Rutten, Lila Finney

Abstract Purpose We examined barriers and facilitators to colorectal cancer (CRC) screening among Alaska Native individuals who had never been screened or were not up to date with screening guidelines. Methods As part of a larger study investigating the use of the multitarget stool DNA test in rural Alaska communities, we conducted focus groups and in‐depth interviews with 28 never screened or not up‐to‐date Alaska Native people in two remote communities between November 2022 and July 2023. Participants shared their barriers to CRC screening and offered suggestions to improve programs to better reach those who are guideline discordant. Findings General screening barriers included lack of knowledge, fear of discovering you have cancer, and cultural health beliefs. Colonoscopy‐specific barriers included embarrassment from knowing the local medical staff, having rectal area viewed or touched, fear of pain and injury, difficulty scheduling a procedure due to traditional food gathering activities, lack of provider referrals/reminders, and the high cost of air travel required to get to a colonoscopy facility. Stool DNA‐specific concerns included not feeling that it was as good as colonoscopy, lack of privacy to do the test, and hesitancy collecting stool samples. Suggestions for increasing screening rates included increasing access via paid air transportation, using local indigenous languages, improving provider relationships and reminder systems, and providing CRC and screening education using trusted messengers. Conclusions This was the first exploration of the perceptions of CRC screening among guideline discordant Alaska Native people. Identified themes can be used to improve screening program outreach effectiveness in the future.

Abstract Background: Multiple guideline-recommended colorectal cancer (CRC) screening options have been shown to reduce CRC incidence and mortality among average-risk patients. Yet, CRC screening continues to be underutilized in the US. Provider recommendation has consistently shown to improve screening completion. Our study aimed to delineate the pathways through which provider communication influences CRC screening completion. We tested how provider communication about the "Why” and “How” of mt-sDNA screening contributes to mt-sDNA screening intention through influencing patients’ screening outcome expectancies and perceived behavioral control. Methods: Data came from a behavioral theory-informed survey that we developed to identify psychosocial factors associated with mt-sDNA screening. The survey was administered between 3/22-6/22 by RTI International, with a sample of US adults ages 45-75 who received a valid order for mt-sDNA screening with a shipping date between 5/21-9/21. Participants completed an electronic or paper survey. We measured patients’ reports of providers’ “Why” communication with items on mt-sDNA screening performance, advantages/disadvantages, and cost. Providers’ “How” communication was measured with items on instructions and need for follow-up testing. We tested the proposed relationships using structural equation modeling and tested indirect effects using bootstrapping. Results: A total of 2973 participants completed the survey (response rate: 21.7%). “Why” communication was positively associated with perceived effectiveness of mt-sDNA screening (b = 0.349, p < .001) and negatively associated with CRC worry (b = -0.078, p = .002). “How” communication was positively associated with perceived ease of use (b = 0.392, p < .001) and perceived comfort of mt-sDNA screening (b = 0.138, p < .001). Perceived effectiveness and perceived ease of use were positively associated with intention to complete mt-sDNA screening (b = 0.404, p < .001; b = 0.339, p < .001). “Why” communication contributed to screening intention through influencing perceived effectiveness (b-indirect effect = 0.141, 95% CI: 0.115, 0.177). “How” communication contributed to screening intention through influencing perceived ease of use (b-indirect effect = 0.133, 95% CI: 0.104, 0.172). Conclusions: Improving patients’ beliefs about the effectiveness and ease of use of screening may be one pathway through which provider communication contributes to CRC screening completion. Efforts are needed to develop and implement provider-patient communication strategies and toolkits that are efficacious at fostering patient understanding of the rationale for CRC screening and the effectiveness of available screening options as well as addressing barriers and enhancing patients’ self-efficacy in completing their preferred screening option. Citation Format: Xuan Zhu, Paul Limburg, Linda Squiers, Leah Helmueller, Gabriel Madson, Brian Southwell, Carlye Gates, Shama Alam, Jennifer Laffin, Lila Finney Rutten. Provider communication contributes to colorectal cancer screening intention through improving screening outcome expectancies and perceived behavioral control [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 770.

Introduction: Little is known about the characteristics and resources that enable patients with heart failure (HF) to engage in effective self-management. To address this gap in knowledge, we measured personal and health care resources for self-management and examined associations with mortality among patients with HF. Methods: We surveyed 5543 residents of 11 counties in Southeast Minnesota with a first-ever code for HF [International Classification of Disease, Ninth Revision code 428 or Tenth Revision code I50] between 1/1/2013 and 3/31/2016. Self-management resources were measured with the health care and personal subscales of the Chronic Illness Resources Survey (CIRS), both of which included 3 questions on a 5-point scale. The responses were averaged and participants were categorized as low if the mean score was below the median of the distribution (range from 1 to 5). The survey was returned by 2866 participants (response rate 52%) and those with complete data on the main items of interest were retained for analysis (N=2212). Cox proportional hazards regression was used to determine the association between each subscale and mortality. Results: Among 2212 participants (mean age 72.8 years, 54.1% men) the median health care score was 4, while the personal score was 3. Those with low health care resources were older and less educated than those with a higher score (p<0.05), while those with low personal resources had less comorbidities and lower education attainment compared to those with a higher score (p<0.05). After a mean (SD) follow-up of 1.3 ± 0.6 years, 207 deaths occurred. Low levels of both self-management resources were associated with an increased risk of death compared with patients with high levels (Table). Conclusions: Having limited self-management resources is associated with an increased risk of mortality among patients with HF. Thus, interventions aimed at supporting self-management among patients with HF may improve outcomes.

Background: Previous studies have indicated that living in a rural or non-urban area may be associated with poor health outcomes. However, data on rurality and death in heart failure (HF) are scarce. Methods: Residents from 11 southeast MN counties with a first-ever code for HF (including codes ICD-9 428 and ICD-10 I50) between 1/1/2013 and 12/31/2016 were identified. Resident address was geo-coded and classified according to the Rural-Urban Commuting Area (RUCA) codes, which classifies US census tracts to measure population density, urbanization and daily commuting. Rurality was defined as living in a non-metropolitan area. Cox proportional hazards regression was used to determine the association between living in a rural vs. urban area and death. Results: Among 6,996 patients (mean age 73 years, 52% male), 54% of patients lived in a rural area. These patients were older and had a lower level of educational attainment and comorbidity burden (p<0.001). After a mean (SD) follow-up of 2.9 (1.3) years, 1,856 deaths occurred. Living in a rural area was univariately associated with a higher risk of death (HR 1.20, 95% CI: 1.09-1.31; Table). After adjustment for age, sex, education status and comorbidity burden, rurality remained associated with an increased risk of death (HR 1.15; 95% CI: 1.04-1.27). Conclusions: Among patients with HF, living in a rural area is associated with an increased risk of death. Further study to identify and address the mechanisms through which rural residence influences mortality in patients with HF is needed.

Abstract Background: Human papillomavirus (HPV) is a causative agent in cervical cancer as well as anal, oropharyngeal, penile, and vaginal/vulvar cancers. Licensed, effective HPV vaccines have been available in the U.S. since mid-2006 for females and late 2011 for males and are recommended up to age 26. Despite this, in 2014, only 39.7% of U.S. girls and 21.6% of boys 13 to 17 years of age completed the three-dose vaccine series. ‘Lack of knowledge’ was a primary reason cited among parents for not vaccinating their children. HPV vaccination rates are lower still among 19-26 year olds, particularly among the uninsured. We assessed awareness and knowledge of HPV disease, HPV-related cancers, and HPV vaccines among working, uninsured adults and used 2014 data from the Health Information National Trends Survey (HINTS cycle 4) as a national benchmark against which to compare our data. Methods: Self-administered surveys were offered to patients attending appointments at the Volunteers in Medicine (VIM) clinic in Jacksonville, FL between September 10, 2014 and October 24, 2014. VIM provides free primary care for working individuals without insurance living and/or working in Duval County. Patients were eligible to participate if they were at least 18 years of age, not in acute distress, and had not completed a survey during pilot-testing. Surveys were available in English and Spanish and contained a validated HPV knowledge measure assessing disease knowledge and vaccine knowledge. Additionally, HPV-related cancer knowledge was assessed: 5 HPV-related (cervical, anal, throat, penile, vaginal/vulvar) and 4 not currently known to be HPV-related (lung, breast, prostate, skin). High knowledge was defined as having a knowledge score in the upper quartile of positive values. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression to assess the association of demographic characteristics with having high knowledge of HPV, HPV vaccines, and HPV-related cancer. Additional models assessed individual cancers. During the study period 356 patients were eligible to participate; of these, 55 declined (84% participation rate). Of the 301 surveys, 5 surveys were excluded from analysis due to excessive missing data; a total of 296 surveys were analyzed. Results: 50.3% of participants (n=149) had heard of HPV, 37.2% (n=110) correctly indicated that HPV is sexually transmitted, and 32.1% (n=95) had heard of the HPV vaccine. In HINTS 4, these estimates were 63.6%, 44.0%, and 62.7%, respectively. In adjusted models, high HPV disease knowledge was associated with race (OR non-white = 0.39 (0.19, 0.78)) and education (OR &gt;high school = 2.34 (1.14, 4.84)) while high HPV vaccine knowledge was associated with race (OR non-white = 0.42 (0.21, 0.82)), education (OR &gt;high school = 5.04 (2.30, 11.06)), and sex (OR male = 0.34 (0.12, 0.94)). Of the HPV-related cancers, 43.9% answered correctly for cervical, 9.1% for anal, 11.1% for mouth/throat, 11.5% for penile, and 30.7% for vaginal/vulvar cancer. Males were less likely than females to know that HPV is a causative agent for cervical (OR=0.41 (0.22, 0.75)) and vaginal/vulvar cancers (OR=0.43 (0.22, 0.86)). Conclusion: Using estimates obtained in HINTS 4 as a benchmark, awareness and knowledge of HPV, HPV-related cancers, and HPV vaccines were low among working, uninsured adult patients. In addition to improving access to HPV vaccination (e.g. volunteer clinics), the findings demonstrate a need for strategies to educate medically underserved adults about HPV. Maximizing access to HPV vaccination, including catch-up vaccination for adults up to age 26 are consistent with the recommendations of the President's Cancer Panel, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the Advisory Committee on Immunization Practices. Citation Format: Carmen Radecki Breitkopf, Lila Finney Rutten, Debra Jacobson, Patrick Wilson, Monica Albertie, Robert M. Jacobson, Gerardo Colon-Otero. Awareness and knowledge of HPV, HPV-related cancers, and HPV vaccines in a working, uninsured clinic population. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B91.

Interventions that cultivate sustainable food systems to promote health, prevent obesity, and improve food security have the potential for many large-scale and long-lasting benefits including improvements in social, environmental, health, and economic outcomes. We briefly summarize findings from previous research examining associations between obesity and food insecurity and discuss the need for greater synergy between food insecurity initiatives and national obesity prevention public health goals in the United States. The common ground between these two nutrition-related public health issues is explored, and the transformation needed in research and advocacy communities around the shared goal of improving population health through individual, environmental, and policy level changes to promote healthy sustainable food systems is discussed. We propose an ecological framework to simultaneously consider food insecurity and obesity that identifies levers for change to promote sustainable food systems to improve food security and prevent obesity.