR = 1.60, 95% CI: 1.34-1.91), or earned Conclusions This study determined three latent subgroups indicating severity of SCD and identified socio-demographic predictors. Using a single categorical indicator of SCD severity instead of six separate items improves the versatility of population-level surveillance.

Introduction OTC medications are generally considered safe and convenient to use without requiring a prescription. However, the safety of an OTC medication and the final health outcome depends in part upon consumers’ perceptions, beliefs, and their decision-making about OTC medication use. This study uses a qualitative approach to explore the knowledge, beliefs, and practices associated with OTC medication use and decision-making in adults aged 65 years and older. Methods A set of focus groups (N = 10) were conducted in a sample of independently living older adult residents of senior apartment buildings (N = 80) using purposeful sampling. All focus groups were recorded, transcribed verbatim, and analyzed qualitatively. Results Most participants considered OTC medications safe and effective to use if following the drug label instructions appropriately. Brand name products were perceived as equally or more effective compared to generic products by participants. Two approaches to OTC treatment decision-making were observed: 1) a decision to treat their symptoms by themselves (self-recommended) or 2) a decision to ask and/or follow their physician's recommendation (physician-recommended). Each of these treatment approaches may lead to the other depending on the person's financial and healthcare resources, the severity of the symptoms, experiences with the medication, and relationship with the physician. Maximum and fast relief was mentioned as the most important attribute in the final OTC purchase decision, followed by the lower cost, and easy to swallow dosage forms. Aspirin and ibuprofen were the two most frequently reported OTC medications associated with adverse effects and inappropriate use. Conclusions Older adults, in general, feel positive about OTC medications and are satisfied with using them. Considering the self-reported malpractices and side effects associated with OTC medications, older adults should be encouraged to make safe and responsible decisions about self-medication.

Introduction Patient–physician communication about colorectal cancer screening can affect screening use, but discussions often lack information that patients need for informed decision making and seldom address personal preferences or barriers. To address this gap, a series of patient focus groups was conducted to guide the development of an online, interactive decision support program. This article presents findings on patient information needs and barriers to colorectal cancer screening after receiving a screening recommendation from a physician, and their perspectives on using electronic patient portals as platforms for health-related decision support. Methods Primary care patients with recent colonoscopy or stool testing orders were identified via the centralized data repository of a large Midwestern health system. Seven gender-stratified focus groups (N=45 participants) were convened between April and July 2016. Sessions were audio recorded, transcribed, coded, and analyzed for commonly expressed themes beginning in August 2016. Results Findings reveal a consistent need for simple and clear information on colorectal cancer screening. Participants desired step-by-step explanations of the colonoscopy procedure and information about bowel preparation options/alternatives. The desired level of additional information varied: some patients wanted to know about and act on test options, whereas others preferred following their physician-recommended testing path. Fears and concerns were prevalent, particularly about colonoscopy, and patients reported challenges getting these concerns and their informational needs addressed. Finally, they expressed consistent support for using the patient portal to gather additional information from their physician. Conclusions Patient portals may offer an opportunity to build sustainable programs for decision support and assistance that are integrated with clinic workflows and processes.

Background Self-medication with over-the-counter (OTC) products is common among older adults. Although OTC self-medication is a convenient way to manage some health issues, older persons may be at higher risk of experiencing medication-related problems. This study examines the prevalence, practices, and preferences associated with OTC medication use in older adult residents of senior living communities. Objectives The study aimed to examine the characteristics of OTC medication users and to quantify the prevalence, attitudes, perceptions, preferences, and practices regarding OTC medication use and decision-making in 2 senior living communities in central Virginia. Methods The study used survey methodology. A 51-item semistructured questionnaire was designed by the research team of geriatrics specialists, and mixed-methods and evaluation researchers. The questionnaire was administered in-person to participants (N = 88). Descriptive analyses were conducted using SAS 9.4. Characteristics of those using OTC medications as directed by a health professional were compared with those of whom were self-medicating with OTC medications. Results Most of the sample were women (55%), black (61%) and had less than or equal to a high school education (55%). Analgesics were the most (76%) prevalent OTC therapeutic category used, and aspirin was the most (65%) prevalent OTC medication. A greater (82%) proportion of respondents reported self-recommended OTC medication use (self-medication with OTC medications) rather than physician recommended use (18%). A high (41%) prevalence of inappropriate use of OTC medications was observed in this sample of older adults. Most (80%) considered OTC medications safe and effective. The pharmacy was the most (93%) commonly reported purchase location to buy an OTC medication. Physicians were the most (90%) commonly reported information source for OTC medications. Conclusion Considering the high percentage of self-reported self-medication, inappropriate use, and experiences of adverse effects, steps should be taken to develop consumer education and relationships with pharmacists to encourage the responsible use of OTC medications in this population.

Patients with cancer are vulnerable to Clostridium difficile infection (CDI); hospitals with larger oncology populations may have worse CDI performance. Among 71 academic hospitals studied, there were significant differences in oncology patient-days per 1,000 admissions across CDI standardized infection ratio categories of better, no different, and worse; worse hospitals had the greatest number of patient-days. Oncology patients' most commonly used high-risk CDI medications were quinolones, third- and fourth-generation cephalosporins, and proton pump inhibitors.

Background Childhood lead exposure is linked to numerous adverse health effects and exposure in the United States is highest among people living in substandard housing, which is disproportionately inhabited by socioeconomically disadvantaged individuals. In this paper, we compared the Vox lead exposure risk score and concentrated disadvantage based on principal component analysis (PCA) to weighted quantile sum (WQS) regression to determine which method was best able to explain variation in elevated blood lead levels (EBLLs). Methods We constructed indices for census tracts in Minnesota and used them in Poisson regression models to identify the best socioeconomic measure for explaining EBLL risk. Results All indices had a significant association with EBLL in separate models. The WQS index had the best goodness-of-fit, followed next by the Vox index, and then the concentrated disadvantage index. Among the most important variables in the WQS index were percent of houses built before 1940, percent renter occupied housing, percent unemployed, and percent African American population. Conclusions The WQS approach was best able to explain variation in EBLL risk and identify census tracts where targeted interventions should be focused to reduce lead exposure.

Introduction Engaging patients to make informed choices is paramount but difficult in busy practices. This study sought to engage patients outside the clinical setting to better understand how they approach cancer screening decisions, including their primary concerns and their preferences for finalizing their decision. Methods Twelve primary care practices offering patients an online personal health record invited eligible patients to complete a 17-item online interactive module. Among 11,458 registered users, invitations to complete the module were sent to adults aged 50–74 years who were overdue for colorectal cancer screening and to women aged 40–49 years and men aged 55–69 who had not undergone a recent mammogram or prostate-specific antigen test, respectively. Results The module was started by 2,355 patients and completed by 903 patients. Most respondents (76.8%) knew they were eligible for screening. Preferred next steps were talking to the clinician (76.6%), reading/research (28.6%), and consulting trusted friends/family (16.4%). Priority topics included how much screening improves life expectancy, comparative test performance, and the prevalence/health risks of the cancer. Leading fears were getting cancer/delayed detection (79.2%), abnormal results (40.5%), and testing complications (39.1%), the last referring to false test results, medical complications, or unnecessary treatments. Men eligible for prostate-specific antigen screening were more likely than women eligible for mammography to express concerns about testing complications and to prioritize weighing pros and cons over gut feelings (p Conclusions Although this sample was predisposed to screening, most patients wanted help in finalizing their decision. Many wanted to weigh the pros and cons and expressed fears of potential harms from screening. Understanding how patients approach decisions may help design more effective engagement strategies.

Lead exposure adversely affects children's health. Exposure in the United States is highest among socioeconomically disadvantaged individuals who disproportionately live in substandard housing. We used Bayesian binomial regression models to estimate a neighborhood deprivation index and its association with elevated blood lead level (EBLL) risk using blood lead level testing data in Maryland census tracts. Our results show the probability of EBLL was spatially structured with high values in Baltimore city and low values in the District of Columbia suburbs and Baltimore suburbs. The association between the neighborhood deprivation index and EBLL risk was statistically significant after accounting for spatial dependence in probability of EBLL. The percent of houses built before 1940, African Americans, and renter occupied housing were the most important variables in the index. Bayesian models provide a flexible one-step approach to modeling risk associated with neighborhood deprivation while accounting for spatially structured and unstructured heterogeneity in risk.

Socioeconomic status (SES) is often considered a risk factor for health outcomes. SES is typically measured using individual variables of educational attainment, income, housing, and employment variables or a composite of these variables. Approaches to building the composite variable include using equal weights for each variable or estimating the weights with principal components analysis or factor analysis. However, these methods do not consider the relationship between the outcome and the SES variables when constructing the index. In this project, we used weighted quantile sum (WQS) regression to estimate an area-level SES index and its effect in a model of colonoscopy screening adherence in the Minnesota-Wisconsin Metropolitan Statistical Area. We considered several specifications of the SES index including using different spatial scales (e.g., census block group-level, tract-level) for the SES variables. We found a significant positive association (odds ratio = 1.17, 95% CI: 1.15-1.19) between the SES index and colonoscopy adherence in the best fitting model. The model with the best goodness-of-fit included a multi-scale SES index with 10 variables at the block group-level and one at the tract-level, with home ownership, race, and income among the most important variables. Contrary to previous index construction, our results were not consistent with an assumption of equal importance of variables in the SES index when explaining colonoscopy screening adherence. Our approach is applicable in any study where an SES index is considered as a variable in a regression model and the weights for the SES variables are not known in advance.

PURPOSE Technology could transform routine decision making by anticipating patients’ information needs, assessing where patients are with decisions and preferences, personalizing educational experiences, facilitating patient-clinician information exchange, and supporting follow-up. This study evaluated whether patients and clinicians will use such a decision module and its impact on care, using 3 cancer screening decisions as test cases. METHODS Twelve practices with 55,453 patients using a patient portal participated in this prospective observational cohort study. Participation was open to patients who might face a cancer screening decision: women aged 40 to 49 who had not had a mammogram in 2 years, men aged 55 to 69 who had not had a prostate-specific antigen test in 2 years, and adults aged 50 to 74 overdue for colorectal cancer screening. Data sources included module responses, electronic health record data, and a postencounter survey. RESULTS In 1 year, one-fifth of the portal users (11,458 patients) faced a potential cancer screening decision. Among these patients, 20.6% started and 7.9% completed the decision module. Fully 47.2% of module completers shared responses with their clinician. After their next office visit, 57.8% of those surveyed thought their clinician had seen their responses, and many reported the module made their appointment more productive (40.7%), helped engage them in the decision (47.7%), broadened their knowledge (48.1%), and improved communication (37.5%). CONCLUSIONS Many patients face decisions that can be anticipated and proactively facilitated through technology. Although use of technology has the potential to make visits more efficient and effective, cultural, workflow, and technical changes are needed before it could be widely disseminated.

Correspondence avoid surgery in rapidly progressive or chemo-insensitive disease. 4 Genotyping of pancreatic tumours via fine needle aspiration could influence the clinical management of pancreatic cancer. Fine-needle aspiration sequencing was used to identify subgroups of patients with specific actionable mutations related to resectable or locally advanced tumours. 5 In patients with radiologically resectable or borderline resectable tumours, preoperative fine-needle aspiration sequencing could distinguish between patients with a genetic pattern associated with micrometastatic tumours, who should undergo neoadjuvant therapy, and those with a truly localised disease that would be amenable to a surgery-first strategy. Michele Reni has served as a consultant for or on the advisory boards of Celgene, Boehringer-Ingelheim, Lilly, Genentech, Baxalta, Novocure, Astra-Zeneca, Pfizer, and Merck-Serono, and has received honoraria from Celgene. Massimo Falconi has received honoraria from Celgene, Ipsen and Novartis. The other authors declare no competing interests. *Stefano Crippa, Michele Reni, Gianpaolo Balzano, Claudio Doglioni, Massimo Falconi crippa1.stefano@hsr.it Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy (SC, GB, MF); Medical Oncology Department, IRCCS San Raffaele Hospital , Milan, Italy (MR); Department of Pathology, IRCCS San Raffaele Hospital , Milan, Italy (CD); Clinical and Translational Research Program on Pancreatic Cancer, IRCCS San Raffaele Hospital, Milan, Italy (SC, MR, GB, CD, MF) e178 Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24 Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefit of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103: 179–91. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer 2011; Sohal DP, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst 2014; 106: dju011 Valero V, Saunders TJ, He J, et al. Reliable detection of somatic mutations in fine needle aspirates of pancreatic cancer with next-generation sequencing: implications for surgical management. Ann Surg 2016; Author’s reply Stefano Crippa and colleagues, in responding to our manuscript, 1 agree that increasing the radicality of surgery for pancreatic ductal adenocarcinoma, including synchronous vein resection, is suspect. Indeed, a recent meta-analysis 2 indicates that synchronous vein resection, as reported, increases mortality and decreases survival. Crippa and colleagues put forward two interesting ideas that warrant further discussion. The first is that the surgery-first approach for pancreatic ductal adenocarcinoma might ultimately be retired, given that pancreatic ductal adenocarcinoma is usually systemic at presentation, local treatments have little effect, and neoadjuvant therapy has possible benefits. For now, the absence of high-level evidence for neoadjuvant therapy leaves largely theoretical benefits; namely that neoadjuvant therapy will reveal the biology (ie, those patients that can progress on neoadjuvant therapy will avoid futile surgery), or alter the biology (ie, those patients that are downstaged will become resectable). The preliminary results of the ALLIANCE trial 3 damages the lustre of these purported benefits with no improvement in the number of resections (10 [50%] of 20 patients who completed all preoperative therapy), and no rescue of aggressive tumour biology. This leads to the second idea, in which Crippa and colleagues suggest a biological (rather than radiological) basis for selecting patients for neoadjuvant therapy with a view to reduce the number of synchronous vein resections. Endoscopic ultrasonography- guided genotyping is a possible way to select subgroups of patients with heterogenous pancreatic ductal adenocarcinoma 4 who will benefit from neoadjuvant therapy. In support of this method, Hruban and colleagues 5 suggested that an intact SMAD4/DPC4 gene might be used to select surgery because there is lesser risk of distant metastases for this genotype. 6 In the future, we hope to more accurately select a subgroup of patients in whom a surgery-first approach, and even synchronous vein resection, is justified, but it is much more likely that precision neoadjuvant therapy will ultimately result in less radical surgery and the introduction of non-surgical techniques to support the response to neoadjuvant therapy. We declare no competing interests. Savio G Barreto, *John A Windsor j.windsor@auckland.ac.nz Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India (SGB); Hepatobiliary Pancreatic and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand (JAW) Barreto S, Windsor J. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24. Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; Varadhachary G, Fleming J, Crane C, et al. Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma. Proc Am Soc Clin Oncol 2015; 33 (suppl 3): abstr 362. Killock D. Pancreatic cancer: a problem quartered—new subtypes, new solutions? Nat Rev Clin Oncol 2016; 13: 201. Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009; The US Cancer Moonshot initiative We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to www.thelancet.com/oncology Vol 17 May 2016

IntroductionHow to provide practice-integrated decision support to patients remains a challenge. We are testing the effectiveness of a practice-integrated programme targeting patients with a physician recommendation for colorectal cancer (CRC) screening.Methods and analysisIn partnership with healthcare teams, we developed ‘e-assist: Colon Health’, a patient-targeted, postvisit CRC screening decision support programme. The programme is housed within an electronic health record (EHR)-embedded patient portal. It leverages a physician screening recommendation as the cue to action and uses the portal to enrol and intervene with patients. Programme content complements patient–physician discussions by encouraging screening, addressing common questions and assisting with barrier removal. For evaluation, we are using a randomised trial in which patients are randomised to receive e-assist: Colon Health or one of two controls (usual care plus or usual care). Trial participants are average-risk, aged 50–75 years, due for CRC screening and received a physician order for stool testing or colonoscopy. Effectiveness will be evaluated by comparing screening use, as documented in the EHR, between trial enrollees in the e-assist: Colon Health and usual care plus (CRC screening information receipt) groups. Secondary outcomes include patient-perceived benefits of, barriers to and support for CRC screening and patient-reported CRC screening intent. The usual care group will be used to estimate screening use without intervention and programme impact at the population level. Differences in outcomes by study arm will be estimated with hierarchical logit models where patients are nested within physicians.Ethics and disseminationAll trial aspects have been approved by the Institutional Review Board of the health system in which the trial is being conducted. We will disseminate findings in diverse scientific venues and will target clinical and quality improvement audiences via other venues. The intervention could serve as a model for filling the gap between physician recommendations and patient action.Trial registration numberNCT02798224; Pre-results.

Background: Clinical guidelines recommend offering patients options for colorectal cancer (CRC) screening, but the modalities vary by frequency, accuracy, preparations, discomfort, and cost, which may cause confusion and reduce screening rates. We examined whether patients reported confusion about the options and whether confusion was associated with socio-demographic characteristics, number of options discussed, and adherence. Methods: Patients ages 50 to 75 years who had visited a clinician within 2 years were randomly selected for a cross-sectional study (n = 6,100). A questionnaire mailed in 2007 asked the following: whether a clinician had ever discussed CRC screening options; which of four recommended tests (i.e., fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema) were presented; and whether the options were confusing. Analyses were restricted to respondents who reported discussing one or more screening options (n = 1,707). Weighted frequencies were calculated and multivariate logistic regression was done. Results: The sample was 55.5% female, 15.6% African American, and 83.2% adherent to screening recommendations, and 56.0% had discussed two or more screening options. In adjusted analyses, nonadherent patients reported greater confusion than adherent patients (P < 0.01). Adults who discussed two or more options were 1.6 times more likely to be confused than those who discussed one option [95% confidence interval (CI), 1.08-2.26]. Patients who reported being confused were 1.8 times more likely to be nonadherent to screening than those who did not (95% CI, 1.14-2.75). Conclusions: Our study provides the first empirical evidence linking multiple options with confusion and confusion with screening adherence. Impact: Confusion may act as a barrier to screening and should be considered in public health messages and interventions. Cancer Epidemiol Biomarkers Prev; 19(11); 2821–5. ©2010 AACR.

Objective Obesity has become a public health epidemic in adults and children. Clinician practices need new models to effectively address overweight in patients, yet, practices lack time and resources. We tested a clinician-delivered intervention that utilized community resources for in-depth counseling for unhealthy behaviors including overweight. Methods Eligible patients in nine primary care practices were identified using an electronic linkage system (eLinkS) which also automated patient referrals to group (Weight Watcher's), telephone counseling (TC), or usual care. Pre/post-survey data were used to assess factors related to counseling choices as well as changes in BMI (kg/m 2 ) and weight-related behaviors using descriptive statistics, unadjusted, and adjusted statistical analyses. Results Study sample ( n = 146) was 70% female with a mean age of 57 years. More patients (57%) selected WW, followed by usual care (27%) or TC (16%). Age, gender, clinician recommendation, and counseling program characteristics were influential in counseling selections. Weight Watcher's participants and those in TC, reported statistically significant weight loss, WW participants also reported significant increases in fruit/vegetable intake; after 4 months compared with usual care. Conclusions This practice-based intervention utilizing community counseling referrals was associated with positive health behavior change. Practice Implications Identifying influential factors related to patient weight counseling choices may help guide referrals to community programs.

Background Colorectal cancer (CRC) screening rates are suboptimal. The most important barriers identified by patients are poorly understood. A comprehensive assessment of barriers to all recommended modalities is needed. Methods In 2007, a questionnaire was mailed to 6100 patients, aged 50–75 years, from 12 family medicine practices in the Virginia Ambulatory Care Outcomes Research Network. People aged 65–75 years and African Americans were oversampled. Patients were asked to rate 19–21 barriers to each of four recommended tests. In 2008, responses were coded on a 5-point scale; higher scores reflected stronger barrier endorsement. Results The response rate was 55% ( n= 3357). Approximately 40% of respondents were aged ≥65 years, 30% were African-American, and 73% were adherent to screening. A clinician's failure to suggest screening and not knowing testing was necessary received the highest mean scores as barriers. Financial concerns and misconceptions were also cited. Barrier scores differed depending on whether respondents were never screened, overdue for screening, or adherent to guidelines. The top five barriers for each modality included test-specific barriers (e.g., handling stool, bowel preparation), which often outranked generic barriers to screening. Not knowing testing was necessary was a top barrier for all tests but colonoscopy. Conclusions Although physician advice and awareness of the need for screening are important, barriers to screening are not homogenous across tests, and test-specific barriers warrant consideration in designing strategies to improve screening rates. Barrier scores differ by screening status, highlighting the need to address prior screening experience. Evidence that patients are more familiar with colonoscopy than with other modalities suggests an opportunity to improve screening rates by educating patients about alternative tests.

Background Barriers experienced by patients influence the uptake of colorectal cancer (CRC) screening. Prior research has quantified how often patients encounter these challenges but has generally not revealed their complex perspective and experience with barriers. Purpose This mixed-methods study was conducted to understand current perspectives on CRC screening. Methods A two-part, mixed-methods study was conducted of primary care patients recruited from Virginia Ambulatory Care Outcomes Research Network practices. First, in June–July 2005 a survey was mailed to 660 patients aged 50–75 years posing an open-ended question about "the most important barrier" to CRC screening. Second, beginning in October 2005, seven gender- and largely race-specific focus groups involving 40 patients aged 45–75 years were conducted. Beginning in October 2005, survey verbatim responses were coded and quantitatively analyzed and focus group transcripts were qualitatively analyzed. Results Responses to the open-ended survey question, answered by 74% of respondents, identified fear and the bowel preparation as the most important barriers to screening. Only 1.6% of responses cited the absence of physician advice. Focus group participants cited similar issues and other previously reported barriers, but their remarks exposed the intricacies of complex barriers, such as fear, lack of information, time, the role of physicians, and access to care. Participants also cited barriers that have little documentation in the literature, such as low self-worth, "para-sexual" sensitivities, fatalism, negative past experiences with testing, and skepticism about the financial motivation behind screening recommendations. Conclusions Mixed-methods analysis helps to disaggregate the complex nuances that influence patient behavior. In the present study, patients explained the web of influences on knowledge, motivation, and ability to undergo CRC screening, which clinicians and policymakers should consider in designing interventions to increase the level of screening.

Objectives. We estimated how many deaths would be averted if the entire population of Virginia experienced the mortality rates of the 5 most affluent counties or cities. Methods. Using census data and vital statistics for the years 1990 through 2006, we applied the mortality rates of the 5 counties/cities with the highest median household income to the populations of all counties and cities in the state. Results. If the mortality rates of the reference population had applied to the entire state, 24.3% of deaths in Virginia from 1990 through 2006 (range = 21.8%–28.1%) would not have occurred. An annual mean of 12 954 deaths would have been averted (range = 10 548–14 569), totaling 220 211 deaths from 1990 through 2006. In some of the most disadvantaged areas of the state, nearly half of deaths would have been averted. Conclusions. Favorable conditions that exist in areas with high household incomes exert a major influence on mortality rates. The corollary—that health suffers when society is exposed to economic stresses—is especially timely amid the current recession. Further research must clarify the extent to which individual-level factors (e.g., earnings, education, race, health insurance) and community characteristics can improve health outcomes.

Broad participation in screening is key to cancer prevention and early detection. Unfortunately, screening rates are low for many modalities. At its core, successful screening involves an individual deciding to take action (e.g., completing self-exams or scheduling appointments). Therefore, the

Purpose. Examine unionized workers' knowledge and attitudes about workplace tobacco use, their exposure to secondhand smoke, and the role of labor unions in addressing smoking and cessation coverage policies. Design. Random-digit dial telephone survey. Subjects. Unionized workers in Minnesota (N = 508). Measures. Knowledge and attitudes about workplace tobacco use and tobacco control policy making. Analysis. Multiple logistic regression. Results. The majority of respondents viewed secondhand smoke exposure as an important workplace health and safety issue, a health risk to nonsmokers, and a driver of increased health care costs, but smokers were less likely than nonsmokers to agree. Only 7% of respondents supported their unions taking the lead in tobacco control policy making. A large majority of those surveyed rated smoking cessation programs as an important benefit for which their labor unions could bargain; however, smokers and those whose workplaces allowed smoking were less likely than their counterparts to agree. Conclusions. Most unionized workers were aware of the health effects of exposure to secondhand smoke and supported union bargaining for restrictions on workplace smoking and cessation programs, although few workers supported their unions taking the lead in initiating worksite smoking policies. Results suggest that campaigns to promote smoke-free worksites should be tailored to unionized workers, and further collaborations with labor unions to promote policy change are needed.

A randomized trial investigated the impact of risk-tailored messages on mammography in diverse women in the Virginia Commonwealth University Health System's gynecology clinics.From 2003 to 2005, 899 patientsor =40 years of age were randomized to receive risk-tailored information or general information about breast health. Multiple logistic regression analyses summarize their breast health practices at 18 months.At baseline, 576 (64%) women reported having a mammogram in the past year. At 18-month follow-up, mammography rates were 72.6% in the intervention group and 74.2% in the control group (N.S.). Women (n = 123) who reported worrying about breast cancer "often" or "all the time" had significantly higher mammography rates with the intervention (85.0%) vs. the controls (63.5%). No significant differences existed in clinical breast examination, self-examination, or mammography intentions between the two study arms. However, intervention women with lower education reported significantly fewer clinical breast examinations at follow-up.The brief intervention with a risk-tailored message did not have a significant effect overall on screening at 18 months. However, among those who worried, mammography rates in the intervention group were higher. Individual characteristics, such as worry about breast cancer and education status, may impact interventions to improve breast cancer prevention practices.

This exploratory study assessed relationships among education, tolerance for ambiguity, and genetic testing awareness in light of implications for cancer genetics education.Cross-sectional analyses were conducted from self-administered written survey data of a breast cancer risk communication trial, including 899 Women's Health patients recruited from 2003 to 2005. The modifying effect of tolerance for ambiguity on the relationship between educational background and breast cancer genetic testing awareness was assessed through logistic regression.There was a statistically significant main effect of education (p0.05), but not tolerance for ambiguity, on genetic testing awareness. However, the relationship between education and awareness was stronger among those with high tolerance for ambiguity (p for interaction0.05), even when controlling for age, race, and breast cancer family history. Among persons with high (1 SD above the mean) and medium tolerance for ambiguity, the relationship between education and awareness was positive and significant (p = 0.048 and 0.002, respectively). Among participants with low tolerance for ambiguity, the association was not significant.Educational background may predict awareness knowledge of breast cancer genetic testing only for those with higher tolerance for ambiguity. These findings could inform future intervention research concerning education about cancer genetic testing.

Background Colonoscopy possesses the highest sensitivity of available screening tests for colorectal cancer and polyps, but it also carries risks. Appropriate intervals for repeating colonoscopy are important to ensure that the benefits of screening and surveillance are not offset by harms. The study objective was to examine whether endoscopists’ recommendations for repeat colonoscopy, as communicated to primary care clinicians after the procedure, adhered to published guidelines. Methods Analysts abstracted medical records at ten primary care practices in Virginia and Maryland in 2006. The records of a random sample of men and women (300 per practice) aged 50 to 70 years were reviewed. The sample included patients who had a colonoscopy and a written report from an endoscopist, and who lacked designated risk factors. The main outcome was concordance between endoscopists’ recommendations and published guidelines regarding repeat colonoscopy. Results Of 3000 charts reviewed, 1282 (42.7%) included records of a colonoscopy and 1021 (34%) included an endoscopist’s report. In 64.9% of communications, the endoscopist specified when retesting should occur. Recommendations were consistent with contemporaneous guidelines in only 39.2% of cases and with current guidelines in 36.7% of cases. The adjusted mean number of years in which repeat colonoscopy was recommended was 7.8 years following normal colonoscopy and 5.8 years and 4.4 years, respectively, when hyperplastic polyps or 1–2 small adenomatous polyps were found. Conclusions Endoscopists often recommended repeat colonoscopy at shorter intervals than are advised either by current guidelines or by guidelines in effect at the time of the procedure. Endoscopists’ communications to primary care clinicians often lacked contextual information that might explain these discrepancies. Unless appropriate caveats apply, adhering to endoscopists’ recommendations may incur unnecessary harms and costs.

This study explored risk perceptions after breast cancer risk appraisal. The study involved a randomized trial of Women's Health clinic patients (≥ 40 years old). Primary outcome was perceived breast cancer risk at baseline, 1 month, 6 months, and 18 months. Perceived breast cancer risks were higher than actual calculated risks at baseline. At baseline, 45% reported moderate/strong risk and 43% reported lower-than-average risk; 53% said that their risk was lower than 15%. Mean perceived lifetime risk was 31 out of 100. Throughout follow-up, the treatment group reported lower risks by all measures, as compared to controls. However, for African American women, perceived risk “out of 100 women” did not change. A brief health risk appraisal tends to lower breast cancer risk perceptions for at least 18 months, but the impact may vary by race/ethnicity. These findings could affect health behaviors, such as annual mammograms, which are influenced by perceived risk.

Background: This article describes the self-reported colorectal cancer (CRC) screening adherence rates of adults, aged 50 years and older, living in five nonurban Minnesota counties. Methods: During the year 2000, 1693 eligible respondents, aged 50 years and older, from a randomly selected sample completed a survey assessing CRC screening adherence (∼86.3% response). The survey allowed differentiation between the four CRC screening modalities but did not differentiate between screening and diagnostic testing. Adjustment for nonresponse was performed using a version of Horvitz-Thompson weighting accounting for unknown eligibility. Results: 24.5% of respondents had a fecal occult blood test within 1 year of the survey, 33.8% had flexible sigmoidoscopy within 5 years, 29.3% had a colonoscopy within 10 years, and 13.7% had a barium enema within the last 5 years. Overall, 55.3% of respondents reported testing by any modality; thus, 44.7% were not adherent to screening guidelines. Conclusions: This study improves on previous attempts to characterize CRC screening adherence by assessing all four modalities of screening as recommended by current screening guidelines, by focusing on nonadherence, and by rigorously accounting for nonresponse. This study confirms that nearly half of the population remains unscreened by any method.

Objectives To determine if intervention school students who received skills-based breast self-exam (BSE)/testicular self-exam (TSE) training were more likely than control school students to report higher intentions to perform BSE/TSE, greater BSE/TSE self-efficacy, and actual performance of BSE/TSE. Methods BSE/TSE behaviors, intentions, and self-efficacy were assessed in a high school-based trial (N = 6 schools; 3 schools randomized/condition) using self-reported data at 3 time points (N = 1058, 9 th grade students). Results At follow-up, intervention students had greater BSE/TSE intentions and self-efficacy than control students. Intervention students were more likely than control students to report monthly BSE (54.8% vs 27.2%, p = .031) and TSE (81.5% vs 31.4%, p = .010). Conclusions Skills-based interventions with goal setting affect teenagers' self-examination behaviors, intentions, and self-efficacy. Teaching self-screening may empower teenagers to become more engaged in their preventive health, which may lead to improved health as they age.

The objective of this study was to create an Adolescent Wisdom Scale, based on Jason et al.'s (in press) Functional Value Scale. The Adolescent Wisdom Scale is a self-rating of 23 attributes that have been shown to be associated with people who are perceived to have wisdom. The sample of 2,027 high school seniors, from 20 school districts in northeastern Minnesota, was administered a survey in spring 1998, as part of an ongoing alcohol use prevention program. The scale was found to have high internal consistency and three subscales which were significantly associated with less involvement with alcohol use, cigarette use, and violent behaviors.

The study purpose is to describe who breast cancer survivors see for their care by years since diagnosis and determine the association between time since diagnosis and the type of clinician providing the majority of care, taking into account receipt of follow-up care instructions. The 2010 Behavioral Risk Factor Surveillance System was used to identify a sample (N = 1024) of women with a self-reported history of breast cancer. Descriptive characteristics were calculated and stratified by years since diagnosis. Multivariate logistic regression adjusting for age, income, and receiving follow-up care instructions was performed to evaluate the association between years since diagnosis and clinician providing the majority of care. The type of clinician reported most frequently was a primary care provider. Women 0–1 year since diagnosis had the highest proportion reporting a cancer-related clinician for their care. After adjustment, women 0–1, 2–3, and 4–5 years since diagnosis were respectively 2.1, 2.6, and 1.7 times more likely to have a cancer-related clinician providing the majority of care compared to women 6+ years since diagnosis (respective 95 % confidence intervals (CIs) 1.0–4.3; 1.4–4.6; 0.9–3.1). Breast cancer survivors receive the majority of their care from primary care providers, and years since diagnosis has a significant impact on who survivors see for their care. Breast cancer survivors have nationally recommended follow-up guidelines; however, the type of clinician that should provide care is not specified. Information regarding who provides the majority of care can be used for future planning and policy development.

Pediatric overweight is associated with numerous physical and psychological health risks, and overweight children are at significant risk for obesity in adulthood. African-American children are at particularly high risk for obesity and related health complications. However, this racial group has traditionally had limited access to obesity treatment and relatively few studies have included sufficient numbers of lower-SES, African American participants. Further, although parental involvement in treatment for pediatric overweight has been found to be beneficial, few studies have examined the efficacy of offering treatment exclusively to parents, a potentially cost-effective approach which could benefit the entire family. This pilot project will evaluate the efficacy of an intensive parenting intervention, (NOURISH; Nourishing Our Understanding of Role modeling to Improve Support and Health), targeting racially diverse parents of overweight children (ages 6–11). NOURISH addresses several urgent research priorities by targeting the underserved and addressing the significant disparity in obesity treatment services. Parents meeting study criteria (having a child between the ages of 6 and 11 with a BMI ≥ the 85th percentile) will be offered participation in the randomized trial comparing NOURISH with a control group. We hypothesize that children whose parents participate in NOURISH will manifest greater decreases in BMI, and greater improvements in dietary intake, and quality of life compared to children whose parents do not participate. This study is designed explicitly to gather preliminary feasibility, acceptability, and effectiveness data to inform a subsequent larger randomized controlled trial.

Objective We implemented a theory-based randomized controlled trial (Living Free of Tobacco, Plus (LIFT +) in ten rural middle schools and assessed impact on tobacco use and fruit/vegetable (F/V) intake in 2008–2010. Data on F/V intake at baseline, immediate post intervention, and 1-year follow-up are presented. Methods Schools were randomized to intervention or control groups. Goal setting, peer leaders, and class workshops with parent involvement, were intervention features; community partners were supportive. Seventh graders filled out surveys on health behaviors, psycho-social variables, and demographic characteristics. Adjusted models comparing intervention and control conditions were analyzed. Results Sample (n = 1119) was 48.5% female, 50% White, with a mean age of 12.7 years. Mean F/V servings were significantly higher in intervention schools at immediate post (3.19 servings) and at 1-year (3.02 servings) compared to controls (2.90, 2.69 respectively). Knowledge of 5-a-day recommendation was significantly higher in intervention schools at immediate post test (75.0%) versus controls (53.8%) but not at 1-year follow-up. Conclusions Intervention schools reported significantly higher mean F/V servings at post intervention and 1-year, and for knowledge of F/V recommendations at immediate post compared to controls. Higher levels of parent and community involvement may further increase F/V intake in future interventions. ClinicalTrials.gov Identifier: NCT01412697 .

Like Neugut and Lebwohl,1 we welcome the recent successes in promoting colorectal cancer screening. We also agree that offering too many testing options can dampen enthusiasm for screening, but we disagree with their solution: to promote a “preferred” test. Setting aside the question of whether colonoscopy is the “best” test—Neugut and Lebwohl themselves acknowledge that only fecal occult blood testing (FOBT) has been proven to lower mortality rates2—promoting a single test is risky because patient preferences are heterogeneous. A sizable proportion of the 50% of the population the authors wish to reach will decline an invasive examination and bowel preparation for screening but will undergo FOBT (and undergo colonoscopy if the results are abnormal). A campaign that makes colorectal cancer screening synonymous with colonoscopy, as espoused by the authors, could potentially “turn off” those reluctant patients who might consider screening by other means. The revamped Web site of Twitter, a social networking and microblogging service utilizing instant messaging, SMS (short message service, usually mobile-to-mobile text messages), or a Web interface. Photograph by David Brabyn. Printed with permission of Corbis. Although we agree that presenting 7 options for screening is excessive, it seems reasonable to offer at least 2 alternatives—FOBT and colonoscopy—which exhibit comparable effectiveness in empirical and modeling studies.2,3 Having options is important not only to accommodate patient preferences and extend screening to people who are averse to colonoscopy but also for communities that cannot supply enough endoscopists4 or offer colonoscopy at an affordable cost but can provide FOBT. FOBT limits the volume of screening colonoscopies, lowering costs5 without compromising health benefits.3 Choosing between colonoscopy and FOBT need not overwhelm patients if clinicians succinctly explain the contrasts—in frequency, invasiveness, and logistics—and present both tests as excellent choices, with a decision to forego screening being the only bad choice. Although gastroenterologists understandably prefer colonoscopy and favor guidelines that invoke a hierarchy6 over those that emphasize choices,2 Neugut and Lebwohl offer little evidence that their approach improves screening rates. The increase in screening that they observed in New York City between 2003 and 2006 (from 40% to 60%) is not unlike the secular trend observed nationally. Between 2002 and 2006, rates for screening by lower endoscopy (approximately 80% involving colonoscopy7,8) increased from 45% to 56% in the United States9 (to 61% in New York State10). Clearly, the increase in New York City is only partly attributable to promoting colonoscopy. A controlled study would help clarify whether “it's time for a colonoscopy” is a message that achieves better results than one emphasizing choices in colorectal cancer screening.

Breast cancer mortality has declined, yet disease outcomes have not improved equally across populations. Disparities may initiate early in the continuum of care, in health behavior patterns, and screening practices. We examined variations in mammography, exercise, fruit and vegetable intake, alcohol consumption, and body mass index (BMI, kg/m2) by age and race in a diverse sample of clinic patients.We analyzed survey data collected at baseline from 855 women (40 years old) in women's health clinics, who were recruited for a risk-tailored intervention. Screening practices, health behaviors, and demographics were surveyed. Statistical analyses were performed using bivariate difference tests and multiple logistic regression.Overall, 47% of the women were African American, with a mean age of 50 years. Older women were twice as likely as younger women to have had mammography within the previous year and significantly more likely than women 10 years younger to exercise at least 3 times weekly. African American women were significantly less likely than white women to exercise at least 3 times weekly, eat more than 2 servings daily of fruit and vegetables, or report a BMI of less than25 kg/m2. Mammography rates were comparable by race except among lesser-educated African American women, who showed higher rates versus comparable white women.New intervention models that link health behavior information with screening messages in clinical settings may be important in reducing breast cancer risk and mortality.

Although intensive health behavior counseling has been demonstrated to help patients lose weight and quit smoking, many payers offer limited coverage for such counseling.This mixed-methods case study examined how coverage affected utilization of an electronic linkage system (eLinkS) to help adult patients obtain intensive health behavior counseling, provided through a collaboration of primary care practices and community programs.Grant support enabled patients to obtain counseling at no cost, but funds were exhausted within 5 weeks as a result of an overwhelming response. To study the influence of cost as a barrier, referrals were resumed for an additional 3 weeks, but patients were required to pay for them. Use of eLinkS, level of clinician counseling and referrals, and patient interest in referrals were measured using electronic medical record data and patient and clinician interviews.When counseling was free, approximately one in five patients with an unhealthy behavior and an eLinkS prompt was referred for intensive counseling. However, when patient charges were instituted, referrals decreased by 97% (from 21.8% to 0.7%, p0.001); clinicians asked fewer patients about health behaviors (37% vs 29%, p0.001); clinicians offered fewer patients referrals (29% vs 6%, p0.001); and patients were less interested in accepting referrals (76% vs 14%, p0.001). In interviews, patients and clinicians cited cost as a major barrier.Coverage for intensive health behavior counseling is important to utilization, particularly for interventions that involve clinician-community partnerships. The potential public health benefits of such collaborations to reduce unhealthy behaviors justify the elimination of financial barriers (e.g., copayments) by payers.

Purpose: To summarize the impact of a family history of breast cancer on mammography practices and beliefs. Method: Survey data concerning breast health practices and beliefs were utilized for a cross-sectional analysis. Participants were 899 racially diverse nonpregnant women 40 years and older without breast cancer. The impact of various aspects of cancer family history on mammography, perceived barriers to and benefits of screening, and perceived breast cancer risk was assessed. Results: More women with a first-degree relative with breast cancer reported a mammogram within the past year and rated their breast cancer risk higher. Death of a first-degree relative impacted the belief that breast cancer can be cured with early detection. Degree of relatedness of affected relative impacted mammography practice and risk perceptions. Conclusion: Family history of breast cancer impacted mammography adherence, beliefs about outcomes with early detection, and risk perceptions. Breast cancer death in a family may be a better predictor of beliefs about breast cancer detection and cure than family history of cancer alone. These findings have implications for how screening recommendations and risk information are communicated to patients with different familial cancer experiences.

Little is known about the validity of self-reported colorectal cancer screening. To date, few published studies have validated all four screening modalities per recommended guidelines or included a general population-based sample, and none has assessed validity over time and by intervention condition. To estimate the validity of self-reported screening, a random sample of 200 adults, ages ≥50 years, was selected from those completing annual surveys on screening behavior as part of an intervention study. Approximately 60% of the validation sample authorized medical record review. Sensitivity, specificity, and positive and negative predictive values were calculated for baseline and year 1 follow-up reports for each test and for overall screening adherence. Sensitivity at baseline ranged from 86.9% (flexible sigmoidoscopy) to 100% (colonoscopy). Sensitivity at follow-up was slightly lower. Adjusting for validity measures, the sample overreported screening prevalence at baseline for each of the four modalities. At follow-up, overreporting was greatest for fecal occult blood test (13.0%). Overreporting across intervention conditions was highest for fecal occult blood test (10.8% for control; 24.8% for the most intense intervention) and overall screening adherence (10.9% for control; 14.3% for the most intense intervention). Sensitivity and specificity of self-reported colorectal cancer screening compared with medical records were high; however, adjusting self-reported screening rates based on relative error rates reduced screening prevalence estimates. Those exposed to more intense interventions to modify screening behavior seemed more likely to overestimate their screening rates compared with those who were not exposed. (Cancer Epidemiol Biomarkers Prev 2008;17(4):777–84)

Colonoscopy possesses the highest sensitivity of available screening tests for colorectal cancer and polyps, but it also carries risks. Appropriate intervals for repeating colonoscopy are important to ensure that the benefits of screening and surveillance are not offset by harms. The study objective was to examine whether endoscopists' recommendations for repeat colonoscopy, as communicated to primary care clinicians after the procedure, adhered to published guidelines.Analysts abstracted medical records at ten primary care practices in Virginia and Maryland in 2006. The records of a random sample of men and women (300 per practice) aged 50 to 70 years were reviewed. The sample included patients who had a colonoscopy and a written report from an endoscopist, and who lacked designated risk factors. The main outcome was concordance between endoscopists' recommendations and published guidelines regarding repeat colonoscopy.Of 3000 charts reviewed, 1282 (42.7%) included records of a colonoscopy and 1021 (34%) included an endoscopist's report. In 64.9% of communications, the endoscopist specified when retesting should occur. Recommendations were consistent with contemporaneous guidelines in only 39.2% of cases and with current guidelines in 36.7% of cases. The adjusted mean number of years in which repeat colonoscopy was recommended was 7.8 years following normal colonoscopy and 5.8 years and 4.4 years, respectively, when hyperplastic polyps or 1-2 small adenomatous polyps were found.Endoscopists often recommended repeat colonoscopy at shorter intervals than are advised either by current guidelines or by guidelines in effect at the time of the procedure. Endoscopists' communications to primary care clinicians often lacked contextual information that might explain these discrepancies. Unless appropriate caveats apply, adhering to endoscopists' recommendations may incur unnecessary harms and costs.

Background: Although colorectal cancer screening by using a fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, or barium enema x-ray reduces the incidence of and death from colorectal cancer, the rate of colorectal cancer screening in the general population is low. We conducted a randomized trial consisting of direct mailing of FOBT kits to increase colorectal cancer screening among residents of Wright County, Minnesota, a community in which colorectal cancer screening was promoted. Methods: At baseline, we mailed a questionnaire about colorectal cancer screening to a random sample of Wright County residents aged 50 years or older who were randomly selected from the Minnesota State Driver’ s License and Identification Card database (estimated N 1451). The sample was randomly allocated into three equal subgroups: one group (control) received only the questionnaire, one group received FOBT kits by direct mail with reminders, and one group received FOBT kits by direct mail without reminders. Study participants were sent a follow-up questionnaire 1 year after baseline. We used the responses to the questionnaires to estimate the 1-year change in self-reported screening rates in each group and the differences in the changes among the groups, along with the associated bootstrap 95% confidence intervals (CIs). Results: At baseline, the estimated response rate was 86.5%, self-reported adherence to FOBT guidelines was 21.5%, and overall adherence to any colorectal cancer screening test guidelines was 55.8%. The 1-year rate changes in absolute percentage for self-reported adherence to FOBT use were 1.5% (95% CI ‐2.9% to 5.9%) for the control group, 16.9% (95% CI 11.5% to 22.3%) for the directmail-FOBT-with-no-reminders group, and 23.2% (95% CI 17.2% to 29.3%) for the direct-mail-FOBT-withreminders group. The 1-year rate changes for self-reported adherence to any colorectal cancer screening test were 7.8% (95% CI 3.2% to 12.0%) for the control group, 13.2% (95% CI 8.4% to 18.2%) for the direct-mail-FOBT-withno-reminders group, and 14.1% (95% CI 9.1% to 19.1%) for the direct-mail-FOBT-with-reminders group. Conclusion: Direct mailing of FOBT kits combined with follow-up reminders promotes more rapid increases in the use of FOBT and nearly doubles the increase in overall rate of adherence to colorectal cancer screening guidelines in a general population compared with a community-wide screening promotion and awareness campaign. [J Natl Cancer Inst 2004;96:770 ‐80]

Project Northland was a randomized trial to reduce alcohol use among adolescents in 24 school districts in northeastern Minnesota. Phase 1 (1991-1994), when the targeted cohort was in grades 6-8, included school curricula, parent involvement, peer leadership and community task forces. The Interim Phase (1994-1996) involved minimal intervention. Phase 2 (1996-1998), when the cohort was in grades 11 and 12, included a classroom curriculum, parent education, print media, youth development and community organizing. Outcomes of these interventions were assessed by annual student surveys from 1991 to 1998, alcohol purchase attempts by young-looking buyers in 1991, 1994 and 1998, and parent telephone surveys in 1996 and 1998. Growth curve analysis was used to examine the student survey data over time. Project Northland was most successful when the students were young adolescents. The lack of intervention in the Interim Phase when the students were in grades 9 and 10 had a significant and negative impact on alcohol use. The intervention used with the high school students as those in grades 11 and 12 made a positive impact on their tendency to use alcohol use, binge drinking and ability to obtain alcohol. There was no impact in Phase 2 on other student-level behavioral and psychosocial factors. Developmentally appropriate, multi-component, community-wide programs throughout adolescence appear to be needed to reduce alcohol use.